Growing rift between Trump, GOP Congress on health care Presented by

The White House and Congress are increasingly far apart on their health care strategies, with the president continuing to threaten the individual insurance market and harangue the Senate on health care.

TRUMP'S DECISION ON SUBSIDIES LOOMING — President Donald Trump at any time could make good on a threat to scrap crucial Obamacare payments to insurers — a decision that could raise Obamacare customers’ costs and potentially leave tens of thousands more without any coverage options next year, POLITICO's Paul Demko writes. And that decision could come as soon as today.


Insurers are incredibly skittish and may hike rates if Trump yanks the subsidies. "We should call this the sabotage surcharge, because that’s literally what this is," said John Gorman, a health care consultant who works with many insurers. "The insurance industry should tattoo this on Trump’s forehead." Some Republicans in Congress also are talking about the need to shore up the market, not destabilize it. More for Pros.

Monday's issue of PULSE explained how Trump's strategy to defund the Obamacare payments could backfire.

WHITE HOUSE URGING SENATE: DON'T QUIT ON HEALTH REFORM — The administration is trying to rebuild momentum for Obamacare repeal, and hosted a meeting Monday between Louisiana Sen. Bill Cassidy, HHS Secretary Tom Price, several GOP governors and top aides to Trump.

Attendees left the meeting saying that it was positive and productive. "I am encouraged that there is a new commitment to finding a solution that is inclusive of the governors," Arkansas Gov. Asa Hutchinson said. More

— How the latest plan, Graham-Cassidy, would work. The plan authored by Cassidy and South Carolina Sen. Lindsey Graham would send billions of dollars in federal funding set aside for Obamacare directly to states in the form of annual block grants, and give them near-complete control over how to use the money. States could pour funds into ensuring Obamacare continues to function, the senators said. And those states that don't would also be free to scrap their health care systems and start anew with little federal interference, POLITICO's Adam Cancryn reports.

More for Pros. | See Graham-Cassidy bill text

GOP SENATORS TO WHITE HOUSE: THANKS, BUT NO THANKS — Leaders say they lack the votes on health care and don't see a path to getting them, with Sens. Lisa Murkowski and Susan Collins remaining hard no's on repeal proposals and Sen. John McCain out for weeks to treat his brain cancer.

"Until somebody shows us a way to get that elusive 50th vote, I think it's over,” said Sen. John Thune of South Dakota, the third-ranking Republican. “Maybe lightning will strike and something will come together but I'm not holding my breath." POLITICO's Burgess Everett and Jennifer Haberkorn have more.

— There's also rising tension between Congress, POTUS. Since Republican senators' health push collapsed early Friday, Trump has publicly berated them as "quitters" and threatened their benefits.

White House budget chief Mick Mulvaney — a former congressman — on Sunday said that the Senate shouldn't take up any other legislation until voting on health care. "I don't think he's got much experience in the Senate, as I recall," Senate Majority Whip John Cornyn (R-Texas) countered on Monday, saying that Mulvaney's "got a big job, he ought to do that job and let us do our jobs."

President Donald Trump has been insisting that Congress take up Obamacare repeal again. | Getty

THIS IS TUESDAY PULSE — Where we're reminded that Obamacare's exchanges offer protections if you suddenly lose your job-based health insurance. (You'd think this would have made Trump advisers more keen to save the program.) Send your recent hirings, firings and other tips to [email protected] or @ddiamond on Twitter

With help from Renuka Rayasam (@RenuRayasam), Victoria Colliver (@Vcolliver), Sarah Karlin-Smith (@SarahKarlin) and Brent Griffiths (@BrentGriffiths).

ON TAP TODAY — The Senate HELP Committee holds a 2:30 p.m. hearing on the nominations of five senior HHS appointees: Lance Robertson to be assistant HHS secretary for aging; Brett Giroir to be assistant HHS secretary for health; Robert Kadlec to be assistant HHS secretary for preparedness and response; Elinore McCance-Katz to be assistant HHS secretary for mental health and substance use; and Jerome Adams to be Surgeon General. The committee's vote on the nominations is scheduled for Wednesday.

COMMISSION TELLS TRUMP: DECLARE OPIOID EPIDEMIC A 'NATIONAL EMERGENCY' — A presidential commission on opioid addiction is recommending that the federal government ramp up federal funding to address the crisis, just as congressional Republicans look to cut Medicaid funding as part of Obamacare repeal efforts, POLITICO's Katie Jennings reports.

The commission's interim report calls for more money for substance abuse treatment, expanding access to medication-assisted treatment and helping states enhance their prescription monitoring programs. The first step would be for Trump to declare drug addiction, which kills more than 142 Americans a day, a national emergency.

More. | Read the interim report.

CBO: DRUG IMPORTATION AMENDMENT COULD SAVE $6.8 BILLION — A drug importation bill introduced by Sens. Bernie Sanders, Cory Booker and Bob Casey in February would save the government $6.8 billion over 10 years, per a CBO analysis. Sanders may try and force a vote on the bill as an amendment to FDA user fee reauthorization, when the upper chamber takes up the must-pass funding bill later this month or in early September.

And the bill has a good shot of passing, POLITICO's Sarah Karlin-Smith notes. While a drug importation amendment failed 46-52 in January, that legislation got the support of 12 Republicans. Although Booker and Casey were among the 13 Democrats who opposed it, the two men joined Sanders to craft a proposal to more thoroughly address safety concerns surrounding importation.

The Affordable and Safe Prescription Drug Importation Act ( S. 469 (115)) would require HHS to issue regulations permitting wholesalers, licensed U.S. pharmacies and individuals to import drugs from licensed Canadian sellers that are manufactured at facilities inspected by FDA. Eventually, HHS could expand the rules to allow importation from other countries. Drug importation has been a politically popular solution to address the high cost of U.S. drugs and has been endorsed by Trump.

Rand Paul says Trump studying 'executive action' on health care. The Kentucky senator said the president is weighing some form of executive action after the Senate's failure on health care last week, Reuters reported.

… Paul said that he told the president that he believed Trump had the authority to create association health plans. The concept — a pet topic of the Kentucky senator — would allow small businesses to band together through trade associations and other groups to negotiate for health insurance. Insurance commissioners have raised questions about who would regulate plans that span state lines.

Obamacare shoppers mistakenly warned that coverage at risk. An unknown number of HealthCare.gov customers were erroneously told on Monday that their coverage would be discontinued on Tuesday unless they updated their information — and were then unable to log into the federal enrollment website, which at one point appeared to stop working entirely. More for Pros.

... "CMS has identified and corrected the issue and will be sending a follow-up email to the affected consumers," a CMS spokesperson said, adding that the website was also experiencing "separate" technical issues. CMS did not respond to requests about how many customers were wrongly warned that their coverage was at risk.

… The notices came at a sensitive time for HealthCare.gov customers, with many worried about the future of their coverage amid GOP efforts to dismantle Obamacare.

“The email I got this morning … scares the hell out of me,” said one HealthCare.gov customer who requested anonymity. He said he has multiple sclerosis and has used the website since January 2016 with no previous problems. “HealthCare.gov has been a lifesaver.”

CMS finalizes 2018 pay raise for skilled nursing facilities. CMS is giving skilled nursing facilities a $370 million pay bump next year. The agency in a final rule published Monday afternoon increased Medicare payments to the providers by 1 percent, compared with the prior year.

CMS rolls back data penalty on inpatient rehab facilities. CMS is eliminating a 25 percent penalty levied on inpatient rehab facilities that are late in reporting certain patient data, it said on Monday. The agency called the penalty unnecessary and a burden for providers, and also proposed a series of other tweaks to payment regulations, such as potentially changing the rule requiring 60 percent of inpatient rehab patients to have certain medical conditions to qualify for federal reimbursement. More for Pros.

California’s big rate reveal. Covered California today will release its 2018 insurance rates, a highly anticipated bellwether showing how a state that fully embraced Obamacare is faring under the market uncertainty. What to expect: the release of two sets of rates — one that assumed the cost-sharing subsidies will continue to be funded, and a second, presumably higher set of rates without the CSRs.

Covered California has come up with a potentially ingenious plan to help mitigate the impact of losing the funds, POLITICO's Victoria Colliver writes from Sacramento. The exchange will allow insurers to artificially load the rate increases onto the Silver-tier plans, where consumers will receive higher subsidies to offset those increases, while making insurers offer consumers who don’t qualify for subsidies comparable options outside the exchange.

“This announcement will show if Covered California’s creativity will be successful to hold consumers harmless, if the Trump Administration in fact carries out its threat,” said Anthony Wright, executive director of Health Access California.

Texas: Efforts to address maternal mortality hit political realities. The House tentatively approved a handful of bills on Monday afternoon that would extend the sunset date of the state’s maternal mortality task force from 2019 to 2023 and direct the body to look more closely at related factors like economic disparities.

The state’s fast-rising maternal mortality rate has embarrassed state lawmakers, giving the task force bipartisan support, POLITICO’s Renuka Rayasam reports from Austin. But conservative lawmakers have largely ignored the group’s recommendations, which include expanding access to health care. Instead they’ve focused on anti-abortion measures and defunding Planned Parenthood, which women’s health advocates say is to blame for the rising rates in the first place. More for Pros.

Collins praises safety progress at NIH center. The site of a 2015 NIH scandal is on its way to making “major achievements” in patient safety, according to a post that NIH Director Francis Collins.

Collins said the NIH Clinical Center has reached a number of safety checkpoints including small group meetings, a tracking system and other improvements aimed at moving beyond a 2015 incident when inspectors found problems like drug vials contaminated with fungus.

… While not mentioned in the statement, Collins’ note comes less than three weeks after a Wall Street Journal story detailing how staff morale at the center was hurt by NIH probes after the fungus was discovered.

HHS Secretary Tom Price is quietly giving doctors — especially conservative doctors — the reforms that they want to see, STAT's Erin Mershon writes. More.

In Slate, David Dobbs argues that McCain's vote against the health bill wasn't especially heroic, especially when compared to the bravery of military service. More.

An Indiana doctor was killed for refusing to prescribe opioids, Kristine Phillips writes in the Washington Post. More.

Writing in The Federalist, Chris Jacobs argues that both Republicans and Democrats are playing fast-and-loose with legal and constitutional requirements for key Obamacare payments. More.

Billionaire Mark Cuban, who has flirted with politics, argues for a health plan that includes taking money set aside for Obamacare and rechanneling it into med schools. More.

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