THE PROGNOSIS

Some Republicans will forever carry a torch for repeal of the Affordable Care Act. But it’s hard to see how the door really opens again in the near future -- at least as widely as it has been since the start of President Trump's tenure. There’s just too much in the way.

The past two weeks on Capitol Hill perfectly illustrate the problem. Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) developed some momentum for their health-care bill after the meltdown in July around a previous measure guided by Majority Leader Mitch McConnell (R-Ky.).

But the same old problems were still there when push came to shove. Not enough moderates were willing to cut Medicaid spending. Independent analysts said the GOP plans would cause millions of Americans to lose coverage. And, of course, Democrats were shut entirely out of the process.

Senate GOP leaders emerging from their weekly lunch yesterday confirmed that they’d canceled a vote on Cassidy-Graham planned for today. The budget reconciliation bill they were going to use for it expires Sunday. They could still try to create space for ACA repeal in the tax code rewrite they’re going to attempt next — or even create another budget reconciliation bill to use for health care. But neither scenario is terribly likely.

“You can change the procedure but you can’t change the underlying terrain,” Tom Miller, a health-care fellow at the American Enterprise Institute, told me.

In their scramble to pass Cassidy-Graham, Republicans sacrificed momentum behind a bipartisan bill to stabilize next year’s marketplaces being crafted by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.). Prices for health plans are now officially baked into next year’s marketplaces in most states, as today is the deadline to finalize insurer contracts in the states using the federal marketplace, Healthcare.gov.

Even so, Alexander said yesterday afternoon that he’ll attempt to revive the effort.

“I will consult with Sen. Murray and with other senators, both Republicans and Democrats, to see if senators can find consensus on a limited bipartisan plan that could be enacted into law to help lower premiums,” he said in a statement.

Yet nine months into the Trump presidency, Republicans are no more unified on their approach to health care than they were early this year, when they couldn’t even agree on whether to repeal and replace Obamacare at once or separately. In fact, you could argue their fault lines are even more clearly demarcated than before.

Some Republicans will never admit their long-touted goal of overturning Obamacare has been shelved.

“Was it over when the Japanese bombed Pearl Harbor?” as one GOP lobbyist put it to me.

President Trump isn't giving up, tweeting this morning (Politico's Seung Min Kim notes Sen. Thad Cochran (R-Miss.) missed the Monday vote because of a medical issue but is not in the hospital):

Others held out hope of a revival, as well. Morning Consult's Eli Yokley: 

From Yahoo News's Liz Goodwin: 

From the Washington Examiner's Kimberly Leonard: 

Others are being more realistic about the situation:

From Sen. David Perdue (R-Ga.)

Sen. Lisa Murkowski (R-Alaska) tweeted that Cassidy-Graham ran up against a "hard deadline and a lousy process:"

Sen. Cory Gardner (R-Colo.) is now focusing on a repeal of just a small part of the ACA: its health insurance tax set to resume in January:

Sen. Rob Portman (R-Ohio) is supportive:

So is Sen. Tom Cotton (R-Ark.): 

For Republicans who are ready to move on, The Health 202 offers five lessons we see emerging from this debacle:

1. You can’t easily cut a government program that 69 million benefit from.

Nearly one-fourth of Americans rely on Medicaid to pay for their doctor visits, prescription drugs and hospital stays. Eligibility varied widely by state before the ACA, but the health-care law looped in a much larger segment of the population by allowing states to enroll childless adults earning up to 133 percent of the federal poverty level.

Republicans don’t like the situation — and make valid arguments about Medicaid’s cost burden on states — but they were scared stiff by the prospect of a political backlash had they passed any of several GOP health-care bills proposing big cuts to the program’s spending.

2. You can’t go up against the health-care industry and win.

Health-care spending accounts for around 18 percent of gross domestic product — and the government has projected it will reach 20 percent of GDP by 2025. The health-care industry — from drugmakers to hospitals to doctors to insurers to device manufacturers — is powerful and influential.

They turned out in force against virtually all the health-care bills Republicans in the House and Senate have proposed this year. Insurers remained pretty quiet about the proposals, but even they publicly rejected Cassidy-Graham last week.

3. You can’t replace concrete health benefits with a big question mark.

The weakness of the ACA is that it didn’t expand coverage as broadly as many hoped and it didn’t tamp down health-care costs. It has, however, ensured that when people buy coverage they are guaranteed it will cover a basic range of services. And they get income-based financial assistance to ensure they can buy plans to begin with.

Cassidy-Graham would have disbanded the marketplaces where this coverage is obtained, instead turning over the subsidies for these plans — along with the extra federal dollars for Medicaid expansion — over to the states to spend as they wished. Many states may have used the money effectively. But Republicans couldn’t guarantee that would be the case, or explain exactly how the dollars would be used.

The plan assumed that just another group of elected officials, namely governors, would improve health coverage and services, without providing certainty that they would. “Cassidy-Graham is saying we’re not going to tell you how this is going to turn out,” Heritage's Miller said.

4. You can’t win with bad grades from the Congressional Budget Office.

For each of the GOP plans, the CBO estimated that more than 20 million fewer Americans would have coverage in a decade. Cassidy-Graham never got a complete CBO score; even so, the agency released a projection on Monday that it would mean millions fewer Americans would be covered.

5. You can’t take away protections for millions of Americans with chronic medical conditions.

All the GOP health-care bills considered this year would have expanded to varying degrees the ability of states to opt out of insurer regulations that ensure people with serious medical conditions can obtain and afford coverage.

This type of approach just doesn’t fly, when you consider that about 1 in 4 Americans have preexisting medical conditions that would have made it harder for them to get coverage before the ACA.

“Americans have come to accept the idea that people should not be excluded from coverage, be charged unaffordable premiums, or be denied essential services because they have preexisting conditions,” Washington and Lee health law professor Tim Jost said.

HEALTH ON THE HILL

--Democrats and other supporters of President Barack Obama's law breathed a big sigh of relief after the news that Cassidy-Graham wouldn't get a vote:

The Independent Women's Voice's Heather R. Higgins: 

From Sen. Amy Klobuchar (D-Minn):

Former Obama spokesman Dan Pfeiffer: 

From Sen. Elizabeth Warren (D-Mass.): 

--Yet upon their second big failure to coalesce around a repeal bill, Senate Republicans showed little interest in moving swiftly to shore up the law's marketplaces (note the stalled action on the Alexander and Murray effort). Enrollment begins in just about one month -- Nov. 1 -- in individual marketplaces in all 50 states and D.C.

Instead, Senate leaders said they would turn their attention to their next major legislative undertaking: a tax rewrite, my colleagues Juliet Eilperin, Sean Sullivan and Amy Goldstein report. "Where we go from here is tax reform,” McConnell told reporters after holding a closed-door policy lunch with members of his caucus.

Republicans said the pressure to pass a tax bill was higher than ever and hoped their base would give them a bit more time to take another shot at repealing the ACA. “They’re going to be frustrated, and I don’t blame them,” said Sen. John Thune (R-S.D.). “I hope they’ll have a little bit of patience.”

--McConnell and his deputies warned their conference yesterday that continuing the seemingly doomed health-care effort would cripple plans to pass a tax bill by the end of this year. Pairing the two issues together into one budget reconciliation bill -- as some had suggested -- would lead to certain defeat on both issues, leaders said.

“We’re not going to do that,” said Senate Finance Committee Chairman Orrin G. Hatch (R-Utah). “It would screw up the budget.”

"Republican leaders have been eager to move on from their repeated failures on health care in hopes of passing a tax bill that will demonstrate their ability to govern," Kelsey and Dave Weigel write. "McConnell and other GOP leaders believe that the 52 Republican senators can unite over taxes and salvage a year that is absent any major legislative victories for their side. They plan to attach the tax measures to the budget bill, which under special Senate rules could be passed by the Republican majority without help or input from the Democrats."

Sen. John McCain (R-Ariz.) laid down the same marker on tax legislation as he did on health care, demanding regular order and support from both parties.

“We need to do it in a bipartisan fashion,” McCain said, per Bloomberg. The senator argued that the major congressional reforms that have stood the test of time since the 20th century have included buy-in from both parties. “I am committed, as I’ve said before, to a bipartisan approach, such as we’ve been doing in the Armed Services Committee for the last 53 years,” he told reporters in the Capitol.

AHH, OOF and OUCH

AHH: Acting Drug Enforcement Administration head Chuck Rosenberg, an Obama administration holdover who has found himself at odds with the Trump administration in recent months, told staff members yesterday he is planning to step down from his post on Oct. 1. In an email to his staff, Rosenberg said he was proud to have led the “remarkable agency.”

“The neighborhoods in which we live are better for your commitment to the rule of law, dedication to the cause of justice, and perseverance in the face of adversity,” he wrote. “You will continue to do great things. I will continue to root for you, now from the sidelines.”

"His departure is not completely surprising," the Post's Devlin Barrett and Matt Zapotosky report. "President Trump has always been expected to nominate someone of his own choosing to lead the nation’s premier agency on narcotics enforcement. Rosenberg, who had been running the agency in an acting capacity since 2015, had earned a reputation as someone willing to put himself at odds with his bosses in the White House and the Justice Department."

OOF: More details have emerged about Health and Human Services Secretary Tom Price's use of taxpayer-funded private jets. Price took a jet in August to get to St. Simons Island, an exclusive Georgia resort where he and his wife own land, a day and a half before he addressed a group of local doctors at a medical conference that he and his wife have long attended, Politico reports.

"The St. Simons Island trip was one of two taxpayer-funded flights on private jets in which Price traveled to places where he owns property, and paired official visits with meetings with longtime colleagues and family members," Dan Diamond and Rachana Pradhan report. "On June 6, HHS chartered a jet to fly Price to Nashville, Tennessee, where he owns a condominium and where his son resides. Price toured a medicine dispensary and spoke to a local health summit organized by a longtime friend. He also had lunch with his son, an HHS official confirmed."

OUCH: McConnell lost just about every way possible on Tuesday, my colleague Paul Kane writes.

First, he had to abandon, again, an effort to repeal Obamacare amid an uprising from the more moderate wing of the GOP caucus. Then he learned that one of his most influential Republican chairman would not run for reelection next year, setting up a potentially divisive race to succeed the senator. Finally, before 9:30 p.m. Tuesday, McConnell suffered the final indignity: His preferred candidate in Alabama, Sen. Luther Strange (R), lost the GOP nomination in embarrassing fashion to a conservative insurgent.

"While no stranger to defeat in the past — he spent eight years as minority leader — McConnell’s string of losses in such a short timespan Tuesday punctured much of his well crafted image as the consummate insider who could deliver," Paul writes. "Each blow had its own unusual circumstances, with President Trump’s own erratic performance playing a role, but McConnell’s failures came in nearly every facet of congressional leadership."

STATE SCAN

Stop the presses: this is some bipartisan health-care work happening this week. Democrats and Republicans on the House Energy and Commerce Committee wrote to drug distributor Miami-Luken announcing an expanded probe into the company’s alleged pill dumping in West Virginia.

The letter detailed the expansion of the investigation, which began following reports in the Charleston Gazette-Mail and The Washington Post about an unusually large opioid presence in West Virginia. It was sent Monday by Chairman Greg Walden (R-Ore) and top Democrat Frank Pallone Jr. (D-N.J.), who highlighted a few small towns where pharmacies are getting a huge volume of pain-killers.

One such town is Kermit, West Virginia, with a population of 392, where a single pharmacy received nearly nine million hydrocodone pills over two years. Another was a ‘mom-and-pop pharmacy’ in the small town of Oceana that received an unusually high level of prescription medicines -- 600 times as many oxycodone pills than a Rite Aid drugstore that was ‘just eight blocks away. “If these reports are true, it would appear that the state of West Virginia may have received extraordinary amounts of opioids from distributors beyond what that population could safely use," the lawmakers wrote.

In a March story, The Post’s Scott Higham and Lenny Bernstein described a new kind of lawsuit in West Virginia and other states targeting corporations that distribute painkillers. "The suits are among the first of their kind in the country," Scott and Lenny wrote. "They accuse the companies of creating a hazard to public health and safety by shipping inordinate quantities of opioids into the state in violation of a West Virginia law."

Some other good reads from The Post and beyond:

The situation on Puerto Rico was becoming increasingly critical as residents struggled to find medical care amid a shortage of power, water and gasoline.
New York Times
Former Health and Human Services Secretary Kathleen Sebelius called her successor Tom Price’s repeated use of chartered aircraft “stunning” and said the only time she ever flew a private jet while in office was to visit a trio of remote Alaskan villages.
Bloomberg
MEDICAL MISSIVES
More than 2 million new cases of chlamydia, gonorrhea, and syphilis were reported in the United States last year — the most ever.
AP
DAYBOOK

Coming Up

  • The House Financial Services Subcommittee on Housing and Insurance will hold a hearing on “examining insurance for nonprofit” on Thursday.

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

  • The National Press Club will have a headliners luncheon with FDA Commissioner Dr. Scott Gottlieb on Friday.

SUGAR RUSH

Senate Republicans postpone health-care vote: 

President Trump: "We are disappointed in certain so-called Republicans" on health care: 

Watch Stephen Colbert on the latest GOP health-care failure: 

Jimmy Kimmel is grateful the GOP health care bill is dead: