THE PROGNOSIS

Based on President Trump's fury Tuesday in Arizona over the Obamacare overhaul failure, you'd never guess the president was speaking yesterday in one of the GOP-led states most friendly to the health-care law.

In a measured and focused speech in Reno, Nev., on Wednesday, Trump ignored the key roles the state's Gov. Brian Sandoval (R) and Sen. Dean Heller (R) played last month in derailing a Senate bill repealing and replacing big parts of the ACA. Instead, he thanked the two men for being there.

Just a day earlier, Trump had barely suppressed his rage at Sen. John McCain (R) in the senator's home state of Arizona for being the third Republican to oppose a less sweeping version of overhaul that ultimately derailed the entire effort. (Of course, Trump and McCain have quite a history and that probably influenced Trump's remarks).

“One vote away — I will not mention any names. Very presidential, isn’t it?” Trump said at Monday's campaign-style rally in Phoenix, in an indirect but obvious jab at McCain. 

Yet Trump did a 180 yesterday, refraining from any direct or indirect criticisms as he addressed the national convention of the American Legion. Instead, it was the kind of unity message you might expect Pope Francis to deliver, my colleague Philip Rucker writes. “It is time to heal the wounds that divide us and to seek a new unity based on the common values that unite us,” Trump said, reading from a teleprompter.

But over the past three months, as the White House and Senate GOP leadership struggled to gain enough support for a bill repealing Obamacare,  one of Trump's foremost campaign promises -- moderate Republicans from politically purple Nevada were among the sharpest thorns in their sides.

Heller's done a bit of an about-face on health care ever since it became clear the Senate effort was stalled, expressing more public skepticism for parts of Obamacare. But in a speech yesterday, he bragged about his role in pressuring Senate Majority Leader Mitch McConnell (R-Ky.) to bring to the floor a bill that would have left the ACA's Medicaid expansions intact.

“There’s only one reason why Medicaid was kept in that final version and that’s because of me,” Heller told a Hispanic group in Las Vegas, according to the Nevada Independent. “It was because of me and my efforts that we were able to protect low-income families in this state with the Medicaid expansion.”

Heller almost immediately bucked McConnell on his initial Better Care Reconciliation Act, joining with Sandoval in a news conference to announce his opposition just a day after the bill was rolled out in late June. The two men cited a laundry list of problems with the bill, most notably its gradual rollback of the ACA's Medicaid expansion. More than 200,000 Nevadans have enrolled in Medicaid ever since the state expanded the program for low-income Americans.

“It’s going to be very difficult to get me to a yes,” Heller said at the time.

Heller basically maintained that skeptical posture until the end, when he ultimately did vote for a dramatically scaled-down version of Obamacare repeal. Resistance from him, and the Senate's other most moderate and conservative Republicans, kept McConnell constantly trying to negotiate his way out of the Obamacare box, which he sorely wanted to close by now. 

Trump hasn't always held his tongue on Heller. During a lunch with Senate Republicans before the Senate votes, the president joked that the senator -- one of the only GOP incumbent's in a tough 2018 reelection race -- might lose. And after Heller first came out against the Senate bill, a conservative organization aligned with Trump vowed to launch an expensive ad campaign against him, angering and shocking many mainstream GOP allies of the senator. Later, the group backed off.

Sandoval, who greeted Trump at the airport yesterday, has largely welcomed the ACA in his state, which narrowly voted for Hillary Clinton in 2016.

Back in 2012, Sandoval became the first GOP governor to embrace a central component of the law that lawmakers in more conservative states have eyed with suspicion – its expansion of Medicaid for childless adults earning less than 133 percent of the federal poverty level. As McConnell was writing his health-care bill in secret this summer, Sandoval joined six other governors on a bipartisan letter opposing the House’s version of Obamacare repeal for its steep Medicaid cuts.

“It calls into question coverage for the vulnerable and fails to provide the necessary resources to ensure that no one is left out, while shifting significant costs to the states,” the letter said.

As it became clear the Senate version would also deeply cut Medicaid, Sandoval kept heavy pressure on Heller to oppose it. In that June news conference with Heller, Sandoval praised the effects of the ACA.

“Today, Nevada’s in a much better place than it was six years ago, four years ago, even two years ago,” Sandoval said at the time. “And I want to keep that momentum going, because your health is the base of everything.”

Indeed, Nevada's uninsured rate fell from 29 percent in 2013 to 14.5 percent last year. Its childhood uninsured rate has dropped more than any other state in the wake of the ACA. And in addition to the new Medicaid enrollees, 90,000 more people obtained coverage through the state’s marketplace.

Of course, those aren't the effects of Obamacare that Trump has been emphasizing. Every time an insurer has announced it's leaving the marketplaces in 2018, his Department of Health and Human Services has issued a news release charging that the ACA is melting down with fewer and fewer options for consumers.

But even though moderate Republicans don't see eye-to-eye with Trump on health care, the president's diplomatic behavior in Reno shows they can duck his attacks as long as someone else (McCain) is in his cross-hairs. Trump's volatility means unexpected aggression but unexpected grace, too. It's Trump whiplash, as my colleague Philip characterizes it.

"In the span of 48 hours this week, President Trump has boomeranged among three roles: the commander in chief, the divider and the uniter," Philip writes. "Like a contestant on one of his reality TV shows, Trump has taken on contrasting personas, showcasing divergent traits with flourishes seemingly to survive another day of his beleaguered presidency. Or, as Trump the television producer might put it, to keep up the ratings."

AHH, OOF and OUCH

AHH: At that Tuesday rally where Trump attacked McCain for his health-care vote (without naming him), an attendee reportedly called for the senator's death A picture shared by journalist David Catanese showed a man wearing a Make America Great Again hat outside the rally in Phoenix. “This Trump supporter is shouting at protestors: ‘McCain needs to die now!'” Catanese tweeted.

McCain is currently undergoing treatment for glioblastoma, an aggressive form of brain cancer. McCain's daughter Meghan retweeted Catanese a few hours later (but didn't mention her father's medical condition):

OOF: The American Psychological Association has warned against trying to diagnose Trump's mental state if you aren't his doctor, but California Democrats are nonetheless stoking a debate over the president's mental health and fitness for office. 

Amid questions about Trump’s stability after his volatile responses to the violence in Charlottesville — most recently raised by GOP Sen. Bob Corker and former Director of National Intelligence James R. Clapper Jr. — California’s Democratic House delegation has seized on an issue that until recently was limited to the Internet fever swamps, Politico's Carla Marinucci writes.

--Rep. Zoe Lofgren introduced a congressional resolution urging Trump to seek a medical and psychiatric evaluation to determine if he is unfit for the office.

--Rep. Jackie Speier called for invoking the 25th Amendment — which empowers the vice president and Cabinet to remove a president who is incapable of serving — after last week's news conference from Trump Tower in which the president appeared to equate white supremacists with counterprotesters.

--And Rep. Ted Lieu has advocated for legislation requiring a psychiatrist at the White House.

"[Trump] has demonstrated that his mental capacity and his erratic behavior are issues we need to be concerned about for our national security,” Speier told Politico. “And I think I’m not the first person that’s talked about it. I’m just the first person that’s been public about it.”

"Yet the concentrated focus on Trump’s mental health worries many Democrats — even in the blue-state stronghold of California — who fear the party is expending too much energy obsessing over Trump at the expense of winning over voters to the party message," Carla writes.

OUCH: In the wake of reports detailing the splintering relationship between Trump and top Senate Republican Mitch McConnell, both GOP leaders issued statements yesterday talking up their “unity” on key agenda items.

In a statement Wednesday afternoon, White House press secretary Sarah Huckabee Sanders said that Trump and McConnell “remain united on many shared priorities, including middle class tax relief, strengthening the military, constructing a southern border wall and other important issues.” She seemed to acknowledge that the two do not plan to speak until Congress returns from the August recess after Labor Day.

“They will hold previously scheduled meetings following the August recess to discuss these critical items with members of the congressional leadership and the president’s Cabinet,” Huckabee Sanders said. “White House and leadership staff are coordinating regarding the details of those meetings.”

In his own statement, McConnell more sharply refuted the reports of conflict with Trump.

“We have a lot of work ahead of us, and we are committed to advancing our shared agenda together and anyone who suggests otherwise is clearly not part of the conversation,” McConnell said. The leader also gave a list of his priorities, which included providing "relief from Obamacare" (not repealing and replacing it, notably). Unlike the White House, McConnell didn't mention funding for a border wall.

"Trump has waged a public war with McConnell in recent weeks, blaming him for the Senate's failure to approve the Republicans' health-care bill and pushing him to change Senate rules so that most legislation would require only a simple majority to be approved," The Post's Abby Phillip reports. "A rift between Trump and McConnell would be a highly unusual roadblock for a president in his first term hoping to move forward with major legislation in a Congress controlled by his party....Come September, Congress must approve funding for the government for the remainder of the year and increase the debt limit to keep the government open. The White House hopes to also revisit health-care legislation and tackle a tax overhaul."

HEALTH ON THE HILL

House Speaker Paul D. Ryan (R-Wis.) deflected questions yesterday about Trump's criticisms of McCain and Sen. Jeff Flake, Arizona's other GOP senator, saying simply that Republicans must stay united to pass their agenda.

 

"I think the president feels that's a strategy that works for him," Ryan said at an event at Intel's campus in Hillsboro, Oregon, according to the Washington Examiner. "I think it's important that we all stay unified as Republicans to complete our agenda."

--The Republican and Democratic leaders of an influential health-care committee (Senate Health, Education, Labor and Pensions, more commonly known as HELP) announced earlier this week they'll hold two bipartisan hearings on improving the ACA marketplaces. The biggest goal here is to pass legislation providing long-term funds for extra subsidies known as cost-sharing reductions -- something insurers say they've got to have and which GOP Chairman Lamar Alexander (R-Tenn.) is determined to give them.

The hearings open up a rare bipartisan door to improve Obamacare. But it might not open very wide, according to Axios, which is reporting that another potentially bipartisan idea won't be part of negotiations. Republican aides say that reinsurance programs, which would help cover insurers' costs for their most expensive enrollees, aren't on the table -- even though reinsurance was part of several versions of health-care legislation Republicans took up this year.

A few more good reads from The Post and beyond:

Text on climate change can still be found on the NIEHS website, but some headlines and menu titles have been scrubbed.
Lenny Bernstein
MEDICAL MISSIVES
Antismoking group will release the ads during MTV’s Music Awards Sunday.
William Wan
If a fetus can be transferred to a fabricated womb, can the right to abortion survive?
Vox
STATE SCAN
Iowa asked for federal permission to alter major provisions of the Affordable Care Act next year, a proposal that will be closely watched by officials in other states who hope to rewrite parts of the health law.
Wall Street Journal
REPRODUCTIVE WARS
The decision comes a year after Texas hired the Heidi Group to help strengthen small clinics that specialize in women's health like Planned Parenthood
AP
DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee will hold health care hearings on September 6 and 7.
SUGAR RUSH

Learn more about the interesting past of the man behind the ‘Blacks for Trump’ signs:

On script vs. off the cuff: Comparing Trump’s speaking styles:

Hillary Clinton calls Trump a 'creep' in her new book, 'What Happened':