This map shows where Obamacare enrollees are getting extra subsidies for copays and deductibles, based on 2016 data from the Centers for Medicare and Medicaid Services. Yellow represents states with the fewest recipients of the extra subsidies while dark red represents states with the most recipients. About 58 percent of all marketplace customers in the U.S. are getting these cost-sharing reductions, available to those earning between 100 percent and 250 percent of the federal poverty level.


President Trump will hurt his own voters if he refuses to fund Obamacare subsidies that help low-income people afford extra insurance costs beyond just their monthly premiums.

Even with federal subsidies, health insurance can still be impossibly expensive for low-income people if they actually want to visit the doctor. That’s why the Affordable Care Act requires insurers to discount extra, out-of-pocket expenses like copays and deductibles for people who earn less than $29,700 annually (the bar is $60,750 for a family of four).

And that prompts a big question the Trump administration must decide soon: Whether it will reimburse insurers for offering those discounts, or whether insurers will just have to shoulder the losses. Congress has refused to fund the subsidies — memorably called “cost-sharing reductions,”or CSR’s — so now their fate is up to Trump and his Cabinet.

It was difficult to ascertain what Trump will do from an interview with The Economist last week where he seemed to indicate he could halt the payments "anytime I want" but didn't clarify whether he actually would. "I'd have to decide what I want to do because I want people to have health care," Trump said.

Who hurts if Trump withholds the payments? Many of his own voters. The highest concentrations of Americans with CSR’s live in states that voted for Trump (see the map above). Out of the 15 states with the highest share of qualifying consumers, only three went for Trump's opponent, Hillary Clinton. More than 70 percent of people who bought Obamacare marketplace plans get the extra subsidies in Mississippi, Alabama, Florida and South Carolina -- all states Trump won in November.

“These are people in Trump country,” as Bill Pierce, a health policy expert at APCO Worldwide, told me.

Were Trump to view the map above, he might decide to give the thumbs-up to funding the CSR’s for the forseeable future. After all, maps have prompted him to switch positions before. At the end of April, Trump reportedly halted plans to scrap the North American Free Trade Agreement (NAFTA) after Agriculture Secretary Sonny Perdue and Commerce Secretary Wilbur Ross showed him a map noting that the move could cost jobs in states that sided with him in the presidential election. Data might not sway Trump, but visuals at least seem to affect his thinking.

(On that note: Health and Human Services Secretary Tom Price, if you’re reading this, feel free to send the map above over to your boss).

The administration is still noncommittal about whether it will maintain the subsidies to insurers, who say they would otherwise have to hike premiums by double-digits, to cover their losses from the mandatory discounts. Officials say they will make the payments in May, but haven’t decided beyond that. Mick Mulvaney, director of the White House’s Office of Management and Budget, stressed earlier this month that no decision has been made.

“Nothing in this bill obligates us to make any Obamacare CSR payments at any point in this process,” Mulvaney said. “We are not making any commitments in this bill.”

Doctors, hospitals and insurers, who are deeply worried the federal payments might be cut off, are pointing to heavy support among Americans — including low-income conservative voters — for continuing them. Last week, the American Medical Association and other health associations ran an ad in print and online noting a Morning Consult poll finding that “68 percent of conservatives who make under $50,000” support help with out-of-pocket costs.

There’s a court deadline on May 22 for the administration to at least indicate how it will approach a House lawsuit over the issue. Two and a half years ago, the GOP-led House sued the Obama administration for providing the insurer payments without specific funding from Congress. Now that a federal judge has sided with the House, the Trump administration will need to decide whether to appeal that ruling or let it stand.

The House could have decided to provide the payments in its funding bill keeping the government open through Sept. 30, but leadership ducked under pressure from conservatives who didn’t want to look like they were propping up the Affordable Care Act. Yet many members of Congress, conservative thinkers and state officials are on the record saying insurers must get the payments in order to shield marketplace consumers from heavier premium hikes.

“It was a commitment made by the government to the insurers and the people,” I heard Energy and Commerce Chairman Greg Walden tell constituents at a town hall in his district last month. “That needs to happen.”

Sen. Lamar Alexander, who heads the Health, Education, Labor and Pensions Committee, has warned that people won’t have access to health insurance without the payments. Doug Holtz-Eakin, former director of the Congressional Budget Office under George W. Bush, had said he wanted Congress to fund the payments. So had Arizona Gov. Doug Ducey (R) and insurance commissioners in Wisconsin, Tennessee, Maine and elsewhere.

What to watch for next: Whether the Trump administration appeals the House lawsuit. If it doesn't ask for a reversal of the ruling upholding Republicans’ lawsuit, the administration won’t be allowed to issue the payments since Congress hasn’t appropriated them. If the Department of Justice does appeal, the issue could be drawn out much longer with continued uncertainty for insurers.

Ivanka Trump waits for a news conference with President Donald Trump and Jordan's King Abdullah II at the White House. (AP Photo/Andrew Harnik)

AHH: Did Ivanka edit her dad's statement on Women's Health Week? In it, Trump mostly called for improving health care for women, but also reiterated his past support for paid family leave. "I am committed to working with Congress to help mothers--and fathers--to have paid family leave so that child care is accessible and affordable," it says. Last fall, Trump released a campaign proposal to provide women with a minimum of six weeks paid leave, echoing his daughter's concerns from working women but putting him at odds with many in his party.

OOF: At least you can tweet when you get dumped by Trump. Vivek H. Murthy, who was fired last month from his position as surgeon general, has confirmed to STAT that he was aiming a series of tweets last week at Health and Human Services Secretary Tom Price, who suggested during a West Virginia visit that he's skeptical of using medications to treat addictions. "If we're just substituting one opioid for another, we're not moving the dial much," Price said last Wednesday.

--Murthy's worried the administration isn't taking evidence into enough consideration in responding to opioid abuse. A report issued under his watch concluded that medication-assisted treatments lead to better outcomes than just behavioral treatment alone. Here are some of Murthy's rather passive-aggressive tweets, his first since being removed as surgeon general:

OUCH:  It's good for both The Health 202 and my 5k time that I don't take my exercise advice from Trump. The president mostly stopped exercising after college because he "believed the human body was like a battery, with a finite amount of energy, which exercise only depleted," according to The Post's 2016 biography of him. Yet the opposite is true: The human body actually becomes stronger with exercise. Don't think of energy stores as a battery, but rather as a fire that you continue to fuel.

BONUS: Our colleague Glenn Kessler fact checks the president's aides and Republican lawmakers on the cost of premiums under Obamacare and the AHCA. Bottom line: they'll likely go up under both plans.

Sen. John Thune (R-S.D.) is circulating a draft of a health care compromise. (Photo by Aaron P. Bernstein/Getty Images)

--The Senate's 13-member working group on health care has met four times, and there are early signals that a pathway to consensus on Obamacare repeal-replace may involve pegging the insurance subsidies in the House-passed bill to income instead of age, Politico's Jen Haberkorn reported last week. A draft of such a proposal from Sen. John Thune (R-S.D.) would phase on the tax credits at 621 percent of the federal poverty level. 

We hate to point out the obvious here, but this proposal would give federal subsidies to a wider range of people than Democrats' health-care law, which cut them off at 400 percent of the federal poverty level. If you're wondering how Republicans, who constantly criticize federal spending, might defend this, you've in good company with The Health 202. Perhaps sensing this, lawmakers are already playing down any resemblance to Obamacare, Jen writes.

--A bipartisan deal on health care seems about as likely as my potted plants staying alive for any length of time. But a handful of Republicans wish it could be so, according to another report from Politico. Two of them are Sens. Lindsey Graham of South Carolina and Susan Collins of Maine have said they're "hopeful." A few Republicans have reached out to Democrats, including Tim Kaine of Virginia, Tom Carper of Delaware, Joe Manchin of West Virginia and Heidi Heitkamp, to talk health care in general terms. Yet whether there's any political appetite for cooperation is highly questionable:

"Any cooperation on health care undercuts both parties’ political strategy," write Burgess Everett and Elana Schor. "Republican leaders are wary of handing any bipartisan accomplishments to the dozen or so vulnerable Senate Democrats up for reelection next year. And Democratic leaders want the GOP to fully own the beleaguered health care system going into the midterm s... So leaders in both parties are leaning hard on the rank and file not to cooperate."

--Of the people with marketplace plans -- and it should always be noted that this is a small minority of Americans -- the ones most angry about cost spikes are middle-class earners who don't qualify for subsidies yet can't afford to pay a thousand or more dollars a month in premiums. The New York Times spoke with a number of people who are happy about a possible repeal of the Affordable Care Act, including one Illinois family that recently dropped their $1,100-a-month marketplace plan for a cheaper, bare-bones plan that doesn't fully comply with ACA requirements.

"Middle-class Americans who feel squeezed by the full cost of insurance under the law are among its fiercest critics, and could in many cases be winners of a sort under the House bill, which would provide subsidies to families that earn far more than the Affordable Care Act’s income limit," Abby Goodnough writes.

A few more reads:

Under pressure to balance the budget and align with Trump, the House GOP has its eye on food stamps, welfare and perhaps even veterans’ benefits ... GOP budget writers will also likely include Speaker Paul Ryan’s (R-Wis.) proposal to essentially privatize Medicare in their fiscal 2018 budget, despite Trump’s unwavering rejection of the idea. While that proposal is more symbolic and won’t become law under this budget, it’s just another thorny issue that will have Democrats again accusing Republicans of “pushing Granny off the cliff.”
The lawmakers are showing increasing signs of separating from the president to pursue a more traditional conservative agenda and protect their political futures ... Republicans are also pushing back on the president’s impending budget request — including, notably, a provision that would nearly eliminate funding for the national drug control office amid an opioid epidemic.
The World Health Organization (WHO) confirmed on Sunday a second case of Ebola in Democratic Republic of Congo after an outbreak this week of 17 other suspected cases.
President Trump, left, listens as Robert Hugin, chairman of Celgene Corp., speaks during a meeting with representatives from the Pharmaceutical Research and Manufacturers of America (PhRMA) at the White Hous on Jan. 31, 2017. (Ron Sachs/Pool via Bloomberg)

--Washington's powerful pharmaceutical lobby is launching a new set of TV ads today, part of its massive PR effort to convince Americans that drug makers aren't the big, bad wolf. Alzheimer's, breast cancer and heart disease are the theme of these new ads, which feature clinical researchers and patients talking about the promise of new cures on the horizon.

It's part of PhRMA's "Go Boldly" campaign to reshape how Americans think about the pharmaceutical industry, not as greedy patient-gougers but as innovators on the brink of a hopeful new world. The drug industry plans to spend hundreds of millions of dollars trying to sway public opinion in its favor, and avoid potential steps by the White House and Congress to crack down on drug prices.

Here's the Alzheimer's-themed ad:

Here are some more reads on the industry:

"Single-payer, I think we should have that debate as a nation," said Aetna chief executive Mark Bertolini.

This company was co-founded by Jared Kushner's brother, Joshua:

For the 54,000 New Yorkers who used those exchanges to join Oscar—a millennial-beckoning insurance startup cofounded by Jared Kushner’s younger brother, Joshua—the 2017 enrollment period wasn’t just uncertain. It was, well, kind of bleak ... But somehow, Oscar convinced almost all of those 50,000-plus members to stay. The pitch they made was simple, if not exactly intuitive: Choose better care and service over a thicker phonebook of doctors. They threw in perks like concierge care teams and direct scheduling from your smartphone to sweeten the deal. And it worked.
Diabetics need insulin to stay alive. Increasingly, they can't afford it.

This fertility clinic in Maryland has become the biggest in the country. But it uses some controversial techniques. Washingtonian's Caroline Cunningham does a deep dive:

Bring up Shady Grove Fertility in a room of women of a certain age in Washington and it’s likely someone will know a woman who’s been a patient there. It’s not just the biggest fertility clinic in the area; it’s the biggest in the country, with 39 physicians spread across 25 clinics in four states ... In 2014—the most recent year for which data is available from the Society for Assisted Reproductive Technology—Shady Grove Fertility started 7,648 cycles of IVF at its Rockville headquarters alone ... Shady Grove did something kind of controversial. In 1992, Levy piloted a Shared Risk Program, in which patients who meet certain health standards—for instance, women must be under age 39 at the completion of their IVF cycles—can choose to pay roughly twice the amount for IVF with the promise of a refund if they don’t go home with a baby.

And don't miss this read from our Washington Post colleagues on how the divide between rich and poor in America plays out when it comes to dental care:

Matello was No. 503. The small-business owner who supports President Trump had a cracked molar, no dental insurance and a nagging soreness that had forced her to chew on the right side of her mouth for years. “It’s always bothering me,” she said. And although her toothache wasn’t why she voted for Trump, it was a constant reminder of one reason she did: the feeling that she had been abandoned, left struggling to meet basic needs in a country full of fantastically rich people ... As the distance between rich and poor grows in the United States, few consequences are so overlooked as the humiliating divide in dental care. High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter. Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth. Unable to afford expensive root canals and crowns, many simply have them pulled. Nearly 1 in 5 Americans older than 65 do not have a single real tooth left.
Two of the most endangered senators up for reelection next year, West Virginia Democrat Joe Manchin and Nevada Republican Dean Heller, are being targeted by their opposition for stumbling over the issue recently. And there's plenty more in store: If the Senate calls up a bill to repeal Obamacare, controversy over Planned Parenthood funding will come to the fore — ensuring the 2018 campaign won’t lack for that perennial lightning rod.
The conversations I have with other pro-life Americans seem tone-deaf and baffling.

Watch the newly-crowned Miss USA say health care is a privilege, not a right:

Watch Ellen DeGeneres address an audience with preexisting conditions: