THE PROGNOSIS

For all the obstacles Senate Republicans face in passing an Obamacare overhaul, they’ve got one thing boosting them: Their leader is bound and determined to get it done.

Despite mounting skepticism that such a feat is possible, Senate Majority Leader Mitch McConnell (R-Ky.) is working hard behind the scenes to forge some kind of consensus among Republican senators with the aim of actually passing their version of a health-care rewrite in the near future. For a man who carefully weighs his words, McConnell's statement to President Trump earlier this week that he hoped to get something out of his chamber by the July 4 recess was telling.

McConnell is a skilled negotiator -- he has proven adept at quietly but effectively building support among the rank-and-file for whatever goal is in his sights. If there was ever a time for him to cash in on the trust his conference has in him, it’s now -- as the Republican congressional majority tries to deliver a major win and make good on one of its signature political promises before the 2018 midterms.

“If anyone can get this done, it’s going to be Mitch McConnell,” said Megan Hauck, who served as McConnell’s health policy adviser as the Affordable Care Act was being passed in 2010. “He understands this is ultimately about keeping our word and voting and moving on.”

But nabbing 50 Republican votes will be no easy task (McConnell needs just a simple majority because Republicans are using budget reconciliation to move the health-care measure). There are several possible routes to victory: McConnell could bring the Ted Cruz (R-Texas) and Mike Lee (R-Utah) duo on board but lose some moderates in the process. Or he could count the two hardest-to-get senators (moderate Susan Collins (Maine) and libertarian-leaning Rand Paul (Ky.)) as a loss and focus on everyone else.

But convincing all but two Senate Republicans to vote for rolling back the ACA remains an uphill climb for the Kentucky Republican. He recently admitted he’s not yet sure how to get there, telling Reuters last month “I don’t know how we get to 50 [votes] at the moment, but that’s the goal.”

No matter the route, however, McConnell will approach the challenge in a truly McConnell way – by listening to every member, taking it one vote at a time and not celebrating before crossing the finish line, those who know him say.

It’s the only way he has a shot of wooing both moderates -- who fear Medicaid rollbacks -- and conservatives, who are wary of leaving too much of the ACA in place. In order to pass a GOP health-care measure, nearly every Republican must find it within their self-interest to vote yes. And to find it within their self-interest means each Republican must feel their voices have been heard and their concerns addressed.

Even so, McConnell still might fail -- or decide not to bring such an explosive measure to the floor if he deems it politically undesirable. But right now, the leader seemed to be leading the sales charge.

Yesterday, in the Senate chamber, McConnell ticked through a list of ACA problems including premium hikes and insurer exits in the marketplaces. “That’s why Senate Republicans believe we must act, it’s why we’re working to keep our commitment to the American people and finally provide relief from Obamacare,” he said. He’s been tweeting a lot about a replacement plan, too:

McConnell has a strong, internal drive to pass a Senate bill replacing much of the ACA, former aides say. While his political style stands in stark contrast to the firebrand approach of some other Republicans, particularly in the House, he has been no less vocal in calling for rolling back Obamacare.

The leader has called for repealing the ACA “root and branch.” For awhile, his staffers hauled around the U.S. Capitol a seven-foot stack of the rules and regulations resulting from Obamacare implementation, which they dubbed the "Red Tape Tower." After Republicans seized back Senate control in 2014, he promised to hold a vote on repealing the law – and followed through next year, bringing to the floor a budget reconciliation bill repealing some of the ACA ( a measure that President Obama subsequently vetoed). 

McConnell didn’t make ACA repeal the biggest issue in his tough reelection race that year against Alison Lundergan Grimes, often focusing instead on energy and economic issues. But it was a part of his platform and he ran some ads portraying the law in a negative light:

The above ad featured a doctor discussing her son’s diabetes treatments. “Our insurance was canceled under Obamacare,” the woman says, praising McConnell for “leading the fight” against Obamacare because “he cares about patients and families like mine.”

McConnell’s a realist, and he’s at times gotten in trouble with other Republicans for qualifying their promises to repeal the ACA.

During the 2014 election, McConnell conceded to Fox News’s Neil Cavuto that Republicans still couldn’t repeal the ACA even if they won Senate majority because Democrats could still filibuster their attempts -- and Obama could veto anything that was approved. His spokesman Brian McGuire later clarified, saying “Leader McConnell is and has always been committed to the full repeal of Obamacare.”

But McConnell’s approach to leadership might be just what Republicans need right now to rally around a single piece of legislation (text of which may be available next week). The most likely holdout senators need a strong sense that the party will back them up if they take a vote that could expose them to attacks from Democrats that they’re taking away people’s health insurance.

McConnell has turned his conference’s thrice-weekly lunches into health-care education sessions, complete with PowerPoint presentations. But don’t expect him to play school teacher with the press, as Ryan did with the House bill (for which he was widely mocked).

Instead, McConnell is approaching ACA repeal with his own blend of tenacity and pragmatism. “In four straight elections we told the people that we wanted to repeal and replace Obamacare,” McConnell told Newsmax in April. “Obviously, that's a lot harder to do than to say.”

“He’s without question the best listener in the entire Senate,” a source who has worked closely with McConnell told me.

We'll see if those listening skills cause McConnell to give the green light to a deal or stop Republicans before they do something that might endanger, in his judgment, their majority.

AHH, OOF and OUCH

AHH: What was President Trump doing yesterday, the same day his former FBI director was testifying before Congress? Talking about health-care, of course. In a speech to the Faith and Freedom Coalition's annual gathering, Trump pledged to always support the right of evangelicals to follow their faith, which some conservatives feel is under siege by the federal government (some also took Trump's words that "we're under siege" to be an oblique reference to the Russia investigation).

"Trump spoke about his actions to safeguard religious freedom and continued, for the second straight day, to label congressional Democrats as 'obstructionists' who are blocking his agenda," the AP reports"Yet it is differences of opinion among Republicans, who control both houses of Congress, that are standing in the way of what Trump wants to do on health care and other issues.

"...Trump said restoring freedom also meant repealing and replacing the health care law enacted in 2010 by then-President Barack Obama, saying high deductibles and premiums have turned it into a 'catastrophe.' But a replacement health care bill has yet to clear Congress despite seven years of pledges by Republicans to scrap the law and start over, and despite the fact that the GOP has full control of the White House and Congress."

(Vice President Pence will also speak about health care on Saturday, when he is scheduled to travel to Milwaukee to meet with business leaders and families to discuss the “adverse effects” of the law, according to the AP.)

OOF: The FDA has, for the first time ever, asked a drug company to stop selling an opioid pain medication because of the public health consequences of abuse. The agency had approved Endo Pharmaceuticals' Opana ER in 2006, to be used for moderate to severe pain when a round-the-clock painkiller is needed, but has now concluded after extensive review that the "benefits of the drug may no longer outweigh its risks."

"The company reformulated the drug in 2012 to make it more difficult to snort, but the FDA said that move actually led to more injections — and a major HIV outbreak," the Post's Laurie McGinley and Lenny Bernstein report. "FDA Commissioner Scott ­Gottlieb, who has pledged to take “more forceful” steps to curb the nation’s opioid epidemic, said the agency’s action reflects its increased focus on the risks posed by the illicit use of opioids."

"The FDA “is looking broadly at the whole policy framework” used for the painkillers, Gottlieb said Thursday.

OUCH: A pharmaceutical company is recalling nationally-distributed birth control pills which were mislabeled in a way that could result in an unplanned pregnancy. The first four days of tablets are actually placebos; if taken as labeled, women won't receive the right hormones to prevent conception, the FDA said in a statement yesterday. The pills are sold under the name Mibelas 24 F-E, so check your medicine cabinet, ladies.

HEALTH ON THE HILL

--In those McConnell-led health-care huddles, Senate Republicans are openly talking about keeping many of the ACA's taxes in order to pay for keeping more of its benefits around for longer -- like more slowly rolling back the law's Medicaid expansion. McConnell himself has proposed a three-year phase out, and he's also suggested keeping Obamacare's protections for people with preexisting conditions.

"Senate Republicans are considering preserving or more gradually eliminating key elements of the Affordable Care Act that the House voted to discard, creating an uncomfortable political situation for the party after years of promises to fully repeal the law," my colleagues Sean Sullivan and Kelsey Snell report. "McConnell has proposed to senators the possibility of a three-year phaseout, according to a GOP senator familiar with the discussions who spoke on the condition of anonymity. McConnell has also personally proposed not including the House provision allowing states to opt out of the coverage cost protection for patients with preexisting conditions."

Were the Senate to adopt these provisions in their health-care bill, the measure would be markedly to the left of the House bill. Which means we're closely watching the trio of conservatives -- Sens. Ted Cruz (Tx), Mike Lee (Utah) and Rand Paul (Ky.) -- to see how they'd feel about it. “The conversations are continuing,” Cruz said yesterday. “We still have a lot of work to do. What is most critical is that we honor our promise to repeal Obamacare and that we enact meaningful reforms to lower premiums.”

--Retaining the law's protections for people with preexisting conditions (called "community rating" and "guaranteed issue") could help get the most moderate Republicans on board. Sen. Deal Heller (R-Nev.) said yesterday he doesn't want to chip away at those parts of the ACA:

--Let's talk more about the Medicaid phaseout because that's one of the biggest flashpoints here. Centrist Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia are pushing for a seven-year phaseout of Medicaid expansion instead of the three-year phase out leadership wants. Conservative activist groups are pouring cold water on that idea; they want an expansion phase out even earlier than in the House bill.

“There has to be a give and take, and right now it seems like conservatives are being told just to take it all and not get anything,” Heritage Action spokesman Dan Holler told the Hill's Peter Sullivan.

--Here's another tricky issue few have paid attention to. At the insistence of abortion-opposing groups, the House bill bans federally-subsidized insurance plans from covering abortions. But that language might not pass muster under budget reconciliation rules in the Senate, potentially forcing Republicans there to strip out the language that conservatives feel is essential for keeping taxpayer dollars from funding the controversial procedure. Politico's Jen Haberkorn explains more here.

--Of course, the overwhelming focus on Capitol Hill yesterday was on ousted FBI Director James B. Comey's testimony in the Senate. But Democrats and supporters of the ACA tweeted reminders that Republicans are still working hard behind the scenes on repeal-and-replace:

PRICE CHECK

Don't forget that Health and Human Services Secretary Tom Price was also on the Hill yesterday, testifying about Trump's budget proposal before the Senate Finance Committee in the morning and the House Ways and Means Committee in the afternoon. Price defended the budget's cuts medical research funding, Medicaid and the CDC and wouldn't answer lawmakers when pressed repeatedly to explain whether the administration will keep paying extra Obamacare subsidies in the long term.

--“President Trump’s budget does not confuse government spending with government success,” Price said, as Democrats sparred with him over the sweeping, proposed cuts. The problem with many federal programs “is not that they are too expensive or too underfunded. The real problem is that they do not work — they fail the very people they are meant to help,” Price said, according to Kaiser Health News.

--Democrats also asked Price about an HHS draft rule that would allow any employer to get exempted from the ACA's mandate to cover birth control by citing religious objections. "I think that for women who desire birth control, it should be available,” said Price, adding that HHS is currently soliciting input on the proposed rule.

--Several members pressed Price in both hearings on whether the administration will keep paying subsidies to insurers for cost-sharing discounts they're required to provide the lowest-income marketplace customers (uncertainty about these subsidies is a big reason insurers are citing for withdrawing from state marketplaces). Each time, Price noted that Trump's budget includes the payments through 2018 and said he couldn't comment further because of the ongoing lawsuit over them.

Interestingly, Ways and Means Chairman Kevin Brady (R-Tex.) stressed that the payments should keep going to insurers to stabilize the marketplaces. "We should act within our constitutional authority now to temporarily and legally fund (subsidy) payments as we move away from Obamacare," Brady said. "Insurers have made clear the lack of certainty is causing 2018 proposed premiums to rise significantly."

REPRODUCTIVE WARS

--My colleague Sandhya Somashekhar writes about 17-year-old Deja Foxx, a young woman who visited Capitol Hill this week to tell members of Congress how the organization helped her get birth control when she was 15 -- and to argue against defunding it.

"Today, Foxx is a fresh young face in the effort to block government cuts to Planned Parenthood, a 100-year-old women’s health organization that is under attack for its role as the nation’s largest abortion provider," Sandhya writes. "She has taken on her state’s elected officials and this week brought her message to Washington: Without Planned Parenthood, she says, her future would be in doubt."

The House passed an Obamacare overhaul last month that would block Medicaid dollars from flowing to Planned Parenthood clinics -- and it's likely such a provision will be included in the version senators are working on. Foxx credits her Planned Parenthood visit with keeping her life on track. "So this week, for her first visit to Washington, Foxx donned a suit and a Planned Parenthood pin to tell her story to members of Congress in hopes of preserving funding for the organization," Sandhya writes.

But March for Life President Jeanne Mancini pushed back, saying she sympathizes with Foxx but that the teenagers could have abstained from sex until marriage. She also said other health centers could have provided Foxx with the same birth control services she sought out at Planned Parenthood.

“Getting free birth control from Planned Parenthood … is not the means for her to achieve the American Dream,” Mancini told Sandhya. “That’s a really reductive view of the American Dream.”

Here are some more interesting health-care reads from around the Web:

INDUSTRY RX
The physicians want to conduct clinical trials to show whether some drugs can be taken in lower doses and for shorter times.
Laurie McGinley
STATE SCAN
Washington state has no insurer willing to offer Affordable Care Act plans next year in two counties, opening up a third U.S. region that is poised to be without coverage through the health law’s marketplaces.
Wall Street Journal
Nevada passes a law, awaiting the governor's signature, that would create a state healthcare plan.
LA Times
DAYBOOK

Coming Up

  • Vice President Pence is scheduled to travel to Wisconsin on Saturday for a listening session and speech on Obamacare.
  • 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.
  • The House Energy and Commerce subcommittee on Health will hold a hearing on “Examining the Extension of Safety Net Health Programs” on June 14.
  • Axios is hosting an event in Los Angeles on June 14 on the "impact and possibilities of artificial intelligence, virtual reality, biopharmaceuticals and research for the brain."

 

SUGAR RUSH

At the Faith and Freedom Coalition conference on Thursday, President Trump said "restoring freedom and opportunity also means repealing and replacing the disaster known as" Obamacare: 

If you weren't glued to your screen watching James B. Comey testify before the Senate Intelligence Committee yesterday, here's a brief recap of his testimony:

Or you can watch Stephen Colbert's version of Comey's hearing: