Mulvaney says administration doesn't want Obamacare fight over taxes Presented by

Congress is away, but the battle over Republicans' tax legislation raged on across the weekend.

MICK MULVANEY: WHITE HOUSE IS 'OK' WITH DUMPING MANDATE REPEAL FROM BILL — The White House budget chief said Sunday that the administration doesn't want the emerging Obamacare fight to slow down Republicans' tax overhaul, even though Trump had called for repealing the individual mandate in the tax bill.

The administration is “OK with taking [mandate repeal] out” of the tax bill if “it becomes an impediment," Mulvaney said on CNN's "State of the Union."

SWING VOTE WATCH: SUSAN COLLINS WANTS MANDATE REPEAL OUT OF TAX BILL — The Maine senator said Sunday that including a provision to strike down Obamacare's individual mandate was "the biggest mistake" in Senate Republicans' push to overhaul taxes.

"I hope that will be dropped," Sen. Susan Collins told ABC’s “This Week,” adding that she wants "to see changes" in the Senate bill and again called for Congress to protect consumers in the fragile individual insurance market.

"I’m worried about the impact on premiums" from repealing the mandate, she added. "And that’s why we’re going to need to pass legislation. And I would like to see that done before we go to the tax bill."

Collins was among the senators last week who personally lobbied President Donald Trump to support a bill to shore up Obamacare markets if the mandate is repealed, POLITICO's Jen Haberkorn and John Bresnahan scooped on Friday.

— Meanwhile: Lisa Murkowski says bipartisan ACA fix isn't 'precondition' for her support of tax plan. The Alaska Republican said she still wants the stalled Alexander-Murray bill to pass, especially if the mandate is repealed. But "one should not assume this is a precondition for my support for the tax bill," Murkowski told POLITICO in a statement on Friday — contrary to an earlier Roll Call report.

Murkowski also said she will take the Thanksgiving holiday to review the tax package "before coming to any conclusion on the legislation.”

IMPACT OF MANDATE REPEAL? — The Congressional Budget Office has projected that rolling it back would save the government $338 billion over a decade but result in 13 million more Americans being uninsured by 2027. However, some experts say that eliminating it might not radically change behavior — or fulfill the dire predictions of spiking premiums and vast increases in uninsured people that economists, health providers and politicians once predicted.

TAX BILL CONSEQUENCES: AUTOMATIC CUTS TO MEDICARE LOOM — Under Congress's current pay-as-you-go rules, Republicans' bill would trigger deep cuts to programs like Medicare because the legislation adds $1.5 trillion to the deficit. That means the GOP would need votes from Democrats to avoid a hypothetical doomsday scenario — but Democrats are making no promises they’d help out, POLITICO's Sarah Ferris reports.

“I think if that were the ultimate outcome, we wouldn’t get blamed for it,” Rep. John Yarmuth, the top Democrat on the House budget panel, told Sarah.

What's at stake: The automatic cuts would kick in every year for a decade, potentially stinging assistance programs for crop subsidies, the Census Bureau, the hospital insurance trust fund, wetlands conservation, and Customs and Border Protection.

Medicare would be chopped $25 billion per year, CBO estimates.

More here.

A message from PhRMA: Today, there are several promising vaccine candidates in stage three clinical trials. These trials have tens of thousands of participants, from every walk of life. From development to robust clinical trials, and throughout manufacturing, these vaccine candidates follow the same rigorous process of other vaccines that have saved millions of lives. More.



MEMO SAYS DEMOCRATS SHOULD FOCUS ON BILL's HEALTH CARE EFFECTS — The party's leading super PACs is urging lawmakers to focus attacks about the GOP tax reform plan on its cuts to health care programs, POLITICO's Kevin Robillard reports.

Priorities USA, citing polls from Garin-Hart-Yang Research Group and Global Strategy Group, argues Democrats can make the case Republicans are more focused on appeasing donors than helping regular people.

The most potent lines of attack for Democrats include: 1) Noting the proposal would force cuts to Medicare and Medicaid and 2) eliminate medical expense deductions. The lines of attacks make at least 73 percent of likely presidential-year voters feel less favorably about the plan, and at least 61 percent of voters much less favorable.

More for Pros | See the memo.

PROGRAMMING NOTE: PULSE won't publish from Nov. 23-Nov. 26, but we'll return on Nov. 27.

THIS IS MONDAY PULSE — Where Washington is winding down and Thanksgiving travel is looming, although your author won't be going far.

We're thankful for helpful readers: Send tips to [email protected] or @ddiamond on Twitter.

With help from Victoria Colliver (@vcolliver)

CDC TO REORGANIZE FOR 'INCREASED SYNERGY' — Director Brenda Fitzgerald on Friday announced a shake-up of the agency, stressing the need to improve the focus on “science, surveillance and service,” your PULSE correspondent scooped on Friday.

Speaking at an all-hands meeting, Fitzgerald said that CDC will refocus around “communities of practice,” with four deputy directors steering the agency’s work. The reorganization will not take effect immediately and is currently going through an administrative review.

“The intent of this refocus is on creating increased synergy and effectiveness of our approach,” Fitzgerald said in an agency-wide email on Friday afternoon. “We ALL need to work together and start thinking of ourselves as One CDC."

CDC confirmed Fitzgerald held an all-hands meeting and the new roles of the four deputy directors but did not respond to requests for elaboration. More for Pros.

COST OF OPIOID CRISIS? MORE THAN $500 BILLION IN 2015, WHITE HOUSE SAYS — That's according to a new economic analysis that said the annual impact was nearly 3 percent of GDP and is significantly higher than previous projections of $79.9 billion per year or less.

“[T]he crisis has worsened, especially in terms of overdose deaths which have doubled in the past ten years,” the Council of Economic Advisers concluded.

— But the White House has its own model. One big difference is that the CEA says it's quantifying the full “value of a statistical life,” rather than just projecting the lost earnings from a premature death, and that they're incorporating the cost of illegal opioids too. See the report.

Some health policy experts questioned the administration's methodology. "Would be nice to see the [White House] estimate for cost of ACA repeal using same VSL estimates," Yale economics professor Howard Forman tweeted. "(Spoiler: would make repeal prohibitive)."





Medicare premiums, deductibles will largely remain flat for 2018. The standard monthly premium for Medicare Part B, which covers doctor visits and outpatient hospital services, will be $134 next year, unchanged from 2017, CMS announced on Friday.

About one in four Part B beneficiaries will pay slightly less than the standard premium because of a “hold harmless” provision tied to Social Security benefits. Individuals who earn more than $85,000 and couples with incomes above $170,000 — about 5 percent of Medicare beneficiaries — will pay higher Part B premiums, with a top rate of $429 per month in 2018.





National uninsured rate stays low. A CDC report last week found that about 9 percent of all Americans were uninsured in the first half of 2017 —not significantly different from 2016. But deeper in the report, the survey noted differences between states that operate their own marketplaces versus those that rely on the federal exchange, POLITICO’s Victoria Colliver notes.

For instance, the uninsured rate in states that run their own exchanges was 8.3 percent, nearly half of the 16.1 percent rate in states that rely on HealthCare.gov, the federal exchange. States that used HealthCare.gov also saw their first upticks in uninsured rates since 2014.

In addition, the uninsured rate in states that expanded Medicaid was 8.8 percent, compared to a 19 percent rate in states that didn’t expand the program.

FIRST IN PULSE: California boasts record low uninsured rate. The state’s uninsured rate dropped to 6.8 percent for the first six months of the year, an all-time low, Victoria reports first.

“It was nice to see that California also had good company among states dramatically reducing their uninsured,” said Peter Lee, executive director of Covered California. He cited other states that either run their own exchanges or do so in partnership – including Illinois, Michigan, New York, Ohio and Pennsylvania – that all had an uninsured rate of less than 8 percent.

Diana Dooley, who chairs Covered California’s board and is the state’s HHS secretary, said the data shows that states that sought to make their Obamacare markets work are “delivering” by dramatically lowering premiums. “While California and many other states are helping lower health care costs and reducing the rate of the uninsured, much of the rest of the nation is moving in the wrong direction amid great uncertainty at the federal level,” Dooley said in a statement.





Texas: State asks CMS to redistribute CHIP funds. Texas estimates it has sufficient funding to last through the end of January without congressional reauthorization of the children’s health program, but it wants to delay sending out potentially disruptive notices to families whose coverage is about to expire, POLITICO's Renuka Rayasam reports from Austin.

The state is required to send out notices to families 30 days before coverage expires — which means that if Congress doesn’t renew funding before the end of the year, families will start getting the letters in December. Texas is asking CMS to retain $90 million of a $190 million balance on the state’s account. If granted, it would cover the state’s CHIP expenditures through the end of February.

— 51 days: That's how long it's been since Congress let funding for the Children's Health Insurance Program lapse.

Agriculture chief touts investments in rural health care services in 41 states. USDA made more than $1 billion in investments in fiscal 2017 to fund rural health care projects and initiatives that enhanced services for 2.5 million people, Agriculture Secretary Sonny Perdue said in a statement on Friday.

“USDA invests in a wide range of health care facilities — such as hospitals, clinics and treatment centers — to help ensure that rural residents have access to the same state-of-the-art care available in urban and metropolitan areas,” Perdue said in a statement, noting that the agency helped fund 97 rural health care projects through the Community Facilities Direct Loan Program.

— One sample project: USDA highlighted its $91.4 million loan to Avita Health System in Ontario, Ohio, which was used to build a hospital in a vacant portion of a shopping mall. The facility provides a host of vital health services to 124,000 rural residents in two counties. It also provides substance-abuse disorder treatment and mental health services to help combat the opioid epidemic.

STATE WEEK: Another state weighs Medicaid overhaul. West Virginia is considering adding work requirements to its Medicaid expansion, and Tennessee's governor is preparing to release a wide-ranging plan to prevent overdose deaths. More for Pros.







Patients are getting squeezed as emergency doctors and insurers feud over balance billing, the Houston Chronicle's Jenny Deam reports. More.

A North Korean soldier who defected to South Korea had dozens of parasites, including a nearly-foot-long tapeworm, a likely signal of the poor health and hygiene in the nation. More.

At Fox News, Ted Squires touts Medi-Share — his cost-sharing health care ministry that has more than 300,000 members — and says that lawmakers should look closer at ministry plans. More.

Venture capitalist Bill Gurley told CNBC that it's "extremely dangerous" to invest in health care because the normal laws of supply and demand don't work, but he's doing it anyway. More.

Pope Francis denounced health care inequality, particularly in wealthy nations, especially when access to care is influenced by a person's economic resources. More.

Follow us on Twitter Joanne Kenen @joannekenen



Adriel Bettelheim @abettel



Jason Millman @jasonmillman



Lauren Morello @lmorello_dc



Sara Smith @sarasmarley



Dan Diamond @ddiamond



Zach Brennan @ZacharyBrennan



Adam Cancryn @adamcancryn



Tucker Doherty @tucker_doherty



Brianna Ehley @briannaehley



Dan Goldberg @dancgoldberg



David Lim @davidalim



Susannah Luthi @SusannahLuthi



Alice Miranda Ollstein @aliceollstein



Sarah Owermohle @owermohle



Carmen Paun @carmenpaun



Mohana Ravindranath @ravindranize



Rachel Roubein @rachel_roubein



Darius Tahir @dariustahir