Vitals - Axios


Good morning ... All Comey-ed out? Then back to our safe health care space. Senate Republicans are hung up on what to do about Medicaid, an insurer's Tennessee decision doesn't fix everything, and Scott Gottlieb is about to start his job as the newly confirmed Food and Drug Administration commissioner.

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Senate GOP working group struggles with Medicaid

The working group that's going to take the next crack at an Affordable Care Act repeal had its big Medicaid meeting yesterday. The bottom line? Caitlin Owens reports that senators showed how divided they are between two conflicting desires. They want to make the program — and the federal budget — more sustainable by reducing future spending, but they also want to avoid forcing millions of vulnerable, low-income people off of their coverage.

The main quotes after the meeting:

  • Finance Committee chairman Orrin Hatch: "We've got to get it under control," he said when asked whether he supports the House Medicaid cuts. "Right now it's out of control and it's really going to be out of control if we don't do something."
  • One senior GOP aide: "We will definitely cut Medicaid as much as possible."
  • Sen. Rob Portman said the Medicaid expansion does "not necessarily" need to go, but the extra federal funding would need to go away. Portman's working on a more gradual expansion phaseout, but he also mentioned the idea of "funding for a tax credit that's not available currently."
  • Another senior aide said members aren't on the same page about ending the enhanced federal contribution to Medicaid expansion.
  • Sen. Shelley Moore Capito, another senator from a state that expanded Medicaid, wants to preserve the expansion — though not necessarily in the same form, per The Hill.

Why this matters: Senators are just beginning to wade into the painful tradeoff between reducing government spending and people losing health insurance. While some members and aides insist Medicaid spending will be massively cut, as it was in the House bill, the political risk of millions of people in expansion states losing coverage will only get more real.

The other problems: Besides Medicaid, the other two biggest disagreements among Senate Republicans are over coverage for pre-existing conditions and health care tax credits, the Washington Post reports.

The challenge for CBO and the governors

Axios contributor Steven Brill has a piece this morning about how those state waivers in the House bill made the Congressional Budget Office's job harder. It has to find some way to estimate how many states will apply for the waivers from Affordable Care Act benefits and pricing rules, Brill writes, because that's the only way to know how many people will still have what it considers "comprehensive" health insurance.

Watch the governors, too: Time for reporters to start going from state to state to figure out which governors might apply for the waivers. (Sit down, Scott Walker. We wrote about you already.)

Before you celebrate Tennessee too much ...


Consumers who feared the eastern part of Tennessee would have no Affordable Care Act insurers next year got a dose of good news yesterday when Blue Cross and Blue Shield of Tennessee said it will offer ACA health plans there next year. It also said its ACA business was doing better this year. But Bob Herman notes that there are still some clouds hanging over Tennessee and elsewhere:

  • The premiums are likely to be expensive, since the Tennessee Blues will factor in the political uncertainty of the cost-sharing subsidies and individual mandate.
  • The company could still pull out by September. Remember: The Tennessee Blues originally discontinued its ACA plans in the Knoxville area for this calendar year because of the population's high medical costs.
  • While Tennessee is saved, momentarily at least, Iowa still faces the prospect of zero ACA insurers statewide if the last two companies decide to bail. And Iowa's Blue Cross and Blue Shield company, Wellmark, has already exited. A savior would have to come from outside the Blues affiliates.

Drug price amendment might make it onto user fee bill

The Senate HELP Committee will mark up a must-pass drug user fee bill today, and Caitlin Owens reports that an amendment co-sponsored by Sens. Susan Collins and Al Franken has a good shot at being approved. If so, it would be the Senate's first real step towards taking action on drug prices this year.

What the amendment does, per Collins: It's similar to what she and Sen. Claire McCaskill worked on last year through the Aging Committee (McCaskill isn't on HELP). The primary goal is to "get generics through the market much more quickly," Collins said. To do that, it:

  • Sets "firm timetables" for the Food and Drug Administration to act in situations when there's only one generic equivalent to a brand-name drug.
  • Creates more transparency. For example, if a drug were to be removed from the market, there'd be a report to the Food and Drug Administration. The FDA would then advertise this, "which would encourage more generic companies to file an application for approval," she said.

Expect some partisan fireworks: Sen. Chris Murphy, a Democrat, said "there's a growing frustration that we're not going to have the opportunity to talk about some pretty big issues in the HELP committee, and this may be the last train out of town."

He said he has a "handful of amendments" with a mind to the GOP's health reform attempts, like protecting people with pre-existing conditions and making sure people don't lose coverage through the effort.

The backdrop for the fight over an HHS memo

Here's what to read into the harsh letter Health and Human Services secretary Tom Price got from two Republican committee chairmen about a memo telling HHS employees not to talk to Congress without going through the HHS legislative office:

  • Every agency in every administration wants to control its external messages, as one HHS veteran points out. And Congress always wants to be able to talk to agency employees directly, so there's always some kind of conflict when a new administration begins.
  • That explains HHS's reaction to the letter yesterday, per an agency spokesperson: "This type of memorandum is nothing new. It reflects consistent agency policy which has been in place for decades."
  • But there are whistleblower protections that every federal employee is supposed to have, and the two chairmen — Senate Judiciary Committee chairman Chuck Grassley and House Oversight and Government Reform Committee chairman Jason Chaffetz — were furious that the HHS memo didn't mention them.
  • If HHS had just added a few words about the whistleblower protections, it could have avoided a lot of headaches.
  • Grassley is known for his dedication to congressional oversight, and a lot of the fury over whistleblower protections likely comes from him. (Chaffetz is retiring, so it's hard to see him as the driving force.)

Look how fast it leaked: The memo was dated May 3. Grassley and Chaffetz had it in their hands and fired off the letter the next day.

The rising Democratic hopes for 'Medicare for all'

It's not just Bernie Sanders who's talking up "Medicare for all" these days. Other Democrats, like Murphy, are warming to the idea as they watch Republicans try to tear apart the Affordable Care Act. Remember that some liberals always considered the ACA a compromise because it preserved the private insurance industry.

Key quote: "I think you can argue that if we'd done Medicare for all in 2009, it might have been much more popular and much harder to attack than the bill that we passed," Murphy said on the "Primary Concerns" podcast, hosted by The New Republic's Brian Beutler (h/t Bob Herman for flagging). He said it would be "much easier to explain and easier to comprehend" than the ACA.

Yes, but: It's easy to talk about "Medicare for all" or single-payer, much harder to see it as a serious prospect — not just because Republicans are in charge now, but because Democrats didn't even try it in 2009 when they were in charge.

And don't forget: If Americans went into an uproar over a few million canceled health plans in 2013, how are they going to react to changing the entire system? Murphy's answer: It would be easier to win over the public if they're given a choice of moving to Medicare or staying in their plan. "You do have to think about how you transition to that system," he said. "When I think about that, it looks very much like a very aggressive robust public option."

Where in the world is Kellyanne Conway? Talking opioids

The Saturday Night Live question has been answered! Before she was spinning the Comey firing, she was in Lansing, MI, yesterday with Price, attending a listening session on opioid abuse and talking up President Donald Trump's commission on drug addiction. "It's a bipartisan commission tackling what we see as a nonpartisan issue with a bipartisan solution," Conway said, per the Detroit News.

For the non-Twitter crowd: "@onetoughnerd" is Michigan Gov. Rick Snyder.

What we're watching today: Senate HELP Committee marks up FDA user fees reauthorization bill, 10 a.m. Eastern. Livestream here.

What we're watching this week: Office of Management and Budget director Mick Mulvaney and Centers for Medicare and Medicaid Services administrator Seema Verma speak on health care changes at the LIGHT Forum at Stanford University, Thursday.

Thanks for reading, and we are always open for tips and feedback:


Uber gets competitive in the food-delivery service

McDonald's ordered through the Postmates service. Photo: Chandice Choi/AP

Along with the development of ride-sharing services came food-delivery services: ordering food through an app and having it delivered to your door. The New York Times cited a study by McKinsey that found food delivery "is a $100 billion-plus market, or about 1 percent of the total food market." And Uber wants a piece of that market.

Key numbers: UberEats is available in more than 120 markets around the world. The number of trips for UberEats drivers grew more than 24 times in one year, and by last July it was "profitable in 27 of the 108 cities where it operated," per NYT.

UberEats "sometimes eclipses Uber's main ride-hailing business in markets like Tokyo; Taipei, Taiwan; and Seoul, South Korea," the company told NYT.

But as UberEats continues to thrive, competition looms large:

  • Postmates has raised over $250 million since it started and the company makes 2.5 million deliveries each month. Like UberEats, Postmates is a full delivery service system.
  • Grubhub has "an active base of 8.17 million customers," and Matt Maloney, the company's founder, told the Times their sole focus on take-out ordering sets them apart.

Price will stop using taxpayer-funded private jets

Trump and HHS Secretary Tom Price arrive on Capitol Hill to rally support on health-care reform. Photo: J. Scott Applewhite / AP

Health and Human Services Secretary Tom Price has racked up more than $400,000 after using a private jet to embark on his taxpayer-funded travels, Politico found. Now, Politico reports that Price will stop using a private jet for these travels because "We've heard the concerns. We take that very seriously and have taken it to heart," Price told Fox & Friends earlier today.

What's next: His department's inspector general will review his travel and the associated costs, and a decision will be made after that review is complete. A federal contract noted that Price cost taxpayers at least $65,000 in the last week alone, Politico notes.


Golden State Warriors will not visit the White House

A rally to celebrate the Golden State Warriors' NBA basketball championship. (AP Photo/Marcio Jose Sanchez)

After Trump called out Stephen Curry in a tweet this morning (rescinding his invitation to the White House), his team stood with him and announced they will not be attending the White House visit at all.

"While we intended to meet as a team at the first opportunity we had this morning to collaboratively discuss a potential visit to the White House," the statement read, "we accept President Trump has made it clear that we are not invited."

"We believe there is nothing more American than our citizens having the right to express themselves freely on matters important to them," the statement continued. "We're disappointed that we did not have an opportunity during this process to share our views or have an open dialogue on issues impacting our communities that we felt would be important to raise.

Big picture, from Axios' Mike Allen: Trump is wading into culturally sensitive territory that could freshen opposition elsewhere, and ignite a debate wholly unrelated to anything he's trying to accomplish.

Go deeper: Trump vs. Curry, LeBron and pro athletes.


N. Korea: strike on U.S. is "inevitable"

In this unverified image from the North Korean government, Kim Jong-un is said to inspect loading of a hydrogen bomb into an ICBM, at unknown location (Korean Central News Agency / Korea News Service, via AP)

North Korea's foreign minister said today a strike on the U.S. is "inevitable," just after it was revealed that there were American fighter jets flying over the seas of North Korea.

"None other than Trump himself is on a suicide mission" and said that Trump's insults against North Korea and its leader make "our rocket's visit to the entire U.S. mainland inevitable all the more."

Context: Trump called Kim Jong-un "Rocket Man" in a recent tweet, which he restated during his UN speech, saying "Rocket Man" is "on a suicide mission."

North Korea's foreign minister shot back at Trump, saying POTUS has "turned the White House into a noisy marketing place full of crackling sounds of abacus beads and now he has tried to turn the U.N. arena into a gangsters' nest where money is respected and bloodshed is the order of the day."


Mexico hit with massive aftershock from earthquake

A woman attends an outdoor Catholic Mass near the school that collapsed during the earthquake in Mexico City. Photo: Rebecca Blackwell/AP

An aftershock of the 8.1-magnitude earthquake earlier this month went through the southern state Oaxaca this morning, measured at a magnitude of 6.1, according to the Associated Press.

Why it matters: Mexico is still recovering from the 7.1 quake on Tuesday that killed over 300 people. This is the third one this month. A resident of one of the cities hit by the earthquake on Sept. 7, Nataniel Hernandez, told the AP that Saturday's tremor is "one of the strongest movements he has felt" since then, but that "it has not stopped shaking."


American fighter jet flies over North Korea

North Korean leader Kim Jong Un, right, and Choe Ryong Hae, vice-chairman of the central committee of the Workers' Party, Photo: Wong Maye-E/AP

The Pentagon reported B-1B bombers from Guam and F-15 fighter escorts from Okinawa, Japan, have flown over the waters of east North Korea, the "farthest north of the Demilitarized Zone...any American fighter or bomber has flown this century," the Associated Press reports.

Why it matters: Dana White, Defense Department spokeswoman, said it was a "demonstration of U.S. resolve and a clear message" that Trump "has many military options to defeat any threat."

Go deeper: The psychological profile of Kim Jong-un, and how he and his "massive ego...reacts harshly and sometimes lethally to insults and perceived slights."


Trump: NFL players shouldn't "disrespect" our flag

Photo: AP

After numerous professional athletes tweeted about Trump (who made offensive remarks about the NFL and its players who kneel during the national anthem), he kept the conversation going:


Iran tested a ballistic missile

Iranian President Hassan Rouhani sits before addressing the United Nations General Assembly. Photo: Jason DeCrow / AP

Iran unveiled its latest ballistic missile Friday and said it tested it today, Reuters reports. State television carried footage of the test. Iran said it is capable of carrying multiple warheads, of flying 2,000 km is capable of hitting parts of the Middle East, including Israel, a key American ally, per the AP.

The Trump effect: This is a challenge to Trump, since Trump signed a bill imposing penalties on those involved in Tehran's ballistic missile program last month. (The U.S. has said Tehran's tests violate a UN resolution endorsing the Iran nuclear deal.)

Iran's defense minister said "we will certainly not be the least affected by any threats and we won't ask anyone's permission" about its missile program.


  • Trump said this week he has "decided" whether to exit the Iran nuclear deal, but wouldn't reveal the decision.
  • Iranian president Hassan Rouhani said earlier this week if Trump follows through on his threats to nix the nuclear deal, America would pay "such a high cost."

The Trump administration re-approved sanctions waivers for Iran as part of the nuclear deal last week. The deadline to re-certify the deal as a whole is coming mid-October.

Go deeper: Secretary of State Rex Tillerson said Iran may be honoring technical aspects of the deal


Scott Pruitt met regularly with industry lobbyists

EPA Administrator Scott Pruitt speaks to the media during the daily briefing. Photo: Pablo Martinez Monsivais/AP

Environmental Protection Agency chief Scott Pruitt has made decisions that benefit certain lobbying groups — soon after meeting with the corporate executives that represent them, according to his schedule obtained by the Washington Post.

Why it matters: While WaPo reports that Pruitt met with three public-health and environmental advocates, the meetings with industry advocates far outweighed them.

Mining, automobile, and fossil fuel executives are some of the big groups Pruitt has met with. Before relaxing Obama-era automobile fuel-efficiency standards, he met with General Motors, Ford Motor Co., and the "industry's lobbying arm" Auto Alliance. He met with the biggest commercial truck "glider" manufacturer in the U.S. before announcing he would "revisit an October 2016 decision to apply greenhouse gas emissions standards for heavy-duty trucks to gliders."


Steve Bannon to headline Roy Moore rally in Alabama

Photo: Carolyn Kaster / AP

Steve Bannon is heading to Alabama Sunday night to rally for Judge Roy Moore on Monday night with Phil Robertson of Duck Dynasty.

Why it matters: This rally is three days after President Trump, Bannon's former boss, was in Alabama rallying for Moore's opponent — Mitch McConnell's favored candidate Luther Strange. For Bannon to make a rare public appearance in such close proximity to Trump shows how invested he is in this race specifically, and attacking McConnell more generally. Another former White House adviser, Sebastian Gorka, rallied with Sarah Palin for Moore on Thursday.

From a source close to Bannon: "Steve is coming to Alabama to support President Trump against the Washington establishment and Mitch McConnell. Steve views Judge Moore as a fierce advocate of Trump and the values he campaigned on."
Allies of Strange and Republicans close to the White House dispute that premise, and Trump points out Strange offered his support for Obamacare repeal with no strings attached, whereas Roy Moore has said he won't support anything less than full repeal.
Trump last night seemed conflicted about his Strange endorsement, suggesting he'd made a mistake and would support Moore if he wins. Moore leads Strange by 9 percentage points in the RealClearPolitics polling average.
"I'll be honest, I might have made a mistake... If his opponent wins, I'm going to be here campaigning like hell for him." — President Trump on Friday night
Breitbart has gone all in for Moore and is doing its national radio show on Sirius XM from Alabama today through Wednesday.

Multiple senior Breitbart editors are in Alabama, including Washington editor Matthew Boyle, London editor Raheem Kassam, the editor-in-chief of Breitbart London, and Jeff Poor, an Alabama native and the head of Breitbart TV.

"As of now, everyone is working on the Alabama race," Boyle wrote in a Breitbart Slack channel, per CNN's Oliver Darcy. "If anyone has any questions please let me know."