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Fissures and factions
Taking control did not end
Intra-party strife.

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Capitol Hill Watch

The Trump Ultimatum: House Must Vote Friday On GOP Health Plan

After days of negotiations, President Donald Trump sent a message to Capitol Hill: It's do or die. If the measure fails, he plans to pivot away from the repeal-and-replace effort and move on to his other legislative priorities.

The Washington Post: Trump Delivers Ultimatum To House Republicans: Pass Health-Care Measure On Friday Or He’ll Move On
For Trump, who campaigned as a skilled negotiator capable of forging a good deal on behalf of Americans, it could either vindicate or undercut one of his signature claims. If the measure fails, it would be a defeat for Trump in his first effort to help pass major legislation and it may also jeopardize other items on his wish list, including a tax overhaul and infrastructure spending. Defeat would also mean that Obamacare — something that congressional Republicans have railed against for seven years — would remain in place. (DeBonis and Eilperin, 3/23)

Bloomberg: House GOP Plans Friday Health Bill Vote After Trump Pressure
House Republican leaders expect to vote Friday on their embattled health-care bill, moving on the legislation under pressure by Trump administration officials who voiced urgency during a closed-door meeting on the Capitol with conservative holdouts...The chamber plans to vote on a revised version of the health-care bill that includes a provision that conservatives negotiated with senior White House officials to remove Obamacare’s requirements that certain essential benefits be covered by insurance, according to several lawmakers and aides. (Kapur, House and Dopp, 3/23)

Politico: Trump Demands Friday Vote On Health Care Plan
The move by Trump and Ryan is an enormous gamble, setting up a real cliffhanger when the legislation hits the floor on Friday. ... A loss on the House floor would be a glaring embarrassment for the new president and House speaker — one that could undermine other parts of the GOP legislative agenda, including tax reform. A victory, on the other hand, would provide not just a shot of badly-needed momentum for both men, but undermine the House Freedom Caucus, the group of conservative hard-liners who've fought the GOP health care plan because it doesn't go far enough. (Bade, Cheney and Dawsey, 3/23)

The Wall Street Journal: Trump Says If Vote On Health-Care Bill Fails, Obamacare Stays
The decision to bring the bill to the floor appeared to put an end to days of negotiations, amounting to a calculation that lawmakers would view the vote as a do-or-die moment and opt to follow through on campaign promises to replace former President Barack Obama’s signature legislation with a more conservative alternative. (Peterson, Hughes and Radnofsky, 3/24)

NPR: Trump Ultimatum For House GOP: Vote On Health Bill Or Obamacare Stands
Trump, famous for his deal-making abilities, has tried to woo both unhappy factions of the GOP conference with little success. No consensus was reached during a meeting with the president and the roughly 40 members of the House Freedom Caucus at the White House earlier Thursday. Vice President Pence met with the maybe two dozen moderates in the so-called Tuesday Group, many of whom are also opposed to the bill. (Montanaro and Taylor, 3/23)

The Hill: Trump Threatens To Leave ObamaCare In Place If Repeal Bill Fails 
If the vote fails, Trump will move on to other priorities and ObamaCare will stay as the law of the land, Mulvaney said. The developments set up a likely vote on the measure Friday afternoon. Dozens of Republicans have vowed to oppose the bill, putting them into a direct confrontation with their president. With all of the House's Democrats expected to vote against the bill, the GOP can only afford 22 defections. (Wong, 3/23)

Los Angeles Times: Trump Threatens To Leave Obamacare In Place If GOP Bill Fails
"The message is tomorrow it's up, it's down — we expect it to be up — but it's done tomorrow,” Mulvaney said Thursday night. It remained unclear whether Trump’s extraordinary ultimatum was real or a pressure tactic designed to bring unruly Republicans in line. Despite personal appeals from the president and a flurry of last-minute negotiations with House Speaker Paul D. Ryan (R-Wis.), wary GOP lawmakers remained unconvinced, leaving leaders shy of the votes needed to advance the legislation. (Mascaro and Levey, 3/23)

The Hill: The Hill's Whip List: 34 GOP 'No' Votes On ObamaCare Repeal Plan 
House GOP leaders on Thursday delayed a vote on legislation to repeal and replace ObamaCare as they scrambled to win enough votes to pass the measure. House Republicans had planned to vote on the bill on Thursday's seventh anniversary of ObamaCare becoming law. But GOP leaders appeared to be short of the 215 votes they needed. (3/8)

San Francisco Chronicle: Trump Delivers Ultimatum In Move To Pass Health Care Bill 
Trump’s move was an astonishing use of power wielded at precisely the moment he appeared weakest. Amid a day of turmoil and frenzied meetings at the White House and the Capitol, the legislation, called the American Health Care Act, was on the brink of collapse. Republicans were dozens of votes short, having timed the repeal for the seventh anniversary of the day the Affordable Care Act became law. House Speaker Paul Ryan of Wisconsin had postponed the vote and called a recess, his GOP factions hopelessly divided over their fundamental approach to health care. Trump’s risky move sets up a dramatic showdown on the House floor Friday. (Lochhead, 3/23)

Reuters: Trump Demands Support In Do-Or-Die Friday Vote On Healthcare Plan
However, the vote has been seen by financial markets as a crucial test of Trump's ability to work with Congress to deliver on his other priorities, such as tax cuts and infrastructure spending. Even if their replacement plan does eventually get approval from the House, the legislation faces a potentially tough fight in the Republican-controlled Senate. The House and Senate had hoped to deliver a new healthcare bill to Trump by April 8, when Congress is scheduled to begin a two-week spring break. (Cornwell and Becker, 3/24)

GOP House Leaders Are On Edge With Health Vote Gamble

The vote -- which was scheduled in response to demands by President Donald Trump -- is dicey for the majority and highlights the continuing factions within the Republican caucus as well as their hesitancy to negotiate and compromise.

The Associated Press: House Sets Risky Health Care Vote After Trump Demands It
In a gamble with monumental political stakes, Republicans set course for a climactic House vote on their health care overhaul after President Donald Trump claimed he was finished negotiating with GOP holdouts and determined to pursue the rest of his agenda, win or lose. House Speaker Paul Ryan set the showdown for Friday, following a nighttime Capitol meeting at which top White House officials told GOP lawmakers that Trump had decided the time for talk was over. (Fram and Alonso-Zaldivar, 3/24)

USA Today: Damn The Torpedoes: GOP Sets Friday Vote On Health Care Despite Opposition
Rep. Chris Collins, R-N.Y., told reporters at the Capitol that Mulvaney’s message was: “The president needs this, the president has said he wants a vote tomorrow. If for any reason (it fails) we’re just going to move forward with additional parts of his agenda. This is our moment in time but the president is insisting on a vote one way or the other.” Collins said the message from the administration — Stephen Bannon, Reince Priebus and Kellyanne Conway also attended the meeting — was that negotiations were over and it was time to act. (Kelly, Collins and Shesgreen, 3/23)

Roll Call: House GOP Heads Into Health Care Vote ‘Between A Rock And A Hard Place’
The outcome of Friday’s House vote to partially repeal and replace the 2010 health care law is not certain, but one thing is: All parties to the Republican negotiations will walk away with some losses. ... the chips in this case are a group of conservative hardliners and moderate majority-makers (members leadership typically relies on to help pass bills) that have stood in opposition to bill before the latest round of changes. While at least a dozen of those Republicans have said since the final plan was announced Thursday evening that they remain “no” votes, several others appear to be wavering. (McPherson, 3/24)

News outlets note the difficulties GOP leaders have confronted in this week's negotiations are similar to the ones that dogged them during the Obama administration -

The Wall Street Journal: In Health-Law Fight, GOP Leaders Struggle To Reconcile Factions’ Needs
After years of making the repeal of the Affordable Care Act a signature issue, Republicans are struggling to deliver on the promise, floundering amid warring factions that neither President Donald Trump nor House Speaker Paul Ryan have been able to whip into line. ... They are confronting a thorny challenge that required two things in short supply among today’s Republican rank and file: a willingness to compromise or to defer to leadership. (Hook and Epstein, 3/23)

The Associated Press: New Congress, All-GOP, Same Political Divisions
With control of the White House and Senate and a commanding majority in the House, Republicans were supposed to brush off any challenge from the hardline Freedom Caucus and work their will with impunity. But something happened on the way to governing. Now, House Republican leaders are struggling with the same divisions that plagued them under President Barack Obama. (Ohlemacher, 3/24)

Politico: Trump Vs. The Freedom Caucus
The House Freedom Caucus has threatened to tank the House GOP Obamacare replacement bill unless they get what they want. But Trump is now calling their bluff. White House officials told members of the group on Thursday they have one shot: If they help defeat the American Health Care Act, the Trump administration is going to move on — meaning the Freedom Caucus could be pinned with actually saving Obamacare. The White House is betting that they will cave, given that saving Obamacare is something these conservative Republicans will never be able to stomach. (Bade and Bresnahan, 3/23)

And some tips on how to salvage the repeal-and-replace effort if the bill fails -

Politico: How The GOP Could Still Salvage The Obamacare Repeal
House Republican leaders scrambling to buck up wavering members had portrayed the vote as the only shot to eliminate the GOP’s longtime boogeyman — and as an essential show of support for President Donald Trump. But in fact, they have several options to salvage the repeal effort after they couldn't muster 215 votes. (Cancryn, 3/23)

Conservative Republicans Demand That Essential Benefits Coverage Be Dropped

A core piece of Obamacare is the requirement that insurers offer plans that cover basic health services like maternity care, mental health services, prescription drugs and hospital care. Some Republicans seek to lower costs and have more choice for health insurance sold to individuals by rolling back those requirements.

The Wall Street Journal: Basic-Services Requirement Is At Heart Of Health-Insurance Split
At the heart of the last-minute negotiations over the House GOP health-care bill is a pillar of the Affordable Care Act: the requirement that most insurance policies cover a basic set of health services, including such items as maternity and mental-health care. Repealing that requirement, as many conservatives want, would topple a core element of the ACA that sought to protect patients from the high cost of using a health service not covered by their insurance. (Armour, 3/23)

USA Today: Dropping Obamacare's 'Essential' Benefits Impacts More Than Mammograms
Eliminating required health insurance benefits, a move discussed as part of the Republican move to repeal the Affordable Care Act, also threatens to kill the ACA's annual and lifetime limits on patients' costs, which was enacted to prevent bankruptcies due to medical costs. The limits on out of pocket costs only apply to the ACA-required 10 essential health benefits, which include prescription drugs and hospital care. So eliminating the benefit requirement makes the limits "essentially meaningless," says health care legal expert Tim Jost. (O'Donnell, 3/23)

Kaiser Health News: Late Move To Dump ‘Essential’ Benefits Could Strand Chronically Ill
A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act. But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care. (Hancock, 3/24)

Los Angeles Times: Obamacare 101: 4 Things You Need To Know About 'Essential Health' Benefits
Among the most important — and little understood — new insurance rules put in place by the Affordable Care Act was a requirement that health plans cover a basic set of benefits. The requirement was part of a package of new consumer protections in the healthcare law, including a prohibition on insurers denying coverage to people with preexisting medical conditions and bans on annual- or lifetime-limits on coverage, which were once common. (Levey, 3/23)

NPR: Republican Health Bill Could Remove Pre-Existing Condition Protections
When House Speaker Paul Ryan says he wants to repeal the Affordable Care Act so that people can buy insurance that's right for them, and not something created in Washington, part of what he's saying is that he wants to get rid of so-called essential health benefits. That's a list of 10 general categories of medical care that all insurance policies are required to cover under the Affordable Care Act. Getting rid of that requirement, or trimming it, is central to the Republican strategy, because they say those benefits drive up insurance premiums so much that healthy people won't buy coverage. (Kodjak, 3/23)

Marketplace: Conservatives Want The Government To Stop Mandating What Insurers Must Cover
The latest carrot that House leadership and the White House are using to win conservative Republican votes for the health care bill is repealing an Obamacare provision that standardized insurance policies. Under Obamacare, virtually all insurance policies cover things like hospitalization, mental health, prescription drugs and pregnancies – known as essential health benefits. But guaranteeing those benefits cost money, while doing away with them would drop the price of premiums. (Gorenstein, 3/23)

The Washington Post: ‘I Wouldn’t Want To Lose My Mammograms,’ Male GOP Senator Says — Then Immediately Regrets
It’s a common question among those decrying the cost of health insurance: Why should you have to purchase a plan that covers procedures you won’t ever need? Especially if, say, you’re a guy, and your plan covers maternity care — as Obamacare requires most plans sold through an exchange to do? It’s also a philosophy in conservative circles gaining momentum as Republicans try to deconstruct Obamacare, (Phillips, 3/23)

Bloomberg: Pharma Gets Roped Into The Trumpcare Maelstrom 
As President Donald Trump and congressional Republicans scramble to save their troubled attempt to repeal and replace the Affordable Care Act, they are considering last-second changes -- including one that could add Big Pharma to the list of those damaged by the bill. This would further immiserate an industry already dogged by the president's repeated drug-pricing broadsides. To win conservative support, the White House has reportedly offered to repeal the ACA's requirement that insurers cover a list of what it calls essential health benefits, including hospitalization, maternity -- and prescription drugs. (Nisen, 3/23)

Health Bill Would Cut Medicaid, Which Candidate Trump Said He Would Not To Do

The GOP measure would cut Medicaid spending by hundreds of billions of dollars over 10 years. News outlets also round up the other areas of health care that would be touched if the proposal becomes law.

Stat: Trump Pledged Not To Cut Medicaid. Is He Keeping That Promise?
It’s among his most famous campaign promises: Donald Trump pledged he would not cut Medicaid as president. But the legislation that Trump has aggressively promoted, and that Congress is expected to vote on ... appears to do exactly that. It would reduce Medicaid spending by hundreds of billions of dollars over 10 years, compared with current law, while dramatically altering the financing of a program that covers 70 million Americans.The White House, however, says it is not “cutting” Medicaid. (Scott, 3/23)

The Washington Post: Nine Health-Care Bill Changes Aimed At Wooing Moderates And The Far-Right
The legislation, dubbed the American Health Care Act, faces resistance within the House GOP from both moderates within the party and the most conservative faction. As a result, the bill’s authors have proposed to alter parts of the bill in ways to appeal to one camp or the other — and even offered a change specifically targeting a handful of representatives from Upstate New York. Here’s how the bill has changed. (Goldstein, Schaul, Soffen and Uhrmacher, 3/23)

From Americans' retirement plans to the upcoming tax reform debate, there are other unexpected policy areas that will be impacted by the current legislative action —

Bloomberg: Trumpcare Has Seniors Rethinking Early Retirement 
After decades of saving diligently, Dan Maize, 53, of Williamsburg, Va., made the decision last year to retire early. He stayed at his job, managing a grocery store, until February—just before Republicans in the U.S. House of Representatives unveiled a health-care bill that could make his early retirement much harder to afford. Under the American Health Care Act, the Obamacare overhaul that faced a congressional vote on March 23, costs could fall for many younger Americans. The majority of older people would pay much more, according to the nonpartisan Congressional Budget Office and others who analyzed an early version of the legislation. (Steverman, 3/23)

CQ Roll Call: GOP, Seeking Health Care Votes, Misses Target With Tax Cuts
The House Republican leaders’ attempt early this week to steer more party members behind the proposed health care bill included some inducements they hoped would be hard to resist: tax cuts that take effect sooner. But four days later the attempt appears to have done little to persuade the staunchest conservatives to back the House bill (HR 1628) to repeal and replace the 2010 health care law (PL 111-148, PL 111-152). House leaders abandoned their goal of a floor vote Thursday amid doubts that they could muster a majority. Ways and Means Chairman Kevin Brady, R-Texas, as well as other Republican leaders were apparently trying to thread a needle in the manager’s amendment released Monday. (Ota,3/24)

Kaiser Health News: Popular Guarantee For Young Adults’ Coverage May Be Health Law’s Achilles’ Heel
The Affordable Care Act struck a popular chord by allowing adult children to obtain health coverage through a parent’s plan until their 26th birthday. ... The policy has proven to be a double-edged sword for the ACA’s online health exchanges because it has funneled young, healthy customers away from the overall marketplace “risk pool.” Insurers need those customers to balance out the large numbers of enrollees with chronic illnesses who drive up insurers’ costs — and ultimately contribute to higher marketplace premiums. (Heredia Rodriguez, 3/24)

CBO Score For Revised House Health Bill Still Finds Big Coverage Loss But The Costs Grow

The changes made by Republicans leaders did not alter the original forecast of 24 million Americans losing their insurance. But the Congressional Budget Office said although the new plan would still reduce the deficit, it would cost $186 billion more over 10 years than the earlier legislation.

The Washington Post: CBO: Latest House GOP Health-Care Bill Would Mean As Many Uninsured By 2026
According to the CBO’s projections, a set of amendments that House GOP leaders agreed to support Monday night would cut the federal deficit by $150 billion between 2017 and 2026. The original version of the American Health Care Act, as the bill is called, would have curbed the deficit by an estimated $337 billion in that period. The changes would have less impact on savings because they would make it easier for Americans to deduct the cost of medical care from their income taxes and would accelerate by a year the repeal of several taxes that help pay for the ACA, including taxes on insurers, hospitals, high-income adults and tanning beds. (Goldstein, 3/23)

Modern Healthcare: New CBO Score Could Further Sink Revised Obamacare Repeal Bill 
Federal Medicaid spending reductions would dip from $880 billion over 10 years in the original version of the proposed American Health Care Act to $839 billion. ... The CBO did not score a provision that House Republicans reportedly want the Senate to insert in the bill to boost coverage among people aged 50 to 64. It would establish a “reserve fund” of about $90 billion for tax credits to help Americans in that age group, whom the CBO said would suffer big coverage losses under the AHCA because the new tax credits would not be nearly as generous as the ACA's. (Meyer, 3/23)

Roll Call: New CBO Estimate Does Little To Woo Critics
Democrats pounced on the report’s findings. “As bad as TrumpCare already was, the Manager’s Amendment is crueler to Medicaid recipients, while handing billions more to the richest Americans,” said Democratic Leader Nancy Pelosi in a statement. “Apparently they still do not have the votes to pass the bill, and are working to make it even worse. The Speaker calls the bill ‘an act of mercy.’ TrumpCare is a moral monstrosity. It’s time to pull the plug.” (Mershon and Williams, 3/23)

The Hill: CBO Releases New Score For ObamaCare Repeal Bill 
GOP leaders had pledged that they would wait for the CBO's new score before holding a floor vote on the legislation. That vote could happen as early as Friday. The CBO's score, however, does not reflect last-minute changes that could be made to win over conservatives, including repeal of ObamaCare's minimum coverage requirements. That change would be significant, but it is possible House Republicans could bring up the vote without that revised score. (Sullivan, 3/23)

The Hill: GOP Rushes To Vote Without Knowing Full Impact Of Healthcare Plan 
"Have you read the bill? Have you read the reconciliation bill? Have you read the manager’s amendment? Hell no, you haven’t!” That was then-House Minority Leader John Boehner (R-Ohio) in 2010 in the heat of the debate over ObamaCare. Seven years later, Democrats could easily turn those words around on Republicans for the strategy they're using to repeal and replace the same law Boehner railed against.  House Republicans are moving forward with a vote Friday on their ObamaCare replacement bill even after making significant changes the night before, and without a Congressional Budget Office analysis of those changes.  (Marcos and Sullivan, 3/23)

Health Industries Keep Careful Eye On Capitol Hill Action

The flux surrounding the House health bill vote injects uncertainty into the health care stock markets while hospitals voice worries regarding the changes Republicans have proposed. Meanwhile, the U.S. Chamber of Commerce president urges lawmakers to follow through with repeal efforts.

Bloomberg: Wall Street Frets Over Health Vote's Impact
As Republicans in Congress tried to wrangle enough votes to pass their health care bill Thursday, the S&P 500 Index swung from a gain to a loss, continuing its worst selloff of the Trump era. Meanwhile demand rose for traditional safe havens like Treasuries. By the close of trading, the GOP had decided to delay the vote as conservatives mulled a proposal from the Trump administration. The S&P 500 finished down 0.1 percent, while the Dow Jones Industrial Average was essentially flat and the Nasdaq 100 Stock Index fell 0.2 percent. (Burger, 3/23)

Bloomberg: Hospital Stocks Head For Rocky Ride Through Obamacare Repeal 
Investors in hospital stocks are banking on a key idea: the GOP’s final overhaul of Obamacare won’t be as bad as it looks right now. The current version of American Health Care Act, headed for a House floor vote Thursday, would slash billions from health spending and raise insurance costs for many, according to an analysis by a nonpartisan government body. That would be bad news for hospitals, which must take care of sick patients whether or not they can pay. (Greifeld, 3/23)

Bloomberg: Treasuries Swing As Consensus Eludes GOP On Health-Care Bill 
Treasuries were little changed after a series of price swings driven in part by shifting odds of Republicans reaching agreement on a health-care bill that had been slated for a House vote Thursday. Yields were within a basis point of Wednesday’s closing levels at 4:15 p.m. in New York after a flurry of late activity in which the House first confirmed that the vote was delayed, followed by more upbeat comments from House Freedom Caucus Chairman Mark Meadows. Earlier, yields had reached session lows concurrently with U.S. equities after House Republicans postponed a planned meeting on the bill, began to rebound after the Ways and Means Committee Chairman said the party was near agreement, and retreated anew after the House Freedom Caucus left a White House meeting without reaching an accord. (Stanton, 3/23)

Marketplace: Hospitals Worry As Obamacare Repeal Vote Approaches
The AHA launched a media campaign against the bill and brought dozens of hospital leaders to lobby members of Congress. The real danger, Pollack said, is that the hospital would have to absorb the cost of care for the uninsured patients. So as executives have made their case to lawmakers, one message they carry is that hospitals are businesses. (Gorenstein, 3/23)

The Wall Street Journal: U.S. Chamber of Commerce Chief Tells House GOP: Pass Health Bill Now, Improve It Later
Tom Donohue, the president of the U.S. Chamber of commerce, has a plea for lawmakers wavering in their support for the GOP’s health-care overhaul: stick with it if you want a better outcome. Speaking in a Thursday morning interview, Mr. Donohue said it was imperative for lawmakers to keep their eyes on the ultimate prize – repealing and replacing the 2010 Affordable Care Act. Even if the House Republicans’ bill falls short of their various desires, he said, the only way to improve the bill is to pass it and continue work in the Senate. (Hackman, 3/23)

Majority Of Americans Oppose Republicans' Replacement Bill, New Poll Finds

Only 17 percent surveyed by Quinnipiac University support the American Health Care Act. And as former President Barack Obama makes a rare statement about the debate regarding his signature health care legislation, Democrats mobilize to use the vote against vulnerable Republicans.

The Hill: Poll: Just 17 Percent Of Voters Back ObamaCare Repeal Plan 
A majority of American voters oppose the Republicans' plan to repeal and replace ObamaCare, while very few voters support it, a new poll finds. A poll published Thursday by Quinnipiac University found that 56 percent of voters disapprove of the GOP healthcare plan, while just 17 percent support it. Even among Republicans, only 41 percent support the American Health Care Act, while 24 percent oppose it. And 58 percent of Democratic voters disapprove of the plan. (Firozi, 3/23)

Politico: As Repeal Vote Nears, Obama Pleads To Preserve Affordable Care Act
Former President Barack Obama, who has remained on the sidelines for much of the contentious debate surrounding the Trump administration’s plan to repeal and replace the Affordable Care Act, urged lawmakers Thursday to preserve and build on his signature legislative achievement. The lengthy statement ... celebrated the merits of Obamacare and described the legislation as a watershed moment in determining that health care is “not just a privilege for a few, but a right for everybody.” (Sutton, 3/23)

Bloomberg: Democrats Aim To Weaponize Health Bill Against House Republicans 
Democrats seized on the House health-care vote as an opportunity to inflict political damage on vulnerable Republicans.The Democratic National Committee has begun blanketing the districts of roughly 50 House Republicans with targeted emails and robocalls about the bill, urging recipients to call the lawmakers to express opposition to the bill...It’s the first time the DNC has carried out this kind of campaign since Perez became chair of the party last month and reflects the committee’s efforts to be a hub of anti-Trump activity. (Epstein, 3/23)

Meanwhile, protests against the GOP bill and in support of Planned Parenthood take place in cities like Los Angeles, Chicago, Phoenix and Detroit —

Reuters: Obamacare Supporters Rally Against Congressional Repeal Efforts
Supporters of Obamacare staged rallies across the country on Thursday denouncing efforts by President Donald Trump and Republican congressional leaders to repeal the landmark law that has extended medical insurance coverage to some 20 million Americans. Hundreds of demonstrators turned out in Washington, Chicago and Los Angeles marking the seventh anniversary of enactment of Obamacare, as the Affordable Care Act (ACA) has become widely known. (Simpson, 3/23)

Los Angeles Times: Crowd In Downtown L.A. Protests Obamacare Repeal
Crowds marched through Downtown Los Angeles Thursday afternoon to protest efforts by Republican lawmakers to overhaul the Affordable Care Act. In a rally that occupied a portion of Temple Street outside of the Roybal Federal Building, speakers addressed a crowd of healthcare providers and advocates. (Kohli, 3/23)

Chicago Sun Times: Hundreds Rally, March Downtown To Decry American Health Care Act 
Hundreds of protesters rallied and march through downtown Thursday afternoon, denouncing plans — since delayed — to repeal and replace the Affordable Care Act on the seventh anniversary of the bill becoming law. Rallying in Federal Plaza before heading north on Dearborn, eventually stopping across the Chicago River from Trump Tower, the crowd cheered as they learned that a vote on the American Health Care Act would not be held Thursday, as was originally planned. (Charles, 3/24)

Arizona Republic: Planned Parenthood Advocates Rally In Phoenix Against 'Obamacare' Repeal
As wrangling continued in Washington, D.C., on Thursday over a bill to repeal the Affordable Care Act, Planned Parenthood supporters gathered in Phoenix and cities across the nation to oppose what they call the "worst piece of legislation for women in a generation." In Phoenix, about 50 people gathered outside the Arizona State Capitol to rally against the health bill. (Newman, 3/23)

Detroit Free Press: Detroit Protesters Stage 'Funeral' For Obamacare
Ahead of today's unsure vote on Republican changes to former President Barack Obama's signature health care reform, protesters in downtown Detroit staged a mock funeral of the Affordable Care Act, saying its replacement would leave millions without coverage. Among the protesters was Ed Weberman, a lawyer from White Lake Township whose 24-year-old son, Alex, is in remission from stage 4 non-Hodgkin's lymphoma. Weberman said his son's recovery was possible only because he could keep him on his insurance up to age 26 under Obamacare. (Helms, 3/23)

KQED: As House Vote Approaches, Protesters Of GOP Health Care Bill Get Creative 
Wearing white coats and surgical scrubs, a small group of political activists passed out pink fliers in downtown Oakland Wednesday. They wore toy stethoscopes and shiny, circular mirrors on their heads. They’re not really doctors, but they dressed the part to grab the attention of pedestrians and warn them about the political efforts to dismantle the Affordable Care Act. (Klivans, 3/23)

California Healthline: From ‘Stressed Out’ To Hopeful, Five Californians Weigh In On GOP Bill
[T]he GOP proposal could have a big impact on the nearly 14 million Californians — about one-third of the state’s population — who are covered by Medicaid, the health program for low-income people, known as Medi-Cal in California. The GOP plan would also likely scramble the health care calculations of people who buy their own coverage, especially if they do so through Covered California, the state’s insurance exchange, and get federal help with their premiums. (Gorman and Bazar, 3/23)

San Jose Mercury News: Bay Area Voters Not Surprised By GOP Health Care Vote Delay
Yet no matter where they got the news, and regardless of their political leaning, several people on the Bay Area News Group’s 25-member voters’ panel — assembled to evaluate President Donald Trump’s first 100 days in office — said they weren’t surprised that the dismantling of Obamacare had gotten so gummed up in the nation’s capital that the GOP plan appeared to be going nowhere for now. (Seipel, 3/23)

Policies In GOP Health Bill Leaves Divisions Among Representatives, Many State Officials

News outlets around the country report on how their local congressional delegations -- and state officials -- are leaning on the Republican plan to dismantle Obamacare.

Chicago Tribune: Health Care Vote Delay Leaves Illinois GOP Delegation Uncertain 
After House Republicans suffered a setback Thursday in their bid to overhaul health care, some GOP lawmakers from Illinois refused to commit to future revisions of the GOP plan and expressed skepticism about quick action moving forward. ...While saying Obamacare is in a "death spiral," [Rep. Randy] Hultgren said it's important for House and Senate Republicans "get a replacement that works." He said he could not predict "whether that can happen today or tomorrow or over the weekend or next week" and added: "I really feel like it's unknown right now how this ends." (Skiba, 3/23)

Atlanta Journal-Constitution: In Tom Price’s Backyard, A Republican Split Over Health Plan
Even in Tom Price’s home turf, there’s a sharp divide over the embattled GOP health plan among the Republicans racing to replace him. Several of the top Republicans in the April 18 special election to succeed Price, Donald Trump’s health secretary, say the plan needs broader changes before they can accept it. Others, including those running as Trump loyalists, say they would vote for it in a flash. (Bluestein, 3/23)

The Wall Street Journal: House GOP Super PAC Pulls Support From Iowa Congressman Who Opposes GOP Health Bill
The super PAC overseen by House Speaker Paul Ryan and the House GOP leadership is yanking support from a House Republican who pledged to oppose the health-care legislation pushed by President Donald Trump and House GOP leadership. The Congressional Leadership Fund is pulling staff from and closing an office it opened last month in Iowa Rep. David Young’s Des Moines-based district. (Epstein, 3/23)

Texas Tribune: Gohmert, Weber Among Holdouts As House Postpones Health Bill Vote
The process got somewhat easier on Thursday when two Republicans, U.S. Rep. Joe Barton of Ennis and Michael McCaul of Austin moved into the affirmative column. The Dallas Morning News reported McCaul's change of heart from undecided to yes. "I don't have a comment other than I am glad Donald Trump got elected president so that we have a chance to bring an end to Obamacare," said the fiercest GOP holdout of the delegation, U.S. Rep. Louie Gohmert of Tyler. (Livingston, 3/23)

The Philadelphia Inquirer: Where Philly-Area Representatives Stand On The Health-Care Bill
One local Republican – Rep. Patrick Meehan, whose district mostly covers Delaware County – has yet to decide whether he would support his party's long-promised plan to repeal and replace Obamacare. The stance of another local GOP representative, Ryan Costello of Chester County, remains unclear. Like Meehan, Costello supported the bill in committee but has not committed to voting for the final measure. (Tornoe and Babay, 3/23)

The Baltimore Sun: Rep. Andy Harris Remains A 'No' On GOP Health Care Bill 
Rep. Andy Harris, a Baltimore County Republican and member of the conservative Freedom Caucus, said Thursday that last-minute changes to the Republican plan to replace Obamacare are not yet enough to win his support. Harris, who ran his first campaign for Congress on a vow to repeal the Affordable Care Act, joined about three dozen Republicans who announced opposition to the legislation. Because of that opposition, GOP leaders pulled the measure from a scheduled vote Thursday -- dealing a blow to President Donald Trump. (Fritze, 3/23)

St. Louis Post Dispatch: One St. Louis-Area Republican's Shuttle Diplomacy In The Health-Care Quicksand Of Repeal And Replace 
Rep. Rodney Davis thought he was about to cast a long-anticipated vote to begin repealing and replacing Obamacare on Thursday. Instead, he took another trip to the White House, part of the extraordinary and sometimes confusing shuttle diplomacy that was going on inside the Republican Party on health care reform this week. Davis, R-Taylorville, and Rep. Ann Wagner, R-Ballwin, are among a small group of Republican vote-counters in the U.S. House on the Republicans' American Health Care Act. They're “whips” in the parlance of what is often called legislative sausage making. (Raasch, 3/24)

The CT Mirror: As GOP Health Care Plan Falters, CT Dems Watch And Wait 
President Donald Trump and House Republicans are making both threats and promises to try to salvage the GOP health care bill – but the deal-making is all on the Republican side of the aisle, with Connecticut’s all-Democratic congressional delegation sitting on the sidelines... While Democrats are not sitting at the negotiating table, that doesn’t mean Connecticut’s lawmakers were idle. (Radelat, 3/23)

The CT Mirror: CT GOP Legislative Leaders Urge Delay On Obamacare Replacement 
The Republican leaders of the Connecticut House and Senate politely distanced themselves Thursday from the push by President Trump and U.S. House Speaker Paul Ryan for the immediate passage of an alternative to the Affordable Care Act. In a letter to the president and speaker, Sen. Len Fasano of North Haven and Rep. Themis Klarides of Derby said they shared the national Republican leaders’ concerns about Obamacare, but urged Trump and Ryan to avoid passage of a bill still being digested by state officials and members of Congress. (Pazniokas, 3/23)

Kansas City Star: Brownback, Greitens Sign Letter In Support Of GOP Health Care Bill 
Kansas Gov. Sam Brownback and Missouri Gov. Eric Greitens have both signed a letter in support of a controversial bill that would repeal the Affordable Care Act. Brownback’s office released the letter after U.S. House Speaker Paul Ryan delayed a vote on the American Health Care Act because of a lack of support for the bill. The letter from eight GOP governors thanks Ryan, a Wisconsin Republican, and U.S. Senate Majority Leader Mitch McConnell of Kentucky for their efforts to repeal the ACA, also known as “Obamacare.” (Lowry, 3/23)

The Associated Press: Walker: Up To 45K Alaskans Could Lose Coverage With GOP Bill
Gov. Bill Walker says as many as 45,000 Alaskans could lose health care coverage under a Republican bill proposed in the U.S. House. Walker says that includes 30,000 Alaskans covered by the expanded Medicaid program and roughly two-thirds of the Alaskans with individual plans on the federally facilitated insurance marketplace. About 19,000 Alaskans have individual plans. Walker said about 13,000 could lose coverage. (Bohrer, 3/24)

WBUR: Mass. Democrats Denounce GOP Health Care Bill
Gov. Baker has estimated the state would lose about $1 billion in federal reimbursement, starting in 2020, should the American Health Care Act pass. On Tuesday, Baker said, "I think our hope and our expectation is that the issues that are raised not just by people here in Massachusetts but by people in other states who have similar concerns can help affect the nature of the debate and the discussion." Today also marks the seventh anniversary of the Affordable Care Act. (Bologna, Bruzek and Chakrabarti, 3/23)

Clearing The House Is Just The First Step; GOP Plan Faces Significant Hurdles In The Senate

In the upper chamber, Republicans only claim a 52-48 majority, and many senators have already expressed their dismay at parts of the House's American Health Care Act. Democrats see opportunities to snag parts of the GOP plan. Meanwhile, Sen. Rand Paul (R-Ky.), who argues that the measure does not go far enough to repeal Obamacare, is among those who has raised constitutional issues.

Politico: Trump's Obamacare Repeal Concessions Likely Can't Pass Senate
Democrats say they are certain they can kill any language in the repeal bill that erases Obamacare’s mandate for minimum benefits in insurance plans. And top Republicans are making no promise that the last-ditch changes to win over conservatives will fly in the more centrist Senate, which is beginning to write its own health care plan. (Everett and Haberkorn, 3/23)

The Hill: Senate GOP Hedges On ObamaCare Repeal Timeline 
Senate Republicans are starting to publicly hedge on when they'll be able to repeal and replace ObamaCare as their House counterparts struggle to find a deal. On Thursday afternoon, the House delayed a vote on the bill that was originally scheduled for later that day. Sen. Bill Cassidy (R-La.), who has been skeptical of the House bill, said after a caucus launch that he was told that senators would have "more time" to consider a repeal and replace bill and that the House might not vote until next week.  (Carney, 3/23)

CQ Magazine: Even If The GOP Passes A Health Care Bill, Some Wonder If It'll Be Constitutional
If Republicans rescind the Affordable Care Act mandate that everyone buy health insurance, will their bill be constitutional? GOP Sen. Rand Paul of Kentucky is raising that question, citing the reasoning of Chief Justice John G. Roberts Jr., who wrote the 2012 opinion that upheld the individual mandate penalties in the 2010 health care overhaul. In his opinion in NFIB v. Sebelius, Roberts said the health care law essentially violated the Constitution’s Commerce Clause that gives Congress the power to regulate interstate commerce because it forced people to buy health insurance. But he wrote the requirement that individuals pay a penalty for not obtaining health insurance “may be reasonably characterized as a tax” and let it slide. (Lesniewski, 3/27)

Administration News

Trump, A Self-Avowed Dealmaker, Faces High Stakes In Outcome Of Friday's House Vote

As the GOP health plan became mired in intense negotiations this week, the ability to secure the measure is increasingly viewed as a major test for President Donald Trump. Meanwhile, news outlets also report that the process has caused him doubts about choosing to pursue Obamacare replacement as first item on his agenda.

The New York Times: Trump The Dealmaker Projects Bravado, But Behind The Scenes, Faces Rare Self-Doubt
President Trump, the author of “The Art of the Deal,” has been projecting his usual bravado in public this week about the prospects of repealing the Affordable Care Act. Privately he is grappling with rare bouts of self-doubt. Mr. Trump has told four people close to him that he regrets going along with Speaker Paul D. Ryan’s plan to push a health care overhaul before unveiling a tax cut proposal more politically palatable to Republicans. (Thrush and Haberman, 3/23)

Politico: Delayed Vote A Setback For Trump The Dealmaker
Most Republicans appeared comfortable with the delay, taking the lumps of a single negative news cycle, so long as the legislation eventually passes. But some worried that if Trump can’t muscle the first major bill he’s backed through a single chamber in a Republican-controlled Congress, it could devastate his agenda and weaken his authority moving forward. “This is a reputational deal,” said Scott Reed, the chief strategist for the U.S. Chamber of Commerce. “We have a lot riding on this.” (Goldmacher, Dawsey and Palmeri, 3/23)

The Hill: Report: Trump Regrets Backing Health Plan Before Pushing For Tax Reform 
President Donald Trump regrets throwing his support behind Speaker Paul Ryan’s healthcare proposal before his administration could propose a tax reform plan that more Republicans would favor, according to a Thursday New York Times report. Trump reportedly questioned his decision to several allies, saying he should’ve prioritized tax reform after seeing the immediate Republican fallout from the GOP healthcare proposal. (Beavers, 3/23)

State Watch

KanCare Expansion Headed To Full State Senate Vote

Even as uncertainty swirls in Washington, D.C., supporters of the Medicaid expansion say, "we have to move forward as a state." Media outlets also report on news out of Minnesota, New Hampshire and California.

Kansas City Star: Medicaid Expansion Moves Forward
Kansas state lawmakers advanced a Medicaid expansion proposal on Thursday even as Congress contemplated a bill that could halt states from expanding the program. Supporters of expanding KanCare, the state’s privatized Medicaid program, said the debate in Kansas can’t be dictated by Washington. Opponents urged lawmakers to wait until the federal health care debate progresses. (Shorman, 3/23)

KCUR: KanCare Expansion Bill Heads To Senate For Vote Next Week
Kansas lawmakers are now a step away from what could be a showdown with Republican Gov. Sam Brownback on the political football issue of Medicaid expansion. The Senate Public Health and Welfare Committee on Thursday advanced an expansion bill to the full Senate for a vote supporters say will take place Monday...Since 2013, 31 states and the District of Columbia have expanded Medicaid eligibility. Kansas and Missouri are among 19 that have not. (McLean, 3/23)

Pioneer Press: New Tax Or Dip Into Savings? Dayton And GOP Differ On How To Stabilize Insurance Market 
Minnesota lawmakers are on the verge of approving as much as $300 million per year to try to stabilize the state’s 2018 individual health insurance market and lower premiums. But before the program, known as reinsurance, gets off the ground, lawmakers and the governor first have to settle an important question: where should the money come from? The idea, which DFL Gov. Mark Dayton supports despite some qualms, is a top priority for lawmakers and some business groups. (Montgomery, 3/24)

Kansas City Star: Effort To Keep Guns Out Of Public Hospitals Revived In Kansas Senate Panel 
Officials with the University of Kansas Health System made another effort Thursday to keep guns out of its buildings before a state law that would allow concealed weapons takes effect July 1. Senate Bill 235, which had a hearing Thursday before the Senate budget committee, would allow Kansas’ state hospitals and public hospitals, like the University of Kansas Hospital in Kansas City, Kan., to keep banning handguns. (Woodall, 3/23)

San Francisco Chronicle: California Passes Nation’s Toughest Methane Emission Regulations 
California air quality officials have approved what are widely considered to be the most rigorous and comprehensive regulations in the country for controlling methane emissions, a move that helps cement the state’s status as a standard-bearer for environmental protection. The new rules, green-lighted Thursday by the state’s Air Resources Board, seek to curb methane emissions at oil and gas production plants by up to 45 percent over the next nine years. (Fracassa, 3/23)

State Highlights: Mass. Gov. Proposes Revised Tax On Employee Health Plans; Family Files Wrongful Death Suit Against Opioid Maker

Media outlets report on news from Massachusetts, Illinois, Connecticut, Ohio, Pennsylvania, New Jersey, Mississippi, Tennessee, Iowa, Wisconsin, California, Texas and Minnesota.

Boston Globe: Baker Administration Floats Alternative To Health Plan Levy 
After a backlash from the business community, Governor Charlie Baker is floating a new plan for employers to help cover the state’s soaring health care costs. But the proposal, an alternative to the one the administration included in its January budget proposal, still lacks broad support among businesses. (Dayal McCluskey, 3/24)

Stat: Lawsuit Blames Improper Marketing Of Potent Opioid For Woman's Death
The family of a New Jersey woman who died after using a prescription version of the potent opioid fentanyl filed a wrongful death lawsuit Thursday against the drug’s maker, her doctor, and a specialty pharmacy that provided the drug. The lawsuit, filed in a New Jersey state court, alleges 32-year-old Sarah Fuller was the victim of a nationwide push by Insys Therapeutics to entice doctors to prescribe its Subsys fentanyl spray for patients for which the drug was not suitable. (Armstrong, 3/24)

St. Louis Post Dispatch: Illinois Supreme Court Delivers Partial Win For Hospitals On Property Taxes 
Illinois' not-for-profit hospitals can continue to skip paying property taxes, for now, after an Illinois Supreme Court decision Thursday that follows years of battles between hospitals and municipalities over those dollars. The state Supreme Court on Thursday vacated the ruling of a lower court, which had found that an Illinois law exempting not-for-profit hospitals from paying property taxes was unconstitutional. The justices said the lower court didn't have jurisdiction. (Schencker, 3/24)

The CT Mirror: State Worker Union Launches TV Ad To Fight Layoffs
Two days after Gov. Dannel P. Malloy threatened to lay off 4,200 unionized state workers unless concessions are granted, Connecticut’s largest healthcare workers union launched a television ad urging viewers to keep its members on the job. The 30-second spot, funded by 1199 New England SEIU, also comes five months after the union went to court to block nearly 500 layoffs tied to an administration plan to privatize 40 group homes for the disabled. (Phaneuf, 3/23)

Columbus Dispatch: Ohio Slips In National Mental Health Care Assessment
Ohio continues to slip in terms of mental health prevalence and access to care in a national ranking by Mental Health of America. The Buckeye State's overall ranking, 26th among the 50 states, was a slot lower than last year and a drop of three positions since 2011, according to the report released today. The national organization looked at 15 indicators, including the number of adults and juveniles with mental illness, the incidence of adults with drug or alcohol problems, prevalence of suicide, and people with unmet needs for treatment. (Johnson, 2/23)

Columbus Dispatch: Elderly Often Victimized By Addicted Relatives, Friends
Addiction to prescription painkillers among seniors also is growing, with older adults increasingly seeking emergency treatment or coming to the attention of authorities. With the rise in heroin use, more grandparents are also raising their grandchildren because their parents are dead, in jail, chasing their next high or in rehab. It can be particularly challenging for those with limited financial resources or health problems. (Pyle, 3/24)

The Philadelphia Inquirer: New Digital Health Fund In Philadelphia Makes Its First Deal
A $6 million digital health investment fund launched in December by Ben Franklin Technology Partners of Southeastern Pennsylvania, Independence Health Group, and Safeguard Scientifics has made its first investment, of $150,000 in seed financing. The recipient was VitalTrax, a Philadelphia company started last year to help facilitate clinical trials for patients and researchers through a smartphone app and cloud-based data services. VitalTrax is expected to use the money to continue developing its system. (Brubaker, 3/23)

Stat: Mississippi's Middle Class Carries The Burden Of High Medical Debt
Americans are no strangers to medical debt, and the burden is most severe in Mississippi, where nearly 40 percent of adults under age 65 owe hospitals or doctors, according to the Urban Institute. But the men and women carrying that debt are not always poor – they’re increasingly middle class. And their inability, or refusal, to pay their bills is straining hospital budgets and threatening the availability of care. (Blau, 3/24)

WBUR: Can Cardboard Boxes Save Infants' Lives?
Since January, about 3,800 New Jersey parents have opted to lay their infants to sleep in simple cardboard boxes. It’s a public health initiative to reduce cases of sudden infant death syndrome, which killed 3,700 babies in the United States in 2015. (Young, 3/23)

Nashville Tennessean: Hendersonville Doctor Arrested On Prescription-Related Charges
A Hendersonville doctor has been arrested for issuing prescriptions for narcotics in exchange for money and sexual acts, police said. Special agents with the Tennessee Bureau of Investigation, the 18th Judicial District Drug Task Force and the Gallatin Police Department began investigating Dr. Lawrence Joseph Valdez after complaints he was issuing prescriptions for sexual favors. The investigation found he had made these exchanges to multiple individuals. (Todd, 3/23)

Des Moines Register: These Families With Children Injured By Doctor Mistakes Say They Don’t Want Caps On Malpractice Payouts
Families of Iowans who were severely injured by medical errors traveled to the Statehouse on Thursday to denounce bills that would limit awards in malpractice lawsuits. The families said if the bills were in effect, they probably couldn’t have found lawyers to take their cases, even though medical providers’ mistakes or neglect caused permanent disabilities or death of patients. (Leys, 3/23)

Milwaukee Journal Sentinel: An Epidemic Of Childhood Trauma Haunts Milwaukee 
In Milwaukee, the nation’s third most impoverished big city, trauma researchers contend the seeds of distress were planted years ago when the current generation of adults were children. They say new seeds are being planted right now. That revelation is beginning to shift how Milwaukee and other cities respond to social and economic decline. It also is prompting researchers to explore why some who are exposed to childhood trauma emerge undefeated — and whether their resilience can be coaxed out of others and even scaled to entire neighborhoods. (Schmid, 3/23)

The Philadelphia Inquirer: Why Christie Has More Than Tripled N.J.’s Funding Of Doctor Training
Gov. Christie wants more doctors in New Jersey, and he’s budgeted money to train them. But increasing the number of medical professionals — and getting them to stay in New Jersey — isn’t as easy as graduating more students. The calculation also includes the number of postgraduate residencies offered in New Jersey and the number of doctors who stay afterward. The state already has increased the number of graduates, with Cooper Medical School of Rowan University opening in 2012 and Seton Hall University’s medical school slated to open next year. Older schools also have added seats. (Lai, 3/24)

Sacramento Bee: Sacramento County Sheriff Adds Mental Health Beds To Jail 
As the Sacramento County Main Jail handles more inmates with psychiatric problems, the Sheriff’s Department is developing a new section staffed by UC Davis medical professionals, social workers and deputies that can provide intensive mental services without 24-hour care. The county currently keeps inmates who are suicidal or deemed a threat to others in an 18-bed “acute care” unit, which functions like a residential treatment facility. (Garrison, 3/23)

Houston Chronicle: Confusion Over Medical Facilities Could Cost A Bundle 
Walking into one type of neighborhood medical clinic instead of another can be a $2,000 mistake. Or at the very least, a big surprise. That is the finding of a new Rice University study that examines the proliferation of free-standing emergency rooms in Texas in recent years, which to the uninformed patient can look a lot like their lower-cost storefront cousin, the urgent-care clinic. (Deam, 3/23)

The Star Tribune: State: Waite Park Nurse Did Nothing For Patient's Seizures Before He Died 
A Minnesota Health Department investigation lasting six months ruled that the nurse’s neglect was to blame for the anguish that 58-year-old Kenneth L. Allers endured last August for at least 11 hours at the Sterling Park Health Center in Waite Park. The licensed practical nurse, who is not identified in the state’s findings released this week, was suspended during the investigation and later fired. (Walsh, 3/23)

Health Policy Research

Research Roundup: Ads And Testosterone Use; Home Monitoring With Apps; Per Capita Caps

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA: Association Between Direct-To-Consumer Advertising And Testosterone Testing And Initiation In The United States, 2009-2013
Question: Is there an association between televised direct-to-consumer testosterone advertising and testosterone testing and initiation in the United States? Findings: In this ecological study of 75 US designated market areas, each exposure to a testosterone advertisement was associated with monthly relative increases in rates of new testosterone testing of 0.6%, new initiation of 0.7%, and initiation without a recent baseline test of 0.8%. (Layton et al., 3/21)

JAMA Surgery: Effect Of Home Monitoring Via Mobile App On The Number Of In-Person Visits Following Ambulatory Surgery
Question: For patients undergoing ambulatory surgery, can follow-up care via a mobile app avert in-person visits compared with conventional, in-person follow-up care during the first 30 days after the operation? Findings: In this randomized clinical trial of 65 patients, those who used the mobile app attended fewer in-person visits for follow-up care during the first 30 days after the operation than patients in the in-person follow-up care group. This difference was statistically significant. (Armstrong et al., 3/22)

JAMA Surgery: Costs And Consequences Of Early Hospital Discharge After Major Inpatient Surgery In Older Adults
Question: Do fast-track discharge protocols and shorter postoperative length of stay after major inpatient surgery reduce overall surgical episode payments, or are there unintended increased costs because of postdischarge care? Findings: In a cross-sectional cohort study of 639 943 risk and postoperative complication–matched Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting, or total hip replacement, hospitals with shortest routine postoperative length of stay achieved lowest overall surgical episode payments and did not offset shorter hospital stays with greater postdischarge care spending. (Regenbogen et al., 3/22)

JAMA Internal Medicine: Patient Mortality During Unannounced Accreditation Surveys At US Hospitals
Question: What is the effect of heightened vigilance during unannounced hospital accreditation surveys on the quality and safety of inpatient care? Findings: In an observational analysis of 1984 unannounced hospital surveys by The Joint Commission, patients admitted during the week of a survey had significantly lower 30-day mortality than did patients admitted in the 3 weeks before or after the survey. This change was particularly pronounced among major teaching hospitals; no change in secondary safety outcomes was observed. (Barnett, Olenski and Jena, 3/20)

The Kaiser Family Foundation: Health Insurance Premiums Under The ACA Vs. AHCA: County-Level Data
These maps compare county-level estimates of premiums and tax credits under the Affordable Care Act (ACA) in 2020 with what they’d receive under the American Health Care Act as unveiled March 6 by Republican leaders in Congress. The maps were updated on March 21, 2017 to show estimates of how much a person buying their own insurance would have to pay under both the ACA and the House replacement bill. The maps include premium tax credit estimates by county for current ACA marketplace enrollees at age 27, 40, or 60 with an annual income of $20,000, $30,000, $40,000, $50,000, $75,000, or $100,000. (3/22)

Urban Institute: The Impact Of Per Capita Caps On Federal And State Medicaid Spending
In this paper, we analyze the effect of two per capita cap approaches: that in the AHCA and that in Speaker of the House Paul Ryan’s “Better Way” health care plan, released in June 2016. We estimate the effect of each of these per capita caps on federal and state spending from 2019 to 2028. We estimate that between 2019 and 2028, the Better Way proposal would reduce federal Medicaid spending by $841 billion, or 18.1 percent. The AHCA would reduce federal spending by $457 billion, or 9.8 percent. Assuming the bulk of states that expanded coverage under the ACA dropped eligibility for their expansion populations, we estimate that 8 million enrollees would lose Medicaid coverage, and federal savings would increase to $735 billion between 2019 and 2028. (Holahan, Buettgens and Wang Pan, 3/20)

The Kaiser Family Foundation: What Could A Medicaid Per Capita Cap Mean For Low-Income People On Medicare?
Policymakers are giving serious consideration to proposals, such as the American Health Care Act (AHCA), that would fundamentally change the structure and financing of Medicaid – the federal-state program that provides health coverage for 70 million low-income Americans, including one in five people on Medicare. Federal financing for Medicaid would be converted to a per capita cap model (such as under the AHCA) or block grant, both of which aim to limit and make more predictable federal spending on Medicaid and provide states more flexibility in their management of Medicaid spending. Such a change could affect low-income people on Medicare because Medicaid help cover Medicare’s premiums and cost-sharing, and pays for services not covered by Medicare, such as nursing home care. (Jacobson, Neuman and Musumeci, 3/20)

Editorials And Opinions

Health Debate Opinions: Crisis Is Not Trump's Or Ryan's Fault; GOP Failed Its Voters' Needs

As consideration of the Republican health bill stalls on Capitol Hill, opinion writers find many faults.

The Wall Street Journal: The Freedom-From-Reality Caucus
The delay is said to be a defeat for President Trump and Speaker Paul Ryan, but both men have done about as much as they can. They’ve listened to different points of view across a diverse coalition of Members and 33 Governors, and the House bill is a realistic compromise .... No one has offered a better policy alternative to the American Health Care Act that could pass the House and Senate. The real obstacle to progress has been the 29 or so Members of the House Freedom Caucus, who have the power to deny Mr. Ryan a majority of 216 with a mere 22-vote margin of error. (3/23)

The New York Times: The Trump Elite. Like The Old Elite, But Worse!
Legislation can be crafted bottom up or top down. In bottom up you ask, What problems do voters have and how can they be addressed. In top down, you ask, What problems do elite politicians have and how can they be addressed? The House Republican health care bill is a pure top-down document. It was not molded to the actual health care needs of regular voters. It does not have support from actual American voters or much interest in those voters. It was written by elites to serve the needs of elites. Donald Trump vowed to drain the swamp, but this bill is pure swamp. (David Brooks, 3/24)

Politico: The Health Care Albatross
The lesson of Obamacare is that passage of a major health care law never puts health care behind you, only in front of you. For Republicans, their replacement bill will — one way or the other, pass or fail — loom large in 2018 and presumably 2020, if not beyond. (Rich Lowry, 3/22)

The Washington Post: A Postponed Health-Care Vote, A Big GOP Embarrassment And No Good Options Ahead
Legislative sausage-making is never pretty, but what has been happening all week with the signature legislative priority of the GOP seems beyond the norms. Faced with possible defeat on the floor, House Republican leaders postponed a scheduled vote until Friday, hoping that another day of negotiations could produce what seven years of talking have failed to produce, which is a consensus bill that all factions of the party can support. The difficulties Republicans are confronting are entirely of their own making. (Dan Balz, 3/23)

The Wall Street Journal: The Big Health Fix Bruises Ryan And Trump
Former President Barack Obama tried the big fix in health care and he came away with the scars to show for it. Now, House Speaker Paul Ryan and President Donald Trump are trying for the big health-care fix, and they are coming away with the scars to show for it. Maybe there is a lesson in there. (Gerald F. Seib, 3/23)

Bloomberg: Paul Ryan Is Trying To Save Himself
The basic problem is that Republicans have spent years building up expectations for repealing Obamacare without coming up with two crucial parts of their solution: An alternative that they agree on, and the votes in the Senate to impose whatever they want-- if they could agree on what they want. (Jonathan Bernstein, 3/23)

The New England Journal of Medicine: The Mirage Of Reform — Republicans’ Struggle To Dismantle Obamacare
[A]s its potential demise draws nearer, the popularity of the ACA, now part of the status quo, is growing. In the Republican imagination, Obamacare has been a disaster. The GOP’s problem is that in reality Obamacare has substantially expanded health coverage, with 20 million Americans gaining insurance. Rolling back the ACA means making insurance less affordable for low-income Americans, increasing the uninsured population, and taking vast funds away from states and medical providers. The GOP health plan neither fully repeals the ACA nor provides a compelling replacement. Instead, in my opinion, it offers only a mirage of reform. (Jonathan Oberlander, 3/22)

The Wall Street Journal: Here’s How 51 Senators Can Reduce Premiums
As this week’s jousting between Speaker Paul Ryan and the Freedom Caucus makes clear, the Republican Party’s conservative and pragmatic wings don’t always agree. But there’s consensus on this: The American Health Care Act, the GOP’s bill to repeal and replace ObamaCare, doesn’t do enough to make insurance more affordable. ... The trouble is the Senate’s rules. Republican leaders are counting on passing the AHCA through the budget reconciliation process, which requires only 51 votes, bypassing a filibuster. But for a bill to go through reconciliation, every provision must be budget-related, with clear relevance to either taxing or spending. GOP leaders expect the Senate parliamentarian to rule that repealing ObamaCare’s regulations through the AHCA would have only incidental fiscal consequences. (Avik Roy, 3/23)

USA Today: Obamacare Is Broken, And Republicans Can Fix It
When President Obama signed the Affordable Care Act seven years ago, he saddled Americans with a healthcare system that put the ultra-liberal agenda ahead of our best interests. We were promised that Obamacare would bring down healthcare costs with increased competition between insurance providers. We were promised we could keep our healthcare plans. We were promised that Obamacare would not raise middle class taxes. Instead, the law brought the American people rising premiums, unaffordable deductibles, fewer insurance choices and higher taxes. We were let down. (Ronna McDaniel, 3/23)

The Washington Post: Republicans Have Met The Enemy On Health Care. It’s Them.
The legislation may pass — either Friday or over the weekend. (It almost certainly won’t pass without changes.) But House Republicans had to be feeling a sense of deja vu as it became clear Thursday that despite the efforts of President Trump and Speaker Paul D. Ryan, the votes simply weren’t there to pass the legislation. Republicans — led by then-Speaker John A. Boehner — failed time and time again to rally votes behind proposals, from the fiscal cliff in 2012 to the farm bill in 2013 to the debt ceiling in 2014. (Chris Cillizza, 3/23)

Politico: Trump’s No-Win Health Care Debacle
Now it is Trump who needs wavering members of his party to come to his rescue. ... [B]y 2018, the impact of “Trumpcare” will be start to be felt; and if the analyses of the Congressional Budget Office, the Kaiser Family Foundation and others are correct, the impact will be felt most sharply among older, less affluent, working-class Americans … in other words, Trump’s base. If that prospect ripens into reality, what would be celebrated as a legislative triumph may wind up as an epic disaster. (Jeff Greenfield, 3/22)

Georgia Health News: ACA Repeal Is Too Great A Chance To Take 
People in Georgia are relying on the ACA. If it is repealed, Georgia would lose much of the federal funding that helps sustain its health care system, which has struggled to pay for uncompensated care. Additionally, repeal of the ACA would cost many Georgia jobs. Policymakers are rushing to repeal or restrict the ACA even though that could cause many Georgians to lose their coverage. (Karuna Ramachandran, 3/23)

Arizona Republic: Ducey Not (Yet) Deserting 400,000 Arizonans
The House Republican plan to replace the Affordable Care Act would be huge step back, even for those of us who have insurance (for now). It would be a complete disaster, and in some cases, a death sentence, for Arizona’s most needy citizens. Gov. Doug Ducey knows this. (EJ Montini, 3/23)

Des Moines Register: Branstad Cheerfully Ignores Threat To Medicaid Expansion
Health and Human Service Secretary Thomas Price and Centers for Medicare and Medicaid Service Administrator Seema Verma have sent a letter to Branstad and the governors of 30 other states who expanded Medicaid .... They're also urging the governors to pursue changes in Medicaid, such as charging beneficiaries higher premiums and requiring beneficiaries to pay for emergency-room visits to discourage such visits. ... Apparently, the governor's enthusiasm for Medicaid expansion has been supplanted by his enthusiasm for a CMS director determined to scuttle that effort. Could it be "the health needs of our state" are less of a priority than the president's political agenda? (3/23)

Essential Health Benefits Reviewed: 'Galling' Return To Bad Old Days; Lowering Premiums

Some opinion writers urge caution before jettisoning insurance guarantees, but premium costs appear to be at the heart of the argument to get rid of the health law's essential health benefits.

Los Angeles Times: Remember When You Couldn't Get Insurance With A Preexisting Condition? Those Days Are Probably Coming Back
Raise your hand if you want to go back to the days when you couldn’t get health insurance because you’d been sick or injured. That’s one of the galling possibilities raised by the evolving version of the American Health Care Act, the House GOP leadership’s plan to repeal and replace Obamacare. The blame lies with the changes that President Trump and House leaders reportedly pledged to make in the bill to win the support of members of a group of far-right House members, the Freedom Caucus. (Jon Healy, 3/23)

Forbes: Bring GOP Right-Wingers And Pragmatists Together On Obamacare -- By Making Premiums Affordable
Thursday, March 23 was a wild day in Republicans’ quest to repeal and replace Obamacare, with vote cancellations, last-minute amendments, CBO analyses, and Presidential ultimatums. But the most surprising development of all was this: a way has emerged to get both hard-line and pragmatic conservatives to support the American Health Care Act. ... The GOP’s right wing came to a surprisingly pragmatic realization. While refundable tax credits were not their favored approach to health reform, there were too many Republicans who believed otherwise; stubbornness on this point would jeopardize the success of any bill to replace Obamacare. So, congressional hard-liners reoriented their efforts toward repealing most, if not all, of Obamacare’s insurance regulations. (Avik Roy, 3/24)

The New York Times: Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy But Not Chemotherapy
Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don’t need to pay for benefits they won’t use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. ... But there are two main problems with stripping away minimum benefit rules. One is that the meaning of “health insurance” can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it. (Margot Sanger-Katz, 3/23)

Huffington Post: Spicer Denies That Ending Maternity Care Guarantee Would Mean Women Pay More For Health Care He’s Wrong.
White House press secretary Sean Spicer on Thursday defended the idea of taking away guaranteed maternity coverage in health insurance, denying that it would mean women must pay relatively more for their health care. He’s wrong about that. Ending the guarantee could mean slightly lower premiums for individual men and much older women, but it would just as surely drive up premiums for women of child-bearing age and their families ― unless it left them paying the full cost of prenatal care and delivery, typically many thousands of dollars, out of their own pockets. (Jonathan Cohn, 3/23)

The New York Times: Yes, Senator, You Wouldn’t Want To Lose Your Mammograms — Or Women Voters
Republicans seem to have an evil genius for tone-deafness when it comes to women. On Thursday, a photograph that was widely circulated on Twitter showed a room packed with white men cutting a deal to eliminate maternity care and mammograms from the package of essential benefits that insurers are required to provide in the Republican bill to replace the Affordable Care Act. There were some women out of camera range, including Kellyanne Conway, the White House counselor. Earlier in the day, Senator Pat Roberts, Republican of Kansas, made an ill-judged quip that he quickly had to apologize for: “I wouldn’t want to lose my mammograms,” he said to a reporter from Talking Points Memo. (Susan Chira, 3/23)

Viewpoints: Support For Paid Leave; Immigrants Afraid Of Seeking Care

A collection of opinions on health care from around the country.

Arizona Republic: The Wrong Bill About Dying Went To Ducey's Desk
Gov. Doug Ducey can stand up for individual rights and dignity. Or he can sign Senate Bill 1439 and buck a trend toward letting people control their lives and deaths. The bill is ostensibly about religious freedom. It is supported by the powerful Center for Arizona Policy, which supports conservative social policies and is headed by Ducey supporter Cathi Herrod. SB 1439 is supposed to protect health-care professionals and hospitals from discrimination if they refuse to help people die. (Linda Valdez, 3/22)

Louisville (Ky.) Courier-Journal: Savannah's Funeral - 'Tired Of Burying My Friends'
We should not feel comfortable raising children in a world where they learn how to order flowers for their friend’s funeral before they learn how to buy a house or start a retirement fund. I am a full-time student with a part-time job. I went to decent schools and stayed away from the neighborhoods my parents warned me about. I am not an anomaly, and neither is gun violence. I apologize if I seem insensitive towards the individual’s right to own a gun, but it is time we take a critical look at our society’s priorities. What good is a world full of guns if we must fill our days with this pain? How many of our children are we willing to lose to maintain our sense of entitlement? (Tara Ann Steiden, 3/23)

The New England Journal of Medicine: Chilling Effect? Post-Election Health Care Use By Undocumented And Mixed-Status Families
Navigating the health care system is particularly difficult for people with limited English proficiency and health literacy or without health insurance or a Social Security number. Many undocumented immigrants and their families therefore go without needed care, to their detriment and sometimes that of others, as in the case of a woman with syphilis who is pregnant with a future U.S. citizen. (Kathleen R. Page and Sarah Polk, 3/23)

The New England Journal of Medicine: Patient Inducements — High Graft Or High Value?
In May 2016, Uber announced a partnership with the Southeastern Pennsylvania Transportation Authority (SEPTA) to provide discounted ride-sharing services to “bridge the first and last mile gap” and encourage people to ride the regional rail system. It was a potential win for all — increased ridership for Uber and SEPTA, decreased traffic and pollution. The partnership was lauded for testing an innovative way to advance social goals. Contrast this partnership with one that might be arranged in health care. For instance, a partnership between a health system and a ride-sharing service to provide free rides for patients with transportation barriers might help elderly patients with disabilities or those with limited transportation options get needed care. However, it might be illegal. (Krisda H. Chaiyachati, David A. Asch and David T. Grande, 3/23)

The New England Journal of Medicine: Adopting Innovations In Care Delivery — The Case Of Shared Medical Appointments
Transformative innovations in care delivery often fail to spread. Consider shared medical appointments, in which patients receive one-on-one physician consultations in the presence of others with similar conditions. Shared appointments are used for routine care of chronic conditions, patient education, and even physical exams. Providers find that they can improve outcomes and patient satisfaction while dramatically reducing waiting times and costs. (Kamalini Ramdas and Ara Darzi, 3/23)

JAMA: The Rise Of Crowdfunding For Medical Care
The rise of medical crowdfunding carries the promise of more efficiently matching potential donors with unmet needs in ways that may increase overall giving, mirroring emerging technologies in other industries such as ride-hailing and retail services that aim to more efficiently match supply and demand. Despite its protean promises, however, medical crowdfunding raises a constellation of ethical and legal hurdles for patients, clinicians, institutions, and society. Understanding these issues will be of increasing importance as medical crowdfunding continues to grow in popularity. (Michael J. Young and Ethan Scheinberg, 3/23)