THE PROGNOSIS

A new poll shows Sen. Claire McCaskill (D-Mo.) is holding strong, and maybe even edging ahead, in one of the toughest reelection fights in the country.

And she's doing it with an almost singular focus on health care. 

For the first time since May, public polling found McCaskill leading her Republican challenger, state Attorney General Josh Hawley, 47 percent to 44 percent.

The three-point lead in a CNN poll released Monday is statistically insignificant — the race is effectively tied — but it's a better position than Democrats thought they'd be in a year ago coming off Donald Trump's nearly 20-point victory over Hillary Clinton in Missouri in 2016. 

This time last year, our colleague Amber Phillips ranked McCaskill's seat as the No. 1 most competitive Senate race in the country and most likely to flip parties. In her most recent rankings, Amber ranked the Missouri Senate race third. 

McCaskill appears to have benefited from her opponent's involvement in a federal lawsuit brought by 20 states aimed at having the Affordable Care Act ruled unconstitutional. Democrats have seized on this -- and the Trump administration's refusal to defend any part of the ACA in the case -- as evidence that the GOP would let protections for people with preexisting conditions go down with the law.

Missouri is ground zero for that fight. 

When state-level Republican officials brought the suit in February, public opinion around the ACA had already begun to shift due to congressional GOP's unpopular effort to repeal the law. Once unpopular among voters, the ACA became the guy you never liked until he moved on to someone else. When it looked like the ACA could get overturned, Americans didn't want to give it up. 

This Kaiser Family Foundation tracking poll of the ACA's popularity shows the law gaining favor just after Trump was elected, and it has remained in territory that is more favorable than not ever since. 

For Democrats, it was a welcome and perhaps unexpected shift that health care would return to their corner after a decade of Republicans successfully running on an anti-ACA platform.

Now, voters who care about health care are overwhelmingly supporting the Democratic candidate in polls leading up to November's midterms, where the House and Senate majorities are at stake. Consistent with other polls from battleground states, one third of Missouri voters name health care their most important issue and of that group 69 percent back McCaskill while 27 percent support Hawley. 

But what makes Missouri different from other races is that the Republican candidate's position isn't hypothetical. Hawley is a part of the lawsuit aimed at taking down the ACA, and all of its parts. When McCaskill accused the attorney general of such in an August op-ed published in the Springfield News -Leader, Politifact rated the charge "True." The fact checkers said that because congressional Republicans haven't passed a substitute law to retain consumer protections if the ACA is eliminated, like not charging people with health conditions more forcoverage, then those protections would be lost if the whole law was ruled unconstitutional. 

McCaskill has spent the last several months hammering on this point. She's featured constituents with illnesses in  daily digital ads (like the one below) and aired a TV ad discussing her own battle with breast cancer. 

It's clearly struck a nerve because last week, Hawley put out his own ad pledging to uphold coverage protections for sick or previously sick Americans.

"I support forcing insurance companies to cover all pre-existing conditions, and Claire McCaskill knows it," he says. 

And in a call with reporters on Monday, Hawley did not back off his decision to join the ACA lawsuit, but did say, "We don’t have to have ObamaCare in order to cover people with pre-existing conditions," according to The Hill. 

Vox's Dylan Scott called Hawley's position "funhouse-mirror health care politics." 

Even Trump has picked up on the political problems that arise when Republicans are accused of denying coverage to people with preexisting conditions. In campaign rallies recently, he's begun bringing up the issue. 

"And when it comes to health insurance, Donald Trump and Republicans will protect patients with preexisting conditions," he told a Nevada crowd in late September. "We're going to do that. We want to do that."

Then Monday in Tennessee the president said: "On pre-existing conditions, a lot of people think it's not a very Republican thing. It is now, and it has been for me. I want to take care of people with preexisting conditions. We're doing well. We can do it."

Democrats, for their part, are elated that Hawley has chosen to take this stance because now they are focused on comparing his words to his actions. Just last week, McCaskill aired another new ad charging that Hawley has already broken his promise to protect people with preexisting conditions:

In just five weeks from today we'll know for sure whether McCaskill's decision to focus on health care as her signature campaign issue -- something Democrats are also betting on more broadly -- pays off.

AHH, OOF and OUCH

AHH: Pfizer CEO Ian Read will step down after eight years at the head of the major drug manufacturer. At the beginning of 2019, current chief operating officer Albert Bourla will replace him as CEO and Read will serve as the company's executive chairman "indefinitely," the Wall Street Journal’s Jonathan D. Rockoff reports.

“The handoff, from one long-running Pfizer executive to another, will provide a measure of continuity at a company that has weathered losing $23 billion in sales the last several years as cholesterol drug Lipitor and other big-selling products began facing lower-cost generic rivals,” Jonathan writes.

“Mr. Read steadied the company amid the patent losses through a combination of deal making, expansion in emerging markets like China and cost-cutting, while taking steps to give employees more say in decision-making and improve the productivity of its laboratories. He also focused Pfizer more deeply on prescription drugs and vaccines, shedding animal-health and other noncore businesses.”

OOF: The Trump administration’s “zero tolerance” immigration policy was flawed from the get go, according to an unpublished report by the Department of Homeland Security’s internal watchdog. The policy resulted in separations of parents from their children at the U.S.-Mexico border, and a public outcry that saw the administration end the separations.

“The report, a copy of which was obtained by The Washington Post, is the government’s first attempt to autopsy the chaos produced between May 5 and June 20, when President Trump abruptly halted the separations under mounting pressure from his party and members of his family,” our Post colleagues Nick Miroff, Maria Sacchetti and Seung Min Kim report.

The report details a poorly coordinated interagency process. For example, officials in some cases needed to send minors’ files on Microsoft Word documents over email because the government’s internal systems were not working properly. 

The internal review found there were 860 migrant children left in holding cells longer than the 72-hour limit mandated by U.S. courts. One minor was kept in such a cell for 12 days and another for 25 days. Border officials in the Rio Grande Valley sector held at least 564 children longer than they were supposed to, and officials in the El Paso sector also held 297 children over the legal limit, our colleagues report.

DHS official Jim Crumpacker responded to the report, saying the agency “held children longer mainly because HHS shelter space was unavailable. But he said transferring children to less-restrictive settings is a priority.”

OUCH: Yesterday marked one year since a gunman took aim at hundreds at a country music festival in Las Vegas. More people were injured or killed during the attack than during any other mass shooting in modern American history. The New York Times’s Ash Ngu, Julie Turkewitz, K.K. Rebecca Lai, Anjali Singhvi and Sergio Pecanha report on what one year of recovery has looked like for many of the survivors, still dealing with the physical and emotional wounds from the shooting.

There were 58 killed during the attack, 413 wounded by bullets or shrapnel, and hundreds more who suffered “bruises, cuts, torn ligaments and broken bones in the scramble to flee the venue.”

One woman, 48-year-old Karen Smerber, describes recovery after being shot in the hip. “Her stomach has taken on an uneven shape, and she feels like there is a hard shoe stuck inside,” the Times team writes. “On her back patio, she winced as her dog leapt onto her lap and hit her stomach. It is difficult to sit, she said. She has started taking Zoloft, and she has returned to work part-time… But the hardest thing is looking in the mirror.” “My friends are so good,” she told the Times. “They always reassure me that I’m beautiful and such. It’s just, people don’t realize that I feel bad about myself. And so then I feel — like with Matt — I feel disgusting most of the time.”

AGENCY ALERT

— A Trump administration official says the impact of a new proposed regulation to consider health benefits, like Medicaid and food stamps, when determining immigrant status would be limited to just a small group of immigrants.

Francis Cissna, director of U.S. Citizenship and Immigration Services, said Monday, that the "population of aliens in this country who are eligible to receive public benefits ... is tiny,” according to The Hill. The expansion of "public charge" considerations -- the amount an immigrant may depend on the government resources -- has rallied a wide variety of advocates in opposition from the ACLU to the National Education Association to the American Hospital Association.

Elizabeth Lower-Basch, director of income and work supports at the Center for Law and Social Policy, told The Health 202 that, “Director Cissna’s claim that the public charge regulation will only affect a 'tiny' number of people is deeply misleading. The proposal is a back-door attempt to rewrite our nation’s immigration laws, creating an unprecedented income test that a third or more of U.S. born citizens would fail. While only a limited number of non-citizens apply for a green card each year, these complicated new rules would ensure that millions more will be afraid to apply for food, health care, or housing programs that they or their citizen children are eligible for."

TRUMP TEMPERATURE

—Senate Majority Leader Mitch McConnell (R-Ky.) signaled that the chamber will vote “this week” on the nomination of Brett M. Kavanaugh to the Supreme Court. Meanwhile, the White House gave the FBI permission to  slightly expand its investigation of the nominee following criticism over its limitations, our Post colleagues Devlin Barrett, Josh Dawsey, Matt Zapotosky and Seung Min Kim report.

“The FBI has completed an initial round of interviews as part of its reopened background check of the Supreme Court nominee, and more are likely in the coming days,” they report. “Although the precise parameters of the expanded probe remained unclear Monday, this much was certain: No move by the White House is likely to quell the partisan fires raging in Washington. Republicans charged that Democrats were trying to delay the process to upend Kavanaugh’s nomination, while Democrats countered that the FBI’s investigation seemed to be a sham meant to support his eventual confirmation.”

Meanwhile, Sen. Jeff Flake (R-Ariz.) decried that very partisan battle. Flake “signaled he intends to use the polarizing court fight to amplify his long-standing calls for more civility and cooperation in Washington and across America,” our Post colleague Sean Sullivan reports.

“Tribalism is ruining us. It is tearing our country apart. It is no way for sane adults to act,” Flake said.

“It has become a career-defining moment for the mild-mannered lawmaker, who is at the epicenter of the collision between the #MeToo movement and the Trump presidency as he pursues pragmatism in a Senate riven by strident partisanship,” Sean writes.

— During a “60 minutes” interview, Flake suggested Kavanaugh’s nomination would fail if the additional FBI investigation revealed that the nominee had lied to the Senate committee.

Already, individuals including a former Yale University classmate of Kavanaugh’s have come forward accusing him of not being truthful during the hearing, including about his drinking habits.

 “Charles Ludington, who teaches at North Carolina State University and said he and Kavanaugh were friends in college, called the judge’s testimony a ‘blatant mischaracterization’ of his drinking habits,” our Post colleague Kristine Phillips writes. “The Brett he knew, Ludington said, was a ‘frequent’ and ‘heavy’ drinker who often became ‘belligerent and aggressive’ when inebriated. Ludington told The Washington Post on Sunday that he plans to deliver a statement to the FBI field office in Raleigh detailing Kavanaugh’s violent drinking behavior.”

— President Trump defended his nominee during a news conference, and said he didn't think Kavanaugh lied about his drinking habits during last week's hearing. 

“I watched him and I was surprised at how vocal he was about the fact that he likes beer,” Trump added. “He's had a little bit of difficulty. He talked about things that happened when he drank. This is not a man that said that alcohol was absent - that he was perfect with respect to alcohol." 

— Our colleague Glenn Kessler writes for the Fact Checker about the two dueling narratives about Kavanaugh's drinking. 

Kessler writes "we have diametrically opposed recollections offered by friends and former classmates in media interviews – that he was either a social drinker who never went to excess or that he was a stumbling, sometimes nasty drunk." He adds that there's "not enough consistent information to assign a Pinocchio rating, so readers can judge for themselves."

MEDICAL MISSIVES

— Court-ordered drug treatment is becoming less relevant across California, including in Santa Cruz, where a new county policy this year requires that treatment for low-income residents with drug-related criminal charges must be decided by clinicians rather than the court.

The change has “upended the status quo for judges, attorneys and defendants who often had agreed to residential treatment in lieu of jail — or at least to reduced sentences so inmates could get that treatment,” Kaiser Health News’s Brian Rinker reports.

“The new policy, operating now in a third of the state’s 58 counties, stems from the expansion of Medicaid under the Affordable Care Act,” Brian writes. “That increased access to health care, including drug treatment, to the more than 13 million low-income adults in California who qualify for Medicaid.”

He adds: “In the past, counties had to use general funds or ‘block grants’ to pay for court-ordered drug treatment for those who couldn’t afford it. Now, counties can pay for a range of drug treatment services — outpatient, medication-assisted, detox and residential — through Medicaid, or Medi-Cal, as it is known in California. But the new policy requires everyone seeking residential treatment to have a clinical assessment to determine whether that setting suits their diagnosis.”

STATE SCAN

— California Gov. Jerry Brown (D) on Sunday rejected a bill that would have allowed San Francisco to open the first supervised injection site in the country. “Fundamentally I do not believe that enabling illegal drug use in government sponsored injection centers — with no corresponding requirement that the use undergo treatment - will reduce drug addiction,” Brown said in a statement announcing his veto of the bill, according to the Associated Press’s Janie Har.

The bill would have protected any staff and participants working at such a site from state prosecution. “Safe injection sites save lives,” San Francisco Mayor London Breed said in a statement on Sunday. “If we are going to prevent overdoses and connect people to services and treatment that they badly need to stop using drugs in the first place, we need safe injection sites.”

— And here are a few more good reads from The Post and beyond: 

Gov. Jerry Brown vetoed a bill Sunday that would have required public universities in California to offer abortion pills on campus.
San Francisco Chronicle
INDUSTRY RX
The Food and Drug Administration released a “playbook” Monday to help hospitals and other facilities handle potential cyberattacks on medical devices.
Washington Examiner
A subsidiary of Denver-based DaVita Inc. will pay $270 million to settle allegations it reported inaccurate information about medical patients’ conditions to the government, leading to higher…
The Denver Post
Major drug distributor AmerisourceBergen Corporation will pay the Justice Department $625 million to resolve allegations it improperly repackaged cancer drugs and exposed cancer patients to potentially unsafe products.
Washington Examiner
Powerful PCSK9 inhibitors were supposed to revolutionize care for cardiac patients. But insurers and other payers balked at sky-high prices.
The New York Times
There's very little research on whether medications are safe and effective in pregnant and lactating women, but an expert panel has ideas to change that.
Stat
DAYBOOK

Today

  • The Senate Finance Committee holds a hearing to consider the nomination of Andrew M. Saul to be Commissioner of Social Security.

Coming Up

  • Centers for Medicare & Medicaid Services administrator Seema Verma is set to speak at an event hosted by PhRMA on Wednesday.
  • The Senate Special Committee on Aging holds a hearing on patient-fo used care on Wednesday.
  • The Senate Health, Education, Labor and Pensions Subcommittee on Children and Families holds a hearing on rare disease on Wednesday.
SUGAR RUSH

‘You’re not thinking. You never do,’ Trump tells a female reporter:

Hundreds protested Kavanaugh outside Boston's City Hall Plaza, where Sen. Flake was scheduled to speak: