THE PROGNOSIS

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Abortion opponents believe they’ve built an impenetrable firewall between taxpayer dollars and abortion coverage in the latest Obamacare overhaul plan known as Cassidy-Graham.

The trick: Funnel the money through an existing health-care program, the Children’s Health Insurance Program.

Now, they just have to make sure the Senate parliamentarian agrees with them.

Bear with me, as this gets a little wonky and complicated. The issue is a major pressure point for antiabortion groups, who have long insisted that no government funds should be used to cover elective abortions. And those groups have a big influence on how conservatives vote -- especially in the House. 

Antiabortion groups like the Family Research Council and Susan B. Anthony List care about a few things in revamping the Affordable Care Act. A big one is ensuring the Hyde amendment -- which prohibits taxpayer funds from paying for abortions except in cases of rape, incest or if the woman’s life is at stake -- is now part of the legislation. That means that federally subsidized plans on ACA marketplaces could no longer cover the procedure.

The current language in Cassidy-Graham — which the Senate may vote on next week — complies with conservatives' litmus test. But activists acknowledge the Senate parliamentarian will probably strip the Hyde language from the measure altogether, meaning that federally subsidized plans could keep covering abortions.

In the last go-round, that's exactly what conservatives were worried about, too: that the Hyde amendment would be eliminated from the (now defeated) Better Care Reconciliation Act pushed by Senate Republicans under special rules governing the budget process.(That’s the vehicle Republicans are using to try to overturn much of the ACA because it doesn't require Democratic votes.) Democrats believed that the parliamentarian agreed with them in that the Hyde language had to go, though Republicans said that guidance wasn't final.

This is important because had Hyde been eliminated from BCRA, antiabortion groups might have turned against that bill altogether because it would have maintained marketplace subsidies (albeit reshaping them) that go toward plans that cover abortions.

The same problem exists for Cassidy-Graham. Democrats and Republicans on the Senate Budget Committee are expected to meet early next week with the parliamentarian, who rules on which provisions can go into a budget bill (that process is known as a “Byrd bath”). The Hyde language could get eliminated if the parliamentarian says it’s not closely enough tied to spending.

But these activists will probably just shrug their shoulders if those subsidies are given the green light this time.

That’s because that measure eventually phases out the marketplace subsidies anyway. Starting in 2021, it would funnel them through CHIP, which already contains the Hyde restrictions. States could use the money mostly as they wish – but they would be barred from paying for elective abortions or plans that cover them.

In short, abortion foes feel their goals will be achieved no matter what, as long as parliamentarian Elizabeth MacDonough gives the OK to Cassidy-Graham’s overall structure of turning subsidy money over to states.

“If Elizabeth MacDonough buys that whole structure, then we’re golden,” Family Research Council lobbyist David Christensen told me.

Of course, if the Hyde language somehow stays in Cassidy-Graham and the whole bill becomes law, insurers would face an immediate, pressing question: What to do about dozens of health plans that cover abortions? The prohibition would go into effect immediately, applying to 2018 plans that are up for sale starting in just a few weeks, on Nov. 1.

This wouldn't be an issue in about half the states, which have passed their own restrictions on abortion coverage in the ACA marketplaces. Insurers already had to exclude coverage from the plans they’re selling in those states, so they wouldn’t need to scramble to change anything at the last minute.

But it could complicate the situation in the other states -- particularly in California, New York and Oregon -- that actually require most plans to cover abortions. Even if the Senate passes Cassidy-Graham next week, the House likely couldn’t consider it until October, after the point at which states are supposed to have their marketplace offerings all firmed up for next year.

Of course, that’s not all abortion-rights advocates have to be worried about.

As with previous repeal bills, Cassidy-Graham essentially bans Planned Parenthood from getting Medicaid reimbursements for one year. Medicaid dollars already can’t be spent on abortions (barring the exceptions laid out under Hyde), but conservatives say the women’s health organization shouldn’t get any taxpayer dollars, period, as long as they continue to provide the procedure.

That’s left Planned Parenthood, which relies on federal reimbursements and grants for about 43 percent of its budget, in a defensive posture as it tries to protect itself from deep funding cuts. The group's president, Cecile Richards, stressed to Marie Claire magazine this week that its clinics use Medicaid dollars for a variety of health-care services including cancer screenings and birth control.

Planned Parenthood said this week its supporters have organized more than 2,200 events across the country, made more than 300,000 phone calls and delivered more than 1 million signatures to members of Congress opposing the defunding effort.

“These next 12 days are make-or-break for the health care millions of people rely on,” said Erica Sackin, a spokeswoman for Planned Parenthood Action Fund. “Graham-Cassidy is the worst version of Trumpcare we’ve seen yet.”

PRICE CHECK

--Jetting around the country by private plane has become the norm for Health and Human Services Secretary Tom Price, who has taken at least 24 flights on private charter planes at taxpayers’ expense since early May, according to the latest report by Politico. The trips cost more than $300,000 in total, according to a review of federal contracts and similar trip itineraries, write Dan Diamond and Rachana Pradhan.

"Price’s use of private jets represents a sharp departure from his two immediate predecessors, Sylvia Mathews Burwell and Kathleen Sebelius, who flew commercially in the continental United States," they write.

"Many of the flights are between large cities with frequent, low-cost airline traffic, such as a trip from Washington to Nashville that the secretary took on June 6 to make a morning event at a medication distributor and an afternoon speech. There are four regular nonstop flights that leave Washington-area airports between 6:59 a.m. and 8:50 a.m. and arrive in Nashville by 9:46 a.m. CT. Sample round-trip fares for those flights were as low as $202, when booked in advance on Orbitz.com. Price’s charter, according to HHS’ contract with Classic Air Charter, cost $17,760."

One of the private flights occurred after Politico had first reported on the practice earlier this week, Dan said:

Dan tweeted a picture of the ride:

--Price’s office sought to justify the practice by saying staff has routinely evaluated the most effective way for him to travel and has turned to chartered flights when necessary for Price to manage one of the largest executive branch agencies while also staying grounded with voters.

“This is Secretary Price, getting outside of D.C., making sure he is connected with the real American people,” said Charmaine Yoest, his assistant secretary for public affairs. “Wasting four hours in an airport and having the secretary cancel his event is not a good use of taxpayer money.”

"Revelations of Price’s luxury travel, however, have drawn swift criticism from Democratic members of Congress," The Post's Aaron C. Davis reports, adding the decision to use charters was made after the HHS secretary was forced to wait in an airport for hours after a flight was delayed, missing an event organized by his department (incidentally, something that happens to millions of us who fly).

"Late Wednesday, the ranking members of the House committees on Energy and Commerce and Ways and Means wrote to the inspector general of Price’s agency saying the reported flights appear to violate federal rules and policies, and they demanded an immediate investigation," Aaron reports.

"The flights aboard private jets — including one Price took last week in a cabin with high-backed leather chairs and a kitchen — have even led some senior administration officials to distance the White House from Price’s travel practices," he adds. "A senior administration official who spoke on condition of anonymity said Thursday that the White House did not approve Price’s travel on chartered planes."

AHH, OOF and OUCH

AHH: An internal analysis by the Trump administration concludes that 31 states would lose federal money for health coverage under the Cassidy-Graham health-care bill, with the politically critical state of Alaska facing a 38 percent cut in 2026, The Post's Amy Goldstein and Juliet Eilperin report.

"The report, produced by the federal Centers for Medicare and Medicaid Services, focuses on the final year of a block grant that states would receive under the Cassidy-Graham legislation," Amy and Juliet write. "It shows that government funding for such health insurance would be 9 percent lower overall in 2026 under the plan than under current law."

"The predicted loss is less than that forecast by three independent analyses of the bill’s impact in recent days, but the internal numbers show a similar checkerboard of states that would be big winners and equally big losers. The states that expanded their Medicaid programs under the ACA would be hit with the greatest reversals of federal aid...the greatest winners in 2026 would be Mississippi and Kansas, where federal health-care funding would more than triple and double, respectively. On the other hand, Connecticut’s aid would be cut by just over half."

OOF: Sen. John McCain (R-Ariz.) won't vote for the Cassidy-Graham bill because "he's staring death in the face right now," according to Pennsylvania Democratic Rep. Matt Cartwright. Cartwright was back in his district during the House's week away from Washington and was caught on video making the comment about McCain, who had surgery for a serious form of brain cancer earlier this summer.

"McCain I'm worried about," Cartwright said on Tuesday at a town hall meeting. "Also because the governor of Arizona came out in favor of the Lindsey Graham-Bill Cassidy bill so that puts pressure on McCain...But, man, something tells me McCain, he's staring death in the face right now, so he's probably going to make good choices and he's not going to bend to political pressure."

Watch the remark below:

OUCH: A new working paper shows the fertility rate in Flint, Mich., dropped precipitously after the city decided to switch to lead-poisoned Flint River water in 2014, The Post's Christopher Ingraham reports.

That decline was primarily driven by what the authors call a “culling of the least healthy fetuses” resulting in a “horrifyingly large” increase in fetal deaths and miscarriages. Among the babies conceived from November 2013 through March 2015, “between 198 and 276 more children would have been born had Flint not enacted the switch in water,” write health economists Daniel Grossman of West Virginia University and David Slusky of Kansas University.

Grossman and Slusky compared birth and fetal death rates in Flint with those in other Michigan cities, including Lansing, Grand Rapids, Dearborn and Detroit. “These areas provide a natural control group for Flint in that they are economically similar areas and, with the exception of the change in water supply, followed similar trends in fertility and birth outcomes over this time period,” the authors wrote.

What they found was “a substantial decrease in fertility rates in Flint for births conceived around October 2013, which persisted through the end of 2015. Flint switched its water source in April 2014, meaning these births would have been exposed to this new water for a substantial period in utero (i.e., at least one trimester).”

TRUMP TEMPERATURE

--Senate Republicans have made a calculated decision: Better to fail again trying to repeal the ACA than not to try at all, The Post's Paul Kane writes

"That bet, made out of fear rather than a sense that victory is any nearer than it has been all year, can be traced to this year’s August recess — the five-week stretch back home that immediately followed the Senate’s previous, failed attempt to overhaul the nation’s health-care laws," Paul writes. "The late-summer break, distant as it already feels to many of us, remains fresh in some lawmakers’ minds."

"That’s the driving reason behind Senate Majority Leader Mitch McConnell’s decision to at least 'consider' holding votes next week on new legislation to repeal the ACA. Stuck in what might become the greatest damned-if-he-does, damned-if-he-doesn’t moment of his political career, McConnell is, for now, siding with those clamoring for another vote to repeal the health law."

"All the more remarkable is the lack of evidence that the bill’s chances are any better this time around than they were in July," Paul continues. "In fact, some Republicans openly expect another defeat. Yet they still believe that trying again is the only option."

-- Win or lose, President Trump appears to be all in. He's been dispatching top officials to Congress. And, of course, tweeting about Cassidy-Graham. The president tweeted a warning this morning to Sen. Rand Paul, the Kentucky Republican who says he opposes the measure:

HEALTH ON THE HILL

--Alaska, Alaska, Alaska. Wither goes its GOP Sen. Lisa Murkowski, there goes Cassidy-Graham? Many people sure think so. Murkowski has been negotiating behind closed doors with GOP leaders on the measure, which she has said must not hurt her state if she's going to embrace it. If Sens. Paul and Susan Collins (R-Maine) oppose the bill, Murkowski's vote would be essential or the whole thing would crumble.

Interestingly, there's a provision buried deep in the 140-page bill that would benefit Alaska, The Post's Juliet Eilperin reports. Beginning on page 95, the bill has a provision that exempts low-density states whose block grants either decrease or stay flat between 2020 and 2026 from the Medicaid per capita cap. Under that scenario, both Alaska and Montana would be exempted from the funding cap that applies to all other states during that period.

--Yet Alaska Gov. Bill Walker, an independent, has signed onto a letter with other governors indicating opposition to Cassidy-Graham. Yesterday, Walker told Juliet he was still looking for the kind of assurances that would allow him to support the bill but had not yet received them.

“I’m concerned about protecting Alaskans, and my comfort level is just not there yet,” he said, adding that the bill has to be written “in such a way that Alaska does not get hurt in the process.”

Walker said he's especially worried about constraining federal health-care dollars through a fixed block grant because Alaska has so many remote communities and that, in turn, drives up the cost of health-care delivery.

“You can’t drive to 82 percent of our communities. That’s a concern,” he said. “When it comes to our health-care costs, they’re clearly the highest in the nation.”

You better believe Democrats will be jumping all over the provision benefiting Alaska. From Sen. Chris Murphy (D-Conn.):

What we know about where Republican senators stand on Cassidy-Graham:

--1 opposes the bill (Rand Paul)

--3 have concerns (Murkowski, Collins and Arizona Sen. John McCain)

--22 haven't said how they feel about it

--26 support it

--Keep up with The Post's whip count, right here.

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

It's an arrangement that surprised some of Sanders's Democratic colleagues.
David Weigel
Community Catalyst Action Fund is investing six-figures in a radio ad campaign designed to defeat Cassidy-Graham.
Sean Sullivan
“White people are getting filthy rich from it,” one person at a recent panel said.
Justin Wm. Moyer
MALPRACTICE
Rebutting Jimmy Kimmel, Sen. Cassidy says his plan will boost health-insurance coverage. But the evidence is slim.
Glenn Kessler
STATE SCAN
Gov. Brian Sandoval said Thursday that the flexibility fellow Republican Sen. Dean Heller promised will be good for Nevada in a health-care bill he’s sponsoring is a “false choice” because the legislation will also slash funding.
The Nevada Independent
DAYBOOK

Today

  • The National Institute for Health Care Management Foundation holds a webinar on navigating care choices.

Coming Up

  • The American Enterprise Institute holds an event on “Innovative rethinking of health care delivery and competition” on September 29.
SUGAR RUSH