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Good morning ... Know what Obamacare is getting for its 7th birthday on Thursday? A repeal vote in the House, that's what! Happy birthday, Obamacare. Gonna be the worst birthday party ever. Brings back bad memories of when I lost at miniature golf on my 7th birthday, and then got repealed.

This is going to be one of those weeks where you really need help de-cluttering your news, and that's what we, on the Axios health care team, are trying to do. But if you think we're missing important stuff, please let us know. And keep checking the Axios health care news stream for all the latest, and sign up for our newsletters and breaking news alerts here.

The three big things to know for repeal week

Giphy

Here's what you need to know as we head into the week of the House vote:

  • Republican leaders may be within striking distance of the 216 votes they need for Trumpcare to pass the House.
  • They're nowhere close to the votes they need in the Senate, thanks to conservatives and moderates turning against it for different reasons.
  • The one new change that seems almost certain to happen: The tax credits will be reworked to give more help to the low-income elderly.
There's still a long way to go in the House, but GOP leaders are a lot closer to nailing down the votes after President Trump struck a deal with the Republican Study Committee on Friday morning to win their support. (Caitlin Owens and Jonathan Swan give a rundown here of the Medicaid changes they've been promised.) Here's who to keep your eye on now:
  • Freedom Caucus members: Even after the Republican Study Committee got on board on Friday, the Freedom Caucus tweeted that it "still opposes the GOP replacement bill in its current form." CNN reports that the group's chairman, Rep. Mark Meadows, and Sens. Ted Cruz and Mike Lee met with top Trump aides at Mar-a-Lago this weekend to try to push the bill farther to the right.
  • Reality check: The Freedom Caucus is certainly capable of causing trouble for House Speaker Paul Ryan — they made life miserable for John Boehner. But how many would actually vote against a repeal bill when the time comes? You'll know the tide has turned if you start hearing "I don't like it but won't stand in the way" speeches.
  • Moderates: The Washington Post has a good look at what it calls the "sleeping giants," or the moderates who are appalled by the estimated coverage losses. Many are from states that expanded Medicaid, and don't like how the bill handles the end of the expansion.
  • Reality check: The GOP leaders are trying to win them over, as Jonathan Swan reported yesterday — but when was the last time a bill failed in the House because moderate Republicans all stood their ground against the leadership? It's not impossible, but it doesn't happen very often.
The bigger problem is in the Senate, where senators are more independent and less likely to fall in line than in the House. Sens. Ted Cruz and Susan Collins were on separate Sunday talk shows discussing how they can't support the bill, but from opposite ends of the spectrum: Cruz wants to knock out the Obamacare insurance regulations, while Collins is worried about lost coverage and Medicaid cuts. Try to figure out the formula that makes both happy.

Hospitals have a big labor problem coming up

Obamacare was good for health care jobs around the country, but especially for hospitals. Now, Bob Herman reports that they're going to have a problem on their hands if repeal happens: What are they going to do with all of those expensive new hires if millions of people lose health coverage? The hiring has already slowed down because of all of the uncertainty, and if they have fewer patients who can pay for their medical care, they might have to reduce their staffs through attrition — or layoffs. Read Bob's story here.

Don't spend a ton of time learning about "Phase 3"

I was all set to give you an in-depth look at all of the health care bills Republicans are lining up for "Phase 3" of Obamacare replacement — all the proposals they can't put in the budget "reconciliation" bill. Here's the list so far:

  • Competitive Health Insurance Reform Act of 2017 — eliminating the antitrust protection for insurance providers (House voting this week)
  • Small Business Health Fairness Act of 2017 — association health plans (House voting this week)
  • Medical malpractice reform (later this month)
  • Protecting self-insurance (later this month)
  • Selling health insurance across state lines (House Energy and Commerce subcommittee hearing coming soon)

There are substantive reasons to learn about the pros and cons and all of them. But here's the problem: All of them might be able to pass the House pretty easily, but then they'd all need Democratic votes to pass the Senate, since they'd need 60 votes.

So I asked around about whether any of them could get enough Democratic votes, and here's what a Senate Democratic leadership aide told me: "No they will not. We are happy to work with Republicans to improve health care but they have to drop repeal first. If they manage to pass a repeal bill, they're on their own. There won't be a phase 3."

Cruz actually laughed at the idea on CBS's "Face the Nation" yesterday when John Dickerson asked him about it. "That ain't going to happen," Cruz said, calling it "the sucker's bucket." So, moving along ....

Price is still a fan of Medicare balance billing

Steven Brill points out something for your radar: Price's long fight to let doctors charge more to Medicare patients could now be a big deal. Modern Healthcare reported that in his written responses to questions from the Senate Finance Committee considering his nomination for Health and Human Services secretary, Price didn't back down from his support for a change in the Medicare law that would allow doctors participating in the program to "balance bill" Medicare beneficiaries — meaning they could charge them more than the amount Medicare pays. (You can read the exchange here — it starts on page 8.)

Balance bills are often given to patients with private insurance, usually because they are using a doctor out of the insurance company's network. But the practice has always been banned for doctors treating Medicare patients. Under the change long advocated by Price, a former orthopedic surgeon, the doctors could have their cake and eat it, too: be in the Medicare network, but charge as much extra as they can to as many patients as they can.

Why it matters: Medicare, with about 55 million enrollees, protects about twice the number of Americans who are enrolled through the Obamacare exchanges and the expansion of Medicaid.

While you were weekending ...

  • House Rules Committee chairman Pete Sessions faced chants of "Vote him out!" at a town hall meeting in Richardson, Texas, as he talked about the Obamacare repeal effort.
  • Sen. Rand Paul, on ABC's "This Week," predicting the House GOP bill won't pass: "I believe that the real negotiation begins when we stop them."
  • Ryan, on Fox News Sunday, on Trump's proposed cuts to the National Institutes of Health: "NIH is something that's particularly popular in Congress. We just passed the Cures Act just this last December to increase spending in the NIH."
  • Collins on NBC's "Meet the Press," on Trump's NIH cuts: "If we're serious about reducing health care costs, the last thing that we should be doing is cutting the budget for biomedical research."
  • Price, on ABC's "This Week," on ProPublica's bombshell report that U.S. Attorney Preet Bharara was investigating Price's stock trades before he was fired: "I have -- know nothing about that whatsoever."
  • The New York Times looks at how the GOP is confronting the reality that a lot of blue-collar Trump voters depend on government medical care.
  • The Center for American Progress has a district-by-district breakdown of how many people would lose coverage under the GOP bill, based on the Congressional Budget Office estimates.
  • Avik Roy writes that the GOP bill's premium increases for the elderly could be eliminated by means testing the tax credits and adding a standard deduction.
New on Twitter: Centers for Medicare and Medicaid Services administrator Seema Verma (@SeemaCMS). And if you're not following Tom Price's official account yet, it's @SecPriceMD.

Why Medicaid work requirements won't work

Some think tank is apparently warning that work requirements for Medicaid — the latest thing Republicans are about to add to the Obamacare replacement bill — won't work because "making cash assistance or food stamps contingent on work participation is one issue, denying medical care to sick, poor people is another matter."

Just gonna check and see who wrote that — guessing it's the Center for American Progress or some other lefty think tank that would never...OMG IT'S THE HERITAGE FOUNDATION. Here's what senior research fellow Robert Rector wrote: It's likely to be optional, so most governors would ignore it; the rule would be "almost impossible to administer and enforce;" and, no one's really going to deny medical care to someone who didn't do their work assignments.

Rector isn't really against work requirements in principle — he just thinks they should be applied to food stamps, which would be easier to enforce and covers a lot of the same population. But it will be interesting to see if any Republicans grapple with the practical problems when the Medicaid part of the bill is being rewritten.

What we're watching today: Trump rally in Louisville, Kentucky to build support for the GOP bill, 7:40 p.m. Eastern. Also, Trump meets with Ryan, Price, and Zeke Emanuel, 11:30 a.m. Eastern.

What we're watching this week: House Rules Committee takes up the Obamacare replacement package, probably Wednesday ... and the big House vote, Thursday. The House also votes on bills to eliminate the antitrust protection for insurance providers and to create association health plans. Also, Senate HELP Committee will hold a hearing on reauthorizing the Food and Drug Administration's user fee agreements, Tuesday.

Thanks, and let me know what you'll be drinking on repeal night: david@axios.com.

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Toyota claims a leap that would vastly increase electric-car range

Lazaro Gamio / Axios

In an unusual statement, Toyota says it is nearing a breakthrough in a type of lithium-ion battery system that has vexed researchers for decades, and that it will unveil a family of electric cars with a jump in currently available range in the early 2020s.

Why it matters: Given the high stakes and risk of embarrassment if something goes wrong, Japanese companies virtually never flag a big tech breakthrough before it is actually produced and delivered to the market. Hence, Toyota's comparatively specific announcement suggests it is reasonably confident that it really has mastered a new battery technology, said Venkat Viswanathan, a professor at Carnegie Mellon University.

Toyota says its battery is solid state, which is what has piqued the interest of the battery community: If Toyota really has figured out solid state, that would allow the company sometime in the future to make a second big breakthrough — to swap in an anode made of ultra-energetic lithium metal, a substance that researchers have tried without success to get safely into lithium-ion batteries since the early 1990s. The trouble with lithium metal is its volatility — it can catch fire on contact with liquid electrolyte or even the air. But solid state eliminates that problem because it has no liquid.

In a statement to Axios, Toyota said it will commercialize "sulfide system all-solid batteries" that it hopes will have increased durability and improve the range of electric vehicles in which they are installed.

Go deeper: Toyota declined to say whether it's using a lithium metal anode. But solid state is extremely expensive to manufacture costing hundreds of dollars per square meter, versus the $10 price needed if battery costs are to drop low enough for electric cars to challenge combustion head to head.

Hence, Viswanathan told Axios, even if Toyota's first-generation pure electrics do not start with lithium metal anodes, the company clearly is establishing a pathway to get there. "You need more energy density to bring down the cost," he said.

  • An electric car with a lithium metal anode would go about 20% further than current technology, or almost 300 miles on a charge, he said. As a comparison, the new Chevy Volt goes 238 miles without recharging.
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Scaramucci appears to want Priebus investigated by FBI

Alex Brandon / AP

Minutes after Politico reported that new White House Communications Director Anthony Scaramucci stands to profit from his stake in his investment firm while in the West Wing, based on previously undisclosed financial disclosure forms, Scaramucci tweeted:

It was no accident that Scaramucci tagged Reince Priebus in the tweet. Per the New Yorker's Ryan Lizza: "In case there's any ambiguity in his tweet I can confirm that Scaramucci wants the FBI to investigate Reince for leaking."

Our thought bubble: It appears that Trump is deploying Scaramucci to rip the band aid off with Priebus. He has been fed up with his chief of staff for a while and has totally empowered his new communications director. Remember, shortly before this all happened, Scaramucci was having dinner with Trump, Sean Hannity and Bill Shine. Priebus wasn't at the table.

Minutes after Scaramucci's tweet, the Department of Justice issued a statement reiterating that leakers will be investigated, and even jailed:

Worth noting: financial disclosure forms aren't classified.

Behind the scenes, per the Washington Post's Philip Rucker: "Some in White House are trying to build a case that Priebus is a leaker — 'a diagram' charting leaks, per senior official — to show Trump."

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Scientists edit human embryos for first time in the U.S.

Paul Sancya / AP

Researchers in Oregon have become the first in the U.S. to edit the genome of human embryos, MIT Technology Review reports.

Shoukhrat Mitalipov of Oregon Health and Science University and his team reportedly used the gene-editing technique CRISPR to change "the DNA of a large number of one-cell embryos" and to target a disease-related gene.

"Although none of the embryos were allowed to develop for more than a few days — and there was never any intention of implanting them into a womb — the experiments are a milestone on what may prove to be an inevitable journey toward the birth of the first genetically modified humans," per Tech Review.

Why it matters: The goal is to see whether genes that cause inherited diseases can be corrected. Three previous studies on editing embryos, which took place in China, found errors from CRISPR and that the edited changes were only seen in some of an embryo's cells. Mitalipov and his colleagues are believed to have shown both of those effects can be avoided.


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Maggie Haberman: Trump's attacks on the press are a 'game'

Women in the World / YouTube

Maggie Haberman, the NY Times reporter whose relationship to the president dates back to years covering Trump in the New York tabloids, dished about covering his presidency on the Longform podcast.

She was fresh off an interview with Trump in which the president told her and two other Times reporters, among other things, that he never would have nominated Jeff Sessions if he knew he'd recuse himself from the Russia probe.

The highlights

  • Whether Trump is strategic: "This whole idea that he doesn't know what he's doing, that's stupid. He always has a plan in his head. Now the plan might be impulsive, but he does have some plan. It might not make sense to me or you or whomever, but it isn't like the New York Times led him to water when we were talking to him about Bob Mueller and James Comey and Sessions. He knew what he was doing...What I don't think he always understands is the impact."
  • What he's like in person: "He can seem very engaged with whoever he's talking to, even though I suspect he doesn't remember most of what gets said back to him...Dinners with him are said to be pretty short affairs because he loses interest pretty quickly...He just has no attention span."
  • On Trump's Twitter: "He doesn't actually really get Twitter...the joke of this whole 'he's such a genius at Twitter', he doesn't actually really understand Twitter. He doesn't surf Twitter. He's not pulling the memes that get used."
  • On sourcing within the White House: "A lot of people talk late at night in this administration. There's a real fear for most people that they're being monitored in some way. Some people use different kinds of phones...It has been the case since like Day 20...People are scared."
  • On those sources: "The way they talk about this stuff, not all of them, but some of them — it's not about enacting policy or doing what's best for the country. It's winning — winning their little corner of power."
  • Do you take his attacks on the press seriously? "Yes, because people don't realize he's playing a game" to get his base to distrust what they're reading and hearing.
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Transgender troop ban is victory for Bannon, social conservatives

Evan Vucci / AP

Trump's decision to ban transgender troops was the furthest he has waded into culture wars since taking office — and perhaps his most polarizing decision since the original travel ban. This issue had been quietly burning for months, with social conservative leaders pressing the White House on why it hadn't made a decision.

In May, the Conservative Action Project released a memo calling for Trump to end the "social engineering" of permitting transgender people to serve and paying for gender re-assignment surgeries. Influential movement leaders wondered what the heck was taking so long, why Defense Secretary James Mattis seemed to be stalling rather than reversing the Obama-era policies.

After an amendment to reverse those policies failed, House conservatives, especially Rep. Mark Meadows of the House Freedom Caucus, started threatening not to vote for the military appropriations bill unless the transgender issues were resolved.

Internally, Rick Dearborn, Marc Short, Steve Bannon and Paul Teller were pushing to overturn the Obama-era policy on transgender troops. Meadows' late intervention empowered Bannon and others to make the point to Trump that the security bill, which included Trump priorities like the border wall, could be derailed unless they handled this issue now.

(This article and headline has been updated.)

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Trump discussed recess replacement for Sessions

Pablo Martinez Monsivais / AP

Donald Trump has raised the idea of using a recess appointment to replace Jeff Sessions as Attorney General without needing Congressional approval, the Washington Post reports, adding that Trump "has been warned not to move to push him out because of the political and legal ramifications."

Sessions seems disinclined to resign, and Trump has resisted firing him. I he did, it would be hard to replace him as...
  1. Senate Judiciary Committee chairman Chuck Grassley tweeted tonight that there was "no way" his committee could take up hearings for an Attorney General nominee this year.
  2. Trump's preferred picks, like Rudy Giuliani, would struggle to gain Senate approval anyways.
  3. Democrats have said they'll keep Congress from going into a formal recess, making recess appointments impossible.
The current state of play, per the Post: Trump and Sessions "now seem to be heading toward an uneasy detente."
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First U.S. case of Zika transmission by mosquito this year reported in Texas

Pat Sullivan / AP

The first known instance of local mosquito transmission of the Zika virus in the continental U.S. this year was reported late today by health officials in the state of Texas. The Zika transmission likely occurred sometime in the past few months in South Texas, they said.

The Zika infection occurred in a Hidalgo County resident who had not traveled outside the area, and also did not have any of the other risk factors for Zika infection identified by public health officials monitoring the spread of Zika in South, Central and now North America.

For this reason, the Texas Department of State Health Services said that the infection was "probably transmitted" by a mosquito bite in South Texas. Further lab tests showed that the Hidalgo County resident was no longer at risk of spreading the virus via mosquito populations.

Texas health officials began increased Zika testing of pregnant women and people with Zika-like symptoms in six South Texas counties this past spring. (There were six locally-transmitted Zika cases in Brownsville last November and December.) The local transmission case announced today was a direct result of that increased testing regime.

What's next: Texas officials said that there is no evidence of ongoing Zika transmission in the state, but the news today will almost certainly lead to even more human and mosquito surveillance testing in the southern part of the state. Local health officials had already been going door to door in South Texas counties to share information about Zika with pregnant women and people with symptoms to make sure they were tested.

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Republicans remain unsure how their health care effort ends

Carolyn Kaster / AP

Both the Senate's Affordable Care Act replacement plan and its partial repeal bill have now failed by significant margins, leaving their best chance at passing anything a "skinny" repeal bill, which some members openly say is just a vehicle to a conference committee with the House. But it's hard to see where all of this ends.

The bottom line: The Senate seems to have proven definitively that Republicans can't agree on an ACA replacement plan. It's very hard to see any reason why that would change in conference. So that leaves the option of the House passing the Senate's skinny repeal plan — which sources aren't ruling out — which has major policy flaws and could cause premium increases right before next year's elections.

Yet no Senate Republicans have come out against the skinny repeal plan yet. "This is like a car crash. Everyone will slow down to look at the carnage but no one will get out to help," said one senior GOP aide.

A skinny repeal package would most likely get rid of the ACA's individual and employer mandates as well as its medical device tax, although some members are pushing to add more. While these are unpopular provisions — and therefore easy repeal targets — the mandates help balance out the marketplace so premiums don't rise too much.

But some Senate Republicans openly acknowledge they're not thinking of this package as something that could become law; they're viewing it merely as something that can get 50 votes and keep the process going. "I think people would look at it not necessarily on its content, but as a forcing mechanism to cause the two sides of the building to try to solve it together," said Sen. Bob Corker.

The problems:

  • Almost every GOP aide I've talked to — both House and Senate — are skeptical that a conference committee will come up with something that can pass the Senate. If the Senate couldn't accomplish this feat itself, the reasoning goes, why would a conference committee that must bridge the gap between Senate moderates and the House Freedom Caucus?
    • "Obamacare replace policy is not making it through the United States Senate at this step of the process," a senior Senate GOP aide emailed me last night, referring to the bill as "Corpsicle."
    • The alternative argument is that going to conference can't hurt anything.
  • No one is saying exactly what will happen if and when the Senate passes a skinny repeal package.
    • House aides are saying it all depends what's in it, and Sen. Rand Paul is openly saying he doesn't want a conference committee because it'll probably produce something else like the House or Senate replacement plans.
    • But Mark Meadows, chairman of the Freedom Caucus, says he doesn't support skinny repeal, meaning it probably couldn't pass the House at this point.
  • Still, it could be their only choice. As one former Senate GOP aide put it, "What happens if the ping pong ball is over on the House side and that's all that's left?"
  • And if this does become law, it most likely causes big disruptions in the individual market — right before the 2018 elections, which are already hairy for House Republicans.
What we're watching: Is anyone going to come up with an alternative direction? If not, are any Senate Republicans going to oppose a skinny repeal bill solely because of this lack of clarity about where this is all going? When asked this question, one of the current GOP aides answered, "Nope. Because [Majority Leader Mitch} McConnell has some mystical power to convince people he knows what he is doing."
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Hewlett-Packard Enterprise CEO Meg Whitman steps down as chair of PC spin-off

AP Photo/Richard Drew

What was once known as Hewlett Packard created quite some confusion on Wednesday as it announced that Hewlett Packard Enterprise CEO was stepping down as chair of HP Inc, the PC-making unit that was spun off from the enterprise IT company. Axios has confirmed that Whitman, who is rumored to be a candidate for the vacant top spot at Uber, remains CEO of HP Enterprise.

"Meg is fully committed to HPE and plans to stay with the company until her work is done," a company representative told Axios.

The two HPs: The venerable computer maker split in two in November 2015. Whitman, who had been CEO of the combined company, was named CEO of Hewlett Packard Enterprise and chair of the PC unit, which took the name HP Inc.

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"Clean" repeal bill fails in Senate

J. Scott Applewhite / AP

The Senate has voted down a bill to repeal the Affordable Care Act without replacing it — the leading alternative to the Senate repeal-and-replace bill, a version of which got shot down last night. Seven Republicans voted with the Democrats to defeat the bill, which was supported by Sen. Rand Paul and leading conservative groups. President Trump has also suggested straight repeal as a strategy if the Senate couldn't pass a replacement.

Why it failed: Conservatives were putting heavy pressure on Republican moderates to support it, since most of them voted for a similar bill Congress passed in 2015 (then-President Obama vetoed it). But some moderates, including Lisa Murkowski and Shelley Moore Capito, have said they couldn't support repeal this time without a replacement. Other "no" votes — like John McCain — were a surprise.

Republicans who voted no: McCain, Murkowski, Capito, Lamar Alexander, Susan Collins, Rob Portman, Dean Heller.

What's next: The search continues for a repeal bill the Senate can pass.