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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 ...


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:


Peter Thiel has parted ways with Y Combinator

Peter Thiel. Photo: Kevin Moloney / Fortune Brainstorm Tech

Famed investor Peter Thiel, who publicly supported Donald Trump during his candidacy and as president, is no longer affiliated with startup accelerator program Y Combinator, as BuzzFeed first reported and a blog post update confirms.

Be smart: Thiel isn't the only one departing the program. Y Combinator has shuttered its entire part-time partner program in which Thiel participated, according to BuzzFeed. So it's not quite the symbolic move many wanted YC to make last year.

  • The organization has been experimenting with various ways to involve alumni entrepreneurs who want to advise new startups, such as having "visiting partners" for a 6-month run.
  • And as a venture capitalist with close ties to the startup community and friendships with some of YC's executives, it's hard to believe that Thiel won't continue to meet with and invest in the accelerator program's startups.

Report: War on ISIS killing 31 times more civilians than claimed

Airstrikes target ISIS positions on the edge of the Old City a day after Iraq's prime minister declared "total victory" in Mosul, Iraq. Photo: Felipe Dana / AP

The U.S.-led war against ISIS is claiming civilian lives at a rate 31 times higher than was previously acknowledged by the coalition, according to Azmat Khan and Anand Gopal, NYT reporters who conducted an 18-month investigation in northern Iraq.

Why it matters: This staggering number of deaths "is at such a distance from official claims that, in terms of civilian deaths, this may be the least transparent war in recent American history," per NYT. It also raises questions about civilian casualties in neighboring Syria, and how far this reporting problem reaches around the world.

What they did, per the NYT: The reporters went to roughly 150 airstrike sites in northern Iraq to interview witnesses and local officials, photograph bomb fragments, search local records and news sources, and map out the destruction through satellite imagery. They visited the American air base in Qatar where the coalition is based and interviewed coalition officials and advisers. They provided coalition analysts with coordinates and date ranges of 103 air strikes to examine and compare their responses.

What they found, per the NYT: The coalition claims 1 civilian is killed in every 157 airstrikes but their on-the-ground analysis shows 1 civilian is killed in every 5 airstrikes. They added the coalition is doing a poor job of investigating claims or even to keep proper records to make investigation possible.

"While some of the civilian deaths we documented were a result of proximity to a legitimate ISIS target, many others appear to be the result simply of flawed or outdated intelligence that conflated civilians with combatants," according to Khan and Gopal.


White House on sexual allegations: Franken admitted wrongdoing, Trump hasn't

White House press secretary Sarah Huckabee Sanders speaks during a press briefing at the White House. Photo: Alex Brandon / AP

Press Secretary Sarah Sanders told reporters Friday that the allegations of sexual misconduct against Sen. Al Franken are different from those against President Trump because, "Senator Franken has admitted wrongdoing, and the president hasn't. That's a very big distinction."

Key quote: When asked why allegations against Franken merit an investigation but those against Trump don't, Sanders replied "The American people spoke very loud and clear when they elected the president."

More from Sanders:

  • Is it the WH position that Trump's accusers are lying? "The president has denied those allegations."
  • Does Trump believe the women who accused Roy Moore? "The president certainly finds the allegations extremely troubling ... and he feels it's up to [Alabama] ... to make a determination."

Chairman of the Council of Economic Advisers, Kevin Hassett, joined Sanders to discuss the latest on tax reform:

  • Trickle-down economics: "There's nothing about that's controversial."
  • Difficulty of passing tax reform in the Senate: "I'm hopeful that people can work it out, and that everybody, even Democrats, will end up wanting to vote for it."
  • Temporary tax cuts: Hassett said he hopes future congresses won't let them expire.

Florida Democratic Chair resigns after sexual harassment claims

Stephen Bittel apologized to the women who felt uncomfortable. Screengrab via YouTube

Stephen Bittel, Florida's Democratic Party chairman since last January, resigned today after several women accused him of making inappropriate comments toward them, according to Politico's interviews with six women.

Key quote: "There was a lot of boob stuff in his office," one woman, a former fundraiser for Bittel, told Politico. "I was told by other women not to go into his bathroom. I was warned."

Why it matters: Bittel is another Democrat after Franken who has faced allegations of sexual harassment, and he's likely not going to be the last. His resignation is one example of some of the consequences these men will face in the wake of these revelations.

His statements:

  • To Politico on Thursday, before his official resignation: "Every person, regardless of their gender, race, age or sexuality should be treated with respect and valued for their hard work and contributions to our community and if any of my comments or actions did not reflect that belief I am deeply sorry. I have much to learn, but my goal is and has always been to make sure every member of our party has a safe environment in which to succeed. It seems I've not been successful in that goal, and I will do better."
  • On the day of his resignation: "When my personal situation becomes distracting to our core mission of electing Democrats and making Florida better, it is time for me to step aside. I am proud of what we have built as a Party and the wins we have had for Florida families, but I apologize for all who have felt uncomfortable under my tenure at the Democratic Party. I am working with our leadership to elect my successor."
One more quote: "He's just so f----ng creepy," a former party staffer told Politico. "He just leers at you, and stares. I don't know if you know what that feels like, but he just leers at you. I don't know how to describe the feeling."

Report: Trump administration plans to halt work permits for H-1B spouses

Computer information specialist and immigrant from India, Santosh Pala, right, carries his three-month-old son Hemang during a prayer procession at the Karya Siddhi Hanuman Temple in Frisco, Texas, in 2015. Photo: LM Otero / AP.

The Trump administration plans to halt work permits for the spouses of H-1B visa holders, which would discourage H-1B visa applicants from staying in the country and would revoke the ability to work for thousands of visa holders' spouses, the San Francisco Chronicle reports.

Why it matters: It's another move by the Trump administration to make it more difficult for foreign workers to come to America in its larger effort to safeguard American jobs.

  • Approximately 100,000 spouses and children of H-1B visa holders come to the U.S. every year on a visa known as H-4.
  • These workers were not able to work in the U.S. before 2015, when President Barack Obama created a work permit for some H-4 holders.
  • Silicon Valley will be disproportionately affected, since many high-tech employers employ H-1B workers. Because of the region's high cost of living, It is difficult for a family to survive on one salary and, as a result, may not be able to stay in the country.
  • A decision on the H-4 work authorization will likely come soon, immigration attorneys told The Chronicle.

Other efforts: Earlier this week, a House committee advanced Rep. Darrell Issa's bill to increase restrictions on how "H-1B dependent" companies can obtain the work permits for employees. Find details of Issa's bill here, and the Indian firms' lobbying efforts against crack downs on H-1B visas here.


Franken's former female staffers defend him amid allegations

Jim Mone / AP

Amid a firestorm of criticism for his alleged sexual misconduct, eight of Sen. Al Franken's former female staffers issued a joint statement obtained by the Star Tribune Friday saying the senator treated them "with the utmost respect" and "was a champion for women both in the legislation he supported and in promoting women to leadership roles in our offices."

Franken's former chief of staff, Casey Aden-Wansbury, also told ABC News that during the eight years she had known him, "he has always worked hard to create a respectful environment for his staff." She added that "the inappropriate behavior reported today does not live up to the values I know he holds."


Spotify acquires yet another startup as it prepares to go public

Illustration: Sam Jayne / Axios

Spotify has acquired Swedish collaborative music-making startup Soundtrap, the latter said on its website. Spotify paid at least $30 million, according to Breakit.

The big picture: As Spotify eyes a public listing of its stock next year (as it has been reported and sources tell Axios), the company has to keep growing its music business beyond streaming existing tracks. This way, it can provide more services, such as music collaboration tools to artists.


White House requests 3rd disaster relief package

Volunteers sort supplies for those affected by Hurricane Maria. Photo: Carlos Giusti / AP

The White House requested an additional $44 billion from Congress on Friday for disaster recovery, which if approved would bring the total to almost $100 billion for Texas, Puerto Rico, Florida, and the U.S. Virgin Islands, Politico reports.

Go deeper: The latest on Puerto Rico recovery, per Puerto Rico's government site and FEMA:

  • Almost 82% of the island has water.
  • Nearly 45% of the island has electricity.
  • There are 15,000 civilian/military personnel assisting in recovery, plus 2,800 FEMA personnel.
  • 84% of gas stations are up and running.
  • Almost 89% of supermarkets are running.
  • There are 1,822 people taking shelter in 50 shelters.

Kayla Moore says her husband will not step down

Roy Moore's wife, Kayla, said that he will not step down from the U.S. senate race in the face of sexual harassment allegations.

Moore also said the "liberal press" and others who have attacked President Trump are now attacking them and taking spotlight away from the Russia investigation: "To the President, I would say now is a good time to get some things done in Congress."


How evolution shaped passenger pigeons' DNA — and their fate

Martha, the last known passenger pigeon before dying in 1914, can be seen at the Smithsonian's Natural History Museum. Photo: Susan Walsh / AP

A new study suggests passenger pigeons, which once covered North America with massive flocks before their extinction in the early 20th century, may have maintained stable populations for thousands of years until human hunters came along, per The Washington Post. That counters previous research that found the species had already taken a downturn by that time.

The double whammy: Besides the sudden influx of human predators, the birds' genome had been tuned to the size of its population. It had surprisingly low genetic variation in some parts of its genome, which "provided few avenues for the bird to respond to human pressures, which ultimately drove it to extinction," according to the study, published Thursday in Science.

Role of genetics: One way genomes evolve is via random mutation (also called neutral evolution). Those mutations don't necessarily have an immediate benefit but sometimes can in the long run. Another process is selection in which one version of a gene is preferred — or not — over another because it influences survival. Researchers found the passenger pigeon's genome was diverse overall compared to other birds but that diversity wasn't uniform across their chromosomes. The researchers think that suggests their large population size allowed them to adapt quickly to their environment (via selection) but the cost was that there wasn't much neutral evolution happening, which left them with little genetic variation.

"Large population size appears to have allowed for faster adaptive evolution and removal of harmful mutations, driving a huge loss in their neutral genetic diversity," the researchers wrote. "These results demonstrate the effect that selection can have on a vertebrate genome and contradict results that suggested that population instability contributed to this species's surprisingly rapid extinction."

The bottom line: The study says having a huge population was initially a key survival mechanism for the passenger pigeon. However, the birds' surprisingly low genetic variation caused it to be unable to recover from humanity's overhunting practices. As one of the study authors told WashPost, "It's impossible to adapt to gunfire."

Editor's note: This story has been updated to provide further information.