with Paulina Firozi


Republicans flirting with the prospect of repealing the individual mandate as part of the tax overhaul are facing some troubling questions. Would the move to strike the most-reviled part of Obamacare alienate GOP moderates? Would scrapping the mandate even achieve the savings Republicans are hoping for? And would such a move go too far in muddying the waters of the already-contentious process of rewriting the nation's tax code? 

For all those reasons, Republicans have not yet committed to a rollback of the individual mandate -- which requires all Americans to purchase health coverage or pay a penalty -- as part of the tax rewrite. At least not right now.

It's looking unlikely that a repeal of the mandate will get a ride on the House GOP tax bill -- despite the fact that Republicans most involved in tax negotiations insist a final, final decision hasn’t been made.

The topic didn’t come up much at yesterday’s House Ways and Means tax markup, where Republicans and Democrats instead sparred over the effort to eliminate various deductions, the measure's impact on low-income people and even a provision allowing parents to set up college savings accounts for their unborn children.

And Ways and Means Chairman Kevin Brady (R-Tex.) -- who has previously said he didn't want to attempt individual mandate repeal as part of the tax effort -- didn't include it among several amendments he proposed to the bill. A Brady spokeswoman pointed to those previous comments when asked whether he's still open to including a repeal of the mandate:

From Fox News's Chad Pergram:

From Bloomberg's Sahil Kapur:

GOP leaders -- most notably, Senate Majority Leader McConnell (Ky.) -- are deeply wary of mixing controversial health-care elements into the tax debate. But conservatives aren't giving up, and neither is the White House.

President Trump has made it clear he wants the mandate gone, whether through a vote in Congress or by weakening it through an executive order. In fact, the president has salready prepped such an order, presumably to use if Congress doesn’t act.

The order stops short of rescinding the mandate — only Congress can do that because it’s embedded in the Affordable Care Act’s text. But it would allow even more people to claim a “hardship exemption” that allows people to go uninsured as the result of extraordinary circumstances and was created under the Obama administration, my colleagues Juliet Eilperin and Sean Sullivan reported.

Andy Slavitt, who headed the Centers for Medicare and Medicaid Services under Obama:

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

It’s not surprising that Trump and some Republicans are fixating on the mandate as the single most vulnerable part of the ACA after GOP efforts crashed and burned to repeal the whole law. The mandate polls poorly, with just 35 percent of Americans viewing it favorably, according to Kaiser Family Foundation polling. A repeal of the mandate has been part of every GOP health-care plan in the past seven years.

And remember, the mandate was the centerpiece of the 2012 Supreme Court case that challenged its constitutionality. The court ultimately upheld the mandate by ruling the penalty for being uninsured was a “tax” and therefore within the authority of the federal government to administer.

Of course, the main attraction of repealing the mandate is that such a move would give Republicans some fast cash to help fund their tax overhaul. But here's a wrinkle -- the very same Republicans have actually criticized the official analysis, which concluded repealing the mandate is a money-saver.

This sounds complicated — but it’s not. The Congressional Budget Office assumed 16 million fewer people would choose to buy coverage without the penalty for remaining uninsured, leading it to score big coverage declines under multiple GOP health-care bills this past spring and summer.

At the time, many conservatives balked that the CBO was going way too far in assuming the mandate's effectiveness in incentivizing people to buy coverage. There’s no way so many people would forgo coverage just because the mandate was kaput, they argued.

But here’s the flip side: Fewer people buying coverage means fewer people accessing government subsidies to help cover the costs. And that translates to less government spending. The CBO estimated that repealing the mandate would save the federal government $416 billion over a decade, making it a valuable pay-for as Republicans seek to fund their tax bill.

Thus, the mandate now serves as a big possible funding mechanism for the GOP precisely because the CBO might have overestimated its effectiveness. If the CBO downgraded its confidence in the mandate, that would mean fewer people estimated not to buy coverage and less government savings, ultimately.

Here's the bottom line. Including a mandate repeal in tax reform would help Republicans in two big ways: keeping part of their most hyped political promise to get rid of Obamacare (in part, anyway). And it would also serve as a valuable way of offsetting the exorbitant costs of tax cuts.

In other words, maybe Republicans can have their Obamacare cake and eat it, too. But such a dessert might simply not be in the offing for a bunch of other complex reasons. Stay tuned.

Residents of Sutherland Springs, Tex., grappled with the mass shooting that took 26 lives from the community in November 2017. (Alice Li/The Washington Post)

Here’s what we know about the mass shooting at a church in Sutherland Springs, Tex. that left 26 people dead and 20 injured. The massacre came amid a “domestic situation” between the alleged gunman, 26-year-old Devin Patrick Kelley, and his family, some of whom attended the First Baptist Church. In suggesting a motive behind the attack, officials pointed to his issues with his relatives, report Eva Ruth Moravec and Mark Berman, noting the gunman sent “threatening texts” to his mother in-law, who was not at church when he opened fire Sunday morning.

Kelley, who was discharged from the Air Force for bad conduct after being convicted for assaulting his then-wife and stepson and serving 12 months in confinement, should not have been able to buy a gunThe Air Force “failed to follow policies for alerting federal law enforcement,” about the gunman’s past, our colleague Alex Horton reports. “enabling the former service member... to obtain firearms before the shooting rampage.”

Speaking in Seoul yesterday, President Trump insisted that tougher gun laws would not have prevented the mass shooting. Instead he spoke of a man, Stephen Willeford, who grabbed his own gun and exchanged fire with the gunman outside the church. Trump called Willeford a “brave man” and said “if he had not had a gun, instead of having 26 dead, you would have had hundreds more dead… It’s not going to help,” David Nakamura reportsRead Sen. Chris Murphy’s (D-Conn.) plea here for his colleagues to “think about whether the political support of the gun industry is worth the blood that flows endlessly onto the floors of American churches, elementary schools, movie theaters, and city streets.”

Here’s what we know about the lives lost in Texas. A state official said Monday the victims ranged in age from 18 months to 77 years. And the New York Times wrote about the Holcombes, who lost eight members of their extended family in the shooting.


— It's Day Seven of the ACA's fifth open enrollment season. Monday's The Health 202 about the hefty premiums many unsubsidized consumers are encountering appeared to strike a chord with many readers, who wrote me to share their stories. Over the rest of the sign-up period, we'll try to feature a daily letter in this section, so please send me your story. ( paige.cunningham@washpost.com). We do a lot of high-level analysis on these pages, but it's also important to reflect on the individual experiences -- good and bad -- of readers like you.

Here's today's letter:

“We earn just enough not to qualify for a subsidy. We currently pay about $1,100/month for health insurance for the two of us. Today we found out that next year, the lowest plan on offer is $3,472/month with a $14,000 deductible (a $2,000 hike). As the premiums are about 50% of our pre-tax income and we do not need expensive care, there is no way we can afford it....America used to be an advanced country. Now we are faced with the same situation as in a banana republic...If the media only talk about the very poor who will continue getting help until the GOP can slash that, it is no help. Right now, the plight of the self-employed or self-insured needs highlighting. They are the ones being consigned to the trash."     — Andrew Foss, Albemarle County, Va.


AHH: An administration official has confirmed there's been a spike in sign-ups on Healthcare.gov in the first week it's been open. More people have signed up in the first few days of enrollment compared with the same period in previous years, Juliet Eilperin writes.

"More than 200,000 Americans chose a plan on Nov. 1, the day open enrollment began, according to one administration official. That’s more than double the number of consumers who signed up on the first day of enrollment last year. More than 1 million people visited HeathCare.gov, the official federal website, the official said, which amounts to roughly a 33 percent increase in traffic compared with 2016."

The figures are worth noting as Obamacare advocates worried the word wouldn't get out that it was open enrollment season given the GOP Congress's efforts to eliminate the ACA, and moves by the Trump administration to slash funding for marketing. Experts had predicted a significant drop in enrollment numbers, as we noted last week. A Standard & Poor's analysis forecast up to a 1.6 million drop overall. 

"But on opening day, many state exchange officials said that enrollment had exceeded their projections," Juliet adds.

Thoughts from Vice’s Alexandra Jaffe:

The Daily Beast's Sam Stein:

Liz Allen, former deputy communications director under Obama:

Some used the news as a way to urge even more people to sign up. From liberal group MoveOn.org:

OOF: Today, Maine voters will decide whether -- or not -- to accept the ACA's Medicaid expansion. If they do, the state would be the first to expand the program via ballot initiative, but the 33rd state overall to accept expansion of the insurance program for low-income Americans. About 70,000 Mainers would be able to join the state's Medicaid program, which currently covers about 265,000 people. The question is on the ballot because Maine Gov. Paul LePage (R) vetoed Medicaid expansion five times, the Press Herald writes.

Doctors at University Health System Hospital provided an update on the medical response to the shooting in Texas that killed 26 on Nov. 5. (Reuters)

OUCH: Violent mass shootings might be contagious, catching on and multiplying like an epidemic, The Atlantic’s Derek Thompson writes. Three of the five worst mass shootings in modern U.S. history have occurred in the last two years and two of them were in the last 37 days.

Derek cites research from Arizona State University in 2015 that found “significant evidence that mass killings involving firearms are incented by similar events in the immediate past." Lead author Sherry Towers told The Atlantic that television, radio, and other media exposure might be the means through which one mass shooting infects the next perpetrator.

"Like a commercial, each event’s extraordinary coverage offers accidental advertising for depravity,” Derek writes. “Given the contagion research, one can imagine a sinister feedback loop that might explain the recent spate of murderous sprees. If more victims mean more media coverage, and more coverage means more inspiration, it implies that historically violent mass shootings might be the most contagious.”

Of course, it's not like the media are going to stop covering mass shootings (or should stop covering them), Derek acknowledges. But he suggests that journalists should cover such events "with an awareness that even noble coverage can advertise."

Sen. Rand Paul (R-Ky.) suffered more serious injuries than originally reported from an assault by his neighbor on Nov. 3. (Reuters)

--Why would one medical professional attack another? The details emerging about the altercation between Sen. Rand Paul and his next-door neighbor -- which left the Kentucky Republican with serious injuries -- are confusing.

Here’s what we know four days after Paul was attacked at his home in Bowling Green. Paul was mowing his lawn when his neighbor, retired anesthesiologist Rene Boucher, tackled him, according to the New York Times. Paul, who was wearing sound-muting earmuffs, did not see or hear Boucher coming. He suffered five broken ribs and bruises to his lungs as a result of the attack. A lawyer for Boucher called the incident a “very regrettable dispute between two neighbors over a matter that most people would regard as trivial.”

“We sincerely hope that Senator Paul is doing well and that these two gentlemen can get back to being neighbors as quickly as possible,” Boucher’s lawyer, Matthew Baker, added.

--Three Kentucky Republicans told the Times that the incident resulted over a landscaping dispute. "Competing explanations of the origins of the drama cited stray yard clippings, newly planted saplings and unraked leaves," the Times’s Nicholas Fandos, Noah Weiland and Jonathan Martin write. But a friend, Robert Porter, who visited Paul over the weekend told the Times he was not aware of landscaping drama between the neighbors and that Paul is “still unsure why he was attacked… I don’t know if he knows why he was attacked.”

Boucher was charged with fourth-degree assault and released on Saturday on $7,500 bond, but our colleagues Wesley Lowery and Ed O’Keefe report that given the extent of Paul’s injuries, police and prosecutors may considering upgrading the charges.


— You’ll soon be able to get your medication delivered almost immediately from CVS Health. The company announced yesterday that it will offer next-day delivery from all its 9,700 stores beginning in 2018. Same-day prescription delivery will also begin in major markets, our colleague Carolyn Y. Johnson reports, including in Miami, Boston, Philadelphia, San Francisco and the District. And if you live in Manhattan, you'll be able to get free delivery within hours for prescription medications as well as certain over-the-counter products starting Dec. 4.

How much will this all cost? Unclear. A company spokeswoman told Katie Thomas of theTimes that delivery fees outside of Manhattan CVS locations will vary and haven't been announced.

Monday's announcement reflects a sort of preemptive strike by CVS as it hedges Amazon.com’s possible expansion into the sale of prescription drugs, Katie writes. Although Amazon (whose owner, Jeff Bezos, also owns The Post) has not formally announced plans to sell pharmaceuticals, the online retail giant ... has made several moves, including acquiring state-level permits to be a wholesale pharmacy distributor and hiring drug industry leaders. The potential move by Amazon has also partly driven CVS to enter into talks with Aetna over a potential acquisition, something The Health 202 mentioned last month.

A few more reads from The Post and around the Internet:


DON'T MISS THIS: The Post and Live Nation will bring the “Can He Do That?” podcast to a live audience at the Warner Theatre. In this live taping, political reporters Bob Woodward, David Fahrenthold and Karen Tumulty will join host Allison Michaels to review the past year in President Trump’s White House and the biggest moments that made people wonder “Can He Do That?” Tickets can be purchased now at Live Nation.Attendees will also receive a free 30-day digital subscription to The Washington Post.

MORE POST PROGRAMMING: The Washington Post hosts Secretary of Veterans Affairs David Shulkin for a discussion that will include his department’s efforts to curb the veterans’ suicide rate, address post-traumatic stress disorder and other health concerns on Thursday.


  • The Hill hosts an event on the opioid epidemic featuring Sen. Jeanne Shaheen (D-N.H.) and FDA commissioner Scott Gottlieb.

Coming Up

  • Kaiser Health News holds an event on advance care planning on Wednesday.
  • Axios hosts an event on a new era in cancer innovation with former Vice President Joe Biden and former first lady Jill Biden on Wednesday.

  • The House Education and the Workforce Subcommittee on Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Development hold a joint hearing on opioids on Wednesday.

  • The House Energy and Commerce Subcommittee on Health holds a hearing on MACRA and alternative payment models on Wednesday.
  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on Nov. 13.

  • STAT holds an event on the FDA on Nov. 13.


These are the nine talking points that are repeated after every mass shooting:

As America grapples with the increasing frequency and deadliness of mass shootings, politicians are turning to scripted reactions to respond to the tragedies. (Jenny Starrs/The Washington Post)

What you need to know about semi-automatic rifles like the AR-15:

The AR-15 and its many variants are popular among gun owners, and they have been used in several mass shootings. (Patrick Martin/The Washington Post)

Stephen Colbert responds to the mass shooting in Texas:

Watch Elton John's surprise performance of “Circle of Life” at the 20th anniversary celebration of “The Lion King:”

Elton John gave a surprise performance of “Circle of Life” at the 20th anniversary celebration of “The Lion King” musical on Broadway on Nov. 5. (Reuters)