Did you think the Senate's high-stakes drama over revamping Obamacare was going to wrap up this week? No such luck. Majority Leader Mitch McConnell  (R-Ky.) has been forced to postpone his planned vote on health-care legislation because care, actually. Sen. John McCain (R-Ariz.) will be recovering from surgery for a blood clot over his eye over the next few days, depriving Republicans of an essential vote they'd need to pass the bill.

It's bad timing for McConnell. The din of opposition to the bill is only getting louder -- over the weekend, some key GOP governors reiterated their concerns about the legislation and Sens. Rand Paul (R-Ky.) and Susan Collins (R-Maine) dug in even deeper against it. The libertarian-minded Paul, who is arguing the bill doesn't repeal nearly enough of Obmacare, predicted that prolonging the vote will just push the legislation closer to the edge of the cliff.

“The longer the bill is out there, the more conservative Republicans are going to discover it is not repeal,” the Kentucky Republican said yesterday in an interview with CBS.

And now even health insurers, which had mostly held their fire, are joining the ruckus. According to them, the bill is even worse than before, now that it would dramatically undercut many of the ACA's protections for people with health conditions per an amendment added at the behest of Sen. Ted Cruz (R-Tex.).

“It is unworkable in any form and would undermine protections for those with significant medical conditions, increase premiums and could lead to widespread loss of coverage for people currently enrolled in the individual market,” wrote the insurer trade group, America’s Health Insurance Plans, and the Blue Cross Blue Shield Association.

We're awaiting word from the Congressional Budget Office this week on whether the Cruz amendment would result in even more than 22 million Americans becoming uninsured (that's its projection for the original bill). Insurers are predicting the amendment will prompt even more uninsured people than that -- by a long shot. “This provision will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market," they wrote. "As a result, millions of more individuals will become uninsured.”

It's not that health insurers are so enthused about the present state of things -- they're deeply worried about the Obamacare marketplaces in several states where consumers will have extremely limited plan options next year.

Cigna CEO David Cordani, whose company is selling Obamacare plans in seven states, told me insurers must eventually be "self-sustaining" in the marketplaces for them to keep selling there. And that demands several baskets of policy responses from Congress and the executive branch, including certainty about subsidy payments, the rules around enrollment periods and enforcement of the individual mandate to buy coverage, he said.

"We need to start with the fact that the individual marketplace, as it currently stands, is not stable," Cordani told me.

But insurers don't expect the Cruz amendment to fix the situation. Under Cruz's so-called "Consumer Freedom Amendment," which is now part of the Senate's health-care bill, insurers could sell cheaper, stripped-down plans free of Obamacare coverage requirements like essential health benefits or even a guarantee of coverage, as long as they also sell one ACA-compliant plan. (I explained more in this edition of The Health 202 last week.) People with few health concerns, who rarely have a need to visit the doctor or buy medication, could purchase these bare-bones plans for a much lower monthly premium.

The idea sounds good in theory — free markets and freedom of choice — and it’s an proposal that's long been popular with conservatives. But actuaries and insurance experts say it doesn't comport with how insurance works, and would leave the millions of Americans with preexisting conditions high and dry (especially those who earn too much for federal subsidies).

Here’s how this all would play out if the Cruz language was enacted.:Insurance premiums paid by the vast majority of healthy people, who use relatively few medical services each year, currently cover the costs for those who are ill and require the care provided by the world’s most expensive health system. Ideally, this balances things out. People are covered for much of the care they get, insurance companies make a profit, and health- care providers are reimbursed for their services.

Yet if the sick and the well are sorted — or sort themselves — into separate pools, the system can start to fall apart. With the well no longer subsidizing the sick, the latter may face ever-escalating premiums or fewer choices entirely if insurers no longer are required to sell to anyone who wants to buy a policy.

In a related scenario, people who are priced out of the market because of a preexisting medical condition, who turn to a health plan with minimal coverage, can find themselves unexpectedly facing very high bills. So can individuals on such a plan who are diagnosed with a serious disease like cancer. Meanwhile, everyone else who receives insurance through the workplace or can afford to purchase robust coverage continues in a de facto separate system.

Americans with preexisting conditions without employer-sponsored coverage were in a real bind in pre-ACA days. The system favored young, healthy people who wanted to buy cheaper plans without all the frills. If the Cruz language were to become law, we'd go back to a similar system.

“If they sold you a policy that covered [only] a toothbrush, that qualified,” Karen Pollitz, senior fellow at the Kaiser Family Foundation, told my colleague Lenny Bernstein.

And indeed, those types of people have shied away from many of the Obamacare marketplaces, frustrated by premium hikes and willing to instead pay the relatively small fine for lacking coverage. That's partly why several state marketplaces are facing trouble next year, with no or a single plan option in some areas. So even though insurers are frowning on the Cruz amendment, they also realize the present situation is unsustainable, too.


AHH: Leading antiabortion group Susan B. Anthony List has given the thumbs-up to the Senate's health-care bill -- an endorsement that significantly improves the bill's chances of passing should it ever make it to the House floor. SBA List President Marjorie Dannenfelser announced Friday that her group will spend six figures on ads promoting the legislation because it defunds Planned Parenthood and contains other antiabortion language.

"Obamacare’s assault on innocent unborn children was an unprecedented expansion of abortion funding," Dannenfelser said in a statement on Friday. "This bill includes significant steps toward rolling back that damage and returning to the principle that abortion is not health care. Furthermore, re-directing $400 million of Planned Parenthood’s taxpayer funding would be the biggest ever blow to the abortion industry’s taxpayer funding."

Planned Parenthood couldn't get Medicaid reimbursements for non-abortion health services (it's already prohibited from using federal dollars on most abortions) for one year, under the Senate bill. The revised bill also contains language restricting any federally subsidized health plans from covering abortions -- although that part could still get stripped out under budget reconciliation rules governing the whole process. Dannenfelser acknowledged that reality, but said the final bill will still represent "meaningful progress for the pro-life cause." If other abortion-opposing groups fall in line, too, this would ease the pathway for many conservative House members to vote for the Senate measure.

OOF: If the Senate manages to pass its health-care bill -- and that's a mammoth IF -- the House seems ready to give it the nod, too, my colleague Paul Kane writes.

"Within two or three short weeks, the GOP will probably either be reveling in its unexpected victory or mired in deep infighting over the party’s failure to live up to a pledge it has made over the past seven years," Paul writes. "If McConnell can make it happen, House Republicans seem ready to quickly pass the Senate version of the legislation and send it to President Trump’s desk for his signature....At least that’s the assessment of two key House negotiators, one from the conservative and one from the moderate flank."

“I have no doubt in my mind that if it passes the Senate — in something close to what it’s like now — that it will pass the House,” said Rep. Tom MacArthur (R-N.J.), a moderate who negotiated portions of the bill that passed the House in early May, told Paul.

MacArthur's conservative counterpart, Rep. Mark Meadows (R-N.C.), was also surprisingly positive about the Senate bill, even though it differs in some big ways from the version the House passed in May. The Freedom Caucus Chairman called the latest Senate version “a step in the right direction” and suggested it would “have to be a big move” away from the current draft to sink the bill in the House. Either way, he said, conservatives will not object if the Senate bill comes to the House floor in a take-it-or-leave-it moment.

“I realize the reality is, we’re not going to change it when it comes back here,” Meadows said.

OUCH: A new Post/ABC poll shows Trump's standing with the American people has deteriorated since the spring, buffeted by perceptions of a decline in U.S. leadership abroad, a stalled presidential agenda at home and an unpopular Republican health-care bill. Surprisingly -- and yet not surprisingly -- Trump denounced it over the weekend in a tweet.

Here's where Trump stands with Americans after nearly six months in office. Trump's overall approval rating has dropped to 36 percent from 42 percent in April. His disapproval rating has risen five points to 58 percent. Overall, 48 percent say they “disapprove strongly” of Trump’s performance in office, a level never reached by former presidents Bill Clinton and Barack Obama and reached only in the second term of George W. Bush in Post-ABC polling.

On health care, the public by 63 to 27 percent says it is more important for the government to provide health coverage to low-income people rather than cutting taxes -- even though the Senate bill would repeal many of the ACA's taxes while enacting deep cuts to federal Medicaid spending. It also finds more people would rather keep the ACA at the end of the day.

"The survey points to many causes for Trump’s troubles," The Post's Scott Clement and Dan Balz write. "As Republican senators attempt to pass major health-care legislation, the poll finds about twice as many Americans prefer the Affordable Care Act, otherwise known as Obamacare, to GOP plans for replacing it — 50 percent to 24 percent. About a quarter volunteer either 'neither,' say they want something else or offer no opinion."


--Health-care was the topic du jour at the summer National Governor's Association meeting over the weekend in Providence, R.I., my colleagues Sean Sullivan, Juliet Eilperin and Dan Balz report. The White House dispatched several key officials to aggressively pressure a group of Republican governors to stop criticizing the Senate bill for its deep cuts to Medicaid spending. Vice President Pence joined Tom Price, President Trump’s Health and Human Services secretary, and Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, to work governors in front of cameras and behind the scenes.

"They offered a detailed pitch contrasting with the more general and sometimes contradictory rhetoric Trump has delivered on health care — but one that contained inaccuracies and quickly met with rebukes from health advocates. They claimed, for instance, that the bill would not throw millions off insurance and that disabled Americans have been denied care because of the expansion of Medicaid under the ACA," my colleagues write.

Yet four influential governors reiterated their concerns about the bill’s impact on their states’ most vulnerable individuals.

“I’ve still got to come back to my concerns with regard to the Medicaid population,” said Nevada Gov. Brian Sandoval (R) on his way to a private session with Pence. Pence had earlier delivered a detailed speech to the entire group defending the bill.

Sandoval’s views, along with those of three other Republican governors whose states expanded Medicaid under the ACA — John Kasich of Ohio, Doug Ducey of Arizona and Asa Hutchinson of Arkansas — could prove decisive in determining whether the Senate passes legislation next week. Republican senators from those states are closely watching how their governors respond to the revamped legislation as they decide whether to support it.

Sandoval spent his Saturday morning tucked away in a convention center ballroom where Price and Verma tried to convince him that everything would be okay for Nevada under the Senate health-care bill. They couldn’t, my colleagues reported from the scene.

"Among the 32 state executives who attended the National Governors Association summer meeting here this weekend, no one drew more attention and interest than Sandoval, a square-jawed 53-year-old with neatly parted dark hair, a made-for-TV smile and a political disposition that is the antithesis of President Trump," Sean and Dan write. "All weekend, he has been besieged — by reporters taking his temperature and by administration officials, including Vice President Pence, trying to persuade him that the Senate bill would not hurt his Nevada constituents despite its deep federal spending cuts to Medicaid."

Sandoval wasn't buying it. “I’m no different than I was,” he told reporters after the Price/Verma meeting. Sandoval said he is likely to come to a final decision “early next week.”

--When you understand Sandoval, it's easy to see why Nevada Sen. Dean Heller (R), who is up for reelection next year, may ultimately vote against the Senate bill, fatally derailing it. Heller's Las Vegas office was broken into over the weekend -- details are still emerging, but it comes as he's under tremendous political pressure to oppose the measure.

Some more good reads from around the web:

I debated a former top Senate GOP staffer about why he thinks Republicans need it.
Aaron Blake
It can take 45 minutes for outside ambulances to clear NIH's security perimeter.
Lena H. Sun
An independent health panel looked at what might help prevent cardiovascular disease.
Paul Sisson
A study finds “serious medical outcomes” from taking the wrong dose or the wrong drug.
Rachel Rettner
The Republicans’ proposal to overturn Obamacare could allow insurers to sell bare-bones plans that fail to pay for what is now deemed essential medical care.
The New York Times
Lyon County, Nev., reflects the special vulnerability of rural communities to Washington’s health-care politics.
Amy Goldstein


  • The Center for American Progress Action Fund holds an event on access to prescription drugs with Rep. Frank Pallone Jr. (D-N.J.).

Coming Up

  • The Hill holds an event on mental health care with Virginia Gov. Terry McAuliffe (D) and Rep. Leonard Lance (R-N.J.) on Tuesday.
  • The House Energy and Commerce Oversight and Investigations Subcommittee will hold a hearing on the 340B Drug Pricing Program on Tuesday.
  • The National Pharmaceutical Council holds a webinar on patients’ out-of-pocket costs on Tuesday.
  • The House Ways and Means Oversight Subcommittee holds a hearing on waste, fraud and abuse in Medicare on Wednesday.
  • The Manhattan Institute will hold an event on drug pricing featuring former Rep. Tom Coburn (R-Mich.) on Wednesday.
  • The National Press Foundation will hold an event on preventative health care on Wednesday.
  • The Hill is hosting an event on the prescription drug delivery system on Thursday.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on bipartisan legislation to improve Medicare on Thursday. 

Sens. Susan Collins (R-Maine) and Rand Paul (R-Ky.) criticize revised Senate health-care bill:

Former presidents George W. Bush and Bill Clinton talk about humility in the Oval Office:

Watch flamingos flock to new a habitat at the National Zoo:


And watch Stephen Colbert's book report on the new exposé from Stephen K. Bannon: