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But these groups have also seen some surprising successes for which they don't think they're getting credit.

Some of the groups have fallen short of goals they submitted to HHS for the amount of people they’d help sign up on Healthcare.gov, the insurance marketplace created under the ACA. But when it came to Medicaid enrollment, many of them far exceeded expectations, helping hundreds and even thousands more people enroll in the low-income insurance program than they’d initially projected.

This is what I’ve heard from several navigator groups, who were informed last month by HHS that they’d get much less money for their third and final year of grants to educate people about the new coverage opportunities under the ACA and help them sign up. Their successes with Medicaid enrollments raises questions about whether the Trump administration is interested in allowing more people to sign up for Medicaid in the states that expanded it.

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The Palmetto Project, a health- and education-focused nonprofit in South Carolina, says it met 83 percent of its marketplace enrollment goals for the 2017 grant year, enrolling just 1,672 people instead of the 2,000 people it had aimed for. But it helped almost 3,000 more people sign up for Medicaid than it had planned on, enrolling 5,074.

Nonetheless, the administration cut Palmetto’s grant from $1 million to $500,000 for the upcoming enrollment period, according to Shelli Quenga, the group’s director of programs. Quenga said said the reductions are forcing her to seriously rethink the geographical area Palmetto should aim to reach in the upcoming enrollment season that starts Nov. 1.

“It is devastating internally and not a reflection of the quantity or quality of the work that we’ve provided to the residents of our state,” Quenga wrote in an email.

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HHS shocked and dismayed many of the navigators in September when it announced a 41 percent cut overall to the outreach program. Navigators and other ACA advocates stress that targeted outreach for the upcoming enrollment season will be particularly important, since it’s only half as long this year — from Nov. 1 to Dec. 15 — and because the remaining uninsured people are the most difficult to persuade. Navigators do especially targeted outreach to the hardest-to-reach populations.

Yet the Republicans leading HHS are skeptical about the navigator program, arguing that it’s not a good use of taxpayer money. They have noted that although these groups received $62.5 million last year, they signed up fewer than 1 percent of total enrollees.

For the upcoming enrollment seasons, HHS awarded 98 groups $37 million in grants based, officials say, on whether the groups had met marketplace enrollment goals last year. But navigator groups feel that’s not a fair benchmark because many of the people they helped were eligible instead for Medicaid.

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The ACA tried to lower the historically high U.S. uninsured rate in two chief ways: creating marketplaces with subsidized, private coverage, and expanding Medicaid to include adults earning up to 133 percent of the federal poverty rate. Giving navigators credit only for marketplace enrollments — and not Medicaid enrollments, too — is unfair, some told me. When they start helping someone assess their coverage options, it’s not clear from the outset what they’ll qualify for, some navigators argued.

“When somebody walks through the door, we serve them,” said Lisa Hamler-Fugitt, executive director of the Ohio Association of Food Banks. “We don’t know when they walk through the door what they may or may not be eligible for.”

The Ohio group is getting 71 percent less funding this year. Yet in 2017 it achieved 88 percent of its overall enrollment goals, helping 9,660 people get coverage. But the vast majority of those – 7,860 people — qualified for Medicaid, not the marketplaces.

Other groups tell similar stories, such as Enroll Michigan, which lost 90 percent of its navigator grant this year. The group, which distributes funds to more than a dozen smaller nonprofit groups across the state, says it signed up just 1,700 people for marketplace plans but helped 7,200 enroll in Medicaid.

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Tika Acharya, executive director of the Bhutanese Community of New Hampshire, said his group reached 90 percent of its marketplace enrollment goal but 150 percent of its Medicaid enrollment goal. The group saw its navigator grant slashed by 60 percent.

This all reflects a broader reality of the ACA: It resulted in much higher Medicaid enrollment and much lower marketplace enrollment than many had initially expected.

Some conservatives have even dubbed the law the “Medicaid Expansion Act” because of the unexpected shift. Last year Medicaid and the Children’s Health Insurance Program covered 17 million more people and marketplace plans covered 10 million fewer people than the Congressional Budget Office had originally estimated.

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It’s not surprising that a GOP-led administration wouldn’t view expanding the Medicaid rolls as a positive. Republicans have long argued that the program unduly stresses state budgets, underpays providers and limits patients’ options. All the congressional bills to repeal and replace the ACA would have cut the program significantly.

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“The Medicaid program itself has real problems in it,” former HHS secretary Tom Price said at a CNN town hall in March. “One out of every three physicians in this nation aren’t seeing Medicaid patients. And they should. If we want to be honest, we ought to ask the question to ourselves and our society why, and fix those challenges.”

AHH, OOF and OUCH

AHH: The Post's Katie Zezima writes about the "invisible wounds" of the Las Vegas shooting, at which an estimated 22,000 people were present. Many who didn't suffer physical injuries are still grappling with the psychological scars of the deadliest mass shooting in modern U.S. history. Law enforcement officials, medical professionals, family and friends also may be affected by witnessing carnage that one surgeon described as “exactly like what we have seen in a war zone.”

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"Mandalay Bay has made crisis counselors available for guests and employees, and the Clark County Family Assistance Center has offered counseling to families and victims. Religious organizations and counselors from throughout the city and region also are offering services," Katie writes. Yet offering treatment to all of those who are suffering is complicated by Nevada’s lack of resources. Nevada ranks 51st among states and the District in mental-health resources and access to treatment -- 16 of the state's 17 counties are listed by the federal government as areas with a shortage of mental-health professionals.

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Nineteen-year-old Megan Greene was one of those under fire in Las Vegas. Greene remained calm on the long drive home to Simi Valley, Calif., afterward. But when she finally pulled into her driveway Monday morning, she burst into tears — the first outward sign of the invisible wounds that have come to plague her since the massacre, Katie writes.

“The simple things that used to be so easy are, just — I never want to be alone and I never want to go anywhere alone,” said Greene, adding that she cannot stand the dark, constantly checks around corners and, during a rare stretch of sleep this week, scratched her legs raw.

OOF: President Trump tweeted Saturday that he'd reached out to Senate Democratic leader Chuck Schumer in hopes of brokering a deal for a “great HealthCare Bill.” The president wrote that he called Schumer on Friday to ask whether Democrats would work with him on health care now that Republicans appear stymied on their own efforts to repeal and replace the ACA.

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Schumer responded with a statement saying he was willing to work with Trump to "improve the existing health care system" but not to "repeal and replace" the ACA.

"The president wanted to make another run at repeal and replace and I told the president that's off the table," Schumer said. "If he wants to work together to improve the existing health care system, we Democrats are open to his suggestions. A good place to start might be the Alexander-Murray negotiations that would stabilize the system and lower costs."

Schumer was referring to a bipartisan health-care deal to help stabilize the marketplaces that Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are working on but still haven't been able to finalize.

OUCH: Democrats are trying to turn House Speaker Paul Ryan (R-Wis.) into political villain in advance of next year’s midterm election, using themes that could hurt his image with not only staunch conservatives but also energize liberal activists.

House Majority PAC -- a super PAC affiliated with the leadership team of House Minority Leader Nancy Pelosi (D-Calif.) -- is launching the new round of digital ads throughout the country highlighting the unpopular GOP health-care bill Ryan backed and that the House eventually passed. The group is also trying to brand Ryan with an elitist tag on a new website called “Fancy Paul Ryan.” In addition, the Democratic Congressional Campaign Committee has started running national cable TV ads disparaging the speaker for being part of the Washington establishment looking out for the wealthy.

"The campaign comes as Ryan’s image has cratered in the era of President Trump, giving Democrats an opening to potentially use the speaker in the same fashion that Republicans have used Pelosi for the past seven years," The Post's Paul Kane writes. "According to a Washington Post/ABC News poll late last month, just 31 percent of Americans approve of the job Ryan is doing, while 51 percent disapprove."

"The Democratic groups seem aware that Ryan’s declining popularity comes from conservatives who are disappointed that Trump’s agenda has stalled in the Capitol and have seen the president occasionally take out his frustration on Ryan and Senate Majority Leader Mitch McConnell," Paul writes. "Their TV ads and digital themes are carefully drawn in ways that will energize liberal activists and also irritate Trump voters. Ryan is portrayed as part of the firmament of Washington, a place that Trump voters have essentially declared that they want disrupted."

TRUMP TEMPERATURE

--On Friday, that birth control rule long expected from the Trump administration finally landed. The new guidance carves broad exceptions to the ACA's promise of no-cost contraceptive coverage, touching off fresh lawsuits but pleasing conservatives who had argued it violated their right to religious freedom.

"The rules significantly widen the range of employers and insurers that can invoke religious or moral beliefs to avoid the ACA requirement that birth control pills and other contraceptives be covered by insurance as part of preventive care," The Post's Amy Goldstein, Juliet Eilperin and William Wan report. The rewrite of the federal policy broadens the entities that may claim religious objections to providing contraceptive coverage. They now encompass nonprofit organizations and for-profit companies and higher education institutions that arrange for insurance for their students.

"The rules, among the president’s many moves to dismantle Obama-era initiatives, fulfill a pledge that he made as a candidate to appeal to social conservatives and that he amplified this spring through an executive order to expand religious liberty," Amy, Juliet and William write. "Loosening the contraception mandate is the administration’s most concrete manifestation of that pledge."

--A raft of left-leaning groups and a few Democratic attorneys general swiftly announced plans to try to block the policy change in the courts. California Attorney General Xavier Becerra and the American Civil Liberties Union both filed complaints in federal court alleging the rules violate the First Amendment by favoring certain religious views, discriminate against women and were issued without following correct government procedures. California’s suit also claims the rules will harm the state by leaving “millions of women” without access to birth control and thus increasing contraceptive costs to state-funded programs.

--Capitol Hill also reacted quickly. Ryan termed the move “a landmark day for religious liberty,” while Rep. Nita M. Lowey (D-N.Y.) decried it. “This isn’t ‘The Handmaid’s Tale,’” she said, referring to the popular book and Hulu series about an authoritarian state that controls how women conceive and bear children.

--Meanwhile, Trump is still fuming over the failure of Republicans to help him fulfill a signature campaign promise -- repealing and replacing the ACA. On Saturday he told reporters he'd be open to cutting a one or two-year deal with Democratic rivals as a way to kick-start a plan, after he'd admitted via Twitter that he'd called Schumer about it.

“If we made a temporary deal, I think it would be a great thing for people, but it’s really up to them (Democrats),” Trump said at the White House. “So if we could do a one-year deal or two-year deal as a temporary measure, you’ll have block granting ultimately to the states, which is what Republicans want."

Watch Trump's remarks:

Later Saturday evening, Trump told a gathering of wealthy donors in North Carolina that he'd determined to push forward on a health-care overhaul — but acknowledged facing serious obstacles, Politico's Alex Isenstadt reports.

"According to two people present for the remarks, [the president] underscored the challenges of getting a majority of support for any legislation in the Senate, noting that a small group of GOP holdouts opposed the repeal efforts," Alex writes. "The president walked the group through what had been attempted so far. No matter how you approached it, Trump said, getting to the 50-vote threshold was tough."

Yet the president didn't pinpoint any lawmakers for criticism, as he has done previously with Arizona Sen. John McCain and Kentucky Sen. Rand Paul, nor did he attack Senate Majority Leader Mitch McConnell, another past target of his frustration, the two attendees said. The White House didn't respond to Alex's request for comment.

A few more good reads from The Post and beyond:

HEALTH ON THE HILL

MEDICAL MISSIVES

INDUSTRY RX

DAYBOOK

Coming Up

Wednesday . The House Energy and Commerce Subcommittee on Oversight and Investigations holds a hearing on the 340B Drug Pricing Program on

Wednesday . The House Energy and Commerce Subcommittee on Health holds a hearing on the opioid crisis on

Wednesday . The Bipartisan Policy Center holds an event on retirement on

Wednesday . The Section National MACRA MIPS/APM Summit begins on

Thursday. The U.S. Chamber of Commerce holds an event on the opioid epidemic on

SUGAR RUSH

Fact Check: Do only 7 countries allow elective abortions after 20 weeks of pregnancy?

Watch Vice President Pence's full speech honoring victims of Las Vegas shooting:

A look at the lives lost in the Las Vegas shooting rampage:

On Saturday Night Live, Kate McKinnon as Ruth Bader Gisburg shares her thoughts on working with Justice Neil Gorsuch: