Senate Republicans are increasingly resolved to infuse more funding into the Obamacare marketplaces, even as they work on a parallel measure to undermine the health-care law by erasing its mandate to buy coverage.

In an email sent to senators Tuesday night, Senate Majority Leader Mitch McConnell (R-Ky.) promised imminent action on a pair of measures designed to stabilize the marketplaces and help mitigate the premium hikes that some consumers are experiencing. “We will address legislation that Lamar, Susan and others are drafting to protect our constituents from skyrocketing premium increases,” McConnell wrote, referring to Sens. Lamar Alexander (R-Tenn.) and Susan Collins (R-Maine).

Yesterday, Collins told reporters she has a fresh promise from Alexander that the Senate will take up the marketplace funding bills, probably as part of a big, year-end spending deal. And although members of the House Freedom Caucus have often characterized the measures as an Obamacare “insurer bailout,” their leader, Mark Meadows (R-N.C.) indicated he might be willing to back them, after all.

Characteristic of their rather helter-skelter approach to the Affordable Care Act, McConnell and his leadership team seem intent on passing the marketplace stabilization measures right on the heel of voting to dismantle the health-care law’s centerpiece — its requirement to buy health insurance. The two-prong approach is designed to keep both the GOP's right flank as well as those closer to the center on board as Republicans heave themselves toward the heavy year-end lifts of a major tax overhaul, plus a bill to keep the government funded.

It appears virtually certain that repeal of the law’s individual mandate to buy coverage will be included in a final tax bill. Two of the moderate senators most likely to defect over that issue — Collins and Lisa Murkowski of Alaska — are okay with getting rid of the mandate, arguing it has been less effective than expected and its associated penalty is paid chiefly by lower-income Americans.

The question is whether Republicans will also manage to pass the two bipartisan measures essentially infusing cash into marketplace plans — a move that analysts say will help insurers lower premiums, which have been spiking across the country.

A measure from Alexander and Sen. Patty Murray (D-Wash.) would fund $7 billion in extra cost-sharing discounts; another one from Collins and Sen. Bill Nelson (D-Fla.) would provide $4.5 billion in reinsurance funding. If either one passes, it probably would be as part of a big spending measure.

No. 2 Senate Republican John Cornyn (R-Tex.) said yesterday that at least Alexander-Murray will get a vote. “I do think we’re going to take up the Alexander-Murray proposal to try to stabilize the insurance markets in the interim and bring premiums down,” he told reporters.

Underlying the whole issue is a complex web of political considerations and policy disputes, as Republicans remain divided over whether they have a responsibility to improve the ACA and Democrats stew over their colleagues’ recent move to undermine the law by repealing its individual mandate.

“Alexander-Murray should have been passed months ago to reduce damage Republicans have already done to families’ health care, and is not designed to fix the higher premiums, coverage losses, and health-care chaos that the Republican tax bill will cause if it becomes law,” a Murray aide said.

(Here's a helpful idea: Perhaps Sens. Alexander and Murray could hash all this out on a joint visit to fortuitously-named Scottish whiskey bottler Alexander Murray & Company. The Health 202 would be glad to accompany them to cover the deal-making.)

Collins has emerged as a central player in this debate, hinging her support for repealing the mandate in the Senate’s tax bill on promises from GOP leaders they’d also bring up the stabilization bills. Yesterday, she told reporters that after meeting Tuesday with Alexander, she has been reassured that is leadership’s intention.

Of course, things aren’t playing out in exactly the order Collins would wish. Congress probably will pass a temporary two-week spending patch on Friday, then finish taxes and end the year with some kind of spending agreement. Collins would rather the stabilization measure happen first, but she’s not going to die on that hill.

“I want to make sure if the timing is not as I would prefer … that we will have the commitment that it will be done before the end of the year,” Collins told me.

Of course, it may not be so crucial at the end of the day that Collins supports a final tax overhaul. The Senate bill passed last week with 51 votes, and Republicans need just 50 votes with tiebreaking help from Vice President Pence. Still, it’s a tight margin, and there’s no guarantee other Republicans might not defect at the last minute over other issues, such as action on the federal DACA program for young immigrants.

House Speaker Paul Ryan (R-Wis.) is another big question mark. His office indicated this week he hasn’t committed to passing any Obamacare stabilization bills, which the most conservative Republicans have characterized as insurer “bailouts.” A spokeswoman didn’t respond Wednesday to a request to clarify his stance.

But Collins dismissed Ryan’s seeming indifference, saying she’s confident because she also has a promise from President Trump to prop up the ACA marketplaces, which cover about 11 million Americans.

“[Ryan] has not said he’s not on board — and the president is on board — so I think we’ll have significant influence with House members,” she said.

In another positive sign for the funding bills, Meadows indicated Wednesday that he’s open to passing Alexander-Murray if it would bring Senate Democrats on board a government spending bill, even though he previously said it’s not a move he’d back. Other Republicans have also suggested they wouldn’t withhold votes on a spending bill over the stabilization measures.

“I will support whatever we have to do to keep the government open,” Rep. Chris Collins (R-N.Y.) told my colleague Erica Werner on Tuesday. “I do not support the CSRs, but I will not let that stand in the way of me voting for" a spending measure. 

Democrats are furious that Republicans moved to repeal the mandate, even after Murray worked extensively with Alexander on their marketplace stabilization bill. But there’s little they can do; they can’t block the GOP from passing its tax overhaul, and it seems unlikely at the end of the day that they’d oppose a bill to improve the ACA.

So for now, they’re taking a step back as Collins takes the lead on the issue.

“This is a check McConnell needs to cash to Collins,” a Democratic aide told me.

The policy question underpinning all of this: Does infusing more cash into the Obamacare marketplaces compensate for the damage done by repealing the mandate?

Eliminating the mandate would cause marketplace premiums to increase 10 percent annually, as more healthy people, freed of the penalty, choose not to buy coverage, according to the Congressional Budget Office. The CBO has said that providing the cost-sharing subsidies to insurers, although it would help them lower premiums, wouldn’t be enough to offset the premium hikes from the mandate repeal.

“It’s like putting a Band-Aid on a leg that’s been cut off,” a GOP lobbyist characterized it to me last week.

But yesterday, Collins pointed to a new analysis from the firm Avalere, which found that the CSR payments in combination with the reinsurance she has proposed, would lower individual market premiums by 18 percent next year and the following year — although the report also said that repealing the mandate could “overshadow” the effects.

HuffPost's Jonathan Cohn:

“The combination of the two bills more than offsets the premium increase that is caused by the repeal of the individual mandate,” Collins said. “This is something I’ve said from the beginning.”


AHH: Los Angeles is set to become the largest city in the country legalizing recreational marijuana. Members of the L.A. City Council unanimously passed new regulations allowing pot cultivation and sales next year, according to the Associated Press. But under the regulations,  pot businesses would be prohibited in residential neighborhoods and in zones around schools, libraries and parks.

It’s not yet clear how many businesses, if any, would be ready to begin selling by the start of 2018. And businesses that want to sell marijuana will need local permits before they can apply for state licenses required to open their doors. The rules are now headed to L.A. Mayor Eric Garcetti, who is expected to approve them.

While some cities around the country have banned commercial pot sales, many California municipalities have embraced them, partly because of the tax revenue such sales could bring in. Also yesterday, the mayor of San Francisco signed legislation allowing the sale of recreational marijuana possibly beginning in January if local businesses get licensed in time. And San Jose will allow its 16 medical marijuana dispensaries to start selling recreational pot starting next year.

OOF: Women who use birth control pills or IUDs that release hormones are at a slightly elevated risk for breast cancer, a new study finds. Researchers found that for every 100,000 women who use hormonal contraceptives, there are 68 cases of breast cancer every year, compared with 55 cases annually among women who use birth control without hormones, the New York Times reports. The possible culprit might be the commonly used hormone progestin.

A connection between birth-control pills and breast cancer has previously been acknowledged, but the new study is the first to assess the risks linked to the currently used pill formulas and other devices, the NYT writes. Researchers found there’s only a minor difference in the risks from either pills or devices, which means women cannot necessarily protect themselves from the elevated breast cancer risk by switching to a birth control implant or intrauterine device.

So what have we leaned? Dr. Marisa Weiss, an oncologist who founded and wasn't involved in the study, told the Times the research is important because doctors didn't know how modern-day pills compared to the "old-fashioned pills" -- and had no idea at all whether IUDs (which are increasing in popularity) caused an increased breast cancer risk.

“Gynecologists just assumed that a lower dose of hormone meant a lower risk of cancer. But the same elevated risk is there,” Weiss said.

The increase of just 13 cases per 100,000 women is significant when you consider the millions of  women who use birth control, Weiss said. Nearly 10 million American women use oral contraceptives, per the Times, including 1.5 million women who use them for reasons other than to prevent pregnancy. Still, the American College of Obstetricians and Gynecologists emphasizes that hormonal birth control options are “among the most safe, effective and accessible options available" for preventing pregnancy.

OUCH: What in the world provoked one wealthy, accomplished doctor to attack another wealthy, accomplished doctor? Justin Jouvenal explores this question for The Post from Bowling Green, Ky., where Sen. Rand Paul (R-Ky.) experienced the worst attack on a sitting senator in decades, right in his own yard.

"Rand Paul was on the verge of becoming a powerful senator and the nation’s leading libertarian. His neighbor was a successful doctor and Kennedy-style Democrat who favored nationalized medicine," Justin writes. "They might have sparred over health care or taxes, but an acquaintance of both said they stood in their yards roughly a decade ago shouting at each other over the grass clippings Paul’s mower had shot on Rene Boucher’s property."

Boucher’s attorney said in an interview his client attacked Paul over long-simmering disagreements between the two about the care of grass, trees and other landscaping on their adjacent properties in an exclusive gated community. Yet Paul has been more cryptic about the cause, telling Fox News last week that he hasn't spoken with Boucher in a decade. The assault left Paul with six cracked ribs, a case of pneumonia and briefly sidelined during a crucial debate over a tax overhaul in Washington.

“After my ribs were broken then he said things to me to try to indicate why he was unhappy but I think the, I guess to me the bottom line is it isn’t so important — if someone mugs you is it really justified for any reason?” Paul said.

"Intrigue has deepened in the weeks since the Nov. 3 assault as Paul and Boucher have remained largely quiet about what prompted it," Justin writes. "Into the vacuum, competing theories for the assault have been floated, like so many Washington trial balloons. They range from the mundane, such as bad blood over spoiled views of a lake, to the outlandish — an Antifa plot."


--House Speaker Paul Ryan (R-Wis.) says his agenda items for 2018 include shrinking federal health-care and welfare programs, which are the biggest drivers of government spending.

“We're going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said on Ross Kaminsky's talk radio show. "Frankly, it's the health care entitlements that are the big drivers of our debt, so we spend more time on the health care entitlements — because that's really where the problem lies, fiscally speaking.”

That would mean making cuts to Medicare spending, as our colleague Jeff Stein writes. That task is politically tricky not only because Medicare is popular, and because it's an election year, but also because President Trump vowed during his campaign that he wouldn't cut spending on Social Security, Medicare or Medicaid. But Ryan said he has discussed the possibility of Medicare cuts with the president.

“I think the president is understanding that choice and competition works everywhere in health care, especially in Medicare,” Ryan said. "This has been my big thing for many, many years. I think it's the biggest entitlement we've got to reform.”

Ryan’s remarks add to a chorus of Republicans who have targeted government spending as a critical item on next year’s to-do list, even as they strive to pass a tax plan that nonpartisan analysts say would increase the deficit by at least $1 trillion over a decade.


— U. S. health-care spending in most categories — including for Medicare, Medicaid and retail prescription drugs — grew at a slower rate in 2016 compared to the year prior, according to the annual health expenditures report released yesterday by the Centers for Medicare and Medicaid Services. Overall spending grew 4.3 percent last year, down from 5.8 percent growth the year prior. Spending growth had increased in 2014 and 2015, as more Americans obtained coverage via the ACA, but that growth has slowed as the insured rate has stabilized.

"The overall rate of increase in health care spending experienced a slight slowdown over the previous year, driven in part by the expected moderation in growth after the expansion of insurance coverage through the Affordable Care Act," my colleague Carolyn Y. Johnson reports. "There was also a sharp decrease in the growth of prescription drug expenditures, as hepatitis C treatment costs have declined and fewer patients are receiving them."

But spending did accelerate for one important category that directly affects consumers: The extra costs such as copayments and deductibles they must pay out of pocket for care or medications. Out-of-pocket spending grew 3.9 percent last year, significantly faster than a 2.8 percent growth rate in 2015. The faster growth reflects a continued shift among consumers toward high-deductible health plans, which carry a cheaper monthly premium but require more on-the-spot payments to visit the doctor or obtain medication from a pharmacy.


--Nine days remain in the 2018 ACA enrollment season. Enrollment on accelerated last week, bringing the total to 3.6 million sign-ups, The Post's Amy Goldstein reports.

"The latest federal snapshot, coming amid fresh political turbulence over the future of insurance marketplaces created under the law, is slightly ahead of the first five weeks’ pace last fall," Amy writes. "But compared with data from two-thirds of the way through the longer enrollment seasons of past years, the number of consumers who have chosen health plans is lagging far behind."

The 3.6 million figure is half of the total at the comparable point in last year's sign-up period, but to reach last year's 9.2 million enrollee total, a huge surge of people would need to take action by the time the season concludes on Dec. 15 or be automatically re-enrolled just afterward, Amy notes.

--A few more good reads from The Post and beyond:

The VA is essentially ending a special $460 million program that has dramatically reduced homelessness among chronically sick and vulnerable veterans.
In a national look at Taser deaths behind bars, Reuters finds 104 fatalities after inmates were stunned, often with other force. Abuses stir torture concerns.
To Your Health
Gene therapy for hemophilia B shows promising results.
Laurie McGinley
Maryland Politics
The shortage was expected, with limited shipments unable to meet demand, operators said.
Fenit Nirappil, Aaron Gregg and Rachel Siegel
Pfizer will begin selling the white pill at half the $65-a-pill retail price on Monday, when its patent-protected monopoly ends.


  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the “Implementation of the 21st Century Cures Act: Progress and Path Forward for Medical Innovation.”
  • The House Veterans Affairs Committee holds a hearing on the VA Medical Surgical Prime Vendor Program.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on prescription drug costs on Dec. 12.
  • The Kaiser Family Foundation holds an event on “Living in an Immigrant Family in America: How Fear and Toxic Stress Are Affecting Daily Life, Well-Being, and Health” on Dec. 13.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on “Implementation of the 21st Century Cures Act: Responding to Mental Health Needs” on Dec. 13.

Watch House Speaker Paul Ryan (R-Wis.) light up the Capitol Christmas tree at an outdoor ceremony:

A majority of Senate Democrats have called on Sen. Al Franken (D-Minn.) to resign as he faces multiple allegations of sexual harassment:

Samantha Bee takes on the Republican tax bill and lawmakers' response to sexual misconduct:

The Daily Show with Trevor Noah compiles "Trump's Best Words of 2017:"