THE PROGNOSIS

Thanks to the Senate's health-care fiasco, we have the perfect example of how easy it is for politicians to cast a staged vote when it has no political repercussion but chicken out as soon as it does. Let's remember that two of the three Republican senators now refusing to support a bill only repealing Obamacare without replacing it voted for exactly this measure a year and a half ago.

As yesterday unfolded, it became clear that not only will the Senate GOP fail to pass its bill partially replacing the Affordable Care Act, but Majority Leader Mitch McConnell (R-Ky.) also lacks the votes to pass legislation simply repealing much of it -- even though nearly every sitting Republican voted for this same measure back in 2015, despite the Congressional Budget Office projection that it would cost 32 million Americans their health coverage.

The difference then was that Republicans knew an outright repeal wouldn't become law, not with a Democratic president in the White House. At the time, it was their way to score points with their base by playing the part of rescuer from President Obama's health-care law, which for years they've used as a political punching bag. They were free to support repeal because the coverage losses were just theoretical --  abstract number they didn't need to reckon with as reality.

It's a totally different story now, with President Trump eagerly waiting on the sidelines to sign whatever bill Republicans send his way chopping away at Obamacare.

McConnell says he'll now try to bring a 2015 repeal-only bill to the floor, instead of the health-care bill his conference has rebelled against, holding a vote early next week to start debate. The health-care push has been “a very, very challenging experience for all of us," McConnell told reporters yesterday. Asked whether he would eventually be open to working with Democrats on something, McConnell said “we’ll have to see what happens” with the repeal-first effort.

But barring some divine intervention, we pretty much know what will happen. Sens. Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska have said they'll vote against even starting debate on a bill that only repeals the ACA, putting leaders one vote short of the 50 they'd need -- and leaving Republicans in massive meltdown mode in their longsanding request to repeal and replace Obamacare.

Capito ruled out the possibility that she'd vote for an Obamacare repeal without a replacement:

Murkowski said that repealing the ACA without a clear path forward "just creates confusion and greater uncertainty:"

But when Capito and Murkowski voted for a repeal-only bill in December 2015, they said its two-year delay would give Congress enough time to pass a replacement so that insurance markets wouldn't be disrupted. That measure would have repealed the ACA's insurance subsidies, Medicaid expansion, taxes and individual and employer mandates. Republicans knew President Obama would veto it -- which he did -- but they said they were preparing for just such a time as now when they have a Republican in the White House to sign repeal legislation.

Capito, who also voted dozens of times as a member of the House to repeal parts of the ACA, said at the time that the bill "will enable us to revisit the problems caused by Obamacare and replace them with reforms that provide quality, affordable care for all Americans." Capito touted the measure's two-year transition period, saying it "will allow us time to enact alternative reforms without disrupting coverage."

"This law is not affordable for us in Alaska and that's why I support the bill that repeals the ACA and wipes out these harmful impacts," Murkowski said on the Senate floor at the time. "We can't stand by and see these premiums shoot through the roof."

Other Republican centrists who are now trashing the idea of repeal-first-replace-later also praised the 2015 bill as they voted for it. Sen. Rob Portman of Ohio, who yesterday expressed concern about a repeal-only bill, said at the time one was passed that it would give Congress "time to come up with bipartisan reforms to better cover the uninsured."

Collins is the only sitting Republican who voted against the 2015 Obamacare repeal bill. Every single other current GOP senator -- with the exception of freshmen Sens. Todd C. Young of Indiana and John Kennedy of Louisiana, who weren't yet around -- signed onto it, most with great enthusiasm. One senator -- Rand Paul of Kentucky -- was eager to point that out yesterday.

"People ought to keep their promise," Paul told Fox News host Martha MacCallum. "If people are no longer for repeal, they’re going to need to go home and explain to their voters why they said they were for repeal and now they’re no longer for repeal."

Reporters noted the flips, too:

From the Washington Examiner’s Robert King:

From Bloomberg's Sahil Kapur:

Rep. Dave Brat (R-Va.), a member of the House Freedom Caucus, spoke with The Hill's Scott Wong: 

YouTube remembers how senators supported the 2015 repeal bill, conservative Club for Growth noted:

Nonetheless, Trump plans to have lunch today with the entire Senate GOP conference. It's unclear what the goals are, but we're sure to get some colorful quotes this afternoon:

TRUMP TEMPERATURE

--President Trump is determined that whoever is blamed for problems with Obamacare, it ain't gonna be him. The president reacted several times yesterday to the collapse of Senate Republicans' health-care effort. First, he cast stones on Democrats for refusing to go along with it all, which in turn prompted Republicans to use the budget reconciliation process so they'd only need 50 votes:

Then Trump attacked his fellow Republicans, telling reporters he was "disappointed" and slamming them for failing to act. For seven years he's been hearing about their plan to repeal and replace, even as a civilian, he noted.

“When we finally get a chance to repeal and replace, they don’t take advantage of it,” Trump told reporters at the White House, The Post's Juliet Eilperin and Sean Sullivan reported.

But instead of admitting to the serious divisions crippling his party, Trump was as bullish as ever. Republicans will still win at basically everything else, he said. "We’ll go on and we’ll win,”  Trump said, adding that “we’re going to win on taxes, we’re going to win on infrastructure and lots of other things that we’re doing.”

As for the health-care situation, Trump's ready to jump ship altogether and let things play out as they will in the Obamacare marketplaces. He is certain that Republicans won't bear any blame, although polls indicate otherwise.

“I’ve been saying for a long time, let Obamacare fail and then everybody is going to have to come together and fix it and come up with a new plan that’s really good for the people, much lower premiums, much lower cost, and much better protection,” he said. “And I think we’re probably in that position where we’ll just let Obamacare fail. We’re not going to own it."

But the president is now threatening to gut the marketplaces he is charged with enforcing, Paul Demko and Josh Dawsey report. Today is the deadline for the administration to distribute cost-sharing subsidies to help support low-income Americans get health care: "Trump has repeatedly told aides and advisers that he wants to end the subsidy payments, and he has not changed his position, according to several people who have spoken with him. 'Why are we making these payments?' Trump has asked ... 'My advice to the plans this morning was, ‘If you get it, cash the check quickly,’ one health care lobbyist who represents insurers said Tuesday. Two White House officials said a final decision on the subsidies had not been made. One person said various aides and advisers had issued conflicting opinions in recent days."

From Trump himself:

My colleague Philip Bump drew a humorous parallel to Trump's history as a business owner:

Trump managed to brag a little bit publicly, saying the vote would still have been close if just four Republicans defected in the end (a highly unlikely scenario). “Essentially the vote would have been pretty close to, if you look at it, 48-4," Trump said. "That’s a pretty impressive vote by any standard.” 

--But behind the scenes, Trump let Republicans see how frustrated he was with their seemingly endless and complicated effort to pass a health-care bill. At a Monday night dinner with key senators, he complained about Sen. Paul, who went on the weekend shows to criticize the measure.

“It is one thing to vote no," Trump told the group, according to the New York Times. "It is another, the president said, to go on all of the Sunday shows and complain about it."

Another senator who was at the White House dinner, Sen. Steve Daines (R-Mont.), recounted the somewhat bewildering experience to my colleagues Robert Costa, Kelsey Snell and Sean Sullivan.

“The president talked about France and Bastille Day,” Daines said, recalling the president’s tales during dinner of parades and pomp from his recent trip to Paris. Daines described the group’s conversation, which also touched on issues ranging from health care to the debt limit, as loose — "as if Trump sat down and went out to dinner with friends, acquaintances, people you work with. It was just dinner to talk about what’s going on.”

"As the dinner ended, reality returned," my colleagues write. "Two more Republican senators had suddenly bolted from supporting the health-care bill, lifting the total number of Republicans opposed to four and effectively killing it....The upheaval Monday night was a tipping point after weeks of burbling discontent within the party about whether passing the legislation made sense. Nearly every GOP senator was eager to check the box of repealing and replacing the Affordable Care Act they had long opposed — but many were also distressed by the possible costs of upending a law that has grown deep roots in states, risen in popularity and is relied upon by some Republican governors."

--My colleague Jenna Johnson takes us on a trip down memory lane to a policy speech Trump made in the Philadelphia suburbs days before the November election, where he promised the crowd he would call a “special session” of Congress as soon as he took office to “immediately repeal and replace Obamacare.”

“If we don’t repeal and replace Obamacare, we will destroy American health care forever,” Trump said. “It’s one of the single most important reasons why we must win on November 8th. We must win.”

“Since Trump became president, his promise to repeal and replace the Affordable Care Act is nowhere close to being fulfilled, despite his repeated, confident assertions on the campaign trail that it could be done in just a day," Jenna writes. "The failure of health-care legislation in the Senate this week shows Trump still has not learned how to navigate Congress — and how much he is struggling to be the dealmaker, fighter and winner he portrayed himself to be to voters.”

--And then there are Trump's many, many tweets. The president's extensive Twitter history — 35,300 tweets and counting, stretching back to 2009 — virtually guarantees that there's a past tweet to serve as an ironic exclamation point for just about any moment of his presidency, The Post's Christopher Ingraham writes.

"But at no point in Trump's tenure has the president found himself contradicted so much by his own prior tweets as the (perhaps) final implosion of his Obamacare repeal aspirations, which he made a major issue in his campaign," Chris writes. "The bill's failure in the Senate has caused Trump to make the kinds of arguments he's criticized in the past."

A few prime examples:

Trump in 2017: “Let Obamacare fail... I'm not going to own it.”

Trump in 2013:

Trump in 2017: “With only a very small majority, the Republicans in the House & Senate need more victories next year since Dems totally obstruct, no votes!”

Trump in 2012:

--Vice President Pence chimed in yesterday on the Senate's health-care denouement, warning that “inaction is not an option.” He seemed a little, shall we say, overly optimistic.

"The Senate should vote to repeal now and replace later or return to the legislation carefully crafted in the House and the Senate. But either way, inaction is not an option," Pence told the National Retail Federation. "Congress needs to step up, Congress needs to do their job and Congress needs to do their job now."

“President Trump and I fully support the majority leader’s decision to move forward with a bill that just repeals Obamacare and gives Congress time, as the president said, to work on a new health care plan that will start with a clean slate,” Pence added.

AHH, OOF and OUCH

AHH: My colleague Dave Weigel lays out Trump's political rescue strategy for Republicans. Step One: Blame Democrats. Step Two: Win more seats and try again.

“We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it,” Trump said yesterday. “In ’18, we’re going to have to get some more people elected. We have to go out and get more people elected that are Republicans.”

"Trump made explicit what Republicans had been hoping since the repeal fight started — that whatever happened, voters would blame the Democrats for their health-care costs," Dave writes. "It’s an audacious strategy that flies against current polling and electoral history. It counts on messaging, distracted voters and a built-in electoral advantage to guide the party past the rocks."

OOF: House Republicans -- who just three months ago struggled through their own drama to pass a health-care bill -- watched the Senate with dismay yesterday. Speaker Paul D. Ryan  (R-Wis.) appeared to express some frustration with his colleagues in the upper chamber with their failure to move forward, although he refrained from any harsh criticisms.

Watch Ryan's remarks below:

"They’re working through their process, I’m not going to get ahead of their next steps because frankly we just have to see what they can do and find out where it is we can go because we have a serious problem on our hands," Ryan said.

OUCH: Only a small minority of voters in "Trump counties" support the (now mostly dead) GOP health-care effort, says a new NBC News/Wall Street Journal poll. Just 12 percent of voters in counties that went for Trump in the election thought the health-care legislation passed by House lawmakers in May was a good idea, while 41 percent said it was a bad idea.

INDUSTRY RX

The collapse of the Senate health-care efforts creates uncertainty for 10 million Americans who buy health-care plans through Obamacare’s marketplaces and they could face another rough few months ahead, my colleague Amy Goldstein and I report. Insurers must decide how to respond to the fate of the Republican bill.

“Some companies could become more skittish about staying in the marketplaces for 2018, while others could try to ratchet up their prices depending on how events in Washington unfold,” Amy and I write.

And although President Trump declared on Tuesday that he believes it’s time to “let Obamacare fail,” Amy notes two decisions the White House has left to make:

“Most immediately, the administration has the power to decide whether to halt the billions of dollars in payments to health plans that help their lower-income ACA customers afford deductibles and other coverage expenses. Those cost-sharing subsidies benefit 7 million Americans. The president could turn off the spigot by dropping an appeal of a federal lawsuit filed by the House of Representatives over the payments’ legality.

The other decision is whether to ease off enforcement of the ACA’s penalty for Americans who shirk the coverage mandate. Trump cannot end the mandate without a change in law, but the Internal Revenue Service recently said it would continue to process refunds even when taxpayers flout a requirement to file proof that they have health coverage. The administration could go further.”

A White House spokesman said the administration is still “considering our options.”

One insurance industry official said the chaos within the Senate and the White House “just continues the sort of volatile environment… It’s adding uncertainty to what was already an uncertain climate.”

Though Republicans have been warning that the ACA marketplaces are on the verge of collapse, last month's study from the Kaiser Family Foundation found the insurers, on average, “are on a path toward regaining profitability in 2017.”

But Larry Levitt, Kaiser’s senior vice president, cautioned: “That could still all blow up through administration actions or what Congress might do.” 

STATE SCAN

--A bipartisan group of senators penned a joint statement urging senators to “immediately reject” the repeal-only plan.

"Congress should work to make health insurance more affordable by controlling costs and stabilizing the market, and we are pleased to see a growing number of senators stand up for this approach," the group said in a statement.

“The senate should immediately reject efforts to ‘repeal’ the current system and replace sometime later. This could leave millions of Americans without coverage.”

The letter, signed by the Republican and Democratic governors from Ohio, Montana, Maryland, Louisiana, Alaska, Colorado, Massachusetts, Pennsylvania, Vermont, Virginia and Nevada warns that a repeal-now, replace-later plan could “leave millions of Americans without coverage.”

It calls for a bipartisan effort from lawmakers that brings governors “to the table to provide input.” 

Ohio Gov. John Kasich (R) tweeted out the statement, adding he was "proud" of the bipartisan group who "pulled together to share an important message on health care reform:"

--Meanwhile, Trump frenemy and New Jersey Gov. Chris Christie (R) called on the president to move on from the health-care effort toward some of the other legislative items on his to-do list.

"I'd advise [Trump] to move on and move on to other priorities like tax reform and infrastructure," Christie said during an interview with Nicolle Wallace on MSNBC, Politico reported. "I just don't think there's a will in Congress right now. I think they've shown that there's no will in Congress for them to work with each other.”

He continued: "I think both tax reform and infrastructure lend themselves to being less partisan than healthcare.. Not nonpartisan, but less partisan than healthcare. I think you can find Democrats who will agree with you on infrastructure. I think you can find Democrats who will agree with you on aspects of tax reform."

And here are a few more good reads from around the web:

HEALTH ON THE HILL
As Republicans' health-care bill went up in flames, Trump was dining with the bill's supporters.
Amber Phillips
As the legislation was about to collapse, Trump talked about his trip to Paris as he dined with supportive lawmakers.
Robert Costa, Kelsey Snell and Sean Sullivan
“It’s very difficult to do big things without the involvement of the president,” said Sen. Marco Rubio (R-Fla.), even as he admitted that senators engaged that strategy when they began work on the health-care bill.
Paul Kane
The GOP had a chance to make good on decades of promises. It blinked.
Damian Paletta
The failure of the Obamacare repeal bill tarnishes the Senate GOP leader’s reputation as a strategist and raises doubts about whether he can deliver on Donald Trump’s agenda.
Senate Republican leaders said Tuesday they would push ahead with a vote to repeal the Affordable Care Act early next week even as GOP defections made it clear the effort would fail.
MEDICAL MISSIVES
The rankings — which are closely watched in the industry and often trumpeted by marketing officials — had already been released to hospitals under embargo.
STAT News
Ashlynn Bailey, a former University of Alabama student, died of an accidental drug overdose Jan. 30, 2016.
Emma Ockerman
SECOND OPINION
The bill that appears to have died in the Senate was unpopular for good reasons. Congress must now look for bipartisan solutions.
We’ve proposed legislation that could easily pass Congress.
Neera Tanden and Topher Spiro
DAYBOOK

Today

  • The House Ways and Means Oversight Subcommittee holds a hearing on waste, fraud and abuse in Medicare.
  • The Manhattan Institute will hold an event on drug pricing featuring former Sen. Tom Coburn (R-Okla.)
  • The National Press Foundation will hold an event on preventive health care.

Coming Up

  • 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. 
SUGAR RUSH

House Minority Leader Nancy Pelosi (D-Calif.) says “there’s some goodness in the hearts of our Republican colleagues”:

 

President Trump says he’s ‘very surprised’ by Sens. Mike Lee (Utah) and Jim Moran’s (Kan.) opposition to health-care bill:

Senate Minority Leader Charles E. Schumer (D-N.Y.) calls on the GOP to work on a bipartisan health-care bill:

The Post's Glenn Kessler explains: No spending cuts to Medicaid? Then no tax cuts either:

Rep. Pramila Jayapal (D-Wash.): Republicans should “actually work with Democrats” on health care:

Rep. Chris Stewart (R-Utah): “Many” House members are “frustrated’ with Senate health bill collapse: 

Sen. Lindsey O. Graham (R-S.C.) says he'd "like to see a bill that people actually liked":

Fans of 'goat yoga' move to a different bleat:

On the Late Show with Stephen Colbert, Keegan-Michael Key brings Luther, Obama's anger translator, out of retirement