THE PROGNOSIS

Take the drama playing out in Congress over a year-end spending bill. Pour on some Obamacare controversy. Then spread some abortion politics on top of that.

It’s a three-layer Capitol Hill delight.

As if Republicans weren’t divided enough over whether to prop up the Obamacare marketplaces with extra insurer payments for reinsurance and cost-sharing discounts, now abortion opponents are injecting more division into the fraught situation, insisting the payments must include long-standing protections to keep taxpayer dollars separate from abortion services.

This morning, more than 60 national, state and local abortion-opposing groups are sending senators a letter warning them not to approve any payments to insurers not covered by the Hyde Amendment, federal language prohibiting federal money from being used for abortions except in cases of rape, incest or when the woman’s life is at stake.

Voting for payments to Obamacare insurers without attaching Hyde language “would not only be voting to sustain what many have called the largest expansion of abortion since Roe v. Wade, but would also be voting to directly appropriate taxpayer dollars for insurance that includes elective abortion,” Susan B. Anthony List, the Family Research Council, March for Life and other groups wrote in a letter provided to The Health 202.

Susan B. Anthony List's Billy Valentine:

The FRC, March for Life and National Right to Life — which all score lawmakers for their votes — say they’ll count it against Republicans if they vote for a spending bill that includes insurer payments without Hyde language. That’s a stern warning that could further spook the most conservative House members, who are already wary of backing legislation that appears to aid the Affordable Care Act.

This is the same old messy fight that always arises when Republicans contemplate sending federal money to health insurers. It was an issue over the summer, as the House and Senate rolled out health-care bills that restructured the ACA’s insurance subsidies for low and middle-income Americans.

Abortion foes wanted the Hyde protections attached to the subsidies, to make sure that no federally subsidized plans cover abortions. Right now, federal subsidies can flow to such plans, but insurers are directed to keep those funds separate from abortion services and to charge customers an extra fee for them.

But there were potential technical problems with adding the Hyde language to the underlying budget bill being used to repeal and replace the ACA. A later health-care bill the Senate considered, one proposed by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), dealt with the issue by funneling the subsidy dollars through the Children’s Health Insurance Program, which is governed by Hyde.

This time, the question isn’t over subsidies that help ACA marketplace shoppers afford their monthly premiums. It’s over extra payments to help insurers discount cost-sharing for the low-income consumers (known as cost-sharing reductions, or CSRs) and cover their costliest patients through what’s known as reinsurance. Independent analysts have said the payments would help insurers lower premiums on the individual market.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) have put forward a bill to fund the CSRs for two years; Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.) have proposed a measure funding the reinsurance program. Republicans leaders — at least those in the Senate — are considering adding both measures to a year-end bill, which Congress must pass by the end of the day Friday or the government will shut down.

Those measures alone — without the abortion funding questions — are controversial. A segment of the GOP wans to help Obamacare insurers lower premiums, now that the party has failed to repeal and replace the law. But there’s also a swath of conservatives reticent to improve the ACA marketplaces they’ve lambasted for years.

In his floor remarks yesterday, Senate Majority Leader Mitch McConnell (R-Ky.) indicated the marketplace stabilization provisions will be in the spending bill.

"Of particular importance – faced with the continued failure of Obamacare to keep health insurance affordable for working Americans, we must take this opportunity to pass bipartisan solutions that will help stabilize collapsing health insurance markets and lower premiums for individuals and families across the country," McConnell said.

Bloomberg BNA's Alex Ruoff:

Fox News' Chad Pergram:

Yet House Speaker Paul Ryan (R-Wis.) has indicated resistance to their inclusion. Lobbyists say it’s looking likely the payments will ultimately be included — but much less likely they’ll be accompanied by the Hyde language.

That's because Republicans need Democrats in the Senate to pass a bill to prevent another government shutdown. If they include the Hyde language, Democrats probably would resist, further muddying troubled waters as they try to negotiate a compromise.

But abortion foes are urging Republicans to embrace the battle, anyway.

“If the Democrats really want to shut down the government over taxpayer funding of abortion, the Republicans should say, 'Bring it on,' ” March for Life lobbyist Tom McClusky told me.

AHH, OOF and OUCH

AHH: FDA regulators are cracking down on homeopathic drugs, saying yesterday the agency will target products posing the greatest safety risks, including those containing potentially harmful ingredients or being marketed for cancer, heart disease and opioid and alcohol addictions, The Post's Laurie McGinley reports.

Homeopathic drugs -- which are based on an 18th-century idea that substances that cause disease symptoms can, in very small doses, cure the same symptoms -- are currently required to meet the same approval rules as other drugs. But under a policy adopted in 1988, the agency has used “enforcement discretion” to allow the items to be manufactured and distributed without FDA approval. Agency officials say now they're going to step-up scrutiny for items deemed a possible health threat.

"The FDA's proposed approach, outlined in a draft guidance that will be open for public for 90 days, comes more than a year after homeopathic teething tablets and gels containing belladonna were linked to 400 injuries and the deaths of 10 children," Laurie writes. 

Once a niche field, homeopathy has grown into to a $3 billion industry that offers treatments for everything from cancer to colds, FDA Commissioner Scott Gottlieb noted in a statement. “In many cases, people may be placing their trust and money in therapies that may bring little or no benefit in combating serious ailments, or worse — that may cause significant and even irreparable harm” because of poor manufacturing quality or unsafe ingredients, he said.

OOF: The Trump administration is so far not releasing more than 10,000 public comments on a proposed plan to roll back regulations for religious and faith-based groups, Politico reports. The comments the Department of Health and Human Services declined to release apparently support regulations advanced under former President Barack Obama requiring providers receiving federal funding to provide abortions and care for transgender people -- regulations the Trump administration is seeking to roll back. 

HHS did, however, post 80 comments that criticize the regulations, and support the department's proposal to roll them back. The decision to post only a select group of comments could lead to legal trouble for the agency, Dan Diamond writes. Rachael Klarman of Democracy Forward told Dan the federal government “can’t discriminate in a public forum,” citing potential First Amendment concerns. But Josh Blackman, an associate law professor at the South Texas College of Law Houston, noted HHS still has time to post all of its comments publicly before any rule would be finalized. 

OUCH: HHS officials confirmed yesterday they had singled out a handful of words to be avoided in the upcoming budget process, but said they hadn't blocked employees from using them outright, The Post's Juliet Eilperin and Lena H. Sun report. A spokesman said the guidance came from within HHS, not from the White House's Office of Management and Budget.

Over the weekend, Juliet and Lena reported that HHS budget writers were given certain words they should not use in narratives they are preparing for the president's 2019 budget proposal. The style guide's written instructions listed three “words to avoid:” “vulnerable,” “diversity” and “entitlement.” It provided just one exception: the words could be used “when the terms are referenced within a legal citation or part of a title.”

And at a budget meeting last week at the Centers for Disease Control and Prevention, employees were also told to avoid four other words not listed in the lengthy document: “fetus,” “transgender,” “evidence-based” and “science-based.” HHS officials gave different accounts of how that took place.

While HHS spokesman Matt Lloyd said yesterday that employees misinterpreted the guidance, saying "it was clearly states to those involved in the discussions that the science should always drive the narrative," officials briefed on the budget guidance said they thought the message was clear. “It was interpreted as 'you are not to use these words in the budget narrative,'" said one person who received a briefing last week. “The idea that it's all a misunderstanding is laughable.”

This, too: The budget guide obtained by Lena and Juliet also instructs employees to use the term "Obamacare" instead of "Affordable Care Act" or "ACA."

HEALTH ON THE HILL

--Sen. John McCain -- who announced over the weekend he would be traveling back to Arizona following treatment related to his brain cancer at a Maryland hospital -- says he plans to return to Washington soon. Yesterday, the 81-year-old Arizona Republican tweeted that he was “feeling well:"

McCain was absent for votes last week and will miss a critical vote this week as Republicans expect to push through their tax plan. He was hospitalized last Wednesday while receiving chemotherapy treatment at Walter Reed National Military Medical Center in Maryland, The Post’s Dan Lamothe reported. In July, McCain announced he was diagnosed with a glioblastoma, an aggressive and highly lethal form of brain cancer.

Republicans hold a slim advantage in the Senate, but are expected to pass their tax overhaul this week after some holdouts and undecideds, including Sen. Susan Collins (R-Maine), announced their commitment yesterday. Sen. Mike Lee (R-Utah) tweeted Monday he would vote for the bill: 

REPRODUCTIVE WARS

--A federal judge in Washington has ordered the Trump administration to “promptly and without delay” allow two pregnant immigrant teens in U.S. custody to get abortions -- two cases that are part of a broader lawsuit challenging the government's new policy of discouraging and even blocking undocumented teens in custody from ending their pregnancies.

In her ruling Monday, U.S. District Judge Tanya Chutkan cited the need to 'preserve [the teens’] constitutional right to decide whether to carry their pregnancies to term,' The Post's Ann E. Marimow reports. Both of the teens are 17. One is 10 weeks pregnant and the other is about 22 weeks pregnant. Within an hour of the judge’s ruling, the administration had simultaneously asked the U.S. Court of Appeals for the D.C. Circuit and the Supreme Court to intervene.

"Since March, the Trump administration has refused to 'facilitate' abortions for unaccompanied minors taken into federal custody after crossing the border illegally," Ann writes. "The government says the minors have the option of voluntarily returning to their home countries or could be released to sponsors in the United States who presumably could help them end their pregnancies."

HHS, which is responsible for caring for detained unaccompanied minors, said in a statement after the new ruling, “We are deeply disappointed in the decision to grant a temporary restraining order that will compel HHS to facilitate abortions for minors when they are not medically necessary.”

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

INDUSTRY RX
Wonkblog
The zigzagging trajectory of the price of Daranide, now known as Keveyis, shows just how much freedom drug companies have in pricing therapies — and what a big business opportunity selling rare-disease drugs has become.
Carolyn Y. Johnson
The potential repeal of the individual mandate, which is looking like a sure thing, has some health insurers worried and already thinking about potential rate hikes that would be needed to keep them from losing their shirts.
Modern Healthcare
STATE SCAN
Gov. Wolf on Monday vetoed a measure passed by the Republican-controlled legislature that would have restricted abortion rights, calling it a “vile assault on women’s ability to make their own decisions about their own health care.”
Philadelphia Inquirer
Virginia Politics
Outgoing governor links federal money to goal of shoring up the state’s reserve funds
Gregory S. Schneider
Mary Beth Bonaventura said a continuation of the policies from Gov. Eric Holcomb's office will "all but ensure children will die."
Indianapolis Star
DAYBOOK

Today

  • The House Committee on Veterans’ Affairs holds a markup of the VA Care in the Community Act.
SUGAR RUSH

At least three people were killed after an Amtrak train derailed in Washington state about 40 miles south of Seattle:

Donors lined up Monday to give blood to the Amtrak derailment victims in Washington state:

Puerto Rico Gov. Ricardo Rosselló ordered a recount of the hurricane death toll:

Trevor Noah reflects on the first year of the Trump administration: