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Republican senators sure aren't sounding psyched about passing a health care bill

Senators wrapped up their week on recess with an unexpected bout of pessimism over the prospects of passing a health care bill. Here's a quick sampling of comments we've seen in the past 24 hours:

Sen. Richard Burr (R-NC) : "It's unlikely that we will get a health care deal, which means that most of my time has been spent trying to figure out solutions to Iowa losing all of its insurers ... I don’t see a comprehensive health care plan this year."

: "It's unlikely that we will get a health care deal, which means that most of my time has been spent trying to figure out solutions to Iowa losing all of its insurers ... I don’t see a comprehensive health care plan this year." Sen. Jeff Flake (R-AZ) : “There are some still saying that we’ll vote before the August break. I have a hard time believing that."

: “There are some still saying that we’ll vote before the August break. I have a hard time believing that." Sen. Ron Johnson (R-WI): Suggesting a short-term bill to stabilize the marketplace followed by a more long-term repeal effort, "To me, this may be a two-part process. I would admit that’s probably a minority view in the Republican Senate right now."

I take the Republican senators' comments here at face value. Writing a health care bill and passing it while keeping a small majority in the Senate united is a very difficult task. It may not work. It gets harder by the day to pass a bill this year, as we're nearly halfway through 2017. The party can only afford to lose two Republican senators and be able to pass a bill. Keeping conservatives and moderates on board with the same bill is hard work!

But as we saw in the House process, passing health reform is hard — but not impossible. The House bill was declared dead a half-dozen times before it squeaked through the chamber in mid-May. House Speaker Paul Ryan even gave a press conference in late March where he conceded defeat, declaring Obamacare the law of the land.

Six weeks later, the House passed their Obamacare repeal bill.

A key lesson I took from the House's health care experience is that the desire to repeal Obamacare is very, very strong — strong enough to get 217 Republican House members to vote for a bill with a 17 percent approval rating.

Ezra Klein has aptly described this phenomenon as "health care hot potato." Even when individual legislators have qualms with parts of the bill they don't like — that it cuts too much money from Medicaid or spends too much money on Medicaid — they really don't want to get blamed for standing in the way of the party's core political promise. In the House, we saw Republicans get on board with a bill they didn't like much at all just to say they accomplished the goal that voters had asked for. I wouldn't underestimate how powerful of a dynamic that could become as these negotiations progress.

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Governors' offices press the Trump administration to be straight with them on CSR payments

Governors' offices met with Medicare administrator Seema Verma this week, once again pushing for more clarity around cost-sharing reduction payments — and once again not getting it.

The cost-sharing reduction subsidies — and whether Trump will pay them — are the biggest uncertainty surrounding the Affordable Care Act right now. Insurers want certainty that the federal government will keep financing this $7 billion fund. The White House hasn't offered any assurances about whether it will keep paying the subsidies that are currently being challenged in court as an illegal program.

The Verma meeting was part of a two-day summit of the National Governors Association's bipartisan working group on health reform, which includes 14 states with both Democratic and Republican governors.

"The top of mind concern was uncertainty around CSRs in 2017 and 2018," Hemi Tewarson, a health policy adviser at the NGA, says. "Filing deadlines are fast approaching, some insurers aren't including the CSRs in their bids in some states. There is a lot of concern about what is happening. From the federal perspective, we just don't know," she says.

Senate aide says taxes on employer coverage "DEFINITELY NOT" on the table

Senate Republicans need a way to pay for their health care bill, which is expected to have more generous subsidies and smaller Medicaid cuts than the House version.

And because of Senate rules, their bill will need to save at least $138 billion, the amount that the House bill did.

To meet that goal, the Wall Street Journal reported Thursday that senators were kicking around the idea of taxing employer-sponsored plans as one solution. WSJ said "a number of senators are open to the idea," citing Sen. Mike Lee (R-UT) as one particularly interested legislator.

But will it really happen? Not so fast: Dylan Scott bounced that idea off a Senate Republican aide familiar with the negotiations this morning. He got a pretty unequivocal response.

“I can tell you that this is DEFINITELY NOT being discussed by any of the folks who are actually working to draft the legislation — in fact it is not even on the table," the aide told him.

Capping the tax break for employer-sponsored coverage is a white whale of American health policy. Democrats and Republicans agree that we should end this regressive policy, which predominantly benefits people who are wealthy enough to get health insurance at work.

This is why you see the idea turn up in Obamacare, which included a "Cadillac tax" on the most expensive health insurance plans. It's why the idea turned up again in an early draft of the American Health Care Act, too.

But the idea of taxing employer-sponsored coverage is also horrifically unpopular with the 155 million Americans enrolled in such plans. And that is why you see legislators or candidates often proposing the idea and then quickly backing away.

A version of this happened on the House side: Big businesses planned to unleash a fierce lobbying campaign when they got wind that legislators were considering such a provision. Obamacare's unpopular Cadillac tax exists on paper but still hasn't taken effect.

As Joe Antos, an economist at the right-leaning American Enterprise Institute, told me months ago, "This is one fight you’re not going to be able to get through the Senate. You can spend a lot of political capital on it, but you’re not going to make any progress.”

Chart of the Day

NIH-funded studies are becoming increasingly rare at medicine's largest cancer conference. Kaiser Health News' Liz Szabo reports that "The number of studies fully funded by the NIH at the annual meeting of the American Society of Clinical Oncology (ASCO) — the world’s largest gathering of cancer researchers — has fallen 75 percent in the past decade."

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day

" Conservative groups push for regulatory changes to ObamaCare " “Two conservative groups are urging the Trump administration to move forward with regulatory action loosening ObamaCare regulations as Congress continues to drag its feet on passing repeal legislation. "ObamaCare's harmful regulations are putting access to affordable healthcare out of reach for millions of people," Freedom Partners and Americans for Prosperity wrote in a letter to Health and Human Services (HHS) Secretary Tom Price.” —Jessie Hellmann, The Hill

" “Two conservative groups are urging the Trump administration to move forward with regulatory action loosening ObamaCare regulations as Congress continues to drag its feet on passing repeal legislation. "ObamaCare's harmful regulations are putting access to affordable healthcare out of reach for millions of people," Freedom Partners and Americans for Prosperity wrote in a letter to Health and Human Services (HHS) Secretary Tom Price.” —Jessie Hellmann, The Hill " Single-payer healthcare plan advances in California Senate — without a way to pay its $400-billion tab " “A proposal to adopt a single-payer healthcare system for California took an initial step forward Thursday when the state Senate approved a bare-bones bill that lacks a method for paying the $400-billion cost of the plan. The proposal was made by legislators led by Sen. Ricardo Lara (D-Bell Gardens) at the same time President Trump and Republican members of Congress are working to repeal and replace the federal Affordable Care Act.” —Patrick McGreevy, Los Angeles Times

" “A proposal to adopt a single-payer healthcare system for California took an initial step forward Thursday when the state Senate approved a bare-bones bill that lacks a method for paying the $400-billion cost of the plan. The proposal was made by legislators led by Sen. Ricardo Lara (D-Bell Gardens) at the same time President Trump and Republican members of Congress are working to repeal and replace the federal Affordable Care Act.” —Patrick McGreevy, Los Angeles Times "100,000 Nebraskans could be left with no options if last insurer pulls out of ACA market" “Nearly 100,000 Nebraskans apparently will have only one choice for individual health insurance next year. And even that choice isn’t certain: Medica Health hasn’t decided whether to offer plans next year that meet the Affordable Care Act’s standards. If Medica joins the ranks of health insurance companies leaving the individual marketplace because they have been losing millions of dollars, Nebraskans seeking individual policies may not be able to find health plans at any price.” —Steve Jordon, Nebraska World-Herald

​Analysis and longer reads

" Swedish double-booked its surgeries, and patients didn't know " "In recent years, some of Swedish’s top brain and spine surgeons routinely ran multiple operating rooms at the same time while keeping patients in the dark about the practice, according to internal surgery data obtained by The Seattle Times as well as interviews with patients and medical staffers." —Mike Baker and Justin Mayo, The Seattle Times

" "In recent years, some of Swedish’s top brain and spine surgeons routinely ran multiple operating rooms at the same time while keeping patients in the dark about the practice, according to internal surgery data obtained by The Seattle Times as well as interviews with patients and medical staffers." —Mike Baker and Justin Mayo, The Seattle Times " How over a million Christians have opted out of health insurance " "The stated Christian mission of these ministries doesn’t always match the reality of what they offer in the face of real, painful need." —Laura Turner, BuzzFeed

" "The stated Christian mission of these ministries doesn’t always match the reality of what they offer in the face of real, painful need." —Laura Turner, BuzzFeed "Dirty, Dingy Hospitals: Doctors Blame Debt-Fueled Takeovers" “There are two groups Community Health Systems Inc. can’t push too far: the doctors at its hospitals, and the debtholders it owes billions of dollars. Right now, the creditors are winning, and the doctors aren’t happy. In Fort Wayne, Indiana, the rancor about Community’s neglect of a local health system has gotten so bad that a group of doctors tried to get rid of corporate ownership and buy the company out.” —John Lauerman and David Welch, Bloomberg

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