with Paulina Firozi


Senators pushing a last-ditch Obamacare repeal effort this week are up against the same old problem: math.

This small group of Republicans — led by Louisiana Sen. Bill Cassidy and South Carolina Sen. Lindsey Graham — appear convinced they can rework the equation to secure  that ever-elusive 50th vote for their measure, finally passing a bill overhauling the Affordable Care Act with a tiebreaking vote from Vice President Pence and moving closer to their goal of repealing and replacing President Barack Obama’s health-care law.

There will be a lot of moving parts to watch this week. Republicans have asked the Congressional Budget Office to rush a score of the Graham-Cassidy bill, Senate Majority Leader Mitch McConnell’s (R-Ky.) office confirmed yesterday. McConnell plans to take the temperature of his leadership team and his entire conference over the next few days. They have only two weeks left to scrape together enough support, since the budget reconciliation bill they’re using expires at the end of the month.

But despite all the noise being generated on Capitol Hill, Cassidy and Co. still appear to be shy of the vote total they’d need to succeed. Cassidy says he’s certain they have 48 or 49 Republican votes for his bill. But getting that final, 50th vote is the crucial -- and the hardest -- part.

Cassidy has sorta, kinda, maybe won over Sen. John McCain (R-Ariz.), who said this month that he favors this latest approach but wanted to see actual text first. McCain is a key figure in all of this, since he cast the third vote in July bringing down a “skinny repeal” bill.

But McCain has also continually expressed frustration at passing a health-care bill entirely along partisan lines — and he reiterated that concern on CBS’s “Face the Nation” yesterday.

“Why did — why did Obamacare fail?” McCain said. “Obamacare was rammed through with Democrats' votes only. "That's not the way to do it.”

McCain spokeswoman Julie Tarallo told me the senator is continuing to "review" the text Cassidy introduced last week.

"Senator McCain continues to review the bill to assess its impact on the people of Arizona," she said. "As he has said before, Senator McCain believes health care reform should go through the regular order of hearings, open debate, and amendments from both sides of the aisle."

But even if McCain does sign on, his support would basically be zeroed out by Sen. Rand Paul (R-Ky.), who voted for the failed “skinny repeal” bill in July. But Paul said Friday he’d defect from Graham-Cassid because it leaves way too much of Obamacare in place.

The two — Paul and Cassidy — got into something of a Twitter fight on Friday:

Paul tweeted this:

Cassidy responded:

Au contraire, Paul said:

If Cassidy ends up just swapping Paul's support for McCain's backing, he needs to net an additional vote from one of two other moderate Republicans – Sens. Lisa Murkowski of Alaska or Susan Collins of Maine. That’s a steep task, since both women voted against “skinny repeal,” which was a much narrower repeal bill that peeled away only small sections of the ACA.

And all this is assuming no other Republicans defect, even though Graham-Cassidy includes steep Medicaid cuts — an idea that gave many Republicans serious pause in previous incarnations. Under Graham-Cassidy, total federal Medicaid spending would be cut 26 percent in 2026 and 35 percent by 2036, relative to spending projections under current law.

Cassidy’s bill actually goes way further than either the House or Senate health-care bills in overhauling the ACA by essentially lumping its spending on ACA marketplace subsidies and Medicaid into block grants for states to cover people as they wish. Here's a useful explanation from the Center on Budget and Policy Priorities.

States would essentially have to create a new health program between now and 2020, when the marketplaces and Medicaid expansion would be disbanded. If they chose, states could abandon the ACA’s regulations on insurers to provide certain “essential benefits” and charge the same premiums to people regardless of their health status. This, too, has been a point of contention among some moderate Republicans.

The Kaiser Family Foundation's Larry Levitt smartly put it this way:

And then there’s President Trump, who has said little publicly about Graham-Cassidy, even though he devoted several tweets last week to slamming Sen. Bernie Sanders (I-Vt.) for the single-payer plan he rolled out. White House officials plan to help whip GOP votes this week, per Politico, but Cassidy wants the president to put his own weight behind the bill, publicly.

You wouldn’t exactly pick up on all these obstacles from talking to Cassidy. As a gastroenterologist who was deeply involved in health policy in the House before joining the Senate in 2015, he wants to be known as the guy who led Republicans across the finish line on the Obamacare overhaul effort eluding them.

Graham and two other important Republicans -- Sens. Dean Heller of Nevada and Ron Johnson of Wisconsin -- are backing the measure too.

On Friday, Cassidy told reporters his bill has support from as many as 48 or 49 Republicans. “I’m confident we’ll get there on the Republican side,” he said. “People are coming out and saying they are for it, either publicly or privately.”

Still, 49 + 1 - 1 = 49.


AHH: For some great visuals on how and where the Trump administration is cutting "navigator" grants for ACA outreach, check out these maps from my colleagues Kim Soffen and Kevin Uhrmacher. These groups are seeing an overall decrease of 41 percent, but some have seen their grants for the 2018 year slashed by 90 percent. The Department of Health and Human Services has said it based the navigator money on whether groups achieved their goals for marketplace enrollment -- and if they didn't, they lost out on much of their expected funding for next year.


OOF: The deaths of eight Florida nursing home residents are being investigated as criminal homicides, after they died within the now-shuttered Rehabilitation Center at Hollywood Hills in the aftermath of Hurricane Irma. The Post's Aaron C. Davis, Katie Zezima and Mark Berman obtained new details from nursing home executives of the deteriorating conditions inside the facility -- but their account is contradicted by law enforcement and state officials on key points, including how aggressively the nursing home had sought assistance and precisely when staffers called 911 as a patient went into cardiac arrest.

Basically, everyone was trying to pass around the blame:

--The Florida Department of Health said that “at no time” did the nursing home “report that conditions had become dangerous or that the health and safety of their patients was at risk.”

“It’s shocking that these trained medical professionals put patients’ lives in needless jeopardy. The fact is that this facility never called 911,” said Mara Gambineri, a spokeswoman for the department. “The Rehabilitation Center at Hollywood Hills is responsible for the health and safety of their patients.”

--The governor’s communications director, John Tupps, wrote in an email that “Every call made to the Governor from facility management was referred to the Agency for Health Care Administration and the Florida Department of Health and quickly returned.” Tupps did not respond to a follow-up email asking if the governor’s office had a record of three calls the nursing home said it made to state authorities.

"The tragedy at Hollywood Hills showed that for billions of dollars and countless hours spent preparing for Florida’s next inevitable hurricane, the lifeline for one of the nation’s largest concentrations of the elderly and disabled remained tenuous in the aftermath of Irma," my colleagues write. "The survival of residents at the home rested not just on the state’s vaunted $3 billion 'smart grid,' intended to limit power outages and target repair efforts, or on lists of critical infrastructure where restoring power is a top priority. Survival also depended on phone tag between nursing-home administrators, state officials and utility providers."

Here's a video explaining the situation:

--On Saturday, Florida Gov. Rick Scott announced new rules requiring nursing homes and assisted-living facilities in the state to have generators capable of maintaining comfortable temperatures for at least 96 hours in the event of a power loss, the New York Times reports.

Under the new rules, all of the state’s nursing homes will have 60 days to obtain what the governor’s statement called “ample resources” to maintain comfortable temperatures for at least four days after a power failure -- including a generator and fuel. The emergency action also requires that the state fire marshal inspect the generators within 15 days of installation.

OUCH: If you want to understand the GOP divisions over how to approach the ACA, look no further than the leaders of the Senate's two powerful health-care committees. Finance Chairman Orrin Hatch, known for being soft-spoken, lit into Health, Education, Labor and Pensions Chairman Lamar Alexander,  in an interview with Politico's Jen Haberkorn.

Alexander is “stealing our jurisdiction,” Hatch told Jen, referring to the turf split between his panel and Alexander’s HELP Committee. “It’s pretty hard to get excited about what he’s doing.”

"The long-simmering battle between the two Senate heavyweights over health care jurisdiction, a precious Senate commodity, came to a head with Hatch’s comments Wednesday, which followed his scathing Washington Post op-ed the week before," Jen writes. "The op-ed didn’t mention Alexander by name but made clear Hatch opposed the bill to stabilize Obamacare, which he called a 'bailout' of insurance companies."

"And the sniping, unusual in the typically staid and well-mannered Senate, has grown bolder and personal in recent days as Republicans wrestle between [Graham and Cassidy’s] last-ditch attempt to repeal Obamacare and Alexander’s attempt to shore up next year’s insurance markets," Jen continues. "Alexander hopes to cut a deal by early this week with Democratic Sen. Patty Murray. If he can do that, Hatch’s opposition could be a huge barrier in getting other Republicans to go along."

"The dispute tracks the GOP philosophical rift on Obamacare: Alexander argues the GOP has a responsibility to protect Americans from a collapsing health care market. Hatch, in a sentiment echoed by Senate leaders Mitch McConnell and John Cornyn, are skeptical of repairing the Democrats’ faulty law without significant structural changes."


--We're waiting on Sen. Alexander and his Democratic counterpart, Sen. Patty Murray (Wash.), to perhaps announce a deal early this week to fund extra Obamacare cost-sharing subsidies for at least one full year. They apparently worked over the weekend on a compromise they hope will ease insurer exits and premium hikes announced for next year. Alexander and Murray have said they're committed to reaching a deal, but the exact contours are still unclear. Republicans want to pair it with more changes to the ACA that Democrats dislike.

--But back on the partisan track, where Republicans are trying to muster enough votes for Graham-Cassidy bill more significantly overhauling Obamacare, Democrats and liberal groups are sounding the warning that this final effort could actually materialize. Ben Wikler, the Washington director of MoveOn, told followers to be ready for a possible vote as early as Sept. 27. Sen. Elizabeth Warren (D-Ma.) tweeted this:

Other Senate Democrats also sounded the alarm:


--Major health insurer Anthem agreed on Friday to sell Obamacare plans next year in the parts of Virginia that were at risk of having no individual marketplace insurers, meaning there are currently no "bare counties" in the United States, CNBC reports.

Last week, Virginia officials said there were 48 counties and 15 cities in that state expected to be bare as a result of Optima Health's decision not to expand its footprint as much as it had earlier expected. Anthem announced in August that it would stop selling its Blue Cross Blue Shield Obamacare plans in all of the state, and two other large insurers, Aetna and UnitedHealthcare, had already dropped out.

Virginia Gov. Terry McAuliffe tweeted praise of Anthem's final decision:

A few other good reads from The Post and beyond:


--Today: FDA Commissioner Scott Gottlieb headlines The Washington Post’s second annual ‘Chasing Cancer’ program, which starts at 3:30 p.m. For full agenda and live stream are here.

Coming Up

  • Anthem and the Patient-Centered Outcomes Research Institute holds an event on the opioid crisis with Sen. Shelley Moore Capito (R-W.Va.) on Tuesday.
  • The Center for Strategic and International Studies holds an event on the drug war and opioid epidemic on Tuesday.
  • Harvard’s School of Public Health holds an event on single-payer health care with Vermont’s former Gov. Peter Shumlin (D) on Tuesday.
  • Bloomberg holds a health care event on Tuesday.
  • Roll Call holds an event on mental health on Tuesday.
  • The Washington Post holds an event on health care on Wednesday.

At last night's Emmys, Stephen Colbert says it's time to tune out reality TV:

And Trump just can't stop taunting Hillary Clinton: