Expect lots of tinkering of the Senate health-care bill in the next few days as Senate Majority Leader Mitch McConnell (R-Ky.) tries to fine-tune his Obamacare overhaul to garner enough votes for passage later this week. The road to success looks steeper than ever as senators appear to dig in against it. Yet McConnell built some spending wiggle room into his legislation, giving him some leeway to bulk up its benefits as a way of gaining more political traction should he need it.

The numbers from the Congressional Budget Office rolled out yesterday: Twenty-two million more people would be uninsured by 2026 under the Senate GOP health-care bill, Congress' official scorekeeper estimated. It's a big number, one that certainly doesn't ease the pathway toward the 50 Republican votes needed to pass the Better Care Reconciliation Act. (Check out our whip count for updates all week long.)

"The release of the 49-page ­report late Monday afternoon seemed to worsen the bill’s prospects," my colleagues Kelsey Snell and Amy Goldstein write. "No new senators immediately said they would back the legislation, and at least three ­wavering members of the GOP caucus said they would vote against starting debate Tuesday on the bill in its current form. A fourth, Sen. Dean Heller (R-Nev.), had expressed his opposition last week."

--Moderate Sen. Susan Collins (Maine) tweeted that she would vote against starting floor debate on the bill (known as a motion to proceed). Sen. Rand Paul (Ky.) told reporters he will vote against a motion to proceed, as did Sen. Dean Heller. (R-Nev.)

Paul called the draft a “terrible bill” and said he has no plans to vote for the motion to proceed with it, per HuffPost reporter Matt Fuller:

Paul said he has reached out to Republican leadership to try to negotiate on the bill to no avail (although he says he did hear from President Trump). From USA Today's Eliza Collins:

Bloomberg's Sahil Kapur tweeted that moderate Sen. Dean Heller (R-Nv.) says he will join Paul and Collins in voting against the motion to proceed: 

--Sen. Ron Johnson (R-Wis.), one of three conservatives to ally with Paul against the bill last week, also took a bearish stance. He said he did not have enough information after the release of the CBO score to make a decision on whether to vote to proceed with the bill. Johnson added he's worried the bill does not go far enough to bring down premiums.

"I'm just not convinced we're doing enough," Johnson told reporters. "I have a hard time believing I'll have enough information to vote on a motion to proceed this week."

--Sen. Ted Cruz (R-Tex.), also part of the conservative foursome, sounded a little more optimistic. He believes “we can still get to yes" although he wants more premium-lowering provisions tacked on. The CBO estimates that average premiums for individual market shoppers would be 30 percent lower in 2020 and 20 percent lower in 2026 than under current law.

From Sahil and BuzzFeed’s Lissandra Villa:

Sen. Lisa Murkowski (R-Alaska) told CNN that if asked to vote today, she doesn’t “have enough information, I don’t have enough data in terms of the impact on my state to be able to vote in the affirmative.” 

Remember, if just three Republicans vote against the health-care measure, it's doomed in the Senate and may forever kill the GOP's chances of repealing and replacing the law they've reviled for so long.

--But there might be a silver lining in McConnell's gathering clouds. The CBO estimates the bill will save $321 billion over a decade -- a much higher threshold of savings than the House's $119 billion in deficit reduction. If McConnell wants to achieve the same level of savings as the House version, he has a budget of about $200 billion to work with for making the measure more attractive to the Collins, Hellers and Cruzes of the world.

McConnell could dip into that funding in ways that would appeal to moderates, like easing back Medicaid expansion even more slowly or taking a gentler approach to Medicaid cuts. Or, he could direct more funds to states for reinsurance pools to lower the costs of premiums for healthy people -- a move that might appeal to conservatives.

We've already seen a modification to the bill this week, which had a continuous coverage requirement added to incentivize healthy people to buy insurance instead of waiting until they're seriously ill. If people lacked coverage for at least 63 days in the previous year, they would have to wait six months before their coverage would kick in.

Capitol Hill staffers are working overtime on more potential tweaks to the BCRA that McConnell will almost certainly have to offer members if he wants a fighting chance at passing the bill by week's end. McConnell's determined to call their bluff by bringing Obamacare-reshaping legislation to the floor -- but even his leadership team is admitting he might have to do it without full assurance it will pass. No. 3 Sen. John Thune (R-S.D.) noted the dilemma, per Vox's Tara Golshan:


AHH: Not everyone is panning the Senate health-care bill. Several major insurers said yesterday it would go far toward shoring up the individual market. Anthem, which recently withdraw from the Obamacare marketplaces in Wisconsin, Indiana and Ohio citing heavy losses and uncertainty, praised the measure's $112 billion in state stabilization funds, repeal of the ACA taxes and two-year provision of extra Obamacare subsidies.

“We believe the Senate discussion draft will markedly improve the stability of the individual market and moderate premium increases” because it appropriates billions of dollars in short-term funding to shore up the exchanges, provides cost sharing reduction (CSR) funds, and eliminates a tax on health insurance plans," the company said in a statement. 

Likewise, the Blue Cross Blue Shield Association, whose Obamacare plans have performed better than most, said it was "encouraged" at steps within the measure aimed at stabilizing the individual market. "We are encouraged that the proposed Senate health reform legislation includes several urgently needed and important steps to help make the individual market for insurance more stable and affordable in 2018 and 2019," BCBS said in a statement.

OOF: But the American Medical Association, which had already expressed “grave concerns” about the Senate health-care bill, took a firm stance against the bill yesterday in a damning letter criticizing its Medicaid cuts, smaller subsidies and repeal of the ACA's public health and prevention fund.

“Medicine has long operated under the precept of Primum non nocere, or “first, do no harm," AMA CEO James Madara wrote to McConnell and Minority Leader Charles E. Schumer (D-N.Y.). "The draft legislation violates that standard on many levels.”

"We believe that Congress should be working to increase the number of Americans with access to quality, affordable health insurance instead of pursuing policies that have the opposite effect," the letter said.

OUCH: Today the AMA released a new poll that found most Americans dislike the idea of cutting federal Medicaid spending and allowing narrower insurance coverage – policies contained within both the House and Senate bills overhauling Obamacare. Medicaid rollbacks were unpopular regardless of whether respondents lived in a state that embraced the ACA's Medicaid expansion or rejected it. Majorities in seven states -- Alaska, Colorado, Nevada, Ohio, West Virginia, Tennessee and Arkansas – were opposed when asked whether Medicaid funding should be rolled back.


--President Trump called several of the Republican holdouts -- including Paul, Cruz and Johnson -- over the weekend, White House press secretary Sean Spicer confirmed yesterday. “The president talked extensively with several Republican members over the weekend and he felt very positive about those discussions, but they’re ongoing,” Spicer said, according to the Hill.

But no matter what happens this week, Trump is likely to break many of his health-care promises, The Post's John Wagner, Abby Philip and Jenna Johnson report.

"As Republicans in the Senate press ahead with legislation that would dramatically cut Medicaid and scale back the Affordable Care Act marketplaces, it is increasingly clear that President Trump is almost certain to fall well short of fulfilling those promises," they write.

"Trump and congressional Republicans will likely hail any bill that reaches the president’s desk as the fulfillment of a long-standing pledge to 'repeal and replace' the ACA, former president Barack Obama’s signature health-care law. But if the House and Senate agree on legislation along the lines of what is now being debated, millions — including some of Trump’s most ardent supporters — are projected to lose coverage, receive fewer benefits or see their premiums rise."

--Technically speaking, the Senate health-care bill doesn't cut Medicaid benefits -- it cuts the federal contribution to Medicaid programs, which are run by the states. In theory, states could choose to make up the difference out of their own pocketbooks in order to keep eligibility and benefits steady. But the reality is that most states won't be able to afford it, resulting in shrinking Medicaid programs around the country. So GOP claims their measure wouldn't cut Medicaid are suspect.

"Republicans have in recent days taken to defending against some of the biggest criticisms of their bill using claims that are highly questionable and misleading, at best," The Posts's Aaron Blake writes. "What's notable in all of it is that the GOP isn't really even trying to sell a more conservative, limited-government approach to health care; they're pretending their bill doesn't actually reduce benefits or coverage, basically at all."

"Chief among these credulity-straining claims was White House counselor Kellyanne Conway's contention Sunday that the GOP bill doesn't actually cut Medicaid," Aaron continues. "But Republicans have also suggested that the bill won't reduce the number of Americans who are insured or enrolled in Medicaid. None of these square with the reality of what the GOP is proposing."


--Senate Democrats led by Cory Booker of New Jersey staged a protest on the steps of the U.S. Capitol last night where they talked for hours as activists filed in and out to watch. The tone alternated between grim stories of people who would lose access to Medicaid and in-jokes between the senators, my colleague Dave Weigel reports.

“We've brought in Papa Smurf!” Booker exclaimed when top Senate Democrat Schumer arrived to participate.

“Michael Bennet is giving such an amazing speech on the floor,” said Schumer, referring to the Colorado Democrat delivering a floor speech at that moment. “He's so passionate and strong.”

Earlier in the day, Schumer and other Democrats blasted the Senate health-care bill for its CBO projection that millions fewer people would have coverage under it, largely due to its deep cuts to federal Medicaid spending.

Sen. Patty Murray of Washington used President Trump's "mean" reference to describe the bill:

--The thing is, Democrats can't do much of anything to stop Republicans from passing a massive Obamcare overhaul. They've been bashing the Senate's Better Care Reconciliation Act all over social media and plan to offer amendments to it. But Sen. Bernie Sanders is their only member capable of pulling big crowds together in a hurry to rally against it, Dave reports from Columbus, Ohio.

"Bernie Sanders took the stage and got right to it, warning 2,200-odd Ohioans that their lives are at risk if Senate Republicans push through their health-care bill," Dave writes. "The Columbus rally, the largest of three that Sanders staged over the weekend in Rust Belt states that Trump won, was part of an aggressive, last-ditch push to stop the Senate bill...Last week, protesters packed Reagan National Airport to hector Republicans before they went home for the weekend. And a pro-Trump super PAC that bought ads to pressure Sen. Dean Heller (R-Nev.) found that AARP had been waging an air war against Heller for months — from the other side."

“Put yourself into someone else’s shoes,” Sanders told the crowd in Columbus. “What does it mean today, if you are struggling for your life, dealing with cancer, dealing with heart disease, dealing with diabetes, dealing with some chronic illness threatening your existence? What does it mean, when you read in the paper that Republicans might take away your insurance?”

A voice in the audience shouted out the answer: “You die!” “I say this not to be overly dramatic,” said Sanders. “If you take away health care from 23 million people, what will happen? People will die, by the thousands!”

--It was clear yesterday that some supporters of the Affordable Care Act hadn't quite done their geographical research. An aerial ad over Charleston, West Virginia, read "Sen. Heller: Keep your word. Vote no on Trumpcare," according to a tweet from Charleston Gazette-Mail Rob Byers. Someone needs to tell the pilot that Heller is from Nevada; the message should have targeted West Virginia Sen. Shelley Moore Capito.

The Health 202 is glad we don't (often) make 2,200-mile mistakes. Here are a few other interesting reads from around the web:

Unfortunately, the Senate Republican alternative, unveiled last week, doesn’t appear to come close to addressing their plight. Like Obamacare, it relies too heavily on government spending, and ignores the role that the private sector can and should play.
Sen. Ron Johnson (R-Wisc.) via The New York Times
They describe it as "a giant step in the wrong direction."
People with anxiety and depression may be consuming a disproportionate share of opioid painkillers.
Lenny Bernstein
The new policy is in line with the search giant's decisions on removing "revenge porn" and "fake news."
Alex Schiffer
The DNA age is here. But what are we supposed to do with the information?
Carolyn Y. Johnson


    Coming Up

    • The Bipartisan Policy Center will hold an event Wednesday on cybersecurity and medical devices.
    • The Cato Institute will hold a briefing Wednesday on Capitol Hill on how the federal government should address the opioid crisis.
    • The Bipartisan Policy Center will hold an event on Thursday on balancing Medicaid cost and coverage.
    • American Enterprise Institute will hold an event on Thursday on the government’s role in medical innovation.

    Fact Check: The GOP's spin on Obamacare premiums:

    What's in the CBO report on the Senate health-care plan:

    'Pharma bro' Martin Shkreli is on trial for securities fraud: 

    Seth Meyers on the CBO score for the Senate GOP's health plan: