THE PROGNOSIS

A Republican congressman in a competitive re-election race is campaigning on his vote against repealing Obamacare.

How's that for a twist? 

In a year that finds Republicans largely ceding health care as a talking point to Democrats, Rep. David Joyce (R-Ohio) has taken a different approach. Rather than ignore the issue, Joyce released a television ad that ran in his northeast Ohio district touting his opposition to his party's attempt to kill the Affordable Care Act last year. 

"When Republican leaders in Congress tried to take away protections for pre-existing conditions, I said no," Joyce says in the ad. 

Yet Joyce, a three-term congressman in Ohio's 14th district, previously voted 31 times to repeal the ACA -- something that until this year was bulleted on his campaign website. Now, his site doesn't mention Obamacare at all. But the campaign hasn't publicized the ad either, and it does not appear anywhere across Joyce's social media. 

This delicate dance represents the dynamic for Republicans in vulnerable districts as they attempt to balance their past disdain for the ACA with its present popularity. 

"It says an awful lot about the political climate that Joyce is running such an ad in a district Trump won by double digits," said David Wasserman, House editor at the Cook Political Report. "It speaks to voters' antipathy toward the Republican Party's all-or-nothing approach."

Across congressional races, Republicans who once campaigned on repealing Obamacare are largely ignoring it this cycle. As our colleague Paige Winfield Cunningham reported in April, Rep. Mike Bishop (R-Mich.) actually scrubbed his campaign website of any mention of the 2010 health-care law. So far, only 15 percent of pro-GOP House campaign ads even mention health care, while a whooping 63 percent pro-Democrat House ads do, according to an analysis by Kantar Media/CMAG with Wesleyan Media Project. 

Republicans, after eight years of promising that with control of the White House and Congress they'd finally repeal and replace Obama's signature legislative achievement, failed to do so last year. It famously went down when Sen. John McCain (R-Ariz.) voted "no," but 20 House Republicans, under tremendous pressure from a successful pro-ACA campaign, also voted against repeal, including Joyce. 

Six of those GOP members are not seeking re-election this year. Of those who are, only two explicitly mention repealing Obamacare on their campaign websites. Others mention Obamacare failing, but don't use the word "repeal," some refer to other health care-related issues, and five appear not to acknowledge health care at all. 

Notably, Rep. John Katko (R-N.Y.), on the issues section of his campaign site, mentioned under health care that he "has pushed Congress to offer a workable alternative, while opposing repeal efforts that aren’t accompanied by an alternative plan."

"It's a smart strategy," a former GOP House member told me. "Republicans who can develop their own brands and identities will be  much better served. A lot of voters are carefully weighing the health care issue right now, once you get past Trump and Russia and Mueller, health care is an issue a lot of voters are focused on. It's very smart separating himself on that issue."

When it appeared last year that Republicans would repeal the ACA, advocacy groups mobilized and the law reached peak approval from voters. Then, when the Trump administration announced this year that it wouldn't defend any part of the law -- including protections for people with preexisting conditions -- Democrats seized on saving that popular provision as their mid-term election rallying cry. 

And even though most Republican lawmakers support prohibiting insurers from discriminating against people based on their past or present illnesses, Democrats plan to hold them responsible for the White House position and any previous effort to repeal the law.  

"There is not a single House Republican getting a free pass on healthcare in the midterms," said Tyler Law, spokesman for the Democratic Congressional Campaign Committee. 

Rep. Joyce, who goes by "JustDave" on Twitter, is considered a moderate in the type of barely-red district Democrats are longing to take over. While the Cook Political Report currently rates his seat "likely Republican" and the district went for Trump over Hillary Clinton by 11 points in 2016, it's within reach for Democrats. Barack Obama only lost it by 3 points in 2012 and by less than half a point in 2008. 

Joyce is running against Betsy Rader, a female candidate with a deep health-care resume, having worked as a senior counsel at the Cleveland Clinic and at the Centers for Medicare and Medicaid Services. While Joyce is, for now, the presumed favorite, running an ad so blatantly bucking his party and President Trump suggests some anxiety, especially given the near-win of a Democrat in a much redder Ohio district in a special election this month. 

GOP consultant John Brabender, whose current clients include Vice President Mike Pence, told me that Republicans are approaching this issue all wrong. He said they could still be talking about health care if they led with their support for pre-existing condition protections and said they won't accept anything without them, but then talked about rising premiums and government overreach. 

"I do worry there are Republicans who get extremely defensive and get weak instead of 'let’s have this debate'," Brabender said. "You better start with what you are for and make sure voters understand that. Otherwise Democrats are going to eat you for lunch whether based on fact or not."

AHH, OOF and OUCH

AHH:  Trump called on senators to act on legislation that would stop the shipment of fentanyl into the country through the U.S. postal system. The Synthetics Trafficking and Overdose Prevention Act was passed by House lawmakers in June after the bipartisan bill was announcement earlier that month.

“Among other provisions, the STOP Act would require the Postal Service to install the same tracking system used by private shippers such as FedEx to attempt to curb shipments of fentanyl,” our Post colleague John Wagner reports. “A congressional report released earlier this year found that online sellers of fentanyl prefer to ship it through the Postal Service rather than private shippers because they see less of a risk that packages will be seized by U.S. Customs and Border Protection.”

The bill has bipartisan support but has yet to move forward in the Senate, though John points out the president’s tweet did not specifically place blame for any delay in moving the legislation.

Some have speculated, as The Health 202 wrote last month, that Senate Majority Leader Mitch McConnell (R-Ky.) is purposefully delaying legislation related to the opioid crisis because it would give red-state Democrats something to tout ahead of the midterm elections. As John reports, his office has denied this a McConnell spokesman said Republicans are working on reaching an agreement on the timing of the legislation.

OOF: A judge has ordered Michigan health director Nick Lyon to stand trial on charges of involuntary manslaughter in connection with two deaths linked to the water scandal in Flint, Mich.

Lyon, who is accused of failing to properly warn the public about the outbreak of Legionnaires, is the highest ranking official to stand trial as a result of the Flint scandal, the Associated Press’ Ed White reports.

"It's a long way from over," Lyon told the AP following the judge’s announcement.

“The Legionnaires' investigation is part of a larger probe into how Flint's water system became poisoned when the city used Flint River water for 18 months,” Ed writes. “The water wasn't treated to reduce corrosion. As a result, lead leached from old pipes.”

“An additional 14 current or former state and local officials have been charged with crimes, either related to Legionnaires' or lead in the water. Four agreed to misdemeanor plea deals; the other cases are moving slowly,” Ed continues.

OUCH: A widespread shortage of EpiPens nationwide could spell trouble as children with allergies return to school this fall, our Post colleagues Rachel Siegel and Carolyn Y. Johnson report.

“The scarce availability, caused by manufacturing issues and local supply disruptions, has been an issue for months,” they write. “Sales of the pens typically spike during the back-to-school season, as parents buy two-packs to leave at school and refill expiring prescriptions to keep in children’s backpacks or at home. Now many parents are heading to pharmacies for fresh medications to find that they are in short supply.”

It’s not clear how many kids are impacted by the shortage. And while federal regulators last week approved the first generic version of EpiPen, it “may not launch soon enough for families urgently searching for a supply now,” they add.

TRUMP TEMPERATURE

— First lady Melania Trump addressed cyberbullying and the potential “destructive and harmful” risks of social media during an event with HHS Secretary Alex Azar yesterday, part of her ongoing “Be Best” initiative to improve children’s well-being.

“Let’s face it,” Melania Trump said during the event “Most children are more aware of the benefits and pitfalls of social media than some adults, but we still need to do all we can to provide them with information and tools for successful and safe online habits.”

She added: “Our children deserve all the opportunity to give them to grow up happy, healthy, socially responsible adults.”

Azar cited statistics that one in five children experience bullying and that 16 percent of children are cyberbullying victims, per the Associated Press’s Darlene Superville reports. “We need to recognize that bullying is bullying wherever it occurs,” the secretary said. “And we need to stop it.”

The first lady's remarks came as the president launched a set of  Monday morning attacks on Twitter that included calling John Brennan “the worst CIA Director in our country’s history.”

“There’s a lot of speculation that the first lady was ‘trolling’ her husband,” our Post colleague Eugene Scott reports.But others find her words more hypocritical than helpful. Her speech left many on social media asking how the first lady could urge Americans to be more mindful of their social media usage while her husband seems to be leaning into the very behavior his wife claims to want to eliminate.”

“The first lady’s presence at events such as today’s cyberbullying summit elevates an issue that is important to children and families across this country," the first lady's communications director Stephanie Grisham said in a statement. ""She is aware of the criticism but it will not deter her from doing what she feels is right. The President is proud of her commitment to children and encourages her in all that she does.”

AGENCY ALERT

— Today marks 100 days since the president first announced his blueprint to bring down prescription drug costs. In a call with reporters yesterday, Alex Azar touted the administration’s efforts, and pointed to a report from the department’s Assistant Secretary for Planning and Evaluation that claims in the time since the blueprint’s release, there have been 60 percent fewer price increases from brand name drugs compared with the same period in 2017. The report also found there has been 54 percent more price decreases for both generic and brand-name drugs compared with the same time last year.

When asked during the call whether such a shift could be attributed to the administration’s plans, Dan Best, senior adviser to the secretary for drug pricing stopped short of suggesting the blueprint should get all the credit. But he said “it is unprecedented to ever see action" like the ones from drug manufacturers altering planned cost increases. 

“What we know is that manufacturers have come out and stated in some instances that they’re going to allow the blueprint to play out before they’re going to move forward with price increases,” he said. “We are tracking from the day of the launch of the blueprint and we do actually see a direct correlation to the reduction of prices to the blueprint.”

MEDICAL MISSIVES

— A new study has found that pregnant women who experience severe nausea and vomiting are more likely to use marijuana compared with women who don’t experience any symptoms.

The research, which was published Monday in JAMA Internal Medicine, looked at data from more than 279,000 pregnant women from 2009 and 2016. It found that 5 percent of women overall who participated in the study had used marijuana while pregnant. But that rate jumped to 11 percent among  women with severe nausea and vomiting and 8 percent among women with mild nausea and vomiting.

But Stat News’s Megan Thielking reports the health impacts are not entirely clear. “Anecdotally, some patients — including pregnant women and people with cancer — have reported marijuana alleviates nausea,” she writes. “But the study didn’t determine whether pregnant women were using marijuana specifically to alleviate nausea and vomiting. It wasn’t designed to determine whether women used marijuana before or after they knew they were pregnant.”

The research also only assessed women who were in the Kaiser Permanente Northern California health care system.

— New York University’s move to provide free tuition for all medical school students may address a key question that arises in the growing conversation about single-payer health care.

Vox’s Dylan Scott points out that one of the main hurdles that have emerged regarding Medicare-for-all would be the impact the payment structure would have on health-care producers. If health-care providers are paid at Medicare rates, there could be pay cuts for those providers.

“And one concern about single-payer I’ve heard from doctors is regarding medical debt,” Dylan writes. “Yes, maybe they could live with a little less money. But the debts that many physicians leave school with are staggering: The median is $190,000. It could make life hard for a lot of people if they have to continue paying their loans while seeing their income cut. There could be a solution to this: Include free medical school tuition in a Medicare-for-all bill.”

“An additional argument in its favor — aside from perhaps relieving some of the concern about provider payment cuts — is that free medical school for everyone could make the medical field more accessible for disadvantaged youth,” he adds. “If subsidizing medical school — and by extension, the education of well-paid doctors — raises some uncomfortable class questions for progressives, another iteration could be free nursing school paired with an expansion of the physician duties that nurses are allowed to perform. Or maybe do both.”

INDUSTRY RX

— Health insurance giant Anthem said yesterday it will partner with Walmart to expand access for seniors to over-the-counter medications. The  program will launch in January 2019 and will allow members of Anthem’s Medicare Advantage plan to use the insurance to cover over-the-counter drugs from Walmart stores and from the website, and will allow first-aid supplies, support-braces and pain relievers to be purchased at discounted prices, Reuters reports.

“The Medicare Advantage plan, which competes with the traditional Medicare fee-for-service program, provides healthcare coverage to about 17 million Americans and is offered by insurers including UnitedHealth Group Inc (UNH.N), and Aetna Inc (AET.N),” per the report.

HEALTH ON THE HILL

— "Medicare-for-all” may be a new Democratic mantra ahead of midterm elections, but Politico’s Paul Demko writes the issue is not playing well in Democratic primaries thus far. He writes the “notion of government-funded health care has proved a tough sell to Democratic voters in swing districts that will determine control of the House.”

“Many Democratic candidates who made that a centerpiece of their campaigns in key districts this year lost their primaries, in some cases getting clobbered by rivals who offered vaguer health care plans or backed a more incremental approach,” Paul writes. “Democratic primary voters in battleground districts in Iowa, Texas, Kansas and New York passed over candidates who emphatically supported single payer.”

Democratic loses may have been a result of issues beyond the push for university health care, however, but Paul writes Democrats may need to avoid a full-throated support for single-payer health care in the general election in order to appeal to moderate voters. Still, he notes “polling shows increasing support for a national health plan, in an apparent backlash to GOP efforts to dismantle Obamacare. More than half of all Americans support a national health plan, up from 40 percent two decades ago, according to Kaiser. And among Democrats, 75 percent now favor it.”

STATE SCAN

— In four swing states, term-limited Republican governors seem to be surprisingly quiet about support for nominees their party has picked to replace them, our Post colleague Dave Weigel reports.

Dave cited Nevada’s Gov. Brian Sandoval, New Mexico’s Susana Martinez, Florida’s Rick Snyder and Ohio’s John Kasich, all of whom “cultivated moderate images,” he writes. All of them supported the expansion of Medicaid and have at some time criticized Trump. Sandoval and Martinez both opposed the repeal of the Affordable Care Act.

“This is all indicative of a Republican Party that’s moving far to the right,” said Democratic Governors Association spokesman Jared Goldberg-Leopold. “It creates a lot of voters who are up for grabs. People who voted for John Kasich or Brian Sandoval need to think hard about what Mike DeWine or Adam Laxalt would do for their state.”

— And here are a few more good reads: 

Wonkblog
Democratic candidate for Florida agricultural commissioner Nikki Fried said her campaign had been “kicked out of a bank for voicing support of a law that is literally codified in the Florida constitution.”
Christopher Ingraham
Virginia Politics
The state is restricting sales to a low-THC oil that it has not even formally legalized.
Laura Vozzella
True Crime
Prosecutors said Shafeeq Sheikh exploited his authority and took advantage of a sedated patient. Defense attorneys said the sex was consensual.
Kristine Phillips
A Trump-backed lawsuit aimed at killing Obamacare poses political problems for GOP candidates praising some of the law‘s provisions.
Politico
A multimillion-dollar Department of Veterans Affairs initiative to help people who care for disabled veterans suffers from poor support for the ailing, delays in funding for caregivers, and other problems, according to the department’s internal watchdog.
Wall Street Journal
Maddy Wilford wanted to be a doctor before a gunman’s rampage left her badly wounded. After shadowing doctors as an intern this summer, she still does.
The New York Times
In an intriguing study, black patients were far more likely to agree to certain health tests if they discussed them with a black male doctor.
The New York Times
For kids, play is completely serious and children should be doing more of it, according to a new report from the nation’s pediatricians. They say play is important for developing a suite of 21st century skills and serves as a buffer against the negative effects of stress.
Los Angeles Times
OPIOID OPTICS
Some hospital emergency departments are giving people medicine for withdrawal, plugging a hole in a system that too often fails to provide immediate treatment.
The New York Times
DAYBOOK

Today

  • Senate Finance Committee holds a hearing on nomination of Elizabeth Darling for HHS commissioner on children, youth and families.
  • The Senate Homeland Security and Government Affairs Committee holds a hearing “Examining CMS’s Efforts to Fight Medicaid Fraud and Overpayments.”

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on “Science and Stewardship at the National Institutes of Health” on Thursday.
SUGAR RUSH

The definition of "truth" keeps changing under Trump:

New Jersey high school installs laundry room to help students bullied for wearing dirty clothes: