THE PROGNOSIS

If you could slay the GOP health-care bill with words, Andy Slavitt would have done it by now. Until four months ago, Slavitt oversaw Obamacare for Obama. Since then, he’s been carving out a niche as a top, vocal critic of Republicans and their one-sided effort to overturn big parts of the Affordable Care Act.

Slavitt was always refreshingly talkative, even during his two years as head of the Centers for Medicare and Medicaid Services, the agency that also runs most of the ACA's biggest components. And now that he's out from under agency shackles, Slavitt prides himself on being candid -- and highly snarky, at times. His Twitter feed has become a must-read for those following the Republican effort to repeal and replace some of the ACA. Here are some choice examples:

Over the weekend, Slavitt appeared to criticize the news website Axios, for ​​​​describing Pence's health-care promises as creating "trouble" for the Senate -- instead of calling them outright falsehoods:

A few weeks ago, Slavitt tweeted that House Speaker Paul D. Ryan (R-Wis.) was “just saying goodbye” to young cancer patients Ryan was photographed with during a visit to a Texas children’s hospital -- insinuating that Ryan’s health-care bill would lead to their fatal demise due to its Medicaid cuts:

“What I meant by that tweet is you can’t cut the program that takes care of half the children in this country and not hurt children’s hospitals,” Slavitt explained to me last week over drinks at a Capitol Hill restaurant.

“So when someone wants to get pictures taken in children’s hospitals [while] at the same time cutting a dramatic amount of resources to those hospitals, it’s not really right, and I was just trying to call that out,” he said.

Slavitt’s son told him no one would listen to him any longer once he left CMS. But Slavitt found his Twitter following grew rapidly in the days after his departure, from 17,000 to more than 70,000 today.

“I don’t know that I can understand it other than people care about health-care -- they want someone to just be straight about what’s going on,” Slavitt told me.

Many ACA foes wouldn't agree that Slavitt always gives an entirely fair assessment of efforts to replace it, but few would disagree that he's straight about his feelings on the matter. Check out his other recent tweets:

Slavitt first came to Washington as part of a rescue team to fix Healthcare.gov back in 2013 while it was floundering in the first enrollment season. President Obama appointed him to lead CMS in March 2015 -- he served until Trump was installed in January. Now, Slavitt is juggling several roles, advising the Bipartisan Policy Center and traveling around the country to speak out against the GOP efforts to dismantle the law he fought to improve.

He chatted recently with The Health 202 (until Rep. Joe Kennedy (D-Mass.) interrupted us) about his growing Twitter presence, what he’d like to change about the ACA and what frustrates him the most about how thing are going under President Trump:

The Health 202: There’s been some pretty bad news about rate hikes and insurer exits from the ACA marketplace for next year. Does that discourage you?

Slavitt: What’s discouraging is it’s a far easier year to keep insurers in the market than it was last year.

We would have killed [last year] for the circumstances we have this year: the insurers are making money, they’re solid. So watching the administration basically cause the markets to self-destruct by not paying [cost-sharing reductions], by saying they’re not going to enforce the individual mandate…I sit here and go ‘if we were still here we would be having a very good year.’”

H202: Is Trump harming the marketplaces by not committing long-term to paying insurers the funds to cover the cost-sharing reductions? [Note to readers: These are discounts insurers are required under the ACA to give the lowest-income marketplace customers, to help with extra costs beyond just their premiums. More from me here on them]

Slavitt: He’s got to commit to paying them for 2018. I guarantee you in 30 days if he said he was paying cost-sharing reductions, he’d have full markets. And if he then said he was going to enforce the individual mandate, you’d see rate increase that are in the mid-single digits.

H202: How much better would the marketplaces be had Hillary Clinton won instead of Trump?

Slavitt: I think there are probably five states that have real challenges, like the risk pools are too small -- like Alaska, like Minnesota. These are mostly states that had real competitive problems before the ACA. They didn’t get fixed with the ACA and they require some surgical solutions.

The majority of the rest of the states, I think, are competitive, so I think this would have been a transitional year, but it would have been a very successful year. That’s not to say there wouldn’t have been problems with the ACA -- I’m not saying that -- but the insurers, they just can’t expand in this environment.

H202: What do you think of Seema Verma, your successor picked by Trump to lead CMS?

Slavitt: So you’re going to uncharacteristically find me restraining myself from being critical. I think there’s a lot of policy things that we clearly aren’t going to see eye-to-eye on, but I really hope she does that job the way I did, which is feeling the weight of 130 million Americans -- delivering their care and their services.

H202: So was there mass panic inside CMS last year when insurers were proposing double-digit rate hikes and some GOP criticisms of Obamacare appeared to be coming true?

Slavitt: In the sane world you would take that fact and you would adjust, you’d say the risk pool is a little sicker and you’d increase subsidies. Unfortunately, there was no chance of any cooperation from Congress. That was just the reality we lived in. It didn’t have to be this bad, but prices did need to adjust and that was just something that needed to happen.

H202: If you could change one thing about the ACA, what would it be?

Slavitt: Subsidies for higher-income people.

H202: Was it hard to implement the ACA amid all the partisanship?

Slavitt: Let me give you an example. If there was a problem with Medicare, I could pick up the phone and I could call a Republican committee chair and talk to them about an issue. Even if we didn’t see eye to eye on the solution, I knew for sure I was talking to someone who was as committed to the Medicare program as I was.

Whereas if it was the marketplace…someone had a pizza party for their staff who was an enroller and we got a congressional letter. This was a role where we had I think I had 170 audits from the [Government Accountability Office] or [Office of Inspector General] at any one time on the marketplace. It was insanity. It was insanity.

H202: So tell me, do you think Republicans will actually pass an Obamacare overhaul?

Slavitt: I think you always have to give the odds to the majority. I think we now are in an environment where people just want a victory and don’t care that much about the content and will stampeded anyone who gets in the way of overturning the ACA. I think Trump has put the equivalent of a gun to the head of the American public by the steps he’s taken to blow up the ACA.

H202: What do you see as your role in all this?

Slavitt: As someone who believes in bipartisanship, I also believe you have to kill rancid, acidic, horrid partisanship when it exerts itself. And that’s what this bill is. People kind of say 'Well gee, Andy, how can you call yourself bipartisan and speak out so against this bill?' That’s because this bill and the process by which it’s being played out is one of the most partisan processes imaginable.

Here’s what I really believe. At the end of the day, if this bill passes, it will hurt a lot of people and people will wait for redress and the next administration and hope for a new administration, and back and forth we’ll go. As long as one party holds full responsibility, good and bad, for what happens to the health-care system and the other party gets to point the finger and says anything wrong I get free rein to criticize, we’re not going to be able to do anything to induce advancement.”

H202: How else are you speaking out against repeal-and-replace efforts?

Slavitt: I’ve been going to all these town halls where I basically challenge representatives who won’t hold a town hall. We’ve talked to over 32,000 people now, so it’s like an extension of Twitter. Obviously people are very engaged in these town halls -- they feel threatened about what’s going on in health care and they can relate to it.

Health 202: Speaking of Twitter, like you’re having a lot of fun with social media these days.

Slavitt: It started when I was [at CMS]. I was way out there relative to the administration on Twitter…I felt like CMS was really opaque and very hard to understand and such an important partner for everyone in health care.

Health 202: So your approach is to be more open and less guarded online?

Slavitt: I believe all of our problems in health care are everyone’s fault -- it’s one of my core beliefs. And I think one of the things people in health care are so good at doing is explaining in really clear terms why things aren’t their fault. When you’re CMS administrator, they come in and tell you all the reasons why everyone is wrong but we’re entitled to your money. You can only listen to that for so long, so what I started to do is…I basically tried to be very clear when CMS was at fault or when we could have done something better.

I made a comment in January of 2016 that I think we’ve ‘lost the hearts and minds of physicians.’ That was quoted thousands of times and I was like why is that a big deal -- it’s true. There were probably people inside the administration who weren’t all that happy about all of that, but I think I got credit for trying to be open and transparent.

AHH, OOF and OUCH

AHH: Delaware has become the first state to enact a law ensuring abortion remains legal there, should the Supreme Court ever overturn its Roe v. Wade ruling with Trump's newly-appointed Justice Neil Gorsuch, Reuters reports. The law codifies at the state level provisions of the court's 1973 ruling declaring a woman's right to an abortion.

"Trump, a Republican whose election was backed by anti-abortion groups, has promised to appoint justices to the nation's top court who would overturn Roe v. Wade and let states decide whether to legalize abortion," Reuters reports. "States have responded by seeking to write Roe V. Wade into their own laws, with Delaware the first to do so successfully."

OOF: Guess who Trump picked for his first fundraising boost as president? Rep. Tom MacArthur, the moderate New Jersey Republican who isn't usually one of the top health-policy players in Congress, but who helped broker the American Health Care Act the House passed last month to overhaul Obamacare.

"Trump raised more than $800,000 at a closed fundraiser Sunday for a Republican New Jersey congressman who helped broker an agreement to pass a bill to dismantle the national health care law," the Associated Press reports. "Trump appeared at an event with Rep. Tom MacArthur at the president's golf club in Bedminster, New Jersey...MacArthur campaign spokesman Chris Russell said the event included 100 guests. Some donated up to $100,000 to attend the event, which is Trump's first for a member of Congress...MacArthur's New Jersey congressional district near the suburbs of Philadelphia was expected to be competitive in 2018."

OUCH: Not that anyone's counting, but there are now 47 counties across Missouri, Ohio and Washington with zero health insurers signed up to sell marketplace plans next year, Vox reports.

"Over the past two weeks, key health insurance plans have quit or scaled back participation in Obamacare marketplaces," Vox's Sarah Kliff writes. "Approximately 38,000 Obamacare enrollees now live in places where no health plans want to sell Obamacare coverage in 2018. This is a small fraction of Obamacare enrollees — about 0.3 percent — who mostly live in rural, sparsely populated areas."

"Health insurance plans pulling back from the marketplace at this point largely cite historical financial losses coupled with growing uncertainty over the law’s future," Sarah writes. "The Obama administration worked hard to recruit health insurers to sell to these empty areas. The Trump administration, however, seems to want to stand aside and let Obamacare run on autopilot so it can explode or survive on its own."

HEALTH ON THE HILL

--As The Health 202 wrote on Friday, there's a strong feeling among health care-watchers that if anyone can move the political mountains currently in the way of a health-care bill, it's Senate Majority Leader Mitch McConnell (R-Ky.). But he's been holding his cards close to his chest, the Wall Street Journal reports

"Before he began clicking through a PowerPoint presentation on Republican health-care options [last] week ... McConnell delivered a private warning to his Senate Republicans: If they failed to pass legislation unwinding the Affordable Care Act, Democrats could regain power and establish a single-payer health-care system," WSJ's Kristina Peterson, Stephanie Armour and Louise Radnofsky write. "Mr. McConnell has been nearly as downcast in his public comments about Senate Republican' chances of passing sweeping legislation to overhaul the country's health-care system."

--We're on the lookout for a draft of a health-care bill that Senate Republicans might have ready this week. If they want to pass something before the July 4th recess, as some in leadership have suggested, they have just three weeks remaining. In the meantime, Vice President Pence and Trump himself are ripping into Democrats for not going along with it.

Pence said in a speech in Wisconsin on Saturday that it's clear to him and most other Republicans that Obamacare is failing, according to the Washington Examiner. "Truth is, you'd have to be blinded by partisanship not to believe otherwise," Pence said. "But, unfortunately, some people are; Democrats in Congress to be exact." 

Wisconsin Gov. Scott Walker tweeted this:

Trump sounded a similar refrain:

--But Republicans aren't exactly inviting Democrats to share their ideas. This video went viral over the weekend, featuring Sen. Claire McCaskill (D-Mo.) lambasting Sen. Orrin G. Hatch (R-Utah) for his intention to not hold a Finance Committee hearing on the health-care bill being cooked up by him and his fellow Republicans:

McCaskill used some of her allotted time for questioning Health and Human Services Secretary Tom Price last Thursday (he was testifying before the committee about Trump's budget proposal) to probe Hatch on whether he intended to hold a hearing on a health-care bill. When Hatch said "I think we've already had one" after conferring with an aide, McCaskill tore into him.

"I heard you say, Mr. Secretary (Price), ‘We’d love your support.’ For what? We don’t even know. We have no idea what’s being proposed," McCaskill said. “There’s a group of guys in a back room somewhere that are making these decisions....There were no hearings in the House. I mean, listen, this is hard to take.”

McCaskill acknowledged that the ACA was passed without a single Republican vote, but also noted that Republicans were allowed to offer amendments. Now, Republicans aren't even considering allowing Democrats to do the same. "You couldn’t have a more partisan exercise than what you’re engaged in right now," McCaskill said.

Her criticisms resonated around the Twitterverse:

It even inspired a #RantLikeMcCaskill hashtag:

--Sen. Bernie Sanders visited Chicago over the weekend, where he rallied liberal activists Saturday night, telling them ideas that once seemed "radical" are now becoming more widely accepted -- including the idea of a single-payer system.

“People have got to understand that we’re at a pivotal moment in American history, and it’s not clear which way we’ll go,” Sanders told my colleague Dave Weigel. “There’s an enormous potential to improve peoples’ lives; on the other hand, there’s an opening for an austerity economy where everybody but the top 1 percent gets poorer. I will do my best to make people to understand that this is a 12-month-a-year operation, not about an election every four years.”

David reports that the summit was organized by National Nurses United, which spent millions of dollars to back the 2016 Sanders presidentil campaign and has since taken a more prominent role on the political left. Sanders told activists that they were already scoring wins despite the Democratic Party’s national defeat.

“Ideas that, just a few years ago, seemed radical and unattainable are now part of Main Street discussion, and in fact, some of them are being implemented across the country as we speak,” Sanders said. “Today, support for the concept of paid family and medical leave is gaining support. Today, states and communities throughout the country are moving forward to make public colleges and universities tuition free. Today, there is growing support for universal health care and in states like California and New York, we are seeing real legislative progress in the fight to pass a Medicare for All, single payer system.”

MALPRACTICE

--My colleague Michelle Ye Hee Lee has fact-checked Planned Parenthood for the group's claim about women's use of contraception in this recent tweet: 

Is that true? The statement needs more context, especially when juxtaposed against the ACA's requirement for employers to cover contraception, Michelle writes.

The backdrop: The Trump administration is considering a new rule that would provide a broad, religious exemption for employers who object to paying for birth control coverage for their workers. Conservatives had viewed the requirement, laid out under the Obama administration, as an infringement on their religious freedom. Planned Parenthood and other ACA supporters are pushing back, arguing that it would harm women's access to affordable birth control.

The 99 percent statistic: That statistic counts women using contraception that employers are not requiring to cover, like condoms, and women who have had sex only once, creating a falsely high impression of the number of women who get their birth control coverage as a result of ACA requirements, Michelle writes. 

"When advocates use this statistic, they’re using the term “birth control” as synonymous as “contraception,” and referring to any method used to prevent pregnancy, regardless of whether it is something that is covered under Obamacare," she writes. "That’s not always made clear. It can create a misleading picture, as if 99 percent of sexually active women would be affected by the Trump regulation to overhaul the Obamacare birth control mandate. Of course, condoms, withdrawal and rhythm method are not covered under Obamacare."

STATE SCAN
As Congress works to repeal President Barack Obama’s signature health law, Kentucky Republican Gov. Matt Bevin is already at work unwinding some of its provisions in his state.
Wall Street Journal
A prominent Blue Cross-Blue Shield insurer is aiming to return to the Affordable Care Act's health insurance exchanges next year in several states, including big markets like Texas and Illinois.
Associated Press
The state exchange will tell insurers to proceed with significantly higher rates on some 2018 health plans if the feds do not commit by mid-August to continue subsidies that lower out-of-pocket expenses.
California Healthline
INDUSTRY RX
The new director will assume the job at a time of rapid changes in the cancer field and looming budget challenges at the institute.
Laurie McGinley
DAYBOOK

Coming Up

  • Politico is hosting an event on Tuesday on “Medicaid as a Driver of Care Innovation in the States.”
  • The Hill is hosting an event on creating “a more value-driven health-care system” on Tuesday with Sen. Bill Cassidy (R-La.) and Rep. Doris Matsui (D-Calif.)
  • The Senate Health, Education, Labor and Pensions committee will hold a hearing Tuesday 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 Wednesday.
  • Axios is hosting an event in Los Angeles on on Wednesday on the "impact and possibilities of artificial intelligence, virtual reality, biopharmaceuticals and research for the brain
SUGAR RUSH

Watch Sen. Bernie Sanders (I-Vt.) call President Trump “perhaps the worst and most dangerous president in the history of our country" on Saturday:

See Sen. Lindsey Graham (R-S.C.) say the media behaves like a "lynch mob" when it comes to Trump:

See the full clip of McCaskill's rant: