Uncertainty is the name of the game these days for health insurers, providers and consumers as Republicans rule Congress and the White House — and in arenas beyond just Obamacare.

It’s been 17 days since Congress let funding expire for two bipartisan health-care programs, potentially affecting 18 million low-income Americans. For now, there’s enough cash flow for states to keep running the Children’s Health Insurance Program and for community health centers to care for low-income people. But if lawmakers don’t renew funds by Jan. 1, big holes will start to open in the country’s social safety net.

“Right now we have a very, very fragile primary health-care system in America, and that primary health-care system is being stretched to its limits,” Sen. Bernie Sanders (I-Vt.) told me yesterday.

You’d think even amid the raging battles over the Affordable Care Act — as Republicans have sought to dismantle the law through legislating, executive orders and administrative rule changes — that Congress would prioritize funding CHIP and community health centers. After all, the programs enjoy support from even most Republicans because they provide care to the most vulnerable Americans.

Community health centers, which serve one out of every 12 Americans, stand to lose $3.6 billion next year if Congress doesn’t extend additional dollars they were provided under the ACA. Similarly, the ACA bumped up CHIP funding temporarily, by 23 percent. Congress is expected to gradually allow that to ramp down, but all the bipartisan program’s pre-ACA spending also needs reauthorizing. Covering 9 million kids, CHIP is the biggest reason the uninsured rate among children has dramatically improved in the United States. 

Yet Democrats and Republicans are bickering over how to pay for it all, and how long to extend the funding. Last week, House Energy and Commerce Chairman Greg Walden (R-Ore.) delayed a vote on a two-year funding extension over Democratic protests that it would pull dollars from Obamacare’s public-health fund and raise Medicare premiums on the highest-income earners.

Walden and his Democratic counterpart, Rep. Frank Pallone (D-N.J.), continued the back-and-forth yesterday. Although Democrats said they’ve made several offers, Walden said no progress is being made and threatened to hold a full vote on the version they oppose once the House returns to Washington next week.

“If Democrats are serious about funding these important programs, I call on them to follow through on their offer,” Walden said in a statement. “There is too much at stake for partisan games and gridlock.”

Yet if Congress were serious about funding the two programs without causing crippling uncertainty for states and providers, it could have tackled the issue months ago. Everyone knew the funding would officially expire Oct. 1, but Senate Republicans spent September rushing headlong toward a second Obamacare repeal effort that dead-ended just like the first one.

President Trump has been talking about health care a lot — but not about funding CHIP (which covers 9 million kids) or community health centers (which serve around 24 million patients per year). Instead, Trump fixated over the past few weeks on signing an executive order that many health-care experts warned could destabilize the marketplace even further by allowing individuals and small-business employees to buy narrower coverage through trade associations.

“Obviously there’s been a whole lot of discussion about health care with the Republican effort to repeal and replace, with Trump’s effort to try to sabotage,” Sanders said. “But what is not being discussed is we have a community health center program which now provides health care to some 27 million people all over this county.”

Sanders was a key Democrat who pushed for massively scaling up funding for community health centers as part of the ACA.  A trust fund set up by the law provides the centers with 70 percent of their federal funding. The idea was that these centers would need more capacity as more low-income Americans became insured under the 2010 health-care law.

The situation is getting direr by the day. Even though there’s still cash flow for states and community health centers, it won’t last forever. The funding will start drying up around New Year’s, and some states could run out of CHIP funding even sooner.

But all that aside, delay on the issue is creating uncertainty that is hurting community health centers right now, Dan Hawkins, senior vice president at the National Association of Community Health Centers, told me. Hawkins said several health centers have told him they recently struggled to recruit doctors because they couldn’t guarantee funding next year.

“The word is out on the street,” Hawkins said. 


AHH: A pair of swing-state Democrats are offering what you could call a way scaled-down version of Sanders' (I-Vt.) "Medicare for All" plan. The proposal, from Sens. Michael Bennet of Colorado and Tim Kaine of Virginia, would create Medicare-style options for non-elderly workers, with a heavy focus on rural areas that have few insurers selling plans on the ACA's marketplaces. The proposal is politically significant because it tries to build on the existing law rather than the tear-it-all-down proposal of a national "single-payer" health-care system that Sanders has offered, my colleague Paul Kane writes.

"The Sanders proposal has gained steam among liberal activists who felt that last year’s failed presidential campaign by Hillary Clinton lacked a big progressive idea to galvanize the Democratic base," Paul writes. "The single-payer plan has already been embraced by many of the potential Democratic contenders for president in 2020....However, overall, it has drawn only a third of the members of the Senate Democratic Caucus as co-sponsors, and even some supporters say the single-payer proposal is more of an 'aspirational' goal. No one is certain how to finance an idea that would use Medicare as the basis for all health plans."

--That's where Bennet and Kaine's plan comes in. They're offering a proposal they believe is both realistic and politically viable, targeting it to rural areas  hardest hit by insurance providers fleeing ACA exchanges. These rural areas broke the most sharply against Clinton last year, which could make the Bennet/Kaine proposal a more palatable offering for the 10 Democrats up for reelection in states that Trump won last year.

"This proposal shows that Democrats have moved to the left ideologically on health care," Paul writes. "Eight years ago, the public option failed because moderate Democrats backed away from it; now a similar proposal is being offered as the safe ground for those facing a tough reelection."

OOF: This morning, President Trump tweeted that his nominee for drug czar, Rep. Tom Marino (R-Pa.), has withdrawn in the wake of an investigation by The Post and CBS' "60 Minutes" which explained how Marino helped steer legislation making it harder to act against giant drug companies. While the president defended Marino as “a very early supporter of mine” and “a great guy," he declined to express specific support for Marino at a press conference yesterday and indicated he would review the reporting. It appears that Trump did just that.

"We're going to be looking into" the investigation, Trump said, per my colleagues  Ed O'Keefe, Scott Higham and Lenny Bernstein.

The president also announced that he'll declare the opioid epidemic a national emergency next week. A presidential declaration, which Trump said he would put in place back in August, could allow the administration to remove some bureaucratic barriers and waive some federal rules governing how states and localities respond to the drug epidemic. One such rule restricts where Medicaid recipients can receive addiction treatment.

--Meanwhile, many Democrats called on Trump to quickly discard Marino in the wake of the report, which detailed how a targeted lobbying effort helped weaken the Drug Enforcement Administration’s ability to go after drug distributors, even as opioid-related deaths continue to rise. Senate Minority Leader Chuck Schumer said nominating him for drug czar “is like putting the wolf in charge of the henhouse. The American people deserve someone totally committed to fighting the opioid crisis, not someone who’s labored on behalf of the drug industry.”

OUCH: Vox's Sarah Kliff is inviting readers to submit hospital bills so she can construct a nationwide picture of one particular hospital charge, called an emergency facility fee. Nearly all hospitals charge one for seeking emergency room care, but the price varies enormously and is typically kept secret. It's a way to shed more light on the "outlandish" health-care prices in the U.S., she writes.

"Americans pay exorbitant prices for all kinds of care. As a health care reporter, I find myself writing about $25,000 MRIs, $629 Band-Aids — even a $39.95 fee just to hold one’s own baby after delivery. People send me these types of bills quite regularly via email," Sarah writes. "The health care prices in the United States are, in a word, outlandish. On average, an MRI in the United States costs $1,119. That same scan costs $503 in Switzerland and $215 in Australia."

"These are uniquely American stories, and they are the key to understanding our dysfunctional health care system. High prices are hurting American families. Most Americans who get insurance at work now have a deductible over $1,000. High prices are why medical debt remains a leading cause of bankruptcy in the United States, and nowhere else."


--Trump had a lot to say about a lot of topics during his pop-up presser in the Rose Garden yesterday. At one point, he returned to his rhetoric about too-high prescription drug prices. "The world is taking advantage of the United States. They're setting prices in other countries, and we're not. The drug companies, frankly, are getting away with murder. And we want to bring our prices down to what other counties are paying," he said.



--Yesterday, Sen. Lamar Alexander (R-Tenn.) said Trump has given his blessing to a bipartisan deal -- that could potentially emerge this week -- to pay the same insurance subsidies that the administration halted last week, Bloomberg reports.

“He called me a week ago and he called me on Saturday,” Alexander said of the effort, which he’s working on with Sen. Patty Murray (D-Wash.). “We had a good conversation each time, and he encouraged me to get a result with Senator Murray. He said, ‘I don’t want people to suffer.’ That’s his words.”

Recall that last Thursday, the administration announced it will no longer make Obamacare’s “cost-sharing reduction” payments, which reimburse ACA insurers for discounts they're required to provide to lower-income people to help them afford deductibles and co-payments. A federal judge ruled last year that the administration can't make the payments without an appropriation from Congress.

Yesterday, Trump said in a Cabinet meeting that creating a crisis by abruptly cutting off the payments was a necessary step to getting legislation moving. “Republicans are meeting with Democrats because of what I did with the CSRs,” the president said. “If I didn’t cut the CSRs they wouldn’t be meeting, they’d be having lunch and enjoying themselves, all right. They’re right now having emergency meetings to have a short-term fix of health care.”

--The ads pushing back on Trump's blocking of the subsidies are here. "Save My Care," a coalition of groups fighting the GOP's ACA repeal attempts, is launching an ad this morning demanding that Congress fund the payments. The ad quotes the nonpartisan Congressional Budget Office estimating ending the payments would raise premiums 20 percent initially, and Rep. Charlie Dent (R-Pa.) appearing to blame ACA woes on his own party should the payments eventually be terminated.

"We the Republican Party will own this," Dent is seen telling CNN, prior to Trump's announcement last Thursday. 

Here are some more interesting reads from The Post and beyond:

A Washington Post and "60 Minutes” investigation underscores the power of the drug industry to change laws at the height of the opioid epidemic. And Washington is listening.
Amber Phillips
The eight-term congresswoman, who is running to replace Bob Corker, backed legislation that hobbled drug law enforcement during the opioid crisis.
Elise Viebeck
Senator Thad Cochran was expected back in Washington on Monday after an extended illness. His failure to appear has increased speculation about his health.
New York Times
President Donald Trump said he believes Cuba “is responsible” for the mysterious ailments that have left at least 22 American government employees and family members in Cuba with cognitive problems and other symptoms.
Wall Street Journal
Anthony Dickerson said doctors want him to prove that he has complied with his parole officer for the next three months.
Lindsey Bever
Researchers say the trend is worth watching in other states.
Christopher Ingraham


  • The Senate Health, Education, Labor and Pensions holds a hearing on “How the Drug Delivery System Affects What Patients Pay.”

Coming Up

  • The Washington Post holds an event on America’s opioid epidemic on Wednesday.
  • The Center for Global Development holds an event on “Allocation Rules to Guide Aid Spending in Global Health” on Wednesday.
  • Axios hosts an event on what's next for health care with Sens. Lamar Alexander (R-Tenn.), Bill Cassidy (R-La.), and Tim Kaine (D-Va.) on Wednesday.
  • The U.S. Chamber of Commerce holds an event on “Advancing Priorities and Innovative Solutions Aid Uncertainty” onWednesday.
  • The Senate Health, Education, Labor and Pensions Committee will hold a hearing on “Examining How Healthy Choices Can Improve Health Outcomes and Reduce Costs” on Thursday.

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