Democrats are holding more than 7 times as many town halls as Republicans Presented by

Welcome back to PULSE. And in case you've been focused on the holiday and not health care, don't worry — nothing's settled on Republicans' repeal effort yet. But POLITICO's been tracking the fight across the recess, and here are key threads to watch.

HOW CLOSE ARE THEY? DEPENDS WHO YOU ASK — Republican leaders took to the airwaves on Sunday and proceeded to give out conflicting messages.


— "We are getting close," according to Marc Short, President Donald Trump’s director of legislative affairs, appearing on "Fox News Sunday."

— "We're at an impasse," said Sen. Rand Paul, on the same show.

Republicans also continued to promote ideas that go against what's in their repeal bill. Louisiana Sen. Bill Cassidy — who's publicly undecided but has dropped hints that he can get to yes — used his appearance on "Meet the Press" to again tout his plan with Maine Sen. Susan Collins, which would allow states to preserve major elements of the ACA.

The idea to 'repeal now, replace later' not getting much traction. Trump's tweet on Friday, urging the GOP to fall back on simply repealing Obamacare if they can't strike a deal to replace it, has the backing of conservatives like Paul and Nebraska Sen. Ben Sasse.

But key decision-makers like Senate Majority Leader Mitch McConnell and HHS Secretary Tom Price have rejected that approach for now. "McConnell and his senator … are working to try to get this piece of legislation on track," Price said on "Meet the Press" on Sunday.

Meanwhile: The CBO is pressing forward. The budget office is analyzing two versions of McConnell's bill — including one with a proposal, backed by Sen. Ted Cruz and other conservatives, that would create parallel health insurance markets in states, POLITICO's Sarah Karlin-Smith reports.

One market would contain protections for people with pre-existing conditions and coverage of essential health benefits like maternity care and mental health services, and the other would allow the sale of skimpier plans, likely without federal subsidies. More. There are questions about whether that proposal would meet budget reconciliation rules, however.

CRUZ, MIKE LEE ARE PLAYING NICE — The two firebrands aren’t firebombing McConnell on TV or on the Senate floor after many tangles with him in the past, but instead are intent on using their status as conservative negotiators inside the room as part of McConnell’s working group, POLITICO's Burgess Everett reports. More.

BRIAN SANDOVAL: THE SENATE'S 53rd REPUBLICAN? — The Nevada governor commands outsize clout in the health care fight and he's been loudly critical of efforts to roll back Medicaid, POLITICO's Jennifer Haberkorn and Rachana Pradhan note. Sandoval was the first Republican governor to expand Medicaid through the ACA, and he appeared with Sen. Dean Heller when the Nevada senator ripped the GOP health effort last month.

But Sandoval also is gettable, congressional Republicans believe — and a switch in the Nevada governor's thinking could trigger Heller to follow suit and give McConnell the votes he needs. “At the end of the day, it comes down to Sandoval,” one Republican aide said of Heller's position. More.

— 200,000-plus. That's how many Nevadans have gained coverage through the state's Medicaid expansion.





THE CONSEQUENCES OF REPEAL

Red-state school leaders fear Medicaid cuts. About $4 billion in annual Medicaid spending goes to U.S. schools to pay for nurses, therapists and school-based screenings and treatment for children from low-income families, POLITICO's Kimberly Hefling reports. And school leaders in economically depressed parts of Appalachia, the Rust Belt and elsewhere say those Medicaid funds are critical to providing services they are required to provide to special education students.

One Kentucky school superintendent said he’s seen firsthand how mental health services funded by Medicaid have connected families to help at a time when his state is struggling with an opioid addiction crisis. More for Pros.

A popular telemedicine program in poor, rural areas would lose funds. The program has helped school nurses become de facto medical guides, POLITICO's David Pittman reports, and GOP leaders have been strong proponents of the technology, arguing that it delivers health care at low cost to far-flung and underserved areas where doctors are few and far between.

But “if the Medicaid reimbursement isn’t there, you’re not going to make it,” Steve North, medical director and founder of the Center for Rural Health Innovation, said of school-based clinics. “You’re not even going to come close.” More.

KEEP YOUR EYE ON THIS: House subcommittee readies provision to stop IRS enforcement of mandate. The House Committee on Appropriations financial services subcommittee approved a bill last Thursday that would restrict the IRS from carrying out key enforcement and reporting activities related to the mandate, the NYT's Robert Pear writes. The restrictions would take effect on Oct. 1 and are intended as a backup if Republicans' effort to repeal-and-replace the Affordable Care Act runs aground.

“While Congress works to pass President Trump’s health care plan, stopping the I.R.S. from implementing the harmful individual mandate helps provide relief for the families suffering under Obamacare," a spokesman for Rep. Tom Graves (R-Ga.), chairman of the subcommittee, told the Times. More.

WELCOME TO WEDNESDAY PULSE — Where we've used this holiday break to pull off a mild makeover. What do you think of PULSE's new look? Send feedback and tips to [email protected] or @ddiamond on Twitter.

TOWN HALLS — Kansas Sen. Jerry Moran is holding several town halls tomorrow and Friday, Cruz held an invite-only event and Cassidy held a pair in Louisiana last week. But that's it among Senate Republicans this recess, according to the Town Hall Project, which has prompted activists to seek other ways to get their message to lawmakers.

In Texas, Cruz got an earful from protesters at one Independence Day event, Patrick Svitek reports at the Texas Tribune. More. Collins, meanwhile, said she was repeatedly thanked for her stand against Republicans' health bills. More.

— Fifty-two vs. seven. That's the discrepancy in town halls scheduled by congressional Democrats versus Republicans across the July 4 recess, according to data that the Town Hall Project shared with PULSE. Congressional Republicans currently outnumber congressional Democrats by more than 50 seats.





Republicans' town halls have dwindled as their health care effort has gained steam. | The Town Hall Project

LIBERAL GROUPS TARGET GOP CLASS OF 2020 — Sens. Cory Gardner (R-Colo.), Thom Tillis (R-N.C.) and Joni Ernst (R-Iowa) aren't up for reelection for more than three years, but they're already being pressured by liberal activists who warn that their vote on health care may haunt them.

Save My Care, the pro-Obamacare group, is touting new polling that the GOP health care proposal is deeply unpopular in Iowa, North Carolina and Colorado — and that Gardner and Tillis are currently trailing a generic Democrat opponent. More.

MORE ON REPEAL

Could Medicaid become the next fiscal cliff? The Senate health bill would set in motion a massive rollback of Medicaid funding beginning in three years. But even some Republican supporters acknowledge the full cuts might never happen.

“I don’t think it will ever be instituted,” Nevada's Heller said of the Medicaid cuts before he came out against the Senate bill. "It’s kind of like the Cadillac tax." More.





HHS report has good news for the Obamacare market. According to an internal review of the ACA's risk stabilization initiatives, the risk management and reinsurance programs were "working as intended" to help insurers and customers — far from the death spiral that some Republicans and even HHS senior leaders have argued this year. More.

"Surprisingly, CMS reports that risk scores remained stable in the individual market and decreased in the small group market" between 2014 and 2016, Tim Jost writes at Health Affairs, noting that some Republicans argued that risk scores had worsened. "The data also would seem to refute the commonly held belief that the marketplace population is becoming sicker." More.





The female sports owners who took a stand on Planned Parenthood. The three owners of the WNBA's Seattle Storm decided to host a fundraiser at an upcoming game, and while they've faced some political pushback, they say it wasn't a hard decision.

"We are a women-owned team, we have women in leadership, we have women players," said co-owner Dawn Trudeau, who added that Planned Parenthood helped her get access to birth control before she first had sex. "I was very low-income at the time, but Planned Parenthood gave me the choice of planning my life. It’s a very special organization to me," Trudeau told Ben Strauss for POLITICO Magazine. More.

The heroin crisis in Trump's backyard. Across the bridge from Palm Beach’s oceanfront mansions and Mar-a-Lago , paramedics responded to 5,000 overdose calls last year, nearly 600 of them fatal. One major problem, Frank Owen writes in POLITICO Magazine, is the proliferation of the county's corrupt “sober homes” — communal houses for addicts who arrive from around the country — which are often unregulated. More.





Dan Farmer heads to the Cleveland Clinic. Farmer, who worked at CMMI and CMS, starts as the Clinic's senior director of government relations on Thursday.





In the Weekly Standard, John McCormick looks closer at Ted Cruz's health care proposal and whether it can bridge the gap among Republicans. More.

Charlie Pierce contends in Esquire that "the phony health care 'compromise' is coming … and the elite political media will buy it." More.

WaPo's Carolyn Johnson looks at Louisiana's possible strategy to address high hep C costs in the Medicaid program: Using march-in rights. More.

Bret Stephens argues in the New York Times that conservatives should abandon efforts to repeal and replace the ACA and instead focus on promulgating health savings accounts. More.

The WSJ opinion page applauds FDA commissioner Scott Gottlieb for his focus on pushing more generic drug competition. More.

In the Los Angeles Times, Michael Hiltzik writes that Republicans' attacks on Medicaid are heavy on bluster and light on facts. More.

Harvard's David Cutler says there's a bipartisan path to health reform: Focus on fixing the opioid crisis and lowering health spending. More.

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