THE PROGNOSIS

Congress will likely renew protections next month for state medical marijuana laws -- but pro-pot lawmakers and advocates are still watching nervously in case Attorney General Jeff Sessions launches a last-minute sabotage campaign.

For nearly three years now, Congress has maintained a policy prohibiting the Justice Department from using federal funds to prevent states allowing medical marijuana – which now number 29 plus the District of Columbia – from carrying out their own laws.

The amendment, offered by Reps. Dana Rohrabacher (R-Calif.) and Earl Blumenauer (D-Ore.), will soon expire unless Congress renews it. And it seems likely lawmakers will include the language in a spending bill keeping the government open past Sept. 30, with one possible hiccup – intervention by Sessions, who’s famously known for his abhorrence to cannabis.

Sessions, who prepared a speech in April whose initial text (later revised) called marijuana “only slightly less awful” than heroin, apparently asked congressional leaders to undo the state medical marijuana protections in a letter that became public in June. In that letter, Sessions argued the Rohrabacher-Blumenauer amendment would restrict the DOJ from enforcing the federal Controlled Substances Act.

“I believe it would be unwise for Congress to restrict the discretion of the Department to fund particular prosecutions, particularly in the midst of an historic drug epidemic and potentially long-term uptick in violent crime,” Sessions wrote. “The Department must be in a position to use all laws available to combat the transnational drug organizations and dangerous drug traffickers who threaten American lives.”

Yet Sessions is up against a Congress filled with an unprecedented number of pro-pot lawmakers from a record number of states where it’s legal.

Last November’s election brought sweeping victories for the pro-marijuana crowd: Seven states plus the District now allow recreational use after voters in California, Massachusetts, Maine and Nevada approved such measures. And four more states – Florida, North Dakota, Arkansas and Montana – approved medical use laws, making it legal in more than half the states for doctors to prescribe marijuana to patients.

It's notable that each time the House has approved the Rohrabacher-Blumenauer language, it’s been by increasingly wider margins. The protections for state medical marijuana laws were included with little controversy in the spring spending bill. And last month, the Senate Appropriations Committee passed such protections, offered by Sen. Pat Leahy (D-Vt.), by voice vote.

“This is the most sympathetic Congress we’ve ever had to issues of cannabis,” Blumenauer told me.

Blumenauer said he’s had no concrete assurances yet from GOP leaders that they’ll include the protections in the spending bill they need to pass by Oct. 1 in order to keep the government funded (and in his Arizona rally remarks last night, Trump  suggested he'd be open to a shutdown over funding for his border wall). But Blumenauer is “reasonably confident” the language will ultimately be renewed, barring an intervention by Sessions.

Advocates are also expecting Congress to keep protecting states with medical marijuana laws, even though they’ve been deeply dismayed by Sessions and his past, well-documented opposition to pot.

“I am cautiously optimistic that we are going to retain the protections,” said Justin Strekal, political director for the pro-pot group National Organization for the Reform of Marijuana Laws (known as NORML).

The Obama administration made clear in the 2013 “Cole” memo – drafted by then-deputy attorney general James Cole – that it would mostly avert its eyes from state laws. The document warns U.S. attorneys in all 50 states to let states go ahead with legalization efforts, as long as pot isn’t being made available to minors or in states where it isn’t legal.

For the moment, it’s unclear how hard Sessions will try to combat the legalized marijuana trend sweeping the country (a Justice Department spokeswoman didn’t respond to my questions about his approach). The AG certainly has the power to make life very, very difficult for users and growers of the drug, which remains illegal under federal law.

Most significantly, Sessions could direct U.S. attorneys to go after those involved with recreational marijuana. He could use a process called asset forfeiture to seize money and property from them. He could choose to prosecute anyone involved in the industry.

That’s because Congress has so far rejected the next step, which would be to protect states that allow recreational use. Two years ago, the House defeated by a 222-206 margin a bipartisan amendment from Reps. Tom McClintock (R-Calif.) and Jared Polis (D-Colo.) to prohibit federal authorities from prosecuting people for use, sale or possession of marijuana in a state in which the drug is legal under relevant state laws.

Yet if Sessions tries to remove pot protections, it’s unlikely to be at the behest of the White House. President Trump said several times during his campaign that legalization should be up to the states, and even at one point expressed support for pot's medical use.

“The marijuana thing is such a big thing,” Trump said at a campaign rally in Nevada in October 2015. “I think medical should happen, right? Don’t we agree? I think so. And then I really believe we should leave it up to the states.”

One thing’s for certain – in a popularity contest between the president and legalized pot, the pot wins (recent polls show that six in 10 Americans now think it should be legal). Blumenauer was happy to note the reality.

“In the nine states where both Donald Trump and marijuana were on the ballot, marijuana got a lot more votes than Trump,” he told me.

AHH, OOF and OUCH

AHH: Just one county -- Paulding County, Ohio -- is now without a single marketplace insurer for 2018. But more than one in Obamacare four enrollees live in counties that could have only one carrier participating. Check out The Post's cool map showing the lay of the land:

OOF: Recent government reports have indicated large increases in the number of Americans addicted to and dying from heroin, but brace yourself for some more bad news: The problem is even worse than government data indicates, The Post's Keith Humphreys writes.

The most-quoted figure is 561,000 people with a diagnosable heroin use disorder, which comes from the federal government’s annual National Household Survey on Drug Use and Health (NSDUH). This survey has two serious flaws that lead it to dramatically underestimate the prevalence of heroin use disorder: It excludes people who are incarcerated and people who are living on the street, both of whom have very high rates of drug use, and it relies on self-reports.

"The degree to which NSDUH underestimates the prevalence of heroin use disorder is enormous," Keith writes. "In 2010, a research team combined NSDUH data with that from other studies to determine that NSDUH could only identify 60,000 of the 1 million Americans who used heroin daily or near daily heroin users.  As most daily or nondaily heroin users would meet diagnostic criteria for heroin use disorder, NSDUH’s most recent estimate of 591,000 probably didn’t even capture the depth of the problem back in 2010, which was before the heroin problem exploded."

"The true level of heroin use disorder today could easily be double or even triple NSUDH’s estimate, but no one can truly know," he continues. "As successive Congresses have clamped down on federal spending, many government agencies have been forced to curtail their research capacity. National programs that gathered substance use data from people entering jails and from emergency room patients fell under the budget ax in 2014 and 2011, respectively."

OUCH: We already knew top Senate Republican Mitch McConnell and President Trump weren't exactly besties. But their relationship has disintegrated to the point that they've not spoken with each other in weeks, and McConnell has privately speculated that Trump won't be able to salvage his administration, the New York Times reports.

"What was once an uneasy governing alliance has curdled into a feud of mutual resentment and sometimes outright hostility, complicated by the position of Mr. McConnell’s wife, Elaine L. Chao, in Mr. Trump’s cabinet, according to more than a dozen people briefed on their imperiled partnership," Alexander Burns and Jonathan Martin write. "Angry phone calls and private badmouthing have devolved into open conflict, with the president threatening to oppose Republican senators who cross him, and Mr. McConnell mobilizing to their defense."

Alex and Jonathan detail a dramatic back-and-forth between the two -- including a phone call that "quickly devolved into a profane shouting match." "During the call, which Mr. Trump initiated on Aug. 9 from his New Jersey golf club, the president accused Mr. McConnell of bungling the health care issue. He was even more animated about what he intimated was the Senate leader’s refusal to protect him from investigations of Russian interference in the 2016 election."

For his part, McConnell has fumed over Trump’s regular threats against fellow Republicans and criticism of Senate rules, and questioned the president's understanding of the presidency in a public speech. But he's made even sharper comments privately, "describing Mr. Trump as entirely unwilling to learn the basics of governing....In offhand remarks, Mr. McConnell has expressed a sense of bewilderment about where Mr. Trump’s presidency may be headed, and has mused about whether Mr. Trump will be in a position to lead the Republican Party into next year’s elections and beyond, according to people who have spoken to him directly."

TRUMP TEMPERATURE

--This won't help the McConnell/Trump relationship, either: Last night, the president delivered a campaign-style speech in Phoenix, where he lurched abruptly from one topic to the next and essentially roasted Arizona's two GOP senators without explicitly naming them. Trump repeatedly referenced the “one vote” by which Senate Republicans fell short last month of passing a health-care bill aimed at keeping their effort to repeal and replace the Affordable Care Act alive. It was an unmistakable reference to Sen. John McCain, whose surprise “no” vote sunk the push. Trump made clear he's still angry about it -- very angry.

“They all said, ‘Mr. President, your speech was so good last night, please, please Mr. President, don’t mention any names.’ So I won’t. I won’t,” said Trump, perhaps referring to his advisers or allies.

“One vote away — I will not mention any names. Very presidential, isn’t it?” Trump said mockingly.

He seemed to relish his mode of attack, my colleague Sean Sullivan reports. Here's footage:

Meghan McCain's post noted the toxic atmosphere:

Reporters noted how Trump unloaded on McCain without ever naming him. The Post's Philip Rucker: 

The Guardian's Ben Jacobs: 

MSNBC's Kyle Griffin:

NBC News' Vaughn Hillyard: 

The New York Times' Maggie Haberman: 

CNN's Manu Raju noted that Republicans were actually one vote away from passing a Senate health-care bill -- not a final repeal bill. The Senate measure then would have faced a House vote or a conference committee.

Then Trump turned his fire on Sen. Jeff Flake, who the president has viewed as -- shall we say? -- flaky on immigration issues. In a newly-released book, Flake was sharply critical of the president and has spoken out against him in recent months.

"And nobody wants me to talk about your other senator, who is weak on borders, weak on crime. No I won’t talk about him. Nobody wants me to talk about him. Nobody knows who the hell he is. And now, we haven't mentioned any names, so now, everybody's happy," Trump said."

McConnell and House Speaker Paul D. Ryan (R-Wis.) have conceded there's no clear path forward at the moment for passing a bill repealing big parts of the Affordable Care Act. That didn't stop Trump from promising it's still going to happen eventually.

"But we are going to get rid of Obamacare. I will never stop — one vote. I will never stop," he said. "We’re gonna get rid of Obamacare."

Near the rally's end, Trump singled out three House Republicans from Arizona — Reps. Paul A. Gosar, Trent Franks and Andy Biggs — and thanked them. All represent safe Republican districts.

“Never let them go, don’t lose them,” Trump said as they departed the stage.

HuffPost's Matt Fuller noted that one of those Republicans actually voted against the House's version of Obamacare repeal-replace (the American Health Care Act, or, AHCA):

HEALTH ON THE HILL

-- Senate Health, Labor and Pensions Committee Chair Lamar Alexander (R-Tenn.) has announced two hearings next month on ways to stabilize the individual insurance market. Scheduled for Sept. 6 and 7, the hearings will focus on stabilizing premiums and helping people without employer-sponsored plans or government insurance get coverage, according to the lawmaker.

“Eighteen million Americans, including 350,000 Tennesseans – songwriters, farmers, and the self-employed – do not get their health insurance from the government or on the job, which means they must buy insurance in the individual market,” Alexander said in a statement yesterday. “My goal by the end of September is to give them peace of mind that they will be able to buy insurance at a reasonable price for the year 2018."

Alexander has been the foremost Republican calling for the Trump administration to deliver extra subsidies, called cost-sharing reductions, to insurers with the goal of shoring up the ACA marketplaces for next year. He warned yesterday that Congress should act by Sept. 27 -- the deadline for insurers to finalize rates -- to fund the subsidies long-term to give insurers needed certainty. He's teaming up with top HELP Democrat Patty Murray (Wash.) in an unusual bipartisan effort.

"I’m pleased to announce with Chairman Alexander that our first two bipartisan hearings in the HELP Committee will be dedicated to hearing from state insurance commissioners and governors from across the country," Murray said in a statement. "Through these and other planned public hearings, we have the critical opportunity to work together toward an agreement by the end of September to help prevent millions of patients and families from paying more for the care they need next year."

--My tireless colleague Dave Weigel reports from Detroit, where health insurance executive Andy Thorburn is the latest Democrat pushing the party to embrace single-payer health care, in his bid to replace Rep. Edward R. Royce (R-Calif). In a video announcement, Thorburn paints the contest as a referendum on health care, between a Republican who voted for the repeal of the Affordable Care Act and a Democrat who wants to move, eventually, to “Medicare for all.”

In an interview, Thorburn presented himself as a candidate who could debate health care from a position of total awareness. He ran Global Benefits Group, an international insurance company, until stepping back to the board this year, Dave writes.

“The part that really bothered me, when Obama first presented his plan, was my friends and colleagues starting their arguments by saying: ‘Hey, we have the best medical system in the world. Why change it?’ I was like, ‘Look, I can’t have a serious discussion with you if you think that.’ It’s the best system if you’re rich. But it’s clearly not the best for everyone. Yeah, the shah of Iran came here for treatment once — that’s not the standard!”

--A few more choice reads from The Post and beyond:

MEDICAL MISSIVES
Drug companies do not want their medicines used in capital punishment.
Carolyn Y. Johnson
A recent move by the Trump administration seems set to undo progress on evidence-based approaches to reduce teen pregnancy.
New York Times
STATE SCAN
The Democrat and Republican are working on a bipartisan plan to stabilize health insurance markets and give more power to states.
Colorado Public Radio
REPRODUCTIVE WARS
The governors of both states signed abortion legislation last week. Texas will restrict insurance coverage while Oregon will require that it be covered.
Kaiser Health News
DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee is set to hold two hearings on September 6 and 7 on how to stabilize Obamacare marketplaces. 
SUGAR RUSH

This was Louise Linton's reaction after a commenter on Instagram called her "#deplorable":

See giant panda Bei-Bei celebrate with a birthday cake: