Vitals - Axios
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Vitals

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.

Gonna give our brand-new newsletters another plug: Axios Science, by Alison Snyder, will offer smart news about medicine, space, neuroscience, and physics; and, Axios Future of Work, by Steve LeVine, has something to do with robots. Sign up for both here.

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 ...

Giphy

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: david@axios.com.

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Police discover trailer with 8 dead in San Antonio

Eric Gay / AP

AP/San Antonio: "Eight people were found dead in a tractor-trailer loaded with at least 30 others outside a Walmart store in Texas' stifling summer heat in what police are calling a horrific human trafficking case. The driver was arrested."
  • "Twenty other people in extremely critical or serious condition and eight more with lesser injuries including heat stroke and dehydration were found inside the truck, which didn't have a working air conditioning system despite blistering temperatures that topped 100 degrees."
  • "A person from the truck initially approached a Walmart employee in a parking lot and asked for water late Saturday night or early Sunday morning, said police in San Antonio, where temperatures on Saturday reached 101 degrees. The employee gave the person the water and then called police, and when officers arrived they found the eight people dead in the back of the trailer and 30 other survivors inside."
  • "Investigators checked store surveillance video, which showed vehicles had arrived and picked up other people from the tractor-trailer. ... [M]any of those inside the truck appeared to be adults in their 20s and 30s but also apparently two school-age children."
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Scaramucci's fiesty exchange with Jake Tapper over deleted tweets

New White House Communications Director Anthony Scaramucci has been deleteting some of his old tweets, including comments on topics like climate change and guns.

Below is his Sunday exchange with CNN host Jake Tapper on the topic:

A sampling:

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Trump's mini-me

Pablo Martinez Monsivais / AP

Look for Anthony Scaramucci, the incoming White House communications director, to take the White House podium more often than his predecessors. In past administrations, it has been a largely behind-the-scenes position, with the press secretary doing the daily on-camera talking.

  • "He's good at it and he's competitive," one friend said. "He's going to want to be out there on the days with the biggest sh--storms. He likes the game. He likes to spar, but he's not nasty about it. And he likes the controversy — he's a typical Wall Street guy."
  • Nevertheless, Mooch plans to elevate the cachet of the new press secretary, Sarah Huckabee Sanders. Expect her to do the vast bulk of on-camera briefings.
  • He's been deleting lots of old tweets, but here they are.

Talker column by Maureen Dowd on "The Mooch And the Mogul":

"A wealthy mini-me Manhattan bro with wolfy smile and slick coif who will say anything and flip any position. A self-promoter extraordinaire and master salesman who doesn't mind pushing a bad product — and probably sees it as more fun. ... The Mogul and the Mooch is a tender love story with dramatic implications for the imploding White House.
"Both enjoy stirring the pot ... They savor counterpunching ... But a change in communications personnel will not solve the central problem for President Trump. He doesn't understand that Robert Mueller is not a contractor he's in a civil litigation dispute with, someone he can intimidate and wear down and threaten and bleed out."
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Scaramucci promises "dramatic action" to stop the leaks

New White House Communications Director Anthony Scaramucci is making the Sunday Show rounds today.

  • From Fox News Sunday with Chris Wallace: "[W]e have to get the leaks stopped. If we don't get them stopped. I'm a businessperson so I will take dramatic action to stop those leaks. ... If the leaks don't stop I'm going to pare down the staff because it's just not right.... Something is going on inside the White House that the president does not like. We will fix it."
  • From an interview with John Dickerson of CBS News, when asked how he'll treat leakers on his watch: "They're going to get fired. I'm just going to make it very, very clear, okay? Tomorrow I'm going to have a staff meeting. And it's going to be a very binary thing. I'm not going to make any prejudgments about anybody on that staff. If they want to stay on the staff, they're going to stop leaking."
  • Bonus: Scaramucci told Wallace that while he thinks some members of the press are stretching or making up stories, he wants to "engage" the mainstream media, adding that he wants to "de-escalate" tensions between the press and the White House.
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Newfound Clinton-era memo: presidents can be indicted

Susan Walsh / AP

"Can Presidents Be Indicted? A Long-Hidden Legal Memo Says Yes," by N.Y. Times' Charlie Savage:

  • "A newfound memo from Kenneth W. Starr's independent counsel investigation into President Bill Clinton ... raises the possibility that Mr. Mueller may have more options than most commentators have assumed."
  • The 56-page memo was written for Starr by constitutional scholar Ronald Rotunda, "locked in the National Archives for nearly two decades and obtained by The New York Times under the Freedom of Information Act."
  • The memo concludes: 'It is proper, constitutional, and legal for a federal grand jury to indict a sitting president for serious criminal acts that are not part of, and are contrary to, the president's official duties ... In this country, no one, even President Clinton, is above the law.'"
  • "In 1974, the Watergate special counsel, Leon Jaworski, had also received a memo from his staff saying he could indict the president."
  • See the Starr memo, posted by The Times.
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Report: U.K. wants Trump test trip before full State visit

President Trump has been asked to visit the U.K. for low-key talks with Theresa May this year, according to a report by the Daily Mail, which says the trip will be a test run for whether to hold a full State visit.

The British tabloid claims U.K. leadership is concerned about Trump potentially violating protocol while visiting the Queen, in addition to fears of a falling out with British PM Theresa May that could risk a bad post-Brexit U.S. trade deal for the U.K., while the White House wants to avoid the embarrassment of major anti-Trump rallies during a visit with an ally.

Then-president Barack Obama's first U.K. state visit in 2011 included meetings with the Queen, the Duke and Duchess of Cambridge, and PM David Cameron and opposition leader Ed Miliband.

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General: "unimaginable" to allow North Korea capability to nuke U.S.

Wong Maye-E / AP

Comments yesterday at the Aspen Security Forum from Marine Gen. Joseph Dunford, the chairman of the Joint Chiefs of Staff, via Politico's Nahal Toosi:

"Many people have talked about military options with words like 'unimaginable'... I would probably shift that slightly and say it would be horrific... [A]nyone who's been alive since World War II has never seen the loss of life that could occur if there's a conflict on the Korean Peninsula.
"[I]t is not unimaginable to have military options to respond to North Korean nuclear capability. What's unimaginable to me is allowing a capability that would allow a nuclear weapon to land in Denver, Colorado. That's unimaginable to me. So my job will be to develop military options to make sure that doesn't happen."

Go deeper: We asked experts how to deal with North Korea.

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Lawmakers agree on Russia sanctions for election-meddling

Evan Vucci / AP

A group of bipartisan lawmakers agreed today to move forward with legislation that would impose sanctions against Russia for their meddling in the 2016 U.S. election, NYT reports. Congress will vote on Tuesday. The expansive sanctions are also for continuing to deploy military forces in Ukraine, annexing Crimea, and abusing human rights.

  • The White House has argued that Congress should allow Trump to have flexibility in his ability to adjust these sanctions as a way to handle Russia how he sees fit. Trump has tried to manage the U.S.' relationship with Russia on his own terms, and these sanctions would make that more difficult.
  • Why it matters: Congress will force Trump into a difficult decision: veto the bill, or move forward and risk his efforts to improve our relationship with Russia. The legislation includes sanctions on North Korea and Iran.
  • Paul Ryan's spokeswoman AshLee Strong told Axios: "This a tough sanctions package that includes measures overwhelmingly supported on a bipartisan basis that would hold three bad actors to account: Iran, Russia, and North Korea. We look forward to moving these sanctions next week before the August work period."
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Major problems plague start of Pokemon Go Fest

Credit: Niantic

The creators of Pokemon Go held their first major in-person event in Chicago on Saturday but things got off to a rough start. Many of those who paid to attend the event reported being stuck in line or unable to log into the app. Attendees would have a chance to catch rare Pokemon — including a Pokemon "monster" if certain goals were met, per Chicago Tribune.
CEO John Hanke was booed as he took the stage in Grant Park, and festival attendees reportedly started chanting "fix the game" at him when they realized they were unable to log on. Niantic is currently working on the issue and the company will reportedly refund participants for their tickets and give them $100 in virtual currency for the game.
Why it matters: Live events are seen as a big part of the company's strategy to keep the game's most active players engaged, so technical issues during a highly-anticipated event do not bode well for the company.
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Scaramucci goes full Breitbart

Breitbart / YouTube

Anthony Scaramucci gave his first interview as White House communications director to Breitbart's Matt Boyle. The two sounded like old friends, with Scaramucci kicking off the early-morning SiriusXM's "Breitbart News Saturday" interview by jokingly asking Boyle, "Did you send your job application form in yet, Matt?...Do you need my email so I can get your resume over here?"

Boyle laughed and replied: "Anthony, I'm honored, maybe we can talk about that later." Scaramucci praised Breitbart for capturing "the spirit of what is actually going on in the country, where there's a large group of people...who've been disaffected from the economic franchise." (FWIW: I asked Boyle whether he'd seriously consider a job in the White House press shop and he declined to comment.)

Between the lines: Sean Spicer had a terrible relationship with Breitbart, the right-wing outlet whose alumni, including Steve Bannon, now work in the White House. Scaramucci now appears to want to elevate the outlet in general, and Boyle in particular. By giving Boyle (Breitbart's most unrestrained attack dog) such prominence from the outset, Scaramucci is signaling that the President wants to make better use of conservative/friendly media outlets to transmit his messages without a critical filter.

Interview highlights:

  • Breitbart First: Scaramucci told Boyle that he and the President talked Friday about the fact that there are "enough outlets, whether it's Breitbart, the President's social media feed, all of the different apparatus that we have where people will allow us to deliver our message to the American people unfiltered."
  • Fresh start: Scaramucci also called his appointment a "fresh start" and said he wanted to see if he could "de-escalate" tensions with mainstream media outlets.
  • Bonding over "fake news": At the end of the interview Boyle asked Scaramucci how he planned to "combat" the "fake news" given he was a "victim of fake news" recently on CNN. Boyle was referring to CNN's recent retraction of a story about Scaramucci, which resulted in CNN management firing three employees. Boyle wrote more than a dozen pieces bashing CNN during that period. Scaramucci said to Boyle: "You've also been a great help in terms of exposure and I do appreciate what you did for me during that incident...I want to thank you publicly in front of your listeners."