The Washington PostDemocracy Dies in Darkness

The Health 202: Conservative activists aren't giving up their Obamacare repeal dream

with Paulina Firozi


Some conservative activists unable to surrender their long-held dream of repealing Obamacare are poised to release a long-shot plan next month to resurrect their failed effort, despite massive political odds against such a measure ever becoming law anytime soon.

But these conservatives are right about one thing: Republicans don’t have a coherent health-care message this election cycle. And they need one.

The plan isn’t likely to garner much — if any — attention from GOP House and Senate leaders, who after last year’s repeal-and-replace debacle resigned themselves to the impossibility of fully ditching the law as they’d promised for so long. Moderate Republicans couldn't stomach dramatic Medicaid cuts, and conservatives refused to vote for a replacement bill that left too much of the Affordable Care Act intact.

Now, health care is one of the last policy issues Republicans want to discuss at this point in the midterm election season, although most of them won’t admit it.

The latest plan is being forged by leaders at the conservative think tanks Heritage Foundation and the Galen Institute, along with former senator Rick Santorum and Yuval Levin of the Ethics and Public Policy Center. They've been meeting regularly over the past eight months to craft a recommendation for Congress to repeal much of the ACA's coverage requirements and taxes, turn over some of its spending to states through block grants and expand the use of tax-free health savings accounts.

Some details of the proposal are still being hashed out. But those involved say the plan will probably be released mid-June, and White House staffers have been briefed on it.

“We’re nailing down the final details … and then boning up support between now and then as much as possible,” Heritage Action’s Dan Holler told me last week.

From former senator and presidential candidate Santorum:

And Heritage:

The group might be aiming for an unrealistic goal in enacting its plan, despite the GOP majorities in Congress and a Republican president.

But at least its members are being brutally honest about the political pickle in which their allies in Congress find themselcves: It’s Republicans – and not Democrats – who are taking heat for Obamacare’s rate hikes since they hold the reins of power and have tinkered with the ACA marketplaces without actually revamping them.

Republicans have “no compelling answer” to charges that they’re to blame for premium increases in the marketplaces, Holler said.

“The party needs to do something,” Holler said. “It’s not entirely their fault, [but] they have no answer to it. The left is sort of extraordinarily motivated, and the Republican base is demoralized.”

Holler and his compatriots are reasoning that the political pressure from Democrats will eventually build to the point that GOP House and Senate members in tough races will decide they must rally around a health-care plan — even though multiple versions of repeal-and-replace failed to gain enough traction in the Senate last year, and the stakes are even higher as Republicans try to hold onto their House majority (I explained more fully in this Health 202 why it’s even harder to repeal Obamacare now compared to last year.)

“At some point they’re going to be looking for a solution, and our goal is to have a solution ready for them,” Holler said.

Some members of Congress are more sympathetic to the cause than others. Sen. Roger Wicker (R-Miss.), who has been tracking the Heritage-led effort, seemed to feel the plan might give Congress another chance to repeal Obamacare.

“There are very thorough efforts underway … to bring forward a bill that might succeed,” Wicker told me recently. “I do not,” he responded when I asked whether he thinks repeal-and-replace is dead for good.

Another Senate Republican, who would speak about the path forward on health care only on the condition of anonymity, said Republicans should “revisit” repealing the health-care law since most of them were elected on an anti-ACA platform.

“[We] campaigned for nearly a decade on repeal of Obamacare, and we ought to bring it back up,” the senator said.

Last year, Heritage and other conservative activists criticized most of the proposed Republican-led health-care bills for leaving too much of the ACA in place — and called for even more dramatic shifts in how the government’s Medicaid program fo low-income Americans works.

In a critique of the Senate’s Better Care Reconciliation Act, several Heritage experts advocated for shifting Medicaid to what’s known as a “premium support system” involving private plans, rolling back Obamacare’s requirements for insurers to cover certain preventive services, and permanently repealing its tax on high-cost health plans.

“Starting with this current legislative effort, the Senate should maximize its opportunity to provide individual Americans with better and more affordable health care options by making further changes to free states from Obamacare’s centralized insurance mandates, improve Medicaid reform, and provide individual Americans with better health care options,” they wrote last June.

Conservatives were also critical of the bill advanced last fall by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.). They liked how it transferred Obamacare’s subsidies and Medicaid expansion dollars to states, but feared states might still use the funds to expand government programs. The plan they’re working on will probably include more rules for how states could use block grant funds, such as restricting states from maintaining an expanded Medicaid program for able-bodied, childless adults.

More than 30 conservative leaders have endorsed the coming plan, signing a letter last month promising it will lower monthly premiums and stabilize markets by giving states more dollars to use as they’d like and expanding private plan options.

“We believe this path could get majority support in Congress and show the American people that members understand their distress,” they wrote. “Congressional Republicans are right to worry about Obamacare’s problems. They would be wise to consider this plan as the true solution to the problems facing America under Obamacare.”


AHH: Rates of opioid abuse declined in younger generations between 2002 and 2014, but they’ve doubled among Americans over 50, our colleague Joe Davidson writes. "Unwittingly, Medicare compounds the epidemic by funding needed opioids that can be abused, but, generally, not funding the care and medicines needed to fight opioid addiction," Joe writes. "Many elderly get hooked on opiates through prescriptions, rather than street drugs like heroin."

“Older Americans are among those unseen in this epidemic,” Sen. Bob Casey, the top Democrat on the Senate Special Committee on Aging, said during a hearing on opioid misuse by the elderly at a hearing last week. “In 2016, one in three people with a Medicare prescription drug plan received an opioid prescription. This puts baby boomers and our oldest generation at great risk.”

Gary Cantrell, a deputy inspector general at the Department of Health and Human Services, told the panel about a half-million Medicare Part D recipients “received high amounts of opioids” in 2016. Almost 20 percent of that group are at “serious risk of opioid misuse or overdose,” he warned, placing the high risk in two categories — those receiving “extreme amounts of opioids” and some “who appeared to be ‘doctor shopping.’"

Fentanyl is a synthetic opioid that is quickly becoming a major contributor to the U.S. addiction crisis. Here are the top things to know about the drug. (Video: Amber Ferguson/The Washington Post)

OOF: Nebraska state troopers seized 118 pounds of fentanyl — containing enough lethal doses to kill tens of millions of people — in a record-breaking drug bust last month, The Post's Lindsey Bever reports. Nebraska State Patrol Col. John Bolduc announced Thursday the massive amount of suspected opioids tested positive for fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin. Nebraska officials said it marked the largest fentanyl seizure in state history and one of the largest in the United States.

“I'm especially proud of our troopers and our staff, because these drugs, as we know, are contributing to the opioid crisis in our country, which is killing Americans every single day,” Bolduc said Thursday at a news conference. “This work is saving lives. We can't even extrapolate out the number of lives that this particular bust has impacted.”

OUCH: Another person has died from Ebola in Congo, bringing the total number of confirmed fatalities from the outbreak to 12, the nation’s health ministry said Sunday. There are also four new suspected cases of Ebola in the rural area of Iboko, where the death occurred, the AP’s Saleh Mwanamilongo reports. There are now 35 confirmed cases of Ebola in the Congo.

“The next few weeks are crucial in determining whether the outbreak announced in May can be brought under control, according to the World Health Organization,” Saleh writes. “Complicating factors include its spread to a major city, that health workers are among those infected and the existence of three or four ‘separate epicenters,’ making finding and monitoring the contacts of infected people more difficult.”


— Republican fears that Sen. John McCain’s (R-Ariz.) battle with cancer could make it harder to keep their Senate majority have receded, with a crucial election deadline just days away, our colleagues Sean Sullivan and Michael Scherer report. Republicans in Arizona and Washington are increasingly hopeful McCain will be in office through May 30, the unofficial date for averting a special election for his seat this year. The GOP, which holds a 51-to-49 Senate majority, is defending the Arizona seat held by retiring Sen. Jeff Flake (R). Another race in the state would give Democrats a new opening to win control of the Senate.

“Under state law, Republican Gov. Doug Ducey would appoint a successor to McCain if the seat is vacant,” Sean and Michael write. “Ducey is not speculating publicly about who he might appoint, even as Republicans in the state have mentioned his chief of staff and the state treasurer as possibilities ... Friends who have visited McCain as he struggles with one of the deadliest forms of brain cancer are encouraged by his recent state, though they recognize the 81-year-old’s condition could deteriorate rapidly.”

— Democrats are pushing for bigger government, feeling liberated from years of countering attacks on big spending ideas after Republicans made some high-cost moves themselves. “In recent months, Democratic lawmakers and candidates have endorsed plans allowing anyone to buy in to Medicare, to make college effectively debt-free, to replace the payday loan industry with small government banks and to provide a ‘job guarantee’ that would spend to put people to work,” our colleagues Dave Weigel and Jeff Stein report.

The new attitude is a concern for some Democrats. “Members of both parties have recently moved to dreaming big dreams without figuring out how to pay for it,” said Sen. Thomas R. Carper (D-Del.). “I came [to Congress] with the idea that we’d be fiscally responsible, and neither party seems to be. My hope is we’ll get back to that sooner rather than later.”

But since the tax cut’s passage, the trend has been in the other direction. “When Sen. Bernie Sanders of Vermont...introduced his universal Medicare bill last year, he did not immediately say how it would be paid for," Dave and Jeff note. "He had offered a list of potential tax hikes to pay for it but didn’t include them in the bill. And in a new ad for her reelection campaign, Sen. Dianne Feinstein (D-Calif.), who is facing a challenge this year from her own party, tells California’s primary voters that she favors a health care 'public option' and the expansion of Medicare to people 55 and older, with no suggestion of how it would be paid for."


— Joe Grogan -- the White House official who is driving part of the Trump administration’s drug price proposals -- is also a former drug industry lobbyist, raising questions about whether he violated ethics rules, Politico reports. 

Grogan didn't obtain a waiver from complying with a directive the president established during his first week in office that would block lobbyists from regulating on a “specific issue area” in the administration for two years, David Pittman reports. (The Health 202 wrote about Grogan back in November.) The administration insists Grogan didn’t need a waiver because his current role doesn't overlap with his former work with Gilead Sciences.

“But with the Trump administration now pledging to take on the high cost of prescription medicines...Grogan, as OMB's associate director of health programs, will be in a pivotal position shaping drug policy — including aspects of Medicare and Medicaid...Some critics see a conflict," David writes. "Grogan is hardly the only former lobbyist or industry official in the top ranks of the administration, but he is an exception among senior federal health policymakers for not completing federal ethics forms that laid out potential conflicts with his past work and what, if any, activities he would recuse himself from. HHS Secretary Alex Azar and Centers for Medicare & Medicaid Services Administrator Seema Verma completed such forms.”


— The Irish backed overturning the country's abortion prohibition late last week in a landslide vote that reflects Ireland’s emergence as a socially liberal country no longer obedient to Catholic dictates, The Post's William Booth and Isaac Stanley-Becker report. With all ballots counted and turnout at a near-historic high, election officials reported Saturday that 66.4 percent voted to legalize abortion and 33.6 percent opposed it.

“The outcome of the referendum Friday was a decisive win for the campaign to repeal the Eighth Amendment to the Irish Constitution,” William and Isaac write. “The 1983 amendment enshrined an 'equal right to life' for mothers and 'the unborn' and outlawed almost all abortions — even in cases of rape, incest, fatal fetal abnormality or non-life-threatening risk to maternal health.”

“What we have seen today is a culmination of a quiet revolution that has been taking place in Ireland for the past 10 or 20 years,” Prime Minister Leo Varadkar said.

“The turnout was 64.1 percent — the third-highest for a referendum vote since the adoption of the constitution in 1937 and the decision to join the European Economic Community in 1972,” our colleagues note. “By comparison, turnout was just over 60 percent when Ireland voted to legalize same-sex marriage in 2015.”

— A few more good reads from the Post and beyond:

‘We wanted John to see this while he still could’: Inside the making of HBO’s new McCain documentary (Steven Zeitchik)


Rep. Garrett announces he is an alcoholic and will not seek reelection (Laura Vozzella and Jenna Portnoy)

What if your doctor offered genetic testing as a way to keep you healthy? (Michelle Andrews)


Origins of an Epidemic: Purdue Pharma Knew Its Opioids Were Widely Abused (New York Times)

Uber, Lyft and other ride-hailing apps are ‘useless’ for disabled riders, NYC advocates say (Fredrick Kunkle)



  • Brookings Institution holds an event on its medical marijuana documentary-short.
  • The Public Health Foundation and Catholic Health Association hold a webinar on community health.

Coming Up

  • The Health IT Expo begins on Wednesday.
  • The National Cancer Institute’s Rural Cancer Control Meeting begins on Wednesday.
  • The Johns Hopkins Bloomberg School of Public Health holds a panel discussion on alternatives to animal testing on Wednesday .
  • The NIH Pain Consortium Symposium begins on Thursday.
  • AHIP holds a webinar on telemedicine on Thursday.
  • The 2018 American Society of Clinical Oncology annual meeting begins on Friday.

Rep. Thomas Garrett (R-Va.) is the latest Republican to leave Congress. Here's what you need to know:

Rep. Thomas Garrett (R-Va.) announced May 28 he is not seeking re-election, joining a growing list of GOP lawmakers on their way out. (Video: Elyse Samuels/The Washington Post)

President Trump lays a wreath at the Tomb of the Unknowns:

President Trump laid a wreath at the Tomb of the Unknowns during the Memorial Day ceremony at Arlington National Cemetery on May 28. (Video: The Washington Post)

Watch President Trump’s full Memorial Day speech:

President Trump honored fallen soldiers and their families in a speech at Arlington National Cemetery on May 28. (Video: The Washington Post)