THE PROGNOSIS

Here’s the big, looming health-care question as congressional Republicans return to Washington today: Will they — or won’t they — try to boost the Obamacare marketplaces they so dramatically failed to eliminate?

The GOP pretty much closed the book on repealing and replacing the Affordable Care Act as the Republicans fled Capitol Hill for the long August recess, after three of their own sunk even a pared-down version in that bleary-eyed, middle-of-the-night vote. (If you want to relive the experience, here's my piece on it)

It remains unlikely that they’ll reopen the repeal debate, as all the same obstacles they faced (most significantly, how to align moderates and conservatives on an approach to Medicaid) are still present.

So we’re on to the sequel: How will Republicans approach the ACA’s marketplaces as they open for a fifth enrollment season in November? It’s a question neither Republicans in Congress nor the Trump administration can avoid addressing for much longer.

One clue came late last week when Tom Price's Health and Human Services Department announced it would slash funds that encourage people to enroll in the marketplaces. HHS cut by 40 percent grants to grass-roots groups known as "navigators" that help people sign up, and slashed an advertising budget that touted the benefits of enrolling from $100 million to $10 million, per my colleague Amy Goldstein. “The HHS officials, who briefed reporters on condition of anonymity, said that they had decided to begin tying the grant awards to navigator groups’ performance. All groups would receive at least $10,000, they explained,” Amy reported.

The news comes as insurers in federal-run marketplaces are scheduled today to finalize their 2018 rates, and they’re supposed to sign final contracts for next year on Sept. 27. Premiums will be an estimated 20 percent higher if insurers don’t get extra subsidies from the federal government to help cover discounts they must give to the lowest-income enrollees.

Funding the subsidies — called cost-sharing reductions, or CSRs — is top of mind for some prominent Republicans, and certainly for Democrats. A top Senate health-care committee (Health, Education, Labor and Pensions, or HELP) is bringing in five state insurance commissioners and five governors tomorrow and Thursday for two days of bipartisan hearings aimed at stabilizing the marketplaces next year.

The governors include one Democrat — Colorado Gov. John Hickenlooper and Montana Gov. Steve Bullock — and three Republicans: Massachusetts Gov. Charlie Baker, Utah Gov. Gary Herbert and Tennessee Gov. Bill Haslam.

HELP's Republican chairman, Sen. Lamar Alexander (Tenn.), is insistent that Republicans must take responsibility and fund the subsidies. He has urged the Trump administration to pay them through September, giving Congress time to vote by month’s end.

But there’s not so much love for the subsidies at the other end of Pennsylvania Avenue.

Last week, an official at the Centers for Medicare and Medicaid Services, the federal agency that runs the marketplaces, played down their impact on the price of marketplace plans, noting that those plans saw some steep hikes even as the Obama administration made the payments.

“CSRs have been paid for the last three years … premiums have gone up over 100 percent,” the official told reporters in a media briefing last week. “We saw 50 and 60 percent increases when CSRs were paid.”

Yet the administration has still been paying the CSRs on a month-to-month basis, helping insurers for the time being but failing to give them long-term certainty. The CMS official wouldn’t respond to questions about the reasoning behind the incremental approach, citing an ongoing lawsuit over the question of whether the executive branch can make the payments without permission from Congress.

Premiums did rise significantly in the first few years of the marketplaces, even as the Obama administration sought to maximize enrollment. They’re set to mostly go up again next year, according to a recent analysis of 21 major U.S. cities by the Kaiser Family Foundation.

But funding the CSRs is a concrete thing the Trump administration — and Congress — could do to shore up premiums and minimize the spikes. If Republicans don’t take this step, they’ll be in the uncomfortable position of explaining why they won’t vote to scrap the marketplaces but won’t assist them, either.

“The issue at hand is the law is not working,” the CMS official told The Washington Post. “There are fundamental problems within the [ACA]. It’s just not working. We can’t fix something that is broken without changes at the congressional level.”

Correction: Montana Gov. Steve Bullock was originally misidentified as a Republican.

-- HAPPENING FRIDAY—THE DAILY 202 LIVE WITH WILBUR ROSS: My colleague James Hohmann will talk one-on-one with Commerce Secretary Wilbur Ross at The Post’s headquarters on Sept. 8 from 9:30 a.m. to 10:30 a.m. We’ll cover the Trump administration's efforts to reshape the playing field for international trade, the future of NAFTA, the push to overhaul the tax code, and a host of other pressing issues. More information is here.

AHH, OOF and OUCH

— AHH: If Senate Republicans want to try to use a slim 51-vote majority to overhaul the Affordable Care Act, they only have until the end of the month to do so.

The Senate parliamentarian ruled that lawmakers have until the end of September to pass an Obamacare overhaul through budget reconciliation, according to ranking Budget Committee lawmaker Bernie Sanders.

Sanders (I-Vt.) announced the parliamentarian’s decision with a statement on Friday, calling the decision a “major victory for the American people and everyone who fought against President Trump's attempt to take away health care from up to 32 million people.”

“Now that the parliamentarian has determined that Senate Republicans cannot use reconciliation instructions to repeal the Affordable Care Act beyond this fiscal year, we need to work together to expand, not cut, health care for millions of Americans who desperately need it.”

The decision damages any chance Republicans have to pass an Obamacare replacement without Democratic support.

--OOF: President Trump returned to the Houston area on Saturday for his second trip to the flood-ravaged areas, this time meeting with storm survivors and shelter volunteers as the city began its recovery from the devastation that officials say has claimed at least 60 lives, the Associated Press reports.

The Post’s Philip Rucker noted, however, that “Trump’s optimism seemed to belie the far more complicated reality of rebuilding lives here, however. After talking with families who had lost their homes to Harvey’s floodwaters, Trump said he was struck by how 'happy' they were.”

“We saw a lot of happiness,” Trump said to reporters ... “It’s been really nice. It’s been a wonderful thing. As tough as this was, it’s been a wonderful thing, I think even for the country to watch it, for the world to watch. It’s been beautiful.”

And as he was leaving the center, Trump told reporters: “Have a good time, everybody.”

Many on social media were quick to question Trump’s remarks in the aftermath of a devastating storm:

From the New York Times's Glenn Thrush:  

From The Daily Beast’s Scott Bixby:

The comment recalled the president’s first visit to Texas last week, during which he boasted about the crowd size at a firehouse in Corpus Christi.

From Brian Klaas, a fellow at the London School of Economics:

— OUCH: Pro-Obamacare health-care experts argue that the Trump administration’s decision to slash funding for advertisements and grants that help with ACA enrollment will only drive up the cost of premiums.

Venrock’s Bob Kocher, who served as a health-care adviser to President Obama, said the move was “not smart”:

Kocher explained why having healthy people in the risk pool would lower premiums:

Andy Slavitt, former head of the Centers for Medicare and Medicaid (who The Health 202 previously dubbed Obamacare’s biggest Twitter defender), chimed in:

Lori Lodes, former communications director for CMS under Obama, underlined the impact of advertising on enrollment:

 

HEALTH ON THE HILL

— Sen. Kamala Harris (D-Calif.) lit a fire under the single-payer health-care conversation with an announcement last week that she plans to co-sponsor the “Medicare for all” Sanders will introduce this month.

“It’s just the right thing to do,” Harris said at the end of a town hall meeting. “It is so much better that people have meaningful access to health care, from birth through the rest of their lives. The alternative is that we, as taxpayers, are spending huge amounts of money to send them to emergency rooms.”

It’s not entirely surprising that Harris, who has vocally supported universal health care since winning her election in November, would announce her support of Sanders’s bill.

In July, Harris told activists at a rally in California that “as a concept, I’m completely in support of single payer,” adding that “we’ve got to work out the details, and the details matter on that.”

Our colleague Dave Weigel noted that “the gusto with which Harris endorsed the bill — “I’m going to break some news,” she said in Oakland — demonstrated Sanders’s inside-outside strategy for legislation that has no chance of passage unless Democrats win back Congress.”

Harris's announcement also fuels the 2020 speculation surrounding the California Democrat. The New York Times's mentioned the California Democrat in a weekend piece noting that as many as 20 possible Democratic contenders were taking steps that could vault them into the presidential sweepstakes. Kenneth P. Vogel and Rachel Shorey report that "packed fund-raising calendars, brisk political spending and trips to early primary states suggest that in fact a shadow campaign for the party’s 2020 presidential nomination is already well underway."

Dave added: “The support of potential 2020 candidates will be most telling. Sens. Elizabeth Warren (D-Mass.) and Kirsten Gillibrand (D-N.Y.) have previously endorsed the idea of single-payer health care; it would be difficult, Sanders said in an interview, for any Democrat to win the 2020 presidential nomination without backing some form of Medicare for All.”

After returning to Capitol Hill today following their August recess, one of the first things on the agenda will be funding the emergency relief response to Harvey. The House Appropriations Committee released over the weekend the text of a bill that includes $7.4 billion in funding for FEMA and an additional $450 million for the Small Business Administration’s disaster loan program, matching the White House’s requested total, reported The Post’s Laurie McGinley and Mike DeBonis. House lawmakers will meet at 10 a.m. on Wednesday to consider the relief bill, with first votes scheduled for 11 a.m.

DeBonis and McGinley add: “The aid bill is expected to be considered under a fast-track procedure for noncontroversial, bipartisan bills that requires a two-thirds majority to pass.” 

Senate Health, Labor and Pensions Committee Chair Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.) are aiming to "pass a few key fixes" to help stabilize the ACA before the end of September, reports Politico's Adam Cancryn. The plan is to focus on the CSRs that Trump has wavered on in what would be the first significant bipartisan health-care effort of the session. Alexander and Murray, however, differ on how long the subsidies for low-income enrollees in the ACA would last.

HELP has announced two more hearings Sept. 12 and 14 to follow on hearings starting tomorrow and Wednesday. The committee will hear from health-care experts on Sept. 12 and from health-care stakeholders on Sept. 14., according to statements.

STATE SCAN

It's been eleven days since Harvey made landfall in Texas, and the city’s health department officials are now concerned about toxic pollutants in Houston’s water, and about having the resources to test for it. The Wall Street Journal reported that the two employees with the Houston Health Department allocated to test the city’s waterway won’t be enough. As of Sunday, the department’s chief environmental science officer told the Journal that she had contacted the Environmental Protection Agency for additional help but hadn’t received a response.

The Journal reports: “Without additional federal or state help, local inspectors will do targeted air testing, but their ability to test water is limited, said Donald Richner, senior project manager for the bureau of pollution control and prevention within the health department’s environmental division. “We would appreciate any assistance,” he said.

-- Meanwhile, over 1 million pounds of "dangerous" air pollutants have been released by oil refineries and chemical pollutants along the Texas Gulf Coast in Harvey's wake, reports Steve Mufson. "Emissions have already exceeded permitted levels, after floating rooftops sank on oil storage tanks, chemical storage tanks overflowed with rainwater, and broken valves and shutdown procedures triggered flaring at refineries ... The chemicals released in the week after Harvey made landfall, including benzene, 1,3-butadiene, hexane, hydrogen sulfide, sulfur dioxide, toluene and xylene. All seven chemicals are toxic air pollutants documented to harm human health; several cause cancer."

REPRODUCTIVE WARS

-- A federal judge in Texas last week temporarily blocked an antiabortion law restricting a common second-trimester abortion procedure, signed by Gov Greg Abbott (R). The 14-day injunction halted the ban on the “dilation and evacuation” procedure, the Associated Press reported, which was set to take effect Friday.

“The court concludes that plaintiffs have established that absent a temporary restraining order they will suffer irreparable harm by being unable to access the most commonly used and safest previability-second-trimester-abortion procedure ahead of any substantial constitutional review of the act,”  U.S. District Judge Lee Yeakel wrote in a 17-page ruling.

Yeakel added: “The act leaves that woman and her physician with abortion procedures that are more complex, risky, expensive, difficult for many women to arrange, and often involve multi-day visits to physicians, and overnight hospital stays."

Here are a few more good reads from The Post and beyond:

MEDICAL MISSIVES
Offering drugs and counseling just before discharge helps patients when they return home.
Fran Kritz
BCG vaccine, used in many countries, protects for nearly twice as long as previously thought, scientists find.
The New York Times
Bill would give residents a way to pick their preferred gender on all state documents, including birth certificates and driver's licenses.
INDUSTRY RX
“They’re trying to keep the market stable” amid premium increases, Trump administration’s threats on the Affordable Care Act.
Julie Appleby I Kaiser Health News
U.S. health insurer Anthem Inc said on Friday that it will no longer offer Obamacare plans in 17 counties in Missouri but will remain in the bulk of the state, covering 68 counties that would not otherwise have Obamacare coverage for their residents.
Reuters
Now comes the hard part: using IT to manage the health of patients whose lives will be disrupted and scattered by the storm.
DAYBOOK

Today

  • Congress returns to Washington from recess.

Coming Up

  • The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies holds a markup on the HHS spending bill on Wednesday.
  • The CATO Institute holds an event on the “Long-term effect of health insurance on near-elderly health and mortality” on Wednesday.
  • The Senate Committee on Health, Education, Labor and Pensions holds hearings on how to stabilize the insurance marketplaces on Wednesday and Thursday, and on Sept. 12 and 14.
  • The Senate Finance Committee is scheduled to hold a hearing on the Children’s Health Insurance Program on Thursday.
  • Colorado Gov. John Hickenlooper (D) and Ohio Gov. John Kasich (R) discuss their bipartisan health care proposal at an American Enterprise Institute event on Friday.
  • The National Institute for Health Care Management holds a webinar on cancer care on Friday.
SUGAR RUSH

President Trump meets first responders in Louisiana in the wake of Harvey:

President Trump and First Lady Melania Trump visit families at a shelter for Harvey survivors:

Watch Stephen Colbert on a Swamp-themed edition of Late Show's "Alter Egos":