Imagine Obamacare repeal as a football team. It has just made it to the Super Bowl.

Late yesterday afternoon, the Senate parliamentarian (read my profile of her) gave the thumbs-up to the House-passed GOP bill overhauling the Affordable Care Act, despite speculation that it might contain some elements that would ultimately prove fatal and force the House to take another vote on it.

But Republicans have not yet claimed the Vince Lombardi trophy. The initial score simply means that the American Health Care Act complies with overall budget reconciliation rules -- the process Republicans are using to pass a health-care bill so they can bypass Senate Democrats with just a simple majority. But it is a big first step for Republicans who have struggled to make good on their seven-year-old pledge to throw out much of Obamacare in favor of a different system.

But now there's a second hurdle. Each of the AHCA's individual provisions will be subject to challenge by Democrats in a process known as a "Byrd bath" and must be stripped out if the parliamentarian decides they aren’t directly enough related to federal spending. This process, which won't be open to the public, will likely take place over the next few weeks.

So, the House bill is not the endgame. Senate Majority Leader Mitch McConnell (R-Ky.) plans to offer his chamber's version of health-care legislation -- one that is likely to differ significantly from the House version because of disagreements between House and Senate Republicans. But the parliamentarian’s treatment of the House bill holds huge sway in how senators craft their own measure  -- and what parts of the ACA they can ultimately repeal and replace. It’s like the Obamacare repeal team is on the field, but players (its individual provisions) must leave if they’re found ineligible to compete.

This is the complicated game Republicans are playing as they seek to knock down big parts of the Affordable Care Act. And as they returned to Washington this week, McConnell and his leadership team appear more determined than ever to advance down the field. Significant details began to emerge on Tuesday about how Senate Republicans might go about creating a measure on which most of them can agree.

Here's what McConnell had to say about the ACA at the end of last month:

GOP senators squeezed through crowds of anxious reporters on Capitol Hill yesterday on the way to their weekly luncheon. They’d been discussing health care there for weeks, but yesterday’s gathering featured a slide presentation by McConnell laying out a smorgasbord of options for how to structure an ACA overhaul.

The buffet of options included ways to structure Medicaid and tax credits to help people pay for insurance, and how to stabilize the insurance marketplace and bring down the cost of premiums, my colleagues Sean Sullivan and Kelsey Snell report.

Probably the biggest current sticking point was how to approach Medicaid. While conservatives want deep cuts to it, moderates could revolt if a measure appears to shred too much of the program for the low-income and disabled. Leaders proposed gradually reducing federal payments to states that accepted Medicaid expansion instead of cutting them off right away, Sen. John Barrasso (R-Wyo.) said.

“We talked about ways to have a smoother glide path rather than an abrupt cutoff,” Barrasso told reporters.

Tax credits were another big discussion point. It seems increasingly likely that a Senate health-care bill will base federal assistance not just on age, as the House bill does, but on income as well. Senate Republican Conference Chairman John Thune (R-S.D.) said he has been looking at ways to adjust the tax credits in the House bill to offer more assistance to elderly and lower-income Americans.

A gentler approach to federal assistance could go a long way in winning over Senate moderates. Several key senators expressed optimism about the way things are going, without explicitly pledging their support.

“You know, the big print giveth, the small print taketh away. I’m looking for the small print at this point,” a cautious Sen. Dean Heller (R-Nev.) told reporters as he exited the lunch. Heller is up for reelection in 2018 in a purple state that expanded Medicaid under the ACA.

“It’s getting there. Needs some work, still, for me,” said Sen. Rob Portman (R-Ohio), whose state also expanded Medicaid. “I think we’re more and more focusing on how do we fix the mess and then what do we do long term to make sure this transitions into something that actually works.”

Despite the challenges in coalescing around a bill, Republicans do have one thing going for them: It’s becoming more clear that the insurance marketplaces in many states need an intervention. The marketplace woes could help give Portman and other moderates cover for voting for legislation even if it's imperfect.

Anthem became the latest insurer to deliver bad news for the ACA, announcing yesterday that it’s exiting Ohio’s marketplace and potentially leaving thousands of residents there with no plan options next year.

Portman tweeted about it:

Other Ohio Republicans also responded:

Anthem’s decision is a major blow to Ohio. It is the only insurer selling marketplace plans in all 88 counties this year, and the only insurer at all in 20 of them. Next year, an estimated 10,500 people in one-fifth of Ohio’s counties may have no plan options at all.

Consumers in several other states – most notably Missouri, Iowa, Nebraska and Tennessee – may also have just one or no marketplace choices next year.

The largest insurers, including UnitedHealth Care, Humana and Aetna, had already scaled back their marketplace participation dramatically. What’s really telling is that even Blue Cross plans, which had been viewed as more successful among marketplace enrollees, are also starting to back away in some places.

Wellmark Blue Cross and Blue Shield announced in April that it won’t sell new individual plans in Iowa in 2018. Last week, Blue Cross and Blue Shield of Kansas City said it won’t sell marketplace plans either, with the company’s CEO citing $100 million of ACA losses in the first three years.

The situation is an Obamacare-hater’s dream come true, especially as Republicans try to push a health-care rewrite through Congress. Republicans are certainly capitalizing on the mayhem. House Majority Whip Steve Scalise (R-La.) told Fox News yesterday that the ACA's "failures" are playing out around the United States:


AHH: Francis Collins, picked by President Obama to lead the National Institutes of Health, will remain as the agency's director under President Trump, the White House announced yesterday.

"Collins, a physician and geneticist, has led NIH since 2009," the Post's Lenny Bernstein reports. "He is renowned for his leadership of the International Human Genome Project, which in 2003 sequenced the complete human genetic blueprint for the first time." Collins could face a funding challenge as the Trump administration seeks to cut the NIH budget for fiscal 2018 from $31.8 billion to $26 billion. "That would mean huge reductions in components such as the National Cancer Institute ($1 billion) and the National Institute of Allergy and Infectious Diseases ($838 million), where HIV research is conducted," Lenny writes.

Collins tweeted his appreciation:

OOF: Now, are Republicans being fully honest about the reasons Anthem and some other insurers cite for leaving the marketplaces? Not entirely, my colleague David Weigel reports. In its decision to exit, Anthem cited "an increasing lack of overall predictability" and a lack of certainty around billions of dollars in federal payments that help reduce out-of-pocket costs for lower-income Americans. But Republicans aren't acknowledging that reality -- that President Trump is contributing to the chaos by refusing to give certainty about whether the cost-sharing subsidies will continue long-term.

"Since the first birth pangs of the AHCA, message-conscious Republicans have insisted that cost increases in the current system should be blamed on the Obama administration, not on them," Dave writes. 

House Speaker Paul D. Ryan (R-Wis.) tweeted that “the collapse of Obamacare continues:"

The comments "demonstrated a strategy as brazen as anything in modern politics — undermining the current operation of the ACA, and arguing that the law, thus undermined, is falling apart," Dave writes. "Despite the clear warnings of state insurance commissioners and of insurance companies themselves, Republicans continue to discuss premium increases and insurer pullouts as if the party fully in control of the government is a terrified observer."

--The Post's Juliet Eilperin and Abby Phillip offer a behind-the-scenes look at how the White House is engaging in this strategy, even as the increasing fragility of the marketplaces has created an increasingly difficult dilemma for the president’s top advisers.

"The issue is whether to take any steps to allay the concerns of skittish insurers, some of which are either hiking up rates or pulling out altogether, or let things deteriorate even further — even at the risk of being blamed," Juliet and Abby write. "The advisers are split, according to several individuals briefed on the deliberations: [Vice President Mike] Pence and Office of Management and Budget Director Mick Mulvaney have argued against intervention, while Health and Human Services Secretary Tom Price backs providing some federal support if a conservative health-care bill fails to pass this summer."

"While the White House tries to prod the Senate into speedy passage of some version of health-care legislation, it simultaneously is using each new revelation about the law’s marketplaces — through which more than 12 million Americans signed up for health coverage this year — to amplify its negative message," they write.

OUCH: Forbes reports that the Trump Organization received payments for the use of Trump's golf club for a children's cancer fundraising event -- even though the event's host, Eric Trump, has bragged that all proceeds go directly to helping kids with cancer since he can use the facility for free. Forbes also found that the Donald J. Trump Foundation used Eric Trump's foundation to funnel $100,000 in donations into revenue for the Trump Organization.

"And while donors to the Eric Trump Foundation were told their money was going to help sick kids, more than $500,000 was re-donated to other charities, many of which were connected to Trump family members or interests, including at least four groups that subsequently paid to hold golf tournaments at Trump courses," Dan Alexander writes.

"All of this seems to defy federal tax rules and state laws that ban self-dealing and misleading donors. It also raises larger questions about the Trump family dynamics and whether Eric and his brother, Don Jr., can be truly independent of their father," Dan writes. "Especially since the person who specifically commanded that the for-profit Trump Organization start billing hundreds of thousands of dollars to the nonprofit Eric Trump Foundation, according to two people directly involved, was none other than the current president of the United States, Donald Trump."


--We've already discussed some possible points of agreement on a Senate bill overhauling the ACA. But a few more are emerging. One could be state waivers that allow insurers to opt out of Obamacare's essential health benefits, its regulation on how much can be spent on overhead (called the Medical Loss Ratio) and its ban on charging older people more than three times what younger people are charged (even though their costs are far greater), Axios's Caitlin Owens reports.

But under the proposal senators are considering, insurers couldn't opt-out of protections for people with preexisting conditions, something the House bill partially included but which made moderates wary. Regardless, Democrats aren't pleased at the prospect that any of the ACA's insurer regulations could get the axe. Here's what Sen. Ron Wyden, top Finance Democrat, tweeted yesterday:


--The Trump administration has named Valerie Huber, a national abstinence education advocate, to a position at the Department of Health and Human Services. Huber will be the chief of staff to the assistant secretary for health at HHS, according to an email obtained by the Hill. Huber is the president of Ascend, a D.C.-based professional association that advocates for abstinence education, formerly known as the National Abstinence Education Association. Huber wrote that she prefers the term "sexual risk avoidance" to abstinence education, in an article published in Focus on the Family's Citizen magazine.

The agency released a video message to emergency responders across the country.
Matt Zapotosky
Drug combinations and costs are hot topics at the 38,000-doctor-strong ASCO cancer conference in Chicago.
Laurie McGinley

--We already know drug abuse is a huge and growing problem in the United States -- and now the New York Times has compiled new data suggesting the overdose death rate may have jumped 19 percent last year. Deaths from drug overdose most likely exceeded 59,000 in 2016, Josh Katz writes. If that's true, it would be the largest annual increase ever recorded in the the nation.

"The death count is the latest consequence of an escalating public health crisis: opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs," Katz reports. "Drug overdoses are now the leading cause of death among Americans under 50. Although the data is preliminary, the Times’s best estimate is that deaths rose 19 percent over the 52,404 recorded in 2015. And all evidence suggests the problem has continued to worsen in 2017."

Nevada, with little fanfare or notice, is inching toward a massive health insurance expansion — one that would give the state’s 2.8 million residents access to a public health insurance option.



  • The Bipartisan Policy Center will host a discussion on obesity care. The event begins at 10 a.m.
  • The American Enterprise Institute will host a panel discussion on opioids, community, and the economy beginning at 10:30 a.m.
  • A House Ways and Means Health subcommittee will hold a hearing on Health Medicare Advantage on “Promoting Integrated and Coordinated Care for Medicare Beneficiaries.”
  • The Atlantic will host a discussion at the Newseum in Washington, D.C. on biosimilars and “the policy and regulatory debates surrounding these complex large-molecule drugs.” The event begins at 8 a.m.

Coming up

  • Health and Human Services Secretary Tom Price will testify Thursday before the Senate Finance Committee and the House Ways and Means Committee on the administration’s budget for the 2018 fiscal year. The department’s budget as proposed includes more than $600 billion in cuts from Medicaid over the next decade, on top of more than $800 billion proposed in the AHCA. 
  • The House Energy and Commerce subcommittee on Oversight and Investigations holds a hearing on Thursday morning on the role of the Department of Health and Human Services in health-care cybersecurity.
  • President Trump is reportedly hosting a fundraiser at his Trump National Golf Club in New Jersey for a Republican lawmaker who played a role in pushing the Republican health-care effort through in the House after a failed first bill. Trump will hold the event for Rep. Tom MacArthur on June 11 in Bedminster, N.J. The Associated Press reported donations are suggested between $5,400 and $100,000.
  • The Hill is hosting an event on creating “a more value-driven health-care system” on June 13 with Sen. Bill Cassidy (R-La.) and Rep. Doris Matsui (D-Calif.)
  • The Senate Health, Education, Labor and Pensions committee will hold a hearing June 13 at 10 a.m on the cost of prescription drugs.

Robert Costa and Sari Horwitz reported last night that Attorney General Jeff Sessions offered to resign amid tension with President Trump:

And on Stephen Colbert Tuesday night, a cartoon version of President Trump would not stop tweeting:

White House Press Secretary Sean Spicer said about health care on Tuesday: "We just don't have time to waste. Obamacare continues to collapse."