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Good morning ... The Senate is still plugging away, as Republican leaders seem to be tightening the reins on the effort even further. They're starting to sound a lot less bullish about the timing and a lot more circumspect about the policy, even as the July 4 recess draws closer and closer.

And since it's not right to pretend everything is normal: Our thoughts are with House Majority Whip Steve Scalise and everyone else who's recovering from yesterday's shooting tragedy.

Why the Senate is still in limbo

AP Photo/Jacquelyn Martin

Senate Republicans say they still have a ways to go before they're ready to vote on a health care bill, despite their (very recent) predictions that the whole thing would be wrapped up before July 4. Republicans aren't there yet, in part, because they're still bouncing proposals off the Congressional Budget Office — and the results of those conversations will affect what's in the final bill.

The latest: Even though Republicans had raised expectations that they were finishing a draft bill, it turns out that GOP leaders actually submitted multiple policy options to the budget office — partly explaining why senators won't say much about their bill, let alone release a draft of it.

Both the bill and its CBO score will be public eventually, and there's nothing inherently scandalous about trying to run the traps on a piece of legislation before bringing it to the floor.

The problem: What happens next? How long will the bill be publicly available before a vote? Will policy experts have time to digest it, and will voters have time to process that analysis? Will there be a real, good-faith opportunity for senators to offer amendments? GOP leaders have already short-circuited an awful lot of the process by not holding hearings or committee markups.

Working with CBO now will likely help Senate Republicans avoid the kind of bad-news bombshells the House experienced — but it's making that July 4 timetable look less and less realistic.

Who could lose from state health benefit limits

Data: CAP analysis, 2015 American Community Survey, Centers for Medicare & Medicaid Services, 2017 Willis Towers Watson Survey; Table: Andrew Witherspoon / Axios

The Senate health care bill is expected to allow states to relax the Affordable Care Act rules only on benefits, not on pricing as the House bill does. But that change could impact people far beyond those states, according to a new analysis by the liberal Center for American Progress — because it could lead to a return of annual and lifetime benefit limits, and not just in the states with the waivers.

The bottom line: As many as 27 million Americans could face annual limits on their coverage, and 20 million could be hit with lifetime limits, according to the analysis. That's because employers that operate in multiple states could use which state's benefit rules they want to use — and there's a good chance they would pick the states that loosened the rules. More here.

Cassidy's cost calculations

Sen. Bill Cassidy went to the GOP lunch on Wednesday with a handout breaking down the factors that have contributed to the higher cost of ACA coverage. Caitlin Owens talked to Cassidy afterwards and got a look at the handout. The analysis — put together by Oliver Wyman — found the biggest contributor to increased per-member-per-month costs is a sicker marketplace.

Here's the breakdown:
  • The pre-ACA cost of coverage was $279 per enrollee, per month.
  • The health and demographics of the ACA marketplace added $98, largely from protecting pre-existing conditions.
  • The ACA's increased actuarial value — or percentage of health costs covered — of plans added another $28.
  • The ACA's essential health benefits added $17.
  • Increased expenses, taxes, and fees added $15.
  • Total addition: Up to $436 per member per month under the ACA in 2015.

Why this matters: It helps explain which levels policymakers can pull to influence premiums. While waiving the essential health benefits might help some, the biggest reason costs have risen under the ACA is because sick people can now get coverage, and that costs money.

What we're watching: Cassidy talked about adding $15 billion to the marketplace to help cover the cost of expensive enrollees in 2018 and 2019, a plan that has serious traction. One senior GOP aide said around 30 members have asked for something like this, to help stabilize marketplaces in the short term, while the ACA structure is still in place.

My oh Mylan

Circle June 22 on your calendar. That's when Mylan holds its annual shareholder meeting, and the controversial drug company that was raked over the coals last year for hiking the price of its EpiPens is getting defensive, Bob Herman reports.

What's happening: The investor advising firm Institutional Shareholder Services recommended that shareholders displace Mylan's existing board (including Heather Bresch, Mylan's CEO and the daughter of Sen. Joe Manchin) and vote against the company's "egregious" executive pay. You can read about the nine-figure pay package for chairman Robert Coury in the Wall Street Journal.

Mylan's response: Board members, led by Bresch and Coury, sent a letter to shareholders this week that explained why they should ignore the recommendations and called themselves "engaged, refreshed and responsive." They spent the first couple paragraphs of the letter bragging about Mylan's market cap and stock price.

Repurposing drugs and other pricing solutions

The Manhattan Institute and the U.S. Chamber of Commerce had a panel discussion on drug prices yesterday, and guess what? Thanks to David's skillful moderating, drug prices are coming down already!

A few of the ideas that came up, which you actually should keep on your radar screen:

  • Benjamin Roin of the MIT Sloan School of Management talked about the potential of "repurposing" — finding new uses for drugs that are already on the market. Here's a paper he wrote on the issue.
  • The Manhattan Institute's Paul Howard, who testified at Tuesday's Senate HELP Committee hearing on drug prices, said it's time to tighten the rules on the "340B" program, which offers discounted drugs to hospitals serving low-income patients. Too often, he said, hospitals turn around and charge full price for those drugs.
  • Ernst Berndt, also of the MIT Sloan School of Management, said the key is to keep the generic drug industry healthy so it can offer low-cost medications.

What we're watching this week: Goldman Sachs Global Healthcare Conference wraps up today.

What we're watching next week: Biotechnology Innovation Organization annual convention in San Diego, June 19-22. Mylan annual shareholder meeting, June 22.

What's on your radar? Let us know: david@axios.com and baker@axios.com

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NYPD responds to explosion of unknown origin at 42nd and 8th

This is a breaking news story and will be updated as we learn more.

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Rohingya women say they’ve been raped by Myanmar military

Portraits of some of the Rohingya Muslim women taken during an interview with The Associated Press.

The use of rape by Myanmar's armed forces has been sweeping and methodical, AP found in interviews with 29 Rohingya Muslim women and girls now in Bangladesh.

Why it matters: "The testimonies bolster the U.N.'s contention that Myanmar's armed forces are systematically employing rape as a 'calculated tool of terror' aimed at exterminating the Rohingya people."

More from AP's Kristen Gelineau:

  • "They were interviewed separately, come from a variety of villages in Myanmar and now live spread across several refugee camps in Bangladesh. Yet their stories were hauntingly similar. The military has denied its soldiers raped any Rohingya women."
  • "Here are the accounts as told by 21 women and girls [ranging in age from 13 to 35]. They agreed to be identified in this story by their first initial only, out of fear the military will kill them or their families."
Featured

Polluters are getting off easier under Trump's EPA

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

"An analysis of [EPA] enforcement data by The New York Times shows that the administration has adopted a more lenient approach than the previous two administrations — Democratic and Republican — toward polluters," Eric Lipton and Danielle Ivory write on the front page:

  • "The Times built a database of civil cases filed at the E.P.A. during the Trump, Obama and Bush administrations. During the first nine months under [Administrator Scott] Pruitt's leadership, the E.P.A. started about 1,900 cases, about one-third fewer than the number under President Barack Obama's first E.P.A. director and about one-quarter fewer than under President George W. Bush's over the same time period."
  • "[T]he agency sought civil penalties of about $50.4 million from polluters for cases initiated under Mr. Trump. Adjusted for inflation, that is about 39 percent of what the Obama administration sought and about 70 percent of what the Bush administration sought over the same time period."
  • Get smart: "The E.P.A. ... can force companies to retrofit their factories to cut pollution. Under Mr. Trump, those demands have dropped sharply. The agency has demanded about $1.2 billion worth of ... injunctive relief ... in cases initiated during the nine-month period, which, adjusted for inflation, is about 12 percent of what was sought under Mr. Obama and 48 percent under Mr. Bush."
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North Korean threat intensifies as it grows its bioweapons program

People watch a TV screen showing an image of North Korean leader Kim Jong Un. Photo: Ahn Young-joon / AP

"North Korea is moving steadily to acquire the essential machinery that could potentially be used for an advanced bioweapons program," the WashPost's Joby Warrick reports atop column 1.

Why it matters: "The gains have alarmed U.S. analysts, who say North Korea — which has doggedly pursued weapons of mass destruction of every other variety — could quickly surge into industrial-scale production of biological pathogens if it chooses to do so."

Details of prorgram expansion:

  • "Kim Jong Un's government also is dispatching its scientists abroad to seek advanced degrees in microbiology, while offering to sell biotechnology services to the developing world."
  • The takeaway: "Such a move could give the regime yet another fearsome weapon with which to threaten neighbors or U.S. troops in a future conflict."
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Report: Mueller focusing on obstruction of justice around Flynn

Former Trump national security adviser Michael Flynn leaves federal court in Washington. Photo: Susan Walsh / AP

Robert Mueller and his team are focusing on the days after White House officials were told Michael Flynn was vulnerable to Russian blackmail, NBC News' Carol Lee and Julia Ainsley report, citing "two people familiar with Mueller's investigation".

Why it matters: This means Mueller's team could be working to determine if Trump obstructed justice and is likely seeking out what President Trump knew about Flynn's conversations with former Russian Ambassador Sergei Kislyak, and subsequently, when Trump learned Flynn lied about them.

That period: January 26 to February 13, 2017.

The focus reportedly includes interviews with White House Counsel Don McGahn, who briefed Trump and senior White House staff about Yates' report that Flynn had lied to White House officials on January 26 and that he was vulnerable to Russian blackmail, according to Sean Spicer. That included Flynn's lie to Vice President Pence, which is what Trump cited in his firing statements.

  • Yates testified before Congress that McGahn asked about Flynn's FBI interview but that she refused to answer questions about that.
  • McGahn briefed Trump and senior White House staff about Yates' report that Flynn had lied to White House officials on January 26, according to Sean Spicer including Vice President Pence, and that he was vulnerable to Russian blackmail.
  • The effort reportedly includes interviews with other White House officials as well.
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Saudi Arabia set to lift ban on movie theaters

Visitors enter the Saudi Comic Con in February 2017. Photo: AP

Saudi Arabia will allow movie theaters to open in the country next year for the first time since the 1980s, per the AP. The government hopes to open 300 theaters with 2,000 screens by 2030, paving the way for a new industry — though it’s unclear what movies might play and edited they might be.

Why it matters: It’s part of a continuing social modernizing push to attract international investment by Crown Prince Mohammed bin Salman, who has announced an end to a ban on women driving and allowed rock concerts to be held in Saudi Arabia. That’s happening in conjunction with his controversial corruption crackdown, which is set to seize hundreds of billions from prominent businessmen for ailing Saudi coffers.

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How Ajit Pai tore up the rulebook for the information age

FCC Chairman Ajit Pai has rewritten the rules of the information age so thoroughly that there's no mode of communication under his control where the rules aren't looser than they were a year ago. Here's a look at what he's done.


Be smart: While some of his deregulation has been bipartisan, his big-ticket proposals have divided the agency and the nation. He's actively courted fans of President Trump's populist rhetoric and inspired scorn on the left.

Why it matters: Many top Republican priorities have been mired in Washington gridlock since Trump took office. Not so at the FCC. Pai swiftly orchestrated the wholesale deregulation of the networks Americans use every day, which will likely alter the way people experience the internet, broadcast TV and even AM radio. Those changes will play out over years — not immediately.
Featured

Ascension and Providence consider mega hospital merger

Ascension CEO Anthony Tersigni is eyeing a large health system merger. Photo: Aijaz Rahi / AP

Ascension and Providence St. Joseph Health are in discussions to merge, which would create the largest hospital system in the U.S., the Wall Street Journal reports citing people familiar with the merger talks. The combined system would have 191 hospitals, numerous clinics and roughly $45 billion in annual revenue.

Why it matters: Although the Ascension-Providence deal is not guaranteed, it shows how health care has turned into the Wild West for mega-mergers. CVS Health is buying Aetna, Catholic Health Initiatives and Dignity Health are merging, and Advocate Health Care and Aurora Health Care are combining, among other deals. Yet, research shows mergers don't lower health care costs or improve care for patients.

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Sneak Peek: Pence to the pyramids

Pence listens as Trump announces his Jerusalem move. Photo: Alex Brandon / AP

With President Trump's announcement on Jerusalem lighting up the Middle East, Vice President Mike Pence embarks Saturday on his first trip to Israel since taking national office.

The vice president will be gone for a week, with stops in Egypt and Germany:

  • Pence takes off from Washington, lands in Tel Aviv and goes straight to Jerusalem for a bilateral meeting with Israeli President Benjamin Netanyahu.
  • Pence then will light a menorah at the Western Wall.
  • An aide said that Pence's message in Israel will be that Trump, as he said in his speech recognizing Jerusalem as the capital, is committed to working for peace between Israelis and Palestinians.
  • Pence will use his meetings with leaders in the region to reaffirm the administration's commitment to work with partners throughout the Middle East and to "defeat radicalism."
  • On Monday, Pence will give the signature speech at the Knesset, the Israeli Parliament. The speech will be aimed at the region overall. Pence will emphasize that he is there on behalf of the president, and detail why Israel is a most cherished ally of the United States.
  • Pence will then fly to Cairo for a bilat with President Abdel Fattah el-Sisi. The two will discuss security and joint efforts to fight ISIS.
  • Pence will visit the pyramids and will talk with media with the ancient wonders as a backdrop.
  • Pence will fly home through Ramstein Air Base in Germany, and will do a meet-and-greet with troops.

The takeaway: A key theme for Pence's remarks and interviews will be U.S. efforts to stop persecution of Christians and other religious minorities in the region.

Go deeper: Palestinians won't meet with Pence.

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Exclusive: Policy official leaving White House

The White House South Portico is adorned with Christmas lights. Photo: Manuel Balce Ceneta / AP

Paul Winfree is leaving the White House, according to a senior administration official with knowledge of the decision. Winfree, who declined to comment, has resigned from his position as Deputy Director of the White House Domestic Policy Council and Director of Budget Policy.

  • Why this matters: Winfree's departure is part of what we've been forecasting will be a wave of White House staff departures after year one of the Trump presidency. His last day in the White House will be Friday.

Winfree, a respected policy wonk with strong ties to the conservative movement, is the second senior official to announce a departure in three days. Deputy National Security Adviser Dina Powell told colleagues she's leaving to return to her family in New York.

What Winfree has been telling friends and colleagues:

  • He and his wife are expecting a second baby boy in a few weeks.
  • He'll return to the Heritage Foundation, where he will run economic policy.
  • He also plans to start his own policy consulting business. -
  • Starting in February, he will teach a seminar on policymaking at a top university, where he will draw on his experiences working in the White House, the U.S. Senate, and with think tanks.