Today, 45 of the top conservative activist groups will send a letter to Senate Finance Committee Chairman Orrin G. Hatch (R-Utah) asking that he ensure all the Affordable Care Act's taxes are repealed in a Republican health-care bill.

“Recent media reports suggest that the Senate may be wavering on repeal of these taxes,” write Americans for Tax Reform, Club for Growth, FreedomWorks and others. “This would be a mistake.”

Industry and outside groups are also pouring on the pressure to eliminate the taxes permanently. More than 50 employer groups, including the U.S. Chamber of Commerce and the American Benefits Council, wrote to Senate leaders on Friday asking them to repeal the law’s so-called “Cadillac tax” on high-cost health plans and its taxes on fully-insured health plans, branded pharmaceuticals and medical devices.

Here's what's setting off alarm bells among the grass roots: my colleagues Kelsey Snell and Sean Sullivan reported last week that Senate Republicans were indeed considering the possibility of retaining some of the ACA's taxes in order to pay for a more expensive health-care legislation that would provide more Americans with insurance for longer. But such a move would likely -- as the above letter suggests -- open a chasm with the outside groups that have successfully driven a wedge among Republicans in Congress over the past several years, and could jeopardize passage of an Obamacare overhaul.

The problem is the tension between moderates and conservatives over how quickly to phase out the ACA's Medicaid expansion and how generous to make its subsidies. A shorter phaseout period and fewer subsidies means more people would lose insurance but it would cost less; a longer fade-out and more subsidies means fewer people would be in danger of losing coverage but the more expensive the measure would be.

The House bill would end extra federal payments in 2020 for the population that got coverage through ACA's Medicaid expansionMcConnell is said to be open to a longer, three-year delay, according to Hill aides, while some moderates including Sens. Rob Portman (R-Ohio), Dean Heller (R-Nev.) and Shelley Moore Capito (R-W.V.) have pushed for a longer delay until 2027.

Enter Sen. Patrick J. Toomey (R-Pa.), a former Club for Growth president who McConnell asked along with Sen. Rob Portman (R-Ohio) to help hammer out a compromise in the GOP conference on Medicaid.

Toomey thinks there's a way to both do away with all of the ACA taxes and pay for phasing out Medicaid expansion more slowly: Extract even more savings from the regular Medicaid program, thereby freeing up money to pay for keeping expansion around for longer.

Toomey -- along with Sen. Mike Lee (R-Utah) -- would do this by pegging the program to the Consumer Price Index for Urban Consumers, the more commonly used CPI that also grows more slowly than the CPI medical index used in the House bill.

The Obamacare overhaul passed by the House in May already extracts deep savings from Medicaid – about $880 billion over a decade. But from Toomey and Lee’s perspective, there’s more savings to be had.

That’s because most of those savings don’t result from converting Medicaid to a per-capita payment system, a part of the House GOP health-care bill that most people blame for driving the overall Medicaid savings. Instead, the CBO has said the savings are expected to come chiefly from the 17 percent fewer people who are anticipated to enroll in the program by 2026. That reality leaves room for more actual cuts to Medicaid in the eyes of some conservatives.

You could argue such a solution could be a bargain for both sides. Conservatives lawmakers like Sen. Ted Cruz (R-Tex.) get to tell constituents they off-roaded hated Obamacare taxes and enacted even deeper cuts to a big, government program. Moderates like Sens. Shelley Moore Capito (W.Va.) and Dean Heller (R-Nev.) could argue they aren't unfairly ripping coverage away from a population that just received it.

Two top conservative leaders – Heritage President Mike Needham and Club for Growth President David McIntosh – wrote in favor of the idea last week. “The only way to put Medicaid on a truly sustainable budget is to ensure it cannot grow faster than the economy as a whole,” they wrote in The Hill.

Except for one big problem: Moderates generally dislike the idea of cutting parts of Medicaid to pay for other parts of Medicaid. Portman is opposed to the idea, a spokesman said. Heller said last week that he would oppose a bill tying Medicaid to a slower growth rate than under the House bill. 

“I just don’t want to do worse than what the House did. And there’s a push to bring it below the House, so that’s an issue,” Heller told Roll Call.

Furthermore, Medicaid expansion and Medicaid cuts are just a piece of the current health-care negotiations in the Senate. Senators are also trying to sort out whether to make insurance subsidies more generous, how much of the law’s insurer regulations to repeal and how to ensure taxpayer dollars don’t go to plans that cover abortions.

Some of this should come into clearer focus today as Senate Majority Leader Mitch McConnell (R-Ky.) is expected to brief his conference at their weekly luncheon on Capitol Hill on the various options available to them. McConnell has said he would like to see a vote on a health-care package before lawmakers leave for their July 4 recess, but some note that deadline could slip. Sen. John Thune (R-S.D.), the No. 3 GOP leader, told Politico's Burgess Everett yesterday that the timeline is “an aspiration” but not a hard deadline. 

At today's lunches, McConnell wants to explain the costs and benefits of various elements in a possible GOP measure -- such as how the speed of the Medicaid phaseout or the generosity of insurance subsidies would affect the bill's overall price tag and how many people might lose insurance coverage under various scenarios. The goal is to tentatively agree on something in the next few days, Hill aides say, so a final bill can be drafted and shipped off to the Congressional Budget Committee for a score -- which could take two to three weeks.

If Senate Republicans have any hopes of forging consensus, their luncheon will need to look more like a trading floor than a boxing ring. The only pathway to the 50 votes needed for passage involves some hard bargaining between moderates and conservatives. All of these differences need to be hashed out – and consensus reached – before they can move seriously ahead on an Obamacare overhaul. How quickly things move (or don't move) this week on Capitol Hill could be a strong indicator of whether Senate Republicans will ultimately be able to succeed.


AHH: President Trump will meet today with 13 Republicans senators to discuss their efforts to remake big parts of Obamacare, White House officials have confirmed to The Health 202. The list of attendees notably includes the two moderates whose votes are considered hardest-to-get -- Sens. Susan Collins of Maine and Lisa Murkowski of Alaska -- and two conservatives -- Sens. Ted Cruz of Texas and Mike Lee of Utah -- who could also refuse to support the bill if they think it retains too much of Obamacare. 

--Sens. John Thune of South Dakota and John Barrasso of Wyoming, both in leadership, are also on the invite list, as are Sens. Rob Portman of Ohio, Patrick J. Toomey of Pennsylvania, Lamar Alexander of Tennessee, Cory Gardner of Colorado, Tom Cotton of Arkansas, Joni Ernst of Iowa and Orrin G. Hatch of Utah.

OOF: Trump is also slated to meet with "Obamacare victims" in Milwaukee today, but he hasn't slated much time, Business Insider's Josh Barro noted:

OUCH: In recent weeks, aides have increasingly sought to push back on the perception that Trump’s agenda in Congress has stalled, touting the House passage of the GOP health-care bill and efforts to roll back Obama administration policies through the Congressional Review Act as proof that they are making progress, the Post's Abby Phillip reports. But with the health-care bill still working its way through the Senate and Trump’s tax overhaul proposals still largely unformed, the White House has been left to tout more incremental agenda items, most of which have struggled to gain traction.

"In an effort to counteract a never-ending stream of news related to the ongoing investigation into possible ties between the Trump campaign and Russia, the White House has taken the everything-but-the-kitchen-sink approach to showing progress on policy issues," Abby writes. "The president’s schedule in June is packed with policy-related meetings and events in Washington and throughout the country, all with the goal of drawing attention away from the Russia probes and toward the White House’s proposals on infrastructure, technology and jobs."


--Senate Republicans have decided not to publicly release a draft of their health-care bill before it gets a score from the CBO showing how much it would cost and how many people it would cover, Axios's Caitlin Owens reported. "We aren't stupid," a Senate aide said, according to Caitlin. "We are still in discussions about what will be in the final product so it is premature to release any draft absent further member conversations and consensus."

(The Health 202 wrote last week about this secrecy -- examining how Republicans are falling even further short of an open process than Democrats did while passing the ACA back in 2010.)

The news prompted a fresh outcry that the Senate is being unduly secretive by hashing out all the details behind closed doors, refusing to hold committee hearings and essentially ignoring Democrats through the entire process. Sen. Kamala D. Harris (D-Calif.) called the approach "dangerous:"

Bloomberg's Sahil Kapur tweeted that even many Republicans still don't have a clue what the bill will look like, and some are concerned about the way it's all being done:

Sahil and IJR's Haley Byrd talked to Sen. Lindsey Graham (R-S.C.), and he didn't sound too thrilled about it all:

Even Sen. Lamar Alexander (R-Tenn.), who heads up the Senate Health, Education, Labor and Pensions Committee that is one of the three committees involved in writing the bill, won't talk about it in public:

The report prompted a series of tweets with hashtags #ProtectOurCare, #ShowUsTheBill and #ReleaseTheBill: 

From the Obama CMS director who I interviewed yesterday:

From the former social media director for Obama and Hillary Clinton:


--Fewer Americans are enrolled in a marketplace plan and are paying their premiums this year compared to 2016, the Trump administration announced yesterday. About 10.3 million people are maintaining coverage through the ACA marketplaces -- 800,000 fewer than at around the same time last year, according to the Centers for Medicare and Medicaid Services. That doesn't come as a huge shock; the new administration rolled back marketing efforts during the last few weeks of open enrollment and premiums were markedly higher than last year.

But CMS's way of announcing the news -- highlighting the relatively large number of people who signed up but never paid the premiums -- is akin to a student loudly and proudly proclaiming their "F" on a test. "Nearly 2 million people had not paid their insurance premium to effectuate and maintain their health coverage," CMS Administrator Seema Verma said in a statement.

Verma also said exit survey data shows cost is the top reason cited for why consumers ended their coverage. “Consumers are sending a clear message that cost and affordability are major factors in their decision to cancel or terminate coverage,” Verma said.

We heard little response from Democrats to the reduced enrollment numbers, but Republicans were quick to chime in. "Today's report makes clear that higher premiums and fewer options are directly impacting patients’ decisions," Energy and Commerce Chairman Greg Walden (R-Ore.) and Health Subcommittee Chairman Michael C. Burgess (R-Tex.) said in a statement. "The truth is that Obamacare is not working."


--Iowa is asking the Trump administration for permission to jettison fundamental aspects of its ACA marketplace, contending that a large-scale rewriting of the rules is the only way to prevent the state from becoming the first without any health plans available under the law next year, my colleague Amy Goldstein reports.

Yesterday, the state submitted to federal health officials a plan where it would essentially take an estimated $350 million in federal ACA money that its residents and insurers would ordinarily receive next year and use it for different purposes, Amy writes. Under the scheme, Iowa residents could get subsidies outside the marketplaces, and the subsidies would more resemble those proposed in the House health-care bill. The ACA's tiers of coverage would be replaced with a single level of insurance for customers buying plans on their own.

“Our market is collapsing, so the normal rules don’t really fit the circumstance,” Doug Ommen, Iowa’s insurance commissioner, said. He said he met last Wednesday with Seema Verma, administrator of the Department of Health and Human Services’ Centers for Medicare and Medicaid Services. “We went through the plan, walked through it in some detail,” Ommen told Amy, adding that he was “very optimistic that we will have a high level of cooperation” from CMS.



  • The Senate Health, Education, Labor and Pensions committee will hold a hearing at 10 a.m. on the cost of prescription drugs.
  • Politico is hosting an event 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” with Sen. Bill Cassidy (R-La.) and Rep. Doris Matsui (D-Calif.).

Coming Up

  • 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 Wednesday on the "impact and possibilities of artificial intelligence, virtual reality, biopharmaceuticals and research for the brain.
  • The Brookings Institution will host an event on Wednesday on the pharmaceutical distribution chain.
  • Bloomberg Law is hosting an event on the future of the Affordable Care Act on Thursday.
  • The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies will hold a hearing with HHS Secretary Tom Price on Thursday on the department's 2018 fiscal year budget request.
  • Mylan, the company that makes EpiPens, is scheduled to have its annual shareholder meeting on June 22. A major advisory firm is reportedly recommending Mylan shareholders vote to remove nearly all the company’s board members.



President Trump again called Democrats “obstructionists” for resisting Republicans' health-care plan: “If we had greatest bill in the history fo the world on health care we wouldn't get one vote from the Democrats:"

President Trump called Democrats in Congress "obstructionists" for resisting his health care reform during a cabinet meeting on June 12. (The Washington Post)

Watch President Trump tell his Cabinet members that “never has there been a president — with few exceptions, in the case of FDR who had a major depression to handle —  who has passed more legislation, who has done more than what we have done":

President Trump outlined some recent accomplishments at a cabinet meeting on June 12. (The Washington Post)

Watch the number of stars who jabbed at President Trump during the Tony Awards yesterday:

A number of stars took thinly veiled jabs at the Trump administration during the Tony Awards June 11. (Taylor Turner/The Washington Post)

Senate Minority Leader Charles E. Schumer (D-N.Y.) posted a video with his staff on Twitter trolling Trump's extraordinary Cabinet meeting:

Schumer trolls Trump, Priebus in Twitter video (Sen. Chuck Schumer)