Which is why, as had been widely reported here at The Health 202 and elsewhere, Republicans have largely divorced themselves from the issue of health care this cycle, especially when it comes to the ACA. Unable to make good on a years-long promise to repeal and replace President Obama's signature domestic law, and caught off guard by a backlash when they tried, Republicans have concluded that health care is not a winning issue for them this cycle.

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But Trump is still campaigning on the issue, believing that getting rid of the ACA is still a winning issue with his base. The president's speeches are full of references to the Obamacare repeal vote last year and Congress's elimination of the individual mandate penalty.

For example, at a rally in Montana this month, Trump called Obamacare a "disaster" and assured the crowd that Republicans would still get a repeal and replace effort done.

"You know, we want to repeal and replace it, and if we get enough Republicans, we will, and we'll have a much better health care -- we've already come up with some of them, association care, et cetera," he said, referring to a White House policy change that expands access to plans that allows small businesses and associations to offer health plans, which don't have to provide all of the ACA's benefits.

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Trump used similar rhetoric in almost every speech this summer. In West Virginia, he railed against Sen. Joe Manchin (D) for voting to "keep the disaster known as Obamacare," but said, "I will tell you, it is being chipped away."

Trump isn't wrong that voters care a lot about health care. Poll after poll show it's the most important issue to voters this year. Just this weekend a new CBS News poll found 70 percent of voters in battleground states named health care as "very important" in their midterm vote. But the same poll also found that only 12 percent said Republican changes to health care laws have helped them.

Which is why Democrats are talking about the issue nonstop while Republicans are focused on the roaring economy and low unemployment numbers. The GOP is so wary of the the issue that some of the party's candidates have even softened or removed references to Obamacare from their campaign websites.

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This phenomenon has been previously documented, and The Daily Beast's Gideon Resnick published a thorough review Friday of GOP House members websites and found 20 such changes between 2014 or 2016 and now.

While Democrats have focused on what repeal of the law would mean for people with preexisting conditions, they've also argued how the changes already made, such as the elimination of the individual mandate, serve only to undermine the law and drive up premiums because healthy people will be less inclined to buy coverage and leave insurers with a sicker pool of patients.

But Trump knows that Republican voters, anyway, still despise the ACA (almost 80 percent of GOP voters have an unfavorable view of the law, according to early September numbers from the Kaiser Family Foundation).

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And he is also using repeal of the individual mandate as a way of telling voters that he dealt a major blow to Obamacare.

"We've done a number on Obamacare. We're coming out with tremendous health-care plans. We've gotten rid of the individual mandate, the most unpopular thing probably in our country. Gone, gone, no individual mandate, where you have the privilege to pay a fortune as a penalty in order not to pay a fortune for bad health care. Think of that. Is that a good thing? I don't think so," he told a Pennsylvania crowd last month.

"You know how many people have come up to me and said, 'Thank you very much for getting rid of the individual mandate?' Sounds so nice. Isn't it a beautiful term? The individual mandate is wonderful. See, I'm acting presidential now. The individual mandate. The individual mandate is a disaster; it sounds good. Like the Affordable Care Act was not affordable."

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And in Ohio last month, Trump also boasted that "we've repealed the core of Obamacare."

Prior to the death of Sen. John McCain (R-Ariz.) Trump was also very caught up on the late senator's vote against ACA repeal, bringing that up whenever he talked about getting rid of the law.

"That was a beauty, Obamacare," he said at the Ohio rally, speaking of the law in the past tense as he often does. "It was repealed and replaced, remember, other than one vote."

AHH, OOF and OUCH

AHH: In a rare weekend rollout of a new proposal, the Trump administration officially announced Saturday a new 447-page effort to make it harder for immigrants to come to or stay in the United States if they will use or do use public assistance programs like Medicaid and food stamps.

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If implemented, the effort would amount t a dramatic change to existing rules that govern decisions around visas and residency. Currently, the government can assess whether a person is a "public charge," in other words, dependent on government aid. But the inclusion in the proposed new rule of other "non-cash" assistance broadens the government's ability to deny entry or residency status to immigrants (some immigrants would be exempted, like green-card holders and refugees).

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Last month, The Health 202 wrote that the looming change was already having a "chilling effect" on immigrants seeking health-care services for fear doing so would threaten their status. Critics say it's an attempt by the White House to make a dent in legal immigration.

In a statement, the Department of Homeland Security Secretary Kirstjen Nielsen, defended the proposed rule. "Under long-standing federal law, those seeking to immigrate to the United States must show they can support themselves financially, " she said, adding that the proposed changes would “promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers.”

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"The agency estimates that about 382,000 immigrants per year would be subject to a more extensive review of their use of public benefits and potentially denied residency. The proposal would also allow some of those who are facing rejection to post cash bonds of $10,000 or more, and the bonds would have to be provided through a government-approved company. The immigrant would lose the money if they began using public assistance and were found to be a 'public charge' on the United States, according to the proposal," our Post colleague Nick Miroff reports.

The proposed rule is now open for public comment for 60 days before a final rule is issued with a start date.

OOF: Health and Human Services Secretary Alex Azar told Congress the agency is shifting "up to $266 million” from health-care services related to HIV/AIDs and biomedical research to cover the exploding cost of sheltering migrant children, our Post colleagues Amy Goldstein and Robert Moore write.

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Amy and Robert report that "HHS also has given its 'unaccompanied alien children' program all $180 million available from a discretionary pot of public health money — a fund the Obama administration used to help implement the Affordable Care Act, a law that President Trump has sought to undermine."

The number of migrant children in HHS's care is at record highs, but an HHS spokeswoman told Amy and Robert that it is not because of the Trump administration policy that separated children from their parents at the border, but rather that children are being sheltered longer.

Azar blamed this on a "broken immigration system." But critics of the administration said White House immigration enforcement policies have scared potential sponsors away from picking up the children, thus resulting in the longer stays.

OUCH: A second woman has come forward accusing Supreme Court nominee Brett Kavanaugh of sexual misconduct in college, reports the New Yorker's Ronan Farrow and Jane Meyer.

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Senate offices learned of the allegations last week, the magazine reports. Several Democratic staffs are investigating these latest claims.

The news broke Sunday night after a weekend of negotiations between the Senate Judiciary Committee staff and Chrstine Blasey Ford, the first woman to accuse Kavanaugh of sexual assault when they were both in high school, ended with Blasey agreeing to testify before the panel on Thursday.

But now, Senate Democrats are asking that any consideration of Kavanaugh's confirmation be delayed to give senators time to look into these new allegations, our Post colleagues Karoun Demirjian, Amy Gardner and Seung Min Kim report.

In a letter to Judiciary Chairman Charles E. Grassley (R-Iowa), ranking Democrat on the committee Dianne Feinstein asked “that the newest allegations of sexual misconduct be referred to the FBI for investigation, and that you join our request for the White House to direct the FBI to investigate the allegations of Christine Blasey Ford as well as these new claims.”

Meanwhile. Michael Avenatti, the attorney for adult film star Stormy Daniels, wrote on Twitter Sunday night that he had additional sources with information about Kavanaugh's misconduct.

The news further divided Democrats and Republicans over Kavanaugh's credibility. The White House called the new allegations a “coordinated smear campaign” by Democrats against the judge. But Democrats said that even if Kavanaugh is eventually confirmed, if they gain control of Congress in November they would continue to investigate the claims against him.

HEALTH ON THE HILL

—Democrats are running on their own preexisting conditions, writes Politico's Miranda Alice Ollstein.

For instance, Sen. Claire McCaskill (D-Mo.), who is in a tough reelection fight, says in a TV ad, “Two years ago, I beat breast cancer. Like thousands of other women in Missouri, I don’t talk about it much. But those who face cancer and many other illnesses have a pre-existing condition when it comes to health coverage.”

She also attacks her Republican challenger, state Attorney General Josh Hawley, for joining a Texas lawsuit seeking to undermine the ACA.

Ollstein points to many other examples of candidates sharing their personal health stories on the campaign trail as a way to connect with voters:

"In a House district in Illinois, registered nurse Lauren Underwood talks about a heart condition that would put her at risk for losing her health coverage if Congress or federal courts strike down the Affordable Care Act and its protections for people with pre-existing conditions. In California’s Central Valley, T.J. Cox tells voters that before Obamacare, his insurance refused to cover his wife’s C-section because it considered her pregnancy a pre-existing condition. And in suburban Detroit, Elissa Slotkin’s brutal television ads includes footage of her mother as a dying cancer patient who for years had been denied insurance."

—The House is this week expected to pass a $854 billion spending measure that includes a full year of spending for HHS and the Pentagon and extends other agencies' budgets until Dec. 7 to avert a government shutdown on Sept. 30. The Senate passed the spending package last week.

Some Republicans, including the White House, are frustrated that the bill does not include money for Trump's border wall, but there's no indication that the president plans to veto the bill.

“This bill funds things we said we wouldn’t, like Planned Parenthood, but doesn’t fund things we said we would, like the border security wall. That’s unacceptable. Republicans need to actually do what we said,” Rep. Jim Jordan (R-Ohio), told The Hill.

MEDICAL MISSIVES

—Researchers reported Sunday that a tiny clip inserted into the heart of patients with severe heart failure significantly reduced death rates.

The study of 614 patients with severe heart failure, according to the New York Times, found that fixing a leaky mitral value resulted in more blood flow to the heart and dramatically improved health outcomes.

The NYT reports:

Among those who received only medical treatment, 151 were hospitalized for heart failure in the ensuing two years. Sixty-one died.

In contrast, just 92 who got the device were hospitalized for heart failure during the period, and 28 died.

The results have left leading researchers unexpectedly optimistic. The trial sends “a very, very powerful message,” said Dr. Gilbert Tang, a heart surgeon at Mount Sinai Medical Center, which enrolled a patient in the trial.

“This is a game changer. This is massive,” said Dr. Mathew Williams, director of the heart valve program at NYU Langone Health, which had a few patients in the study.

INDUSTRY RX

— A federal court ruled this month that a Montana insurer is owed compensation for subsidy payments ended by the Trump administration last year.

The New York Times's Robert Pear reports that a judge determined that Trump's cancellation of so-called "cost-sharing reduction" payments broke a promise to insurers who offered plans on the ACA exchanges. Montana Health sued for $5.3 million it didn't receive at the end of 2017.

"The decision could have broad ramifications for health insurers. Several similar cases are pending in the Court of Federal Claims, a specialized tribunal that handles a wide range of monetary claims against the government. In April, another judge, Margaret M. Sweeney, certified a class action that allows insurers as a group to sue the government over Mr. Trump’s termination of the cost-sharing payments," Pear writes.

The lawsuits could end up costing the federal government millions in payments.

STATE SCAN

— When Virginia's Medicaid expansion goes into effect next year there will be a gap before its recipients are required to meet work requirements, our Post colleague Gregory S. Schneider reports.

The state has to await federal approval for its work requirement waiver, which could come as long as a year after the expansion goes into effect on Jan. 1. State Republicans only accepted the Medicaid expansion because of the addition of the extra parameters, so Schneider writes that they are not pleased that one will start without the other.

"While I don’t support Medicaid expansion, I do believe if we’re going to have it, it needs to have the work requirement, and it needs to be in there as soon as possible,” state Sen. Richard Stuart (R-Stafford), a member of the Senate Finance Committee, told Schneider.

— Here are some more good reads from the Post and beyond:

DAYBOOK

Coming up

The Senate Committee on Health, Education, Labor and Pensions: Subcommittee on Primary Health and Retirement Security hosts hearing to examine health care in rural America Tuesday.

The Senate HELP Committee hosts a hearing on reducing health -costs Thursday.

The House Energy and Commerce Committee: Subcommittee on Health hosts a hearing on reducing maternal mortality in the U.S. Thursday.

Sen. Rob Portman (R-Ohio) speaks at the American Enterprise Institute to discuss combating the international shipment of opioids Thursday.

SUGAR RUSH