Conservatives on Capitol Hill are suddenly face-to-face with a vexing question: Will they vote to boost President Obama’s health-care law after spending the past seven years trying to eradicate it?

A freshly minted bipartisan agreement to stabilize the Affordable Care Act’s marketplaces -- announced yesterday by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) — has restarted the painful, months-long GOP drama over how to handle Obamacare, making it likely the issue will get tangled up in year-end battles over funding the federal Children’s Health Insurance Program — or even the government.

It’s possible the Senate could approve the measure, although Majority Leader Mitch McConnell (R-Ky.) was noncommittal yesterday, saying he'd not yet had the chance to consider “a path forward.” The agreement got resounding applause from many Democrats, and a fair number of Republicans gave it a cautious nod, too.

“I don’t expect the Republicans to give up their goal of repealing ACA,” top Senate Democrat Chuck Schumer said yesterday. “But in the meantime, stabilizing the system, preventing chaos and stopping the sabotage is in everybody’s interest.”

The bigger question is whether the Alexander-Murray framework could ever pass the more conservative House. Although it eases the process for states to pursue alternatives to the Obamacare marketplaces, insurers would still have to abide by the health-care law’s coverage requirements, which Republicans complain have resulted in higher premiums.

“The inflexibility on the plan design is contrary to what many conservative Republicans have been calling for, which leads me to believe this might find some resistance among conservatives in the House as well as in the Senate,” Chris Condeluci, a former Republican Senate Finance Committee staffer, told me.

A spokesman for House Speaker Paul Ryan (R-Wis.) declined to comment on the agreement. Freedom Caucus Chairman Mark Meadows (R-N.C.), whose group forced last-minute revisions to the House’s health-care bill last spring, called it a “good start” but said “much more work needs to be done.”

The Republican Study Committee, another, larger group of conservatives, tweeted this statement from its chairman, Rep. Mark Walker (R-N.C.):

“None of our guys voted for Obamacare,” Rep. Tom Cole (R-Okla.), a moderate Republican and close ally of leadership, told my colleagues Sean Sullivan and Juliet Eilperin. “They’re not very interested in sustaining it.”

The centerpiece of Alexander-Murray is a pool of funding insurers had said was crucial to the success of and state-based marketplaces — a two-year guarantee of federal payments for the cost-sharing discounts they must provide the lowest-income customers.

President Trump said last week that the federal government will no longer make the payments without an appropriation from Congress. Insurers had said they’d raise rates 15 to 20 percent more without the payments — on top of the hefty rate hikes they’d already planned for 2018.

“In my view, this agreement avoids chaos,” Alexander said yesterday. “I don’t know a Democrat or a Republican who benefits from chaos.”

Democrats were also pleased that the deal reinstates spending on Obamacare outreach, albeit in the form of grants to states, after the administration had quashed most advertising that typically takes place around the open enrollment period.

Murray praised the bipartisan deal for funding the cost-sharing payments:

There are also a few goodies for Republicans, chiefly in how states could more quickly and easily apply for and get waivers to shape their marketplaces in alternative ways.

They’d have to wait just 90 days for approval from the Department of Health and Human Services instead of 180 days. States could apply for a waiver with permission from only the governor and not the legislature. The agreement would also allow Americans older than 30 to buy lean, “catastrophic” coverage.

Indicating he’d sign the bipartisan agreement if passed by Congress, Trump nonetheless vowed to keep striving for an ACA repeal. Speaking to the Heritage Foundation last night, the president said he's "pleased" Democrats are working with Republicans to provide "relief" from the law but insisted "Congress must find a solution to the Obamacare mess instead of providing bailouts to insurance companies."

--Earlier in the day, Trump had called Obamacare "virtually dead." "At best you could say it's in its final legs," the president said after a press conference. Speaking in the Rose Garden, he called the deal a “short-term solution so that we don’t have this very dangerous little period.”

“It’ll get us over this intermediate hump,” Trump said. His comments:

But Republicans face a much higher incline — more of a political mountain, actually — when it comes to actually approving the agreement.

The New York Times's Margot Sanger Katz: 

Politico's Jake Sherman: 

The Daily Beast's Sam Stein: 


AHH: We've been hearing the term "single-payer system" a lot more recently, as more Democrats have embraced it as the direction they think the United States should head. Last month, Sen. Bernie Sanders (I-Vt.) introduced his "Medicare for All" bill with 16 Democratic co-sponsors. But what does single-payer even mean? The Post's Kim Soffen explains with a series of visuals examining how the U.S. health-care system is funded and how "single-payer" would change it.

--This might surprise you: Although the governments of other developed countries generally pay a much larger share of the health-care bills than the United States, there's still a broad spectrum of how many benefits they cover and how many residents also purchase supplemental private coverage. 

Sanders’s bill takes universal coverage close to one extreme end, with the government covering so many services with such small co-pays that private insurance would be almost universally unnecessary, Kim writes. Accordingly, it would also be quite expensive -- $32 trillion over 10 years -- that would mark an almost 50 percent increase in all federal spending.

But most universal-coverage systems don’t look quite like this. It’s expensive for a government to fund a comprehensive health-care system, especially somewhere like the United States where costs are so high.

OOF: The nation’s opioid epidemic has unleashed a secondary outbreak: the rampant spread of Hepatitis C, The Post's Katie Zezima reports from Charleston, W.Va. New cases of the liver disease have nearly tripled nationwide in just a few years, driven largely by the use of needles among drug users in their 20s and 30s. The disease's treatment costs tens of thousands of dollars, is limited by insurance and Medicaid, and is mostly unavailable to people who are still using illicit drugs,  so there probably will be financial and public health ramifications for decades to come.

"Here in West Virginia, which has the nation’s highest rates of overdose deaths and new hepatitis C and hepatitis B infections, public-health officials are attempting to identify as many new hepatitis carriers as possible — and are girding for decades of repercussions," Katie reports. "The number of new confirmed hepatitis C cases nationwide rose from 853 in 2010 to 2,436 in 2015, according to the Centers for Disease Control — a 15-year high. But tens of thousands more are believed to have contracted the disease without knowing it."

“If we don’t cure a significant number of the people who are injecting, in 20 years from now, the hospitals in this part of the world will be flooded with these people with end-stage liver disease, which has no cure,” said Judith Feinberg, a professor of behavioral medicine and psychiatry at the West Virginia University School of Medicine. “I can see it coming at me like the headlights of a train. Just coming, coming, coming, and I’m thinking, ‘Doesn’t anybody want to jump out of the way?’”

OUCH: Rep. Judy Chu (D-Calif.) is calling for an investigation of a law hobbling the Drug Enforcement Administration that she co-sponsored last year. Chu said yesterday that the head of the agency personally assured her that the measure would not hamstring law-enforcement efforts, although a subsequent Post/"60 Minutes" investigation has revealed otherwise.

In a letter Tuesday to the chairmen of two key House committees, Chu charged that then-Acting DEA administrator Chuck Rosenberg told her in a Sept. 22, 2016, meeting after the measure became law that it “did not interfere with the DEA’s ability to successfully stop bad actors, my colleagues Scott Higham and Lenny Bernstein report. Her letter is the first to detail Rosenberg’s position on the law since a Post story showing the measure stripped the DEA of its most potent weapon against drug distributors that have allowed hundreds of millions of narcotic painkillers to spill into the black market.

Chu, one of the few Democrats to co-sponsor Rep. Tom Marino’s (R-Pa.) bill, wrote that at the time she “believed the bill would help independent and community pharmacists, most of whom are small business owners who provide vital services for their communities.”


--Rep. Tom Marino (R-Pa.) has withdrawn from the running to be Trump's drug czar in the wake of the Post's report detailing how he helped pass legislation weakening the DEA’s ability to go after drug distributors, even as opioid-related deaths continue to rise.

“As a former prosecutor who has dedicated my life to aggressive and faithful enforcement of our laws, I have reached the difficult decision that the best course of action is to remove the distraction my nomination has created to the utterly vital mission of this premier agency,” Marino said in a statement, although he still defended his legislation, saying it was “a balanced solution for ensuring those who genuinely needed access to certain medications were able to do.”

The president announced Marino's decision via a tweet:

The administration says it is scrutinizing the law, with Deputy Attorney General Rod J. Rosenstein saying yesterday he was “very concerned about it” and planned to review whether the DEA needs “more tools” to carry out its mission. 

But how aggressively will Congress will reassess a bipartisan bill that was passed last year with no opposition? A spokesman for Sen. Chuck Grassley (R-Iowa), chairman of the Senate Judiciary Committee, said the panel was exploring “the idea of holding an oversight hearing” to learn what had changed since President Obama signed the bill.

--Meanwhile, PhRMA came out against the law yesterday, urging its repeal. “We need to ensure the Drug Enforcement Administration (DEA) has sufficient controls and authorities in place to prevent illicit diversion of controlled substances,” Stephen Ubl, president of the Pharmaceutical Research and Manufacturers of America, said in a statement. Ubl also said Congress should consider whether existing criminal and civil penalties are sufficient to ensure reporting of suspicious orders of controlled substances in a timely fashion.


Alex Azar, a former pharmaceutical executive and a top health official during the George W. Bush administration, is now the leading candidate to head HHS after Tom Price's resignation, my colleagues Juliet Eilperin and Amy Goldstein report.

--Azar was president of Lilly USA for five years. Over the decade he spent at the company, he also directly led a biomedicines division that covered neuroscience, immunology and cardiology, and was also responsible for the company’s sales and marketing operations. After stepping down from Lilly USA in January, he founded the health-care consulting firm Seraphim Strategies.

--Under Bush, he served as HHS's general counsel, working on the administration’s response to the 9/11 terrorist attacks and the ensuing anthrax attacks, stem-cell policy and the advent of the Medicare prescription drug benefits. He then served two years as deputy secretary. 

"Azar is well respected by his fellow Republicans — including White House Domestic Policy Council Director Andrew Bremberg, who was with him at HHS — as well as many in the health-care industry," Juliet and Amy write.

Both of the HHS secretaries for whom Azar worked are supporting him for the position. “If the president is looking for an experienced, competent conservative who is confirmable, Alex would be a great choice,” Mike Leavitt told my colleagues. Tommy Thompson praised Azar’s “record of proven competence” and combination of private- and public-sector management. “He is an experienced leader with deep substantive health-care knowledge,” Thompson said in an email.

The White House declined to comment Tuesday, but a longtime Republican health-policy expert said consideration of Azar as the department’s next leader “is extremely far down the road.”

Some other good reads:

John McCain on Monday slammed “half-baked, spurious nationalism” in a thinly veiled critique of Trump’s leadership. Trump responded Tuesday in a radio interview.
Elise Viebeck
The case is the first in which Chinese-based fentanyl manufacturers and distributors have been hit with a label reserved for those with control over major drug organizations.
Matt Zapotosky and Sari Horwitz
The Missouri Democrat has said she was away dealing with health issues at the time. But the record shows that's not true.
Glenn Kessler
A hearing in federal court in Washington on Wednesday could determine whether a 17-year-old who crossed the border illegally can get the procedure.
Maria Sacchetti and Sandhya Somashekhar

POST PROGRAMMING: Today, The Washington Post will bring together policymakers, medical experts and business leaders to discuss the nation's response to the opioid epidemic. The program will also feature an inside look at the Washington Post-CBS News joint investigation on the drug industry and the DEA. The event begins at 9 a.m. Learn more here.


  • The Center for Global Development holds an event on “Allocation Rules to Guide Aid Spending in Global Health.” 
  • 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.).
  • The U.S. Chamber of Commerce holds an event on “Advancing Priorities and Innovative Solutions Aid Uncertainty.”

Coming Up

  • 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.
So, Sen. Claire McCaskill (D-Mo.)  was there when the DEA bill was passed:

A timeline of Senate Majority Leader Mitch McConnell’s (R-Ky.) rough past few months:

President Trump says ‘I want Merry Christmas:’

Many of President Trump's frequent jabs at the press have a Nixonian tone:

Watch Trevor Noah on President Trump and McConnell's "BFF presser:"