THE PROGNOSIS

Families who eat together stay together, as the saying goes. Not necessarily for Senate Republicans and the White House.

The Senate GOP had hoped to unify around a bipartisan plan to stabilize the Affordable Care Act marketplaces after lunching with President Trump on Capitol Hill yesterday. Instead — as in past meals shared with the president and vice president — Republicans emerged just as confused and disorganized as ever.

Senators at Tuesday's lunch said the president didn't vow support for a bipartisan bill to stabilize the insurance marketplaces, which would resume extra subsidy payments that the administration cut off this month. Republican leaders say the only thing holding them back from a vote are mixed messages from the president, who appears to support the effort but later disparages it

“He just encouraged us to continue to work on it. He made it clear that he appreciated what Sen. Alexander was doing,” Sen. Mike Rounds (R-S.D.) told reporters, according to The Hill, referring to the stabilization bill championed by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.).

Alexander said the next step is for the White House and the House to weigh in on the measure -- even though Speaker Paul Ryan (R-Wis.) has said he doesn't want to fund the payments.

“Looks to me like it's the kind of bill that, toward the end of the year, will be discussed by the president and the Senate and the House leaders," Alexander told my colleague Sean Sullivan. "So, hopefully we've given them something to work with. My sense of things is that a growing number of senators of both parties are coming to the conclusion that we're going to need to do something before the end of the year.”

It's surprising -- and yet somehow not surprising -- that Trump's visit didn't produce a spirit of unity among his fellow Republicans over food (especially after an escalation of his feud with Sen. Bob Corker (R-Tenn.) yesterday morning). On several occasions this year, the president and Vice President Pence hosted select groups of GOP senators for dinner at the White House as Trump tried to prod them to pass an Obamacare repeal bill. But those dinners mostly resulted in highlighting their divisions, and even resulted in some embarrassing moments.

As the Senate's Better Care Reconciliation Act teetered on the edge of failure in July, Trump invited senators to dine on lemon ricotta agnolotti and grilled rib-eye steak in the Blue Room of the White House. The following day, the president was forced to admit that four senators had taken positions against the measure, effectively killing its prospects.

Pence hosted several conservative senators for a June dinnerto discuss their concerns with the BCRA. Yet several weeks later, one of those senators -- Mike Lee (R-Utah) -- announced he wouldn't support the bill because it didn't go far enough in undoing the ACA's regulatory infrastructure.

Fast-forward a few months. Open enrollment for Healthcare.gov and state-run marketplaces starts in just one week, and Republicans are still frozen on their approach the law. It's too late to affect 2018 rates with the Alexander-Murray bill, but lawmakers could help insurers lower premiums for the following year even if they passed the legislation closer to the end of the year, perhaps as part of a larger spending bill. At least 60 senators have said they'd vote for it, which would ensure its passage in the Senate -- but 48 of them are Democrats.

Many Republicans, particularly the more conservative ones, are having a hard time reconciling themselves to passing a bill that props up the marketplaces which they spent most of the year trying to erase in several ACA repeal bills. Their lack of agreement became even more pronounced yesterday, as the Republican chairmen of two key House and Senate committees introduced an alternative to the Alexander-Murray bill that Democrats immediately panned.

The competing plan, from House Ways and Means Chairman Kevin Brady (R-Tex.) and Senate Finance Chairman Orrin Hatch (R-Utah) would fund the cost-sharing reduction payments, known as CSRs, just like Alexander-Murray. But it would go further by delaying the ACA's individual and employer mandates and giving states even more leeway in opting out of insurer regulations.

"As I have said all along, if Congress is going to appropriate funds for CSRs, we must include meaningful structural reforms that provide Americans relief from Obamacare," Hatch said in a statement.

From the New York Times's Margot Sanger-Katz: 

Murray said no way to the new plan. “We already know that partisan proposals to take coverage away from millions of people, spike premiums, and inject even more uncertainty into health care markets cannot pass the Senate, and that the agreement Chairman Alexander and I reached on steps to lower families’ health care costs, stabilize markets, and move away from partisan dysfunction on health care can," she said in a statement.

Alexander said he doesn't feel threatened by Hatch, per The Hill's Peter Sullivan:

NBC News's Benjy Sarlin: 

PROGRAMMING NOTE: Join me at 9 a.m. this morning as The Washington Post hosts a kick-off event today for The Health 202’s Live interview series with lawmakers and leaders in the health-care community. If you can't join us in person, watch the live stream here.

AHH, OOF and OUCH

AHH: How do you prepare for widespread life-threatening diseases? Our colleague Lena H. Sun describes a simulation the World Bank held earlier this month: “The government ministers were facing a new infectious disease outbreak. The mysterious virus was sickening and killing people with alarming speed. Some patients had to be placed on ventilators to help them breathe. The new virus seemed resistant to antiviral medicine,” she writes.

“Within a week, officials had closed a major hospital and schools and quarantined thousands of people. Fear and panic spread quickly as people in neighboring countries became infected and died.

That scenario was part of a pandemic simulation held during the World Bank’s annual meeting in Washington this month. It’s not the kind of event that people would typically associate with the World Bank. But it’s the fourth such exercise the bank has helped organize in the past year, reflecting what experts say is the growing awareness outside the traditional global health sector of the increasing threat and economic disruption posed by a global pandemic.”

Why practice this now? The 2014 Ebola epidemic that killed more than 11,000 people in West Africa prompted the simulations, Tim Evans, senior director for health, nutrition and population at the World Bank told The Post.

“We realized that people were just making it up as they were going along, including us,” Evans said. The World Bank wanted to “move from a history of panic and neglect to one where we’re going to start to prepare much more systematically to be ready for the 100 percent probability we will be dealing with this again."

Earlier this year, Lena wrote about the Trump administration's  lack of preparedness for the next outbreak.

OOF: A 36-year-old mother is suing a medical center and members of her medical team after she underwent a double mastectomy and hysterectomy following genetic tests she says incorrectly found cancer-causing genes.

Oregon resident Elisha Cooke-Moore said an OB-GYN told her the tests results "showed she had a 50 percent chance of getting breast cancer and up to an 80 percent chance of getting uterine cancer, so [Cooke-Moore] underwent a recommended double mastectomy and hysterectomy to try to beat the odds,” writes our colleague Lindsey Bever.

Months later, she says she learned the tests were wrong. Now she’s suing Curry County Health District and her doctors for $1.8 million.

“I am damaged for the rest of my life,” she told Lindsey.

“Cooke-Moore said she had expressed concerns to her doctor regarding a family history of cancer, so it was agreed she would be tested for a BRCA 1 and BRCA 2 gene mutation. Although the results were negative, her nurse practitioner misinterpreted them — and Cooke-Moore was told she had the MLH1 gene mutation and Lynch syndrome, according to the medical malpractice lawsuit,” Lindsey writes.

OUCH: It’s been five weeks to the day since Hurricane Maria crashed onto Puerto Rico. More than 75 percent of people are still in the dark. Residents are still waiting for supplies. And many of the drug and device companies on the island are not operating at 100 percent.

FDA Commissioner Scott Gottlieb said in prepared testimony before a Tuesday House Energy and Commerce Committee hearing that while some production has restarted since the storm, the status of the manufacturing facilties doesn't "reveal the true scope of the challenge we are facing" on the island.

Products made on the island make up nearly 10 percent of the drugs consumed nationwide, the FDA said earlier this month. And Gottlieb said the FDA is closely monitoring 30 of them.

“We understand that manufacturing is running at minimal levels, and certainly far from full production,” Gottlieb said ... “with many firms operating around 20 percent capacity, and some even less. We have found no firm operating above 70 percent of their normal operation.”

On Tuesday, Gottlieb warned that one of the main concerns was manufacturing’s access to electricity.

“If [drug and device manufacturing plants] don’t return to the grid by the end of this year, we’re concerned we could face multiple potential shortages,” Gottlieb said, according to STAT.

Pharmaceutical products aren't the only problem. Forty percent of the island's hospitals are operating off the electrical grid, Department of Health and Human Services’s assistant secretary for preparedness and response, Robert Kadlec, told the committee on Tuesday. 

“Sometimes, there’s some reliability issues as it relates to transmission wires and distribution,” Kadlec said when asked of hospitals had consistent power, STAT reported.

HEALTH ON THE HILL

-- It’s been 25 days since Congress let funding expire for the Children’s Health Insurance Program, but lawmakers may not be able to address the issue until December. Many states still have funding leftover from last year to make it through the year, though Axios notes that 27 states are set to run out money for the program, which covers 9 million children, in the first quarter of 2018.

Both the House and Senate have proposed bills to renew CHIP, but the effort has taken a backseat to other pressing legislative priorities.

CHIP may not be renewed until the end of the year “because the House is still fighting over the substance of its bill and floor time in the Senate is limited,” Axios’s Sam Baker reported. In the meantime, CMS is “reaching into old CHIP accounts to provide states with some bridge funding as they need it.”

Former Centers for Medicare and Medicaid Acting Administrator Andy Slavitt is keeping track of the days since CHIP has expired on Twitter:

As are some Democratic lawmakers. 

From Sen. Mark Warner (D-Va.): 

Rep. Gregory Meeks (D-N.Y.):

Sen. Tom Carper (D-Del:)

From former Hillary Clinton senior spokesman Jesse Ferguson: 

TRUMP TEMPERATURE

-- On to tax reform. President Trump’s meh attitude toward health care yesterday led some Senate Republicans to believe the president wanted them to move on. The general takeaway from his lunch with GOPers on the Hill, reports Politico, was a decided ambivalence on whether they should continue to try and find a solution on subsidies for low-income Americans (known as cost-sharing reductions) or put all of their energy toward taxes.

Simply put, “there isn’t anything else other than taxes,” Sen. John Cornyn (R-Tex.) said, per Politico’s Jennifer Haberkorn and Adam Cancryn.

Sen. John Thune (R-S.D.). said the rival CSR plan from Hatch and Brady  “proves that we should be focused on tax reform right now, because obviously we haven't gotten our act together on health care."

But Sen. Lindsey Graham (R-S.C.) expressed optimism to Jen and Adam, saying "If we get taxes done, we'll have momentum for health care... [The president] talked a lot about doing health care again."

MEDICAL MISSIVES

Fentanyl, a synthetic opioid about 50 times stronger than heroin, has ravaged communities across the nation. In this Washington Post original documentary, reporter Wesley Lowery travels to one of the hardest hit cities, Philadelphia, where he finds the crisis is only getting worse: 

--  “As President Trump prepares to declare the opioid epidemic a national crisis, the law enforcement community is racing to contain the spread of fentanyl, which has largely replaced heroin on the streets here in opioid-ravaged New England and is increasingly the cause of fatal overdoses nationwide,” writes our colleague Joel Achenbach in our story on the homepage this morning. Drugs have evolved, and become more easily transportable, he writes, and fentanyl is at the center of that change.

Much of the fentanyl, intended for medical use for patients in severe pain, is manufactured in Mexico and smuggled into the United States. Some of it arrives in the mail.

Often it’s mixed in with other powdered drugs, and addicts are looking for its particularly potent high. “To some addicts, a near-death experience is not an error. It’s the dream,” Joel describes. And the drugs are becoming stronger.

Joel writes: “Brian Kenney, head of the narcotics unit in Nashua, said stepped-up law enforcement, enabled by greater funding, has resulted in some progress in stemming the epidemic. But he has noticed something about the overdoses: There aren’t as many of them, but more of the overdoses are fatal.

‘The potency of the stuff that is out there is so much stronger that I’m still getting my deaths,’ he said.”

Many of the users in Nashua are people who became addicted to prescription painkillers — often after a work accident — and wound up addicted to street drugs, he said. Kenney describes the pitiable scenes when he makes an arrest: “They break down talking to me. They say, ‘I can’t believe this happened to me. I was a regular guy.’ ”

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

Legislation to beef up U.S. Customs and Border Protection’s ability to detect attempts to smuggle opioids into the country passed in the House on Tuesday.
The Hill
U.S. life expectancy is declining, new calculations show.
Bloomberg
STATE SCAN
California will now require drug makers to justify price hikes. The goal is admirable but the law is flawed. Here's why it may not make much difference.
Stat News
REPRODUCTIVE WARS
The 17-year-old is being held in federal custody and has been trying to terminate her pregnancy since September
Ann E. Marimow and Maria Sacchetti
The app Nurx lets patients obtain a variety of contraceptives, including the morning-after pill, from the touch of a smartphone.
Stat News
The case of a pregnant migrant teen held in Texas and blocked by the Trump administration from obtaining an abortion may be heading toward a point of no return.
CNN
DAYBOOK

Today

  • The House Energy and Commerce committee holds a hearing on federal effort to combat the opioid crisis.

Coming Up

  • The NIHCM Foundation hosts a briefing on Capitol Hill on “Transforming Health Care to Drive Value” on Friday.

SUGAR RUSH

Sen. Jeff Flake (R-Ariz.) speaks to reporters after announcing his plan to retire:

Flake joins growing list of GOP lawmakers on their way out:

White House press secretary Sarah Huckabee Sanders on the media: 'I've never been attacked more:'

Former FBI chief James B. Comey's secret Twitter account, according to the Internet: 

Here are 4 things to know about the Iditarod dog doping scandal:

On the Late Show with Stephen Colbert, Jake Tapper responds to a recent Twitter insult from Bill O'Reilly: