THE PROGNOSIS

Out front, the Senate health-care bill is currently stalled. But GOP leaders are working frantically behind the scenes on revisions that could open the door to 50 votes they need to pass the measure next month.

Senate Majority Leader Mitch McConnell (R-Ky.) is aiming to ship an updated version of his Obamacare overhaul to the Congressional Budget Office as early as tomorrow. He’s working on a tight timeline – the CBO needs a week or two to evaluate a revised measure, potentially allowing Republicans a handful of legislative days at the end of July to get it passed before August recess starts.

Among the changes being seriously contemplated are more funding to combat opioid abuse -- a key ask of Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.) -- and expanded use of tax-free health savings accounts. The bill will certainly need components that appeal to the nine or so senators currently refusing to support it: Moderates want to see fewer Medicaid cuts while conservatives are insisting the bill roll back more of Obamacare’s insurance regulations.

Sen. Rand Paul (R-Ky.), who is currently opposing the measure, even suggested yesterday to Fox News that McConnell should split it into two bills -- a narrow one that repeals parts of the ACA and another one with federal assistance that moderate Republicans and Democrats could support. Paul also released details of changes he wants.

With an eye toward building a seemingly impossible consensus, McConnell spent most of yesterday afternoon in a revolving door of meetings which included Capito along with Sens. Dean Heller (R-Nev.), Bob Corker (R-Tenn.), Tom Cotton (R-Ark.) and Alaska’s two Republican senators, Lisa Murkowski and Dan Sullivan.

“It is important to me that lower-income citizens have the ability to actually purchase plans that insure them and give them health care,” Corker told The Post’s Sean Sullivan and Kelsey Snell after his meeting with McConnell. “My hope is and my belief is that it is going to be addressed.”

McConnell and his aides plan to continue negotiations through the end of the week and will be in frequent communication with the CBO, spokesman David Popp said. Yet the majority leader is fresh off a turbulent few days, in which his plans for a vote this week started coming off the tracks over the weekend and completely derailed on Tuesday.

“The process so far has been messy and revealing of tensions between Trump and the GOP Senate, as well as between McConnell and the senators he has long been known for managing with steely efficiency,” Sean and Kelsey write, along with Robert Costa and Juliet Eilperin.

“It’s sad, in a way,” Paul said in an interview Wednesday. “We control all three branches and yet we’re not interested or able to do what we’ve pledged. People are too focused on getting more federal subsidies and other things, not on the pledge itself.”

That Republican disconnect has been a constant ever since the Senate health bill was unveiled. Members even had different takes on their Tuesday meeting at the White House with Trump, where the president encouraged them to come to agreement.

“White House officials and Trump loyalists saw a president diving in to patch up strife and save legislation that had been curbed in the Senate,” my colleagues write. “Some seasoned senators, however, saw a president unable to grasp policy details or the obstacles ahead, and talked with each other after the meeting about what they saw as a bizarre scene.”

At one point, Trump told the room that if they don’t get the bill done, it’s “okay.” That comment prompted some senators to exchange concerned glances during the meeting, my colleagues report. “To a number of them, Trump’s aside had the same ring as his comment a week earlier about the House’s health bill being ‘mean,’” they write. “His enthusiasm, to them, was debatable.”

McConnell’s advisers had quietly turned to the White House last Friday to help with the cause, but did not ask for a full-fledged push, as McConnell wanted to keep the negotiations inside the Senate.

As Republican aides worked through the weekend in hopes of teeing up a vote this week, things began to look bleaker and bleaker. Heller kept backing away under political pressure and the CBO concluded the bill would cause 22 million fewer Americans to be insured in the coming debate.

A lobbyist close to Senate Republicans said the score in particular was a devastating blow to McConnell. Senators felt they had been “sold a bill of goods,” the lobbyist said, and had expected the Senate bill to have greater distance from the House bill.

“It knocked the wind out of all the sails,” a GOP aide told my colleagues.

The question now is whether a gust will kick up again when senators return to town post-fireworks and barbecue. Democrats fear it will.

From Sen. Chris Murphy (D-Conn.):

Senate Minority Leader Charles E. Schumer (D-N.Y.), who's been telling McConnell to "start over" on health care:

And Democratic Sen. Jeff Merkley of Oregon:

AHH, OOF and OUCH

AHH: Some Republican gubernatorial candidates are growing queasy as they are asked to defend the Senate health-care bill — and Democrats are eager to pounce, the Post's John Wagner and Fenit Nirappil report.

"Thirty-eight states are holding gubernatorial contests this year and in 2018," John and Fenit write. "The challenge for Republicans is particularly pronounced in swing states and in those that have expanded Medicaid coverage under former president Barack Obama’s signature health-care law, the Affordable Care Act. Both the House and Senate health-care bills would phase out federal funding for those efforts, leaving the 31 states that took advantage of the provision to pick up the tab if they want to continue it....That is one of several ways in which implementation of the GOP health-care legislation would fall to the states, raising the stakes for gubernatorial candidates to lay out their positions."

--In Virginia, Republican gubernatorial nominee Ed Gillespie is getting peppered with questions about the effort to repeal the ACA and he has declined to take a clear position.

--Maryland Gov. Larry Hogan, a Republican who is up for reelection next year, says the GOP health-care plans “do not work” for his state, but he is still getting badgered by Democrats to speak out more forcefully against Trump.

--And in Illinois, Republican Gov. Bruce Rauner is taking flak for saying he still needs time to study the GOP bills. A mailer sent this week by one Democrat hoping to challenge him in 2018 showed a pair of boxing gloves and called Rauner and Trump “a one-two punch that could knock out your health care.”

OOF: Guess what? Voters generally don't like rolling back government-funded benefits. A Morning Consult/Politico poll published yesterday found that a majority of registered voters do not approve of the Senate health-care bill's cuts to federal Medicaid spending — 53 percent disapprove of the funding reductions while just 27 percent said they support the approach. Trump is likely to sign whatever health-care bill Congress sends his way, but many of his supporters don't approve of deeply cutting Medicaid. Forty-one percent of Trump voters oppose the cuts while 39 percent support them, the poll found.

--Numbers from Wednesday’s Quinnipiac poll don’t look great for Senate Republicans either. The poll found 46 percent of voters are less likely to vote to reelect a member of Congress who supports the plan. Just 37 percent of Republican voters approve of the plan overall and a majority objects to one of its key elements -- 53 percent oppose reducing federal funding for Medicaid. Twenty-nine percent of voters overall approved of President Trump’s handling of the health care effort.

--And one more sucker-punch to the GOP's collective gut: A USA Today/Suffolk University’s poll says just 12 percent of voters overall support the bill.

OUCH: Some schools are worried about how the Senate health bill’s cuts to Medicaid could affect funding for special-education students and students from low-income families. My colleague Emma Brown reported that the bill could strip up to $4 billion annually on money that pays for nurses, social works, physical, occupational and speech therapists, medical equipment and comprehensive health services.

“Many school districts, already squeezed by shrinking state education budgets, say that to fill the hole they anticipate would be left by the Republican push to restructure Medicaid, they would either have to cut those services or downsize general education programs that serve all students," Emma writes. "Schools receive less than 1 percent of federal Medicaid spending...But federal Medicaid reimbursements constitute the third-largest federal funding stream to public schools."

Sasha Pudelski, who tracks health care policy for the School Superintendents Association, told Emma that “the kids who will be hurt first and foremost are special ed kids and kids in poverty, but then everybody will be hurt, because we’ll have to shift dollars from the general education budget.”

TRUMP TEMPERATURE

Trump pushed back yesterday against reports that he lacks effectiveness in rallying Republicans around a health-care bill:

--Trump has been using some big words to frame the whole effort, describing his Tuesday roundtable with Republicans senators as “tremendous." Yesterday, he said that getting approval for the bill will be "very tough" but said "I think we are at least going to get very close or get it over the line.” The president also teased a “big surprise coming” on the GOP health-care effort.          

“And just to do a little official business, health care is working along very well. We could have a big surprise with a great health care package. So, now they're happy,” Trump said at the White House, My colleague Abby Phillips reported.

When asked to elaborate, Trump just repeated: “I said you’re going to have a great, great surprise. It’s going to be great.” 

NBC News' Bradd Jaffy tweeted a video of Trump’s comments: 

--Trump also tweeted yesterday that federal Medicaid spending would increase under the Republican health-care plan, along with a graph: 

--In rough numerical terms, Trump is right: The total amount of money spent on Medicaid under the Senate Republican plan would grow, albeit slowly, from 2017 to 2026. But the number is misleading. Medical costs tend to rise more quickly than inflation, yet the Senate bill is designed so that increases in the cost of health care will eventually outpace annual increases in Medicaid, my colleagues Damian Paletta and Carolyn Y. Johnson write.

"The accounting he uses to show Medicaid spending is wildly divergent from the way budget analysts, policymakers and many lawmakers account for spending levels," Damian and Carolyn write. "Medicaid spending under the Republican plan would not increase when accounting for the inflation of medical costs. In fact, it would mark a 'a reduction of $772 billion in federal outlays for Medicaid' over 10 years compared with what would happen if the Senate bill is not enacted into law, the Congressional Budget Office said Monday."

Vox's Sarah Kliff pointed out that Trump could be right if it weren't for "baselines, population growth, inflation":

BuzzFeed's Paul McLeod made a similar point:

PolitiFact looked into the claim and explained further:

And from Marc Goldwein, policy director for the nonpartisan Committee for a Responsible Federal Budget:

HEALTH ON THE HILL

--If Senate Republicans don't manage to pass their health-care bill, it will be a humbling defeat for McConnell, who thrives on his ability to play the behind-the-scenes game, my colleague Paul Kane writes

"For the last decade, Senate Majority Leader Mitch McConnell has forged a reputation as a closer on big deals," Paul writes. "There was the Wall Street bailout just before the 2008 elections. There was the pact over the summer of 2011 to slash spending and avoid a federal default. And there was the 2012 New Year’s Eve 'fiscal cliff' compromise to avoid massive tax increases....But this week, McConnell (R-Ky.) fell short in crafting a Republican plan to repeal portions of the Affordable Care Act and redraw vast amounts of Medicaid policy."

"It illustrates how, 10 years after taking over as Republican leader, McConnell still struggles to corral his caucus and how this has left something missing in his legacy: a sweeping rewrite of big policy along the lines of revamping the health-care system," Paul continues.

Speaking outside the White House on Tuesday, McConnell said the situation will end "one of two ways." “Either Republicans will agree and change the status quo or the markets will continue to collapse and we’ll have to sit down with Senator Schumer," McConnell said.

--Let's talk biology. Sen. Bill Cassidy (R-La.) said yesterday that he didn't want to see maternity care coverage cut from insurance plans under the Senate bill because men are affected by pregnancy, too. As the measure currently stands, states could get waivers allowing insurers to opt out of coverage essential health benefits which include prenatal care.

“Yes, you want cheaper plans, absolutely ... Unless you have a common risk pool, you end up with policies that don’t cover maternity. As best I tell, women don’t get pregnant without sperm,” Cassidy said to reporters, according to my colleagues Sean Sullivan, Juliet Eilperin and Kelsey Snell.  

The Post’s Dave Weigel tweeted Cassidy’s remarks: 

Cassidy won some praise from an unlikely corner: Planned Parenthood President Cecile Richards, whose group could no longer get Medicaid reimbursements for one year under the Senate bill. Richards offered a sarcastic response, but also said Cassidy is right.

 

--Speaking of Planned Parenthood, the two Senate Republicans who support abortion rights plan to offer an amendment to the health-care bill that would strip out its provision to defund the women's health and abortion provider. Alaska Sen. Lisa Murkowski and Sen. Susan Collins of Maine plan to introduce such an amendment, the Alaska Dispatch News reports. Offering the amendment could give them political cover to vote for the bill even if the defunding provision ultimately remains in.

Planned Parenthood held a rally next to the U.S. Capitol building last night, where activists and Democratic lawmakers slammed Republicans for targeting the group in its bill. As the Senate measure currently stands, Planned Parenthood clinics couldn't get Medicaid reimbursements for a full year if the group continues to provide abortions.

My colleague Ed O'Keefe was there:

--You're not hearing so much about Obamacare repeal from conservative media, Dave Weigel notes. "The lack of 'Obamacare repeal' coverage, unthinkable just six months ago, reflected a general decline of conservative interest in what had united Republicans for seven years," Dave writes. "Conservative grass-roots groups have either ignored the latest health-care details, like Americans for Prosperity, or lobbied against the bill, like the Club for Growth."

PRICE CHECK

--Amid all the drama around the Senate health-care bill, don't forget there are state insurance marketplaces that millions of Americans are relying on for health coverage -- and some areas are not doing so well. The Centers for Medicare and Medicaid Services projected this week that 49 counties won't have any insurers next year and as many as 1,300 counties (more than 40 percent of all U.S. counties) may have only one insurer. About 2.4 million people live in counties with potentially one or no insurer in 2018, CMS said. The agency included a map to illustrate the situation. 

“We continue to see a decline in issuer participation in the Health Insurance Exchanges leaving consumers with fewer and fewer insurance options,” said CMS Administrator Seema Verma.  “I am deeply concerned about the crisis situation facing the individual market in many states across the nation.”

Now, the fat lady hasn't sung quite yet. Insurers are still able to submit bids to federal-run marketplaces over the next seven weeks, and then they have until September 27 to finalize their plans. That means states like Ohio, where dozens of counties are short on marketplace insurers, will be busy cajoling issuers to hop on board so their residents don't have to go without coverage altogether.

MEDICAL MISSIVES

First in The Health 202: One in five people fill at least one opioid prescription annually, according to a survey of medical claims from the Blue Cross Blue Shield Association. The survey, based on data from 2010 to 2016, also found that diagnoses of opioid use disorder spiked 493 percent since 2010. A few other interesting data points from the survey:

--There was a 65 percent increase in the use of medication-assisted treatments over the same time period. States with the highest growth in medication-assisted treatments weren't necessarily the areas most affected by opioid abuse.

--Among those 45 and older, women abused opioids at a higher rate than men, but it reverses for those under 45. Women fill more opioid prescriptions than men across all age groups.

--The highest rates of opioid abuse were in the South and the Appalachian region.

Some more interesting reads from around the Web:

Middleton, Ohio, has spent a tenth of its tax revenue responding to opioid overdoses.
Cleve R. Wootson Jr.
The FDA may relax the rules that force drug makers to cram long lists of potential side effects into their ads. The ad companies can't wait to get creative.
STAT News
An analysis forecasts that things will get worse — maybe much worse — before they get better.
Vox
A report on the first six months of California's End of Life Option Act.
Derek Hawkins
INDUSTRY RX
Analysts predict that higher overall insurance costs would frighten away lower-income Americans.
Amy Goldstein
REPRODUCTIVE WARS
Women in the military and dependents of service members could soon have free access to birth control, even when not on active duty, after a Senate panel included the provision in an annual defense bil
BuzzFeed
DAYBOOK

Today

  • The Bipartisan Policy Center will hold an event on balancing Medicaid cost and coverage.
  • American Enterprise Institute will hold an event on the government’s role in medical innovation.
SUGAR RUSH

Protesters gather outside the Capitol to demonstrate against the Senate Republican's health-care bill: 

President Trumps says he wants a "great, great form of health care":

A new poll finds the Senate health-care plan is deeply unpopular:

And Stephen Colbert says "Trump thinks health care is something you can win":