Republicans in Congress aren't off the hook for failing to make good on their promise to repeal Obamacare, even with the shiny new executive order President Trump is preparing to roll out this week, conservative activists insist.

Ha! Not even close,” Heritage Action spokesman Dan Holler wrote in an email yesterday, after I’d asked whether the executive order eases pressure on Republicans in the House and Senate.

Heritage and other conservative groups were severely disappointed as the GOP-led Congress they’d helped elect crashed and burned on their dearest legislative priority — repealing and replacing President Barack Obama’s 2010 Affordable Care Act.

“It’s a huge disappointment, a huge letdown,” Jason Pye of FreedomWorks told me. Pye said he wrote an internal 46-page retrospective on how the whole thing went down over the spring and summer as the House struggled to pass its health-care bill and then the Senate tried but failed to muster enough votes.

“That’s one thing I think conservatives are taking solace in right now — there are some great conservatives running in 2018,” Pye said.

There’s also a Republican president determined to say he delivered on his Obamacare repeal promises. This week, Trump and his White House are putting the finishing touches on an executive order expanding association health plans aimed at providing more people with lower-cost insurance options (I explained the policy in Tuesday's The Health 202). Sen. Rand Paul (R-Ky.) has been involved, too:

Without details, it’s hard to say how many people would have access to these plans, or whether they’d prompt any significant changes in the insurance markets. Many insurance experts are even warning it could further destabilize the individual market if enough healthy people choser leaner health association plans, tilting the marketplaces towards sicker, more expensive patients.

From the Commonwealth Fund's Shanoor Seervai: 

From Larry Levitt, senior vice president of the Kaiser Family Foundation:

From the left-leaning Center for Budget and Policy Priorities: 

Nonetheless, Trump is framing his upcoming action this way: Congress is lame. So he’s saving people from the evils of Obamacare by taking matters into this own hands.

“With Congress the way it is, I decided to take it upon myself,” the president told reporters yesterday, saying he’ll sign something “which is going to go a long way to take care of the many of the people that have been so badly hurt on health care.”

“It will be great, great health care for many, many people – a big percentage of the number of people that we were talking about for failed Obamacare,” Trump continued.

Some conservatives are more enthused about Trump’s action than others. Club for Growth President David McIntosh said expanding association health plans was among six ideas he presented to Trump for changing the ACA administratively at a meeting of conservative leaders at the White House in March.

“I think it’s fantastic,” McIntosh told me, saying the order will “stop the bleeding” from Obamacare until Congress can move to repeal the law.

Holler said association health plans can increase consumer choice — which has been a key goal for conservatives. But they won’t fix all the problems ailing the health-care system which, in Holler’s view, were caused to a large degree by the ACA.

“Ultimately, Congress and the administration will need to deliver on their promise to repeal and replace Obamacare if we are going to have an actual consumer-oriented health insurance system,” Holler wrote.

An executive order just doesn’t satisfy conservatives’ enduring hunger for total elimination of the ACA, a task that appears impossible with the slim 52-48 GOP Senate majority.

“At the end of the day there’s no substitute for legislation, so we still believe for Congress a top priority should be to repeal Obamacare,” said Geoff Holtzman of Freedom Partners, a group funded by the Koch brothers network.

Conservatives also risk appearing hypocritical for supporting the Trump administration flexing big, administrative muscles to reshape a law passed by Congress. For years they’d criticized Obama for issuing executive orders (even though Obama’s 276 executive orders don’t even come close to FDR’s 3,721). Trump did, too, during his presidential campaign.

Mic's Emily C. Singer: 

That means that right now, conservatives would have to embrace a more expansive view of presidential power in order to be satisfied with action to peel back the ACA. And that's a hard pill to swallow.

“I’m very hesitant with sidestepping law,” Pye said. “I don’t consider this a fulfillment of repeal-and-replace if it’s within the scope of existing law.”


AHH: The Trump administration is playing down health hazards as it seeks to justify its rollback of Obama-era limits on power plant emissions, Bloomberg News reports. "The Environmental Protection Agency will formally begin undoing Obama’s plan on Tuesday, a process that includes revising some of its underlying calculations to emphasize costs and minimize benefits" in order to legalize the change, Jennifer A. Dlouhy writes. "Among the casualties: long-held conclusions about how microscopic air pollution jeopardizes human health."

Former President Obama stressed the public health benefits when he unveiled his Clean Power Plan two years ago. The regulations could result in 3,600 fewer premature deaths, 90,000 fewer asthma attacks in children and a decline in hospital visits, he said at the time. Now as the Trump administration rolls back the limits, it must try to provide good legal and policy explanations under the 71-year-old Administrative Procedure Act that governs federal rulemaking. The same requirement is need to justify repealing other Obama-era rules, including limits on methane leaks from oil wells, Dlouhy writes.

"They are putting their thumb on the scales and changing the math enough so they can say the costs aren’t justified for the Clean Power Plan," Conrad Schneider, advocacy director for the Clean Air Task Force, told Dlouhy. "It’s a game of trying to reach a predetermined outcome."

OOF: The number of obese children has increased more than tenfold in the past four decades — from 5 million girls in 1975 to 50 million in 2016, and from 6 million boys in 1975 to 74 million in 2016 -- according to the most comprehensive database ever assembled on the topic. A study published in the Lancet on Tuesday night provides a sobering look at how the relationship children globally have with food and weight depends on where they are growing up, The Post's Ariana Eunjung Cha reports.

"Overall, one in every five children on the planet is either obese — meaning more than two standard deviations from the median on growth charts — or overweight — meaning more than one standard deviation," Ariana writes.

But there's a flip side to this story. Despite the big increases in obesity, there are still more children who remain moderately or severely underweight, especially in the poorest corners of the world. "An estimated 75 million girls and 117 million boys are moderately or severely underweight, meaning greater than one standard deviation from median on the WHO charts. Almost two-thirds of these children live in South Asia, where some governments' ability to feed their citizens has been unable to keep up with countries' booming populations," she reports.

OUCH: Government leaders should be sure their actions are "motivated by the public good and not by personal interests," the acting federal ethics' chief wrote in a scolding Oct. 5 letter to members of Trump's Cabinet, warning them to double down on their commitment to ethical conduct, my colleagues Lisa Rein and Tom Hamburger report. 

The two-page letter to agency heads from David Apol, acting director for the Office of Government Ethics, was sent six days after former Health and Human Services Secretary Tom Price resigned amid controversy over his use of private jets for official business travel. Apol called it “essential to the success of our republic that citizens can trust that your decisions and decisions made by your agency are motivated by the public good and not by personal interests.”

It's not just Price who's raised eyebrows. Inspectors general are also investigating the use of noncommercial planes by Treasury Secretary Steven Mnuchin, Environmental Protection Agency Administrator Scott Pruitt and Interior Secretary Ryan Zinke. Veterans Affairs Secretary David Shulkin has also come under fire for taking a taxpayer-funded, 10-day trip to Europe over the summer with his wife and two top aides.

While not addressing the Cabinet travel directly, Apol indicated he was disappointed by recent actions of government officials. “I am deeply concerned that the actions of some in Government leadership have harmed perceptions about the importance of ethics and what conduct is, and is not, permissible,” he wrote.


--Don Wright sure didn't get to serve as acting HHS secretary for very long. Trump announced last night he's replacing Wright with Eric Hargan, a former corporate lawyer who served on the president's transition team and was confirmed by the Senate just last week. No firm word yet on who the president will nominate as Tom Price's permanent replacement.

Here's more on the Illinois-based Hargan from a White House statement on his original appointment: "Mr. Hargan previously served the Department from 2003-2007 as Deputy General Counsel, as Principal Associate Deputy Secretary and as Acting Deputy Secretary.  In 2014-2015, he served as Co-Chair and Convener of the Healthcare and Human Services Transition Committee for Illinois Governor Bruce Rauner.  In 2016-2017, he served on President Trump’s transition team for HHS."

Melania Trump visits opioid recovery center:

--First lady Melania Trump visited an infant recovery center in West Virginia yesterday to discuss the opioid epidemic, signaling a ramped-up focus on that issue amid her broader platform of helping children and combating cyberbullying.

“Please tell me how I can help,” Melania told staff members and former clients of Lily’s Place, a nonprofit that has treated around 190 babies suffering from neonatal abstinence syndrome, according to the New York Times. “That’s why I’m here. I want to listen to your stories; I want to hear what I can do to help.”

In an eight-minute appearance in front of the press, Melania said her goal for the visit, which lasted about an hour, was to help “give a voice” to families facing addiction. “We need to open the conversation and teach children and young mothers that it’s dangerous to use drugs,” she said.


Rep. Marsha Blackburn (R-Tenn.) announced her campaign in a video that Twitter blocked for "inflammatory" content:

Twitter has reversed a decision to block Rep. Marsha Blackburn (R-Tenn.) from paying to promote her Senate campaign launch video on its social network, the company told Politico Tuesday. It had initially blocked Blackburn’s video from its ads platform, saying its reference to “baby body parts” was “inflammatory” and violated its guidelines.

“Our ads policies strive to balance protecting our users from potentially distressing content while allowing our advertisers to communicate their messages. Nowhere is this more difficult than in the realm of political advertising and the highly charged issues that are often addressed therein," a Twitter spokesperson said. “While we initially determined that a small portion of the video used potentially inflammatory language, after reconsidering the ad in the context of the entire message, we believe that there is room to refine our policies around these issues.”

The Blackburn campaign said it was pleased with the reversal of a decision it had viewed as politically motivated censorship. “Silicon Valley is in the pocket of the liberal establishment, but our conservative revolution is going to keep on winning,” Blackburn wrote in a fundraising email yesterday. Her video was retweeted at least 18,000 times on Tuesday.

--Twitter and other social media platforms have made plenty of rules about what is and isn't acceptable on their sites -- but they're about as clear as mud, The Post's Hayley Tsukayama writes.

"Even clear lines — i.e., different sets of policies for advertisements and all other content — get blurry when looking at free expression in the digital age. And that's how we end up with a video that's deemed acceptable for sharing but not for advertising," Hayley writes. "Meanwhile, Twitter and other platforms continually find themselves in uncomfortable situations that make them look inconsistent — even when they're abiding by their own rules — and result in them ruffling feathers across the board."

Twitter is known for being historically lenient on speech, making its initial decision on Blackburn's video feel like a major crackdown, said Kate Klonick, resident fellow at the Information Society Project at Yale Law School. But she said Twitter has been inconsistent in its approach, leading to further issues.

“It feels like a lot of these decisions are not being made with consideration about where they will lead [Twitter] down the road,” she said. The social media network, for example, recently said that President Trump could say things other Twitter users would not be allowed to say, because he is a newsworthy public figure. But, Klonick said, couldn't that description also fit Blackburn, a congresswoman and Senate candidate? “It's an insanely slippery slope to draw lines between people,” she said.


--An ACA tax on health plans could result in higher prices for nearly half of all Americans, according to an Oliver Wyman study which says if the tax is allowed to go into effect in January, insurers could pass it along to more than 156 million Americans in the form of higher premiums. Oliver Wyman estimates that the health insurance tax, dubbed the "HIT" by opponents, would increase all premiums an average of 2.7 percent in 2018 and between 2.6 percent and 2.8 percent in subsequent years.

The study was commissioned by UnitedHealth Group, which has joined other insurers in pressing Congress to delay or repeal the tax. Lawmakers agreed to suspend it for this year, and Republicans in the House and Senate sought to repeal it in their health-care legislation, but as things stand the tax is scheduled to kick in Jan. 1.

A few more hand-curated reads: 

FDA Commissioner Scott Gottlieb says he wants to take a close look at health claims that food manufacturers make on their packaging.
Wall Street Journal
Debate has raged about a new law that reduces penalties for knowingly or intentionally exposing someone to HIV. Statistics show it mostly affected sex workers.
Eli Rosenberg
As the island struggles to recover from the devastation of Hurricane Maria, sick people remain in mortal peril. Hospitals are short of medicines, power supplies and staff.
New York Times
One of the only thing stopping Atty. Gen. Jeff Sessions from cracking down on medical pot is an obscure budget amendment passed almost as an afterthought late in the Obama administration. Now Congress may rescind it.
Los Angeles Times


  • The House Energy and Commerce Subcommittee on Oversight and Investigations holds a hearing on the 340B Drug Pricing Program.
  • The House Energy and Commerce Subcommittee on Health holds a hearing on the opioid crisis.
  • The Bipartisan Policy Center holds an event on retirement.
  • The Section National MACRA MIPS/APM Summit begins.

Coming Up

  • The U.S. Chamber of Commerce holds an event on the opioid epidemic on Thursday.

Trump promises health care that 'will cost the United States nothing:'

Unpacking Trump's friction with Rex Tillerson:

Watch as a stolen ambulance leads police on a wild chase: 

Stephen Colbert on Trump's IQ Test: 

Watch Eminem's new four-and-a-half miute Trump-inspired verse: