But hours later, the Senate decisively rejected a Republican proposal to repeal-and-replace Obamacare, a sign of the chaos expected to envelop Capitol Hill as GOP leaders work to find a plan their conference can agree to.

Wednesday morning, floor debate on the legislation to overhaul the Affordable Care Act will continue, even though there aren't any guarantees the votes are there to eventually pass it -- and it's unclear what a final bill will look like.

But little may match the drama of Tuesday's vote on the motion to proceed, when Sen. John McCain returned from Arizona to applause from fellow senators to cast what would be a critical vote for the Republicans. Two GOP senators -- Susan Collins and Lisa Murkowski -- sided with all Democrats in opposition, meaning all remaining Republicans and Pence were necessary for the motion to pass.

The vote came as Senate Majority Leader Mitch McConnell and President Donald Trump dared their fellow Republicans to block their seven-year campaign promise to repeal and replace Obamacare.

Senators late Tuesday cast their first vote on what could be dozens of amendments considered to it.

This first vote dealt with a measure that combined a previous Senate proposal known as the Better Care Reconciliation Act -- that was rejected by several Republican senators -- with $100 billion in extra money for people on Medicaid desired by moderate Republicans and a proposal from conservative Sen. Ted Cruz, R-Texas, to allow bare-bones health insurance plans.

Democrats moved successfully to kill the amendment, which was possible because it had not been officially scored by the Congressional Budget Office and therefore didn't meet the complicated reconciliation rules that the Senate is using to consider the bill.

Republicans needed 60 votes to keep the amendment alive. It died on a 43 to 57 vote.

The vote came after a Senate clerk was forced to read the text of the amendment aloud in the Senate chamber, all part of the delaying tactics Democrats employing to express their overall unhappiness with the bill.

On Wednesday, senators are expected to cast a vote on a "repeal-only" proposal. It too is expected to be defeated because many Republicans as well as all Democrats reject repealing without a replacement ready.

The vote was up in the air until the last moments, when several Republican holdouts announced their support, including Sens. Rand Paul, Dean Heller, Rob Portman and Shelley Moore Capito.

Trump, who has repeatedly said he's ready to sign any repeal legislation, celebrated the vote, which creates a path to give him the major congressional victory that's eluded the White House thus far.

"I'm very happy to announce that with zero of the Democrats' votes, the motion to proceed on health care has moved past and now we move forward toward truly great health care for the American people. We look forward to that. This was a big step," Trump said at a White House news conference.

"I want to thank Sen. John McCain," he added. "A very brave man. He made a tough trip to get here."

But while Trump was happy with the result, he also acknowledged there's a long road ahead for the legislation and criticized the two GOP senators who opposed the motion.

"We had two Republicans that went against us, which is very sad, I think," Trump said. "It's very, very sad -- for them. But I'm very, very happy with the result. I believe now we will, over the next week or two, come up with a plan that's going to be really, really wonderful for the American people."

Democrats are united against the bill, saying it would end health care coverage for millions of Americans.

"Anyone who thinks this is over is sadly mistaken," said Minority Leader Chuck Schumer, D-New York. "There are many, many Republicans who don't like this bill, who don't want to vote for it. They are under enormous pressure to vote for it. ... Anyone who voted to move to proceed and certainly anyone who votes to send this bill to conference is virtually, certainly, voting to kick millions off health care, to make it much harder to get coverage if you have a pre-existing condition, to slash Medicaid and give a huge amount of tax cuts to the rich."

Sen. Bernie Sanders Monday called the bill the "cruelest, most destructive and irresponsible piece of legislation ever brought to the United States Senate in the modern history of this country."

In a speech at the NAACP national convention, highlighted the possible effects of the bill's provisions, which include cutting Medicaid, defunding Planned Parenthood and roadblocks for those with pre-existing conditions.

McConnell won over key holdouts on the procedural vote, but those senators haven't said they will back the final measure.

Paul, a Kentucky Republican, said he would support the procedural motion to open debate on the health care bill, so long as leadership guarantees a vote on a full repeal of Obamacare.

"If this is indeed the plan, I will vote to proceed and I will vote for any all measures that are clean repeal," Paul tweeted. Such an amendment would be expected to fail, however.

Heller, who has complained that Obamacare repeal efforts could hurt Nevada residents dependent on Medicaid, nevertheless said he'd vote to move forward. Heller is facing a tough re-election campaign in Nevada next year.

"Obamacare isn't the answer, but doing nothing to try to solve the problems it has created isn't the answer either," Heller said in a statement. "If the final product isn't improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it."

Republican leaders Tuesday worked thread any needle they can to appease other holdouts.

"The only goal is to get onto the bill. Nothing happens until we do, so that's the only goal," a Republican aide said.

"These are the moments legislatively when you get creative. We're getting creative."

This story has been updated.

CNN's Tami Luhby contributed to this report.

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Senate rejects proposal to repeal and replace Obamacare ...

An explainer:

When the Senate voted 51-50 to begin debating the repeal of the Affordable Care Act, technically senators were bringing the repeal bill that was passed in the House to the Senate floor. For now, that is the bill that senators are trying to reshape.

On Tuesday night, Senate Republican leaders brought to the floor their most complete version of a plan to repeal and replace the Affordable Care Act. That measure had been worked out behind closed doors by the majority leader, Senator Mitch McConnell of Kentucky, and it would dismantle major parts of the current health care law, including the requirement that most people have health insurance.

But it also included an overture to Senate conservatives, a measure championed by Senator Ted Cruz, Republican of Texas, that would allow insurance companies to sell stripped down, low-cost insurance plans as long as they also offer insurance policies that comply with federal standards, including the requirement that plans cover essential services like maternity care, mental health treatment and prescription drugs.

Three major proposals are being discussed.

For moderates, the legislation includes $100 billion to help pay out-of-pocket medical costs for low-income people.

Because that broad version of the Senate health care measure had not yet been assessed by the nonpartisan Congressional Budget Office, it needed 60 votes to overcome a Democratic objection that it violated Senate rules.

But it got only 43 votes, demonstrating that even after weeks of refining the legislation, Senate leaders still fell far short of enough support for their replacement plan, from both ends of the partys ideological spectrum.

Mr. McCain had previously made clear that he wanted to secure amendments to that broad repeal-and-replace bill. The vote on Tuesday night could be interpreted as a sign of support for that general approach.

The debate goes on.

Senator John McCain, who was recently diagnosed with brain cancer, spoke to the Senate after casting his vote to begin debating legislation to repeal the Affordable Care Act.

Mr. Trump opened the day by attacking Ms. Murkowski.

But Mr. Trumps public shaming is not an effective strategy for Ms. Murkowski, who has dealt with worse from her party. In 2010, Ms. Murkowski retained her Senate seat in a historic win as a write-in candidate. She had lost Alaskas Republican primary that year to a Tea Party challenger and was largely abandoned by Republican leadership. Since then, she has not felt beholden to her party.

Senators are set to consider a different repeal measure on Wednesday.

This measure would repeal major parts of the health law but would not provide a replacement. The legislation resembles a bill that passed the Senate in 2015 but was vetoed by President Barack Obama in early 2016.

Senator Rand Paul, Republican of Kentucky, supports that approach. But some Republicans worry that repealing the law without providing a replacement would leave many Americans without health care coverage. Such a repeal only measure is not expected to garner enough votes for passage.

The vote for this measure had been expected to take place around midday Wednesday, but it has now been delayed until later in the afternoon.

Republicans are using special budget rules to try to pass a repeal bill, so the debate is limited to 20 hours, and Democrats cannot delay it with a filibuster. Later this week, the Senate will hold what is known as a vote-a-rama, an exhausting marathon of amendment votes.

The nine Republicans who voted against the comprehensive replacement measure on Tuesday night are an indication of the problem that Senate Republican leaders continue to confront: The party caucus still does not agree on what should be in a health care repeal bill that would have enough support to win Senate approval.

One solution might be to pass a pared-down health plan that has support from at least 50 of the 52 Republican senators, and then turn to working out a compromise with the House.

Read more:

Senate Health Care Vote: Where the Debate Left Off and What Happens Next - New York Times

The Senate has delayed a vote on a proposal to repeal much of ObamaCare.

The Senate had been expected to vote on the amendment, which would repeal most of the law in two years, from Sen. Rand PaulRand PaulSenate delays vote on healthcare repeal Senate rejects ObamaCare repeal, replacement amendment Overnight Healthcare: Senate votes to begin ObamaCare repeal debate | McCain returns to vote | GOP floats scaled-down healthcare bill MORE (R-Ky.) late Wednesdaymorning, but made a last-minute announcement that it was being delayed until3:30 p.m.

There was a kerfuffle over the point of order. They need to ... make some other arguments to the parliamentarian, he told reporters.

Asked if it was tied to abortion language included in the bill, he said, I believe so.

Democrats were expected to use the Senates rulebook to try to strip out a provision in the repeal amendment that included restrictions on using tax credits to buy insurance that covers abortions.

The repeal-only amendment would also cut off federal funding for Planned Parenthood.

The ObamaCare repeal amendment is expected to fail, regardless of the abortion fight.

The Senate also voted down an amendment to repeal and replace ObamaCareon Tuesdaynight. They are the first of what are expected to be hundreds of amendments during the days-long healthcare debate.

Three GOP senators have already come out against a repeal-only approach, and Sen. Lamar AlexanderLamar AlexanderSenate delays vote on healthcare repeal Senate Dems launch talkathon ahead of ObamaCare repeal vote This week: ObamaCare repeal vote looms over Senate MORE (R-Tenn.), chairman of the Senates health committee, predicted the Senate would not get 40 votes to repeal ObamaCare without a replacement.

But conservatives ramped up pressure for GOP senators to support the proposal, noting Senate Republicans passed a repeal bill in 2015 when they knew then-President Obama would veto it.

Republicans promised to repeal ObamaCare, and as we move forward in this process, I urge them to join me in supporting a clean repeal of as much of this disastrous law as possible, Paul said ahead of the vote.

FreedomWorks, a conservative outside group, blasted out a key vote notice hours ahead of Wednesdaysvote, arguing President Trump would sign a repeal-only bill.

Repealing portions of ObamaCare without enacting a replacement could leave 18 million people without health insurance the following year, according to a report released by Congressional Budget Office (CBO) in January.

After the elimination of ObamaCare's Medicaid expansion and insurance subsidies, 27 million people would lose insurance, rising to 32 million by 2026, the CBO found.

The proposal comes as senators are searching to find a path forward to fulfill their yearsofcampaign pledges to repeal and replace ObamaCare.

Senate Majority Leader Mitch McConnellMitch McConnellHuffPost writer: McCain 'will die with dishonor' for yes vote on healthcare White House, GOP close to releasing joint tax-reform principles Senate delays vote on healthcare repeal MORE (R-Ky.) scored a victory Tuesdaywhen he wrangled 50 GOP senators to agree to start debate on the matter. Vice President Pence broke the 50-50 tie.

But during the first amendment voteon Tuesdayevening, nine GOP senators joined with Democrats to vote against a key repeal-and-replace proposal, known as the Better Care Reconciliation Act (BCRA). The setback doesnt prevent GOP leadership from offering another version of BCRA during what is expected to be a days-long floor debate.

McConnell acknowledged the healthcare effort certainly wont be easy.

Well consider many different proposals throughout this process from senators on both sides of the aisle. Ultimately, we want to get legislation to finally end the failed ObamaCare status quo through Congress, and to the presidents desk for his signature, he said Wednesdaymorning.

Republicans have a 52-seat majority and will need the support of at least 50 GOP senators to pass a proposal.

GOP leadership could ultimately try to pass a skinny repeal, which would include a repeal of the individual and employer mandate and the medical device tax, if broader proposals arent able to garner enoughsupport.

The move could buy Republicans time to work out a deal as they try to merge their healthcare bill witha proposal passed earlier this year by the House.

I think the endgame is to be able to move somethingat the end of thisprocess across the Senate floor that can get 50 votes and then get into conference with the House, Sen. John ThuneJohn ThuneSenate delays vote on healthcare repeal Senate might not act on must-pass aviation bill until September Senate votes to begin ObamaCare repeal debate MORE (R-S.D.) told reporters.

Cornyn added Wednesdaythat the GOP is looking for a way to get to conference quick but no decisions had been made aboutwhat the Senate could ultimately pass, or what could be included in a "skinny repeal."

Democrats, however, have blasted that path as a setupto try to ultimately pass full repeal of ObamaCare.

Make no mistake about it, skinny repeal is equal to full repeal. Its a Trojan horse designed to get the House and Senate into conference where the hard-right flank of the Republican caucus, the FreedomCaucus, will demandfull repeal orsomething very close to it, SenateMinority Leader CharlesSchumer (D-N.Y.)said ahead of the vote.

See the article here:

Senate delays vote on healthcare repeal - The Hill

That was Massachusetts Sen. John Kerry trying, unsuccessfully, to explain his vote(s) on federal funding for the American troops in Iraq and Afghanistan during the 2004 presidential campaign. President George W. Bush took that comment and turned it into this devastating TV ad.

Kerry's argument -- and the reason he said the whole voted-for-it-before-I-voted-against-it thing -- was that he had voted for a bill to fund the troops via the repeal of a series of Bush-era tax cuts before he had voted against the Republican-favored plan. The Senate votes a lot, Kerry's case went, and Republicans were cherry-picking what was one in a series of votes.

Sound familiar?

Republican after Republican who got off the fence to support the "motion to proceed" on Tuesday was careful to note that they were not yet supportive of the broader GOP health care bill but rather were expressing their support to allow debate on the measure to begin.

"I voted for the motion to proceed to allow debate to continue and amendments to be offered," John McCain said on the Senate floor. "I will not vote for the bill as it is today."

What that logic presumes is that the average voter distinguishes between a procedural vote to start debate on health care and a vote on some sort of actual health care measure.

Here's some breaking news: They don't!

Just ask John Kerry. Trying to explain the arcane and complicated ways in which the Senate cast votes -- motion to proceed, motion to recommit, final passage etc. -- is a total political loser. Peoples' eyes fog over and it reminds them of all the things they don't like about Washington. It sounds like gobbledy-gook and double speak to them even if, technically speaking, Kerry DID vote for $87 billion for the war and reconstruction efforts before he voted against it.

(Sidebar: The number of votes that senators take -- and the complex ways in which these votes play out -- is the leading reason why senators rarely make good presidential candidates. Too many votes to defend.)

Democrats, stung by Kerry's experience, are already preparing to give Republicans a taste of their own medicine.

The one silver lining, politically speaking, for Republicans is they have very little vulnerability in 2018. Only Sen. Dean Heller of Nevada, who voted for the motion to proceed, is up for re-election in a state Hillary Clinton won in 2016. And, in total, only 10 Republican seats are up for re-election.

Still, health care -- as President Obama and Democrats found out in the 2010 and 2014 elections -- is an issue where voters have a long memory. And the "he voted for the heath care bill before he voted against it" attack is a very, very potent one. Just ask John Kerry.

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The health care problem Republicans didn't anticipate - CNN International

"If you're expecting an instant panacea or an instant cure, it's not going to be provided by anybody here in Washington," Scaramucci said on CNN's "New Day" Wednesday.

Scaramucci cast the current deliberations in Congress on repealing Obamacare as incremental steps on health care.

They are expected on Wednesday to continue the health care debate, and it is unclear what a final bill could look like.

Scaramucci seemed to dismiss the nuances of the debate and advised senators to move forward with something on health care.

"Don't focus on the micro nature of this today if you're a senator," Scaramucci said.

He lamented not being able to push through a major overhaul on health care, and said "we have to start with incrementalism" on the issue because of the "webs in Washington."

As for Attorney General Jeff Sessions, whom President Donald Trump has publicly complained about and left open the possibility of firing, Scaramucci said he advised all Cabinet members to "have a tough skin."

Asked if Trump had talked directly with Sessions, Scaramucci said, "I don't know the answer."

Besides facing opposition from his own party, Trump has also demonstrated a willingness to move against one of his earliest prominent supporters. Scaramucci, however, denied that Trump was demanding loyalty in exchange for returning none back.

"He is a symmetrical loyalist for sure," Scaramucci said. "If you take care of him, he's going to take care of you."

Turning to his own role as the new communications chief, Scaramucci spoke at length about his desire to tamp down on leaks coming from the White House. He said he knew he could not eliminate the leaks entirely, but said he could dial them back.

When asked if the higher-ranking person was Trump, Scaramucci deferred and said he was "getting so subtle and surgical" with his answers.

View original post here:

Scaramucci: Don't expect 'instant cure' on health care - CNN

"Senator @lisamurkowski of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad," he tweeted.

Murkowski and Sen. Susan Collins of Maine were the only two GOP senators to vote against a procedural vote backed by Senate Majority Leader Mitch McConnell Tuesday afternoon. They were also among the nine Republicans who voted Tuesday night against the Better Care Reconciliation Act, a version of the health care overhaul bill.

Murkowski responded to Trump Wednesday afternoon.

"Every day shouldn't be about campaigning," the Alaska senator added. "Quite honestly, I don't think it's wise to be operating on a daily basis thinking about what -- a statement or a response -- that causes you to be fearful of your electoral prospects."

Notably, Trump has not yet publicly criticized Collins on social media in the wake of Tuesday's vote.

But the President subtly warned Republicans that their political futures could be in jeopardy if they don't support his efforts.

"Any senator who votes against repeal and replace is telling America that they are fine with the Obamacare nightmare, and I predict they'll have a lot of problems," he said at a rally in Youngstown, Ohio, Tuesday night.

For her part, Murkowski noted to MSNBC that she is not up for re-election again until 2022, "a long time away."

Trump has publicly pressured other members of his own party who haven't backed him on health care.

At a recent White House meeting, the President predicted that Sen. Dean Heller, who is facing a tough re-election fight in 2018, would reverse himself and vote to advance the GOP's health care bill.

Back in March, Trump called out House members when the chamber was debating the issue.

He added: "Where are @RepMarkMeadows, @Jim_Jordan and @Raul_Labrador? #RepealANDReplace #Obamacare."

CNN's Dylan Stafford contributed to this report.

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Trump calls out Murkowski over health care vote - CNN

Remember: The strategy for passing the bill depends on secrecy. Mitch McConnell, Paul Ryan and their allies understand that their plans are deeply unpopular. So the best way to prevent them from taking health coverage from people is to call attention to their efforts. On Tuesday night, one Obamacare replacement bill had already failed.

Spiro suggested that people with Democratic senators call them to urge them to fight as hard as possible, by filibustering and offering unlimited amendments. Locking in the tentative no votes from the Republican senators Lisa Murkowski (of Alaska) and Susan Collins (of Maine) is also critical.

Meanwhile, people who live in Ohio, Nevada, West Virginia, Arizona, Wisconsin, Kentucky, Kansas, Colorado, Louisiana and Utah are represented by Republican senators who could provide the swing vote.

Senate leadership wants to pass a bill this week, Marianna Sotomayor of NBC reported. One worrisome possibility, as Senator Chris Murphy noted, is the Senate passing a bare-bones bill, under the guise of fixing it during so-called conference negotiations with the House. That would almost certainly lead to massive losses in insurance coverage.

If you were ever tempted to get involved in politics, now would be a good time to make a phone call or urge friends and relatives to do so. And if youre a United States senator who is tempted to put Americans well-being above partisan loyalty, now would be a really good time.

The McCain moment: John McCain, who rushed back to Washington from a diagnosis of aggressive brain cancer, faces an especially stark choice.

He suggested yesterday that he was disgusted by the process so far and blasted it for violating the Senates regular order but he also voted to move ahead. For him, voting against any bill produced by this process would be the most consistent stand in favor of regular order, Adam Jentleson, a former Democratic Senate aide, wrote. If Im wrong & McCain votes for whatever monstrosity comes out of this process, hell lose all authority on the Senate as an institution.

David A. Graham, in The Atlantic, was struck by the same tension: Senate floor speeches can stir the heart strings. But if McCain intends to return the body to regular order, at some point, hes actually going to have to vote to do that.

Intriguingly, FiveThirtyEights Nate Silver argues that younger political writers were more critical of McCains speech than older writers.

See the article here:

Citizen Action on Health Care - New York Times

With the Senate having voted Tuesday to open debate on repealing and replacing Obamacare -- exactly how is yet to be determined -- here's still another possible repercussion from that effort: A hit to the U.S. economy.

If the Republican efforts to replace the Affordable Care Act fail and the exchanges are left to twist in the wind, it's likely the U.S. will see a potential decline in health care consumption, said Paul Ashworth, chief U.S. economist at Capital Economics. In a recent report, he said that "could conceivably become a significant drag on GDP growth next year."

It also casts even more doubt on the Trump administration's rosy predictions of 3 percent GDP growth next year. That estimate has already been met with plenty of skepticism even without the prospect of taking health insurance away from as many as 30 million people by 2026.

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The Congressional Budget Office has signaled that President Trump's budget may be overly optimistic. According to the office's projections, the W...

The U.S. potential economic growth rate has been declining from an average of over 3 percent in the 1990s to between 1.5 percent and 2 percent in the 2010s, according to Jeremy Lawson, chief economist at asset management firm Standard Life Investments. He believes short-term future growth is unlikely to return to previous highs without an acceleration of structural reforms well beyond health care.

If Obamacare is repealed with no replacement, the result would be an estimated $417 billion decline in the budget deficit over a 10-year period, according to the Congressional Budget Office analysis. That would have a modest impact on GDP growth, said Lawson. But that estimate assumes no Obamacare replacement whatsoever is implemented, which is unlikely to happen over a decade.

Both the Senate and House versions of replacement would restrict Medicaid spending and reduce the number of insured people by about 20 million. "Both plans would have a more modest negative effect on the economy than just repeal," Lawson predicted. But because the plans would likely reduce access to health insurance, you may see more personal bankruptcies and other disruptive economic impacts, Lawson said.

It's also important to look at health care's impact on the U.S. economy in terms of productivity, Lawson explained. Health care spending accounts for 18 percent of total U.S. GDP, a much higher percentage than in most other world economies. A lot of that spending is inefficient because individuals, especially those with employer-sponsored insurance, and the health care industry itself don't have incentives to make health care a more cost-efficient and thus productive system.

As health care spending continues to grow more quickly than the rest of the economy, Lawson explained, it squeezes out potential spending in other, more efficient sectors, which would in turn help boost overall economic growth. He added: "One could argue inefficient health care systems are holding back the U.S. economy over the long term."

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What the health care vote may mean for US growth - CBS News

Patient information can be vulnerable when health care facilities are the focus of cyberattacks. Eric Audras/Onoky/Getty Images hide caption

Patient information can be vulnerable when health care facilities are the focus of cyberattacks.

In the neonatal intensive care unit of Cook Children's Hospital in Fort Worth, Texas, a father is rocking a baby attached to a heart monitor. While doctors roam the halls trying to prevent infections, Chief Information Officer Theresa Meadows is worried about another kind of virus.

"The last thing anybody wants to happen in their organization is have all their heart monitors disabled or all of their IV pumps that provide medication to a patient disabled," Meadows says.

Meadows manages IT and cybersecurity for nearly 7,000 employees at more than 50 locations in Texas. After co-chairing an evaluation of hospital cybersecurity across the U.S., she says there's a lot to improve.

Dr. John Halamka, chief information officer of Beth Israel Deaconess Medical Center in Boston, agrees. "Health care has traditionally underinvested in information technology," Halamka says.

Halamka, who has been a CIO since the 1990s, says just a decade ago, pretty much all health records were paper. Then, in a period of a few years, hospitals switched to electronic records. But the security of digital health data has not kept up with its growth. Other industries, like financial services and the federal government, have devoted more than 12 percent of their IT budgets to cybersecurity. Health care averages just half that.

At the same time, the cost of mitigation has soared, with the average breach costing $355 per stolen record for health care organizations. And hackers have gotten creative. Back in 1997, Halamka says, the threats he faced were students trying to hack the network.

"In 2017, what threats do I face? State-sponsored cyberterrorism, organized crime and hacktivism."

It's no wonder demand for cybersecurity talent in health care has exploded. But it's not that easy to recruit.

Digital health care consultant Drexel DeFord jokes that he's a "recovering CIO. CIOs are overly stressed with everything from security to regulation," he says. "When I talk to them about maybe coming into health care, the answer I usually get is 'No way, it's too complicated. It's way simpler to do banking or oil and gas.' "

It's also much more lucrative to work in other industries. According to Burning Glass Technologies, the average advertised pay for health care cybersecurity positions is 25 percent lower than in finance.

Plus you're on the line every minute, not just for keeping someone's social media profile working, but for helping keep them alive.

Meadows says a good CIO is familiar with complex medical devices and comfortable with software and complicated regulations. Also, a CIO needs to keep the hospital staff educated on the latest threats, sometimes by running mock cyberattacks. Meadows conducts regular phishing exercises paired with educational campaigns.

The average cost of a health care breach is estimated to be more than $2.2 million, not to mention the reputation damage. Meadows says the price of hiring a cybersecurity leader might seem high, but leaving the job open is an invitation for trouble.

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Hospitals Face Growing Cybersecurity Threats - NPR

Republican leaders are steering the Senate toward a crucial vote on their bill eviscerating much of President Barack Obama's health care law, buoyed by the near theatrical return to the Capitol of the ailing Sen. John McCain.

No stranger to heroic episodes, the Navy pilot who persevered through five years of captivity during the Vietnam War announced through his office that he would be back in Washington for the critical roll call on beginning debate on the legislation. The 80-year-old has been at home in Arizona since he revealed last week that he's undergoing treatment for brain cancer, but a one-sentence statement said he "looks forward" to returning for work on health care and other legislation.

Senate Majority Leader Mitch McConnell, R-Ky., scheduled the initial health care vote for Tuesday. It seemed unlikely Republicans would bring McCain cross country if they didn't think his vote would make a difference, and his mere presence could make it harder for wavering Republicans to cast a vote against even considering the bill.

Democrats uniformly oppose the effort to tear down Obama's signature legislative achievement. Republicans control the chamber 52-48, meaning they can afford to lose just two Republicans with McCain around and only one in his absence. Vice President Mike Pence would cast a tie-breaking vote.

At least a dozen GOP senators have openly said they oppose or criticized McConnell's legislation, which he's revised as he's hunted Republican support. While it had long seemed headed toward defeat, Republicans Monday began showing glimmers of optimism.

"My mandate from the people of Kentucky is to vote yes, and I certainly intend to do so," McConnell said Monday in what seemed an implicit reminder to his Republican colleagues that they've done the same.

As usual, President Donald Trump was blunter.

"Over and over again, they said, 'Repeal and replace, repeal and replace.' But they can now keep their promise," Trump said of GOP senators in White House remarks.

Senators and aides said talks were continuing that might win over enough Republicans to commence debate. The discussions were covering issues including potentially giving states more leeway to use federal funds to help people losing coverage under Medicaid, the health insurance program for the poor, disabled and nursing home patients.

Should Tuesday's vote fail, it would be an unalloyed embarrassment for a party that finally gained control of the White House, Senate and House in January but still fell flat on its promise to uproot Obamacare. Republicans could try returning to the bill later this year if they somehow round up more support.

Should the initial motion win, that would prompt 20 hours of debate and countless amendments in a battle likely to last all week. Moderate and conservative Republicans would try reshaping the bill in their direction while Democrats would attempt to force GOP senators to cast difficult votes aimed at haunting them in re-election campaigns.

Even then, the measure's ultimate fate still seemed iffy because of GOP divisions.

Obama's law was enacted in 2010 over unanimous Republican opposition. Since then, its expansion of Medicaid and creation of federal insurance marketplaces has produced 20 million fewer uninsured people. It's also provided protections that require insurers to provide robust coverage to all, cap consumers' annual and lifetime expenditures and ensure that people with serious medical conditions pay the same premiums as the healthy.

The law has been unpopular with GOP voters and the party has launched numerous attempts to dismantle the statute. All until this year were mere aspirations because Obama vetoed every major one that reached him.

Ever since 2010, Republicans have been largely united on scuttling the statute but divided over how to replace it.

Those divides sharpened with Trump willing to sign legislation and estimates by the nonpartisan Congressional Budget Office that several GOP bills would cause more than 20 million people to become uninsured by 2026. Polls showing growing popularity for Obama's law and abysmal approval ratings for the GOP effort haven't helped.

The House approved its version of the bill in May after several setbacks. It's similar to the Senate measure McConnell unveiled in June after writing it privately. But he's also revised it in his hunt for GOP votes.

McConnell's bill would abolish much of Obama's law, eliminating its tax penalties on people not buying policies, cutting Medicaid, eliminating its tax boosts on medical companies and providing less generous health care subsidies for consumers.

Moderate Sen. Susan Collins, R-Maine, has remained opposed to beginning debate on any option McConnell has revealed so far. Conservative Sen. Rand Paul, R-Ky., said he would vote no unless leaders agreed to an early vote on simply repealing Obama's statute and giving Congress two years to replace it.

Conservatives were seeking language letting insurers offer bare-bones policies with low premiums, which would be illegal under Obama's law. Moderates from states whose low-income residents rely heavily on Medicaid were resisting the GOP bill's cuts in that program.

Associated Press writers Erica Werner and Andrew Taylor contributed to this report.

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GOP sets Senate health care vote buoyed by McCain return - ABC News

The Senate majority leader, Mitch McConnell of Kentucky, says it is time for a vote.

On Tuesday, he will have the Senate vote on a motion to proceed in this case, on whether to take up a health care repeal bill that narrowly passed the House in May.

Nobody expects that bill to become law. Instead, it would essentially serve as the vehicle for the Senates legislation. The House bills text would be swapped out for the Senates preferred language, whatever that ultimately is.

Republicans hold 52 seats in the Senate, and to be successful, they need a majority for the motion to proceed. In a deadlock, Vice President Mike Pence would break the tie in favor of proceeding.

Only days after announcing he has brain cancer, Senator John McCain, Republican of Arizona, plans to return to the Senate on Tuesday. His presence means Mr. McConnell can afford for only two Republicans to vote against the motion. If Mr. McCain had been absent, Mr. McConnell would have been able to lose only a single Republican.

At least one defection is all but certain: Senator Susan Collins of Maine indicated on Monday that she would vote against proceeding in just about every imaginable circumstance.

One big factor is what Mr. McConnell plans to do after the procedural vote.

For example, Senator Rand Paul of Kentucky is an expected no vote if after clearing the procedural hurdle, the Senate turns to a bill by Mr. McConnell to repeal and replace the health law. Mr. Paul detests that bill.

On the other hand, Senators Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska indicated last week that they would not vote to proceed if Mr. McConnell afterward scheduled a vote on a bill to repeal the health law without providing a replacement.

In addition, a number of other Republican senators have expressed varying qualms, with varying degrees of certitude. They include Mike Lee of Utah, Jerry Moran of Kansas, Rob Portman of Ohio and Dean Heller of Nevada.

Such a vote would start the debate in the Senate on health care. At some point, Mr. McConnell is expected to offer an amendment that would substitute a new measure for the text of the bill that passed the House. But it remains to be seen what that new measure would be. Republicans are trying to pass the bill using special budget rules that limit debate to 20 hours and prevent a Democratic filibuster.

Republicans are not expected to abandon their repeal effort, but its future would appear bleak, at least in the short term.

Well go back to the drawing board, Senator John Thune of South Dakota, a member of the Republican leadership, said on Fox News Sunday. Of voting to repeal and replace the health law, he said, Its not a question of if, its a question of when.

Recent history provides some support for Mr. Thunes optimism. The repeal bill in the House was declared dead before coming back to life and Republicans there ultimately were successful in passing a bill.

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Senate Health Care Vote: What to Expect - New York Times

With a strong, last-minute push from President Trump, Senate Republicans face a pivotal vote Tuesday in their long bid to repeal or replace the Affordable Care Act.

But the outcome remained in doubt, largely because senators have not even been told which of the various GOP plans will be considered.

Senate Majority Leader Mitch McConnell has kept the process highly secretive as he tries to find a path forward amid stark opposition within his Republican majority, and no backing from Democrats. He has only two Republican votes to spare.

In a sign of the votes importance, Republican Sen. John McCain of Arizona who was diagnosed last week with brain cancer following an operation to remove a blood clot announced late Monday he would return to Washington in time for Tuesdays proceeding.

But many GOP senators remain reluctant to begin formal debate on legislation without knowing where the process will end.

Trump warned senators Monday that Tuesdays planned motion to proceed the first legislative hurdle to passing a Senate bill could be Republicans last chance to undo the Affordable Care Act, also known as Obamacare.

He warned in a tweet that the repercussions will be far greater than any of them understand! hinting of political fallout for senators who vote against the measure.

Any senator who votes against starting debate is telling America that you are fine with the Obamacare nightmare, Trump said during an event at the White House.

For Senate Republicans this is their chance to keep their promise. Over and over again they said repeal and replace, repeal and replace, he said. Theres been enough talk and no action. Now is the time for action.

For Trump, a failure Tuesday could expose the limits of his ability to implement his agenda, even with a GOP-controlled Congress.

But neither admonitions from the White House nor pressure from outside conservative groups seemed strong enough to sway some key centrist Republican senators, who continued to express concerns about how the GOP plan might affect low-income residents in their states, particularly those receiving Medicaid.

The nonpartisan Congressional Budget Office estimated that at least 22 million more Americans would not have coverage under the Republicans repeal and replace plan, and as many as 32 million would join the ranks of the uninsured if Republicans simply repealed the Affordable Care Act.

Among the holdouts is Sen. Shelley Moore Capito of West Virginia, a state with a greater share of its population covered by Medicaid than any other. Trump traveled there Monday evening for a rally at the National Jamboree of the Boy Scouts of America.

Many West Virginians have benefited from our states decision to expand Medicaid, Capito wrote in her weekly newsletter ahead of the visit. I am committed to repealing Obamacare and replacing it with a healthcare system that provides access to affordable care to West Virginians... After meeting with President Trump this week, he assured me we are on the same page.

During his remarks in West Virginia, Trump told his Health and Human Services Secretary Tom Price, "You'd better get Sen. Capito to vote for it."

Otherwise, Trump joked, if Price doesnt produce the needed Senate votes, Youre fired!

Ahead of Tuesdays vote, at least one Republican, Sen. Susan Collins of Maine, remained opposed to opening debate on the bill.

McConnell can afford to lose no more than two Republicans from his 52-seat majority. If needed, Vice President Mike Pence could be called on to cast a tie-breaking vote.

With McCains unexpected return, GOP leaders are hoping they will be able to garner at least 50 votes. Though the Arizona senator has not indicated how he would vote, it seemed unlikely that he would make the trip to vote no. He also expressed a desire to vote on other pressing issues, such as a defense authorization bill and Russia sanctions legislation.

Some Republican senators who initially said they would oppose opening debate on the bill, including Sen. Rand Paul of Kentucky, have since indicated they may be willing to start debate.

Paul and other conservatives support repealing Obamacare but oppose the latest version of the replacement plan, saying it did not go far enough in dismantling the current law.

Among the centrists, the votes of Capito and Sen. Lisa Murkowski (R-Alaska) remained the most closely watched.

Also not saying how he would vote was Sen. Mike Lee of Utah, who had joined Paul in opposing the replacement plan.

McConnell nudged senators forward, promising a free-wheeling floor debate that would allow both GOP centrists and conservatives an opportunity to offer amendments to shape the final product.

We ought to have the debate, McConnell said Monday.

The only way well have an opportunity to consider ideas is if senators are allowed to offer and debate them, McConnell said. That means voting to kick off a robust debate.

Senators, though, remained skeptical that their amendments would be included in the final product. Many, including McCain, have called for a return to a traditional legislative process of holding public hearings and debating the bill in committee before pushing it to the floor.

Its highly unusual for senators to vote to proceed on such an important piece of legislation without knowing the preferred plan of GOP leadership.

Technically, the vote Tuesday will be to proceed to the House-passed Obamacare overhaul, the American Health Care Act, which has almost no support in the Senate.

After crossing that initial hurdle, GOP leaders will substitute the House version with the Senate-preferred alternative. But as late as Monday evening, it was unclear which version GOP leadership preferred: a simple repeal or repeal and replace.

Even if McConnell succeeds Tuesday in bringing enough senators to support beginning debate on a bill, final passage remains a challenge.

McConnell appears to be calculating that its better to hold Tuesdays vote and risk an embarrassing defeat in the hopes it will pressure senators to find consensus.

The leader has promised to keep senators in session through the first two weeks of August, cutting into their summer recess, to pass a final bill, meaning Tuesdays vote may not be their last.

Obamacare vs. Trumpcare: A side-by-side comparison of the Affordable Care Act and the GOPs replacement plan

Obamacare 101: A primer on key issues in the debate over repealing and replacing the Affordable Care Act.

"The Tick" cast talks about the humor behind the series and the fan pressure that comes with a cult classic.

"The Tick" cast talks about the humor behind the series and the fan pressure that comes with a cult classic.

Melissa Benoist, David Harewood, Mehcad Brooks, Jeremy Jordan, Chris Wood, Katie McGrath, Odette Annable, plus two EPs:Jessica Queller, Robert Rovner talk "Supergirl" at Comic-Con 2017.

Melissa Benoist, David Harewood, Mehcad Brooks, Jeremy Jordan, Chris Wood, Katie McGrath, Odette Annable, plus two EPs:Jessica Queller, Robert Rovner talk "Supergirl" at Comic-Con 2017.

Lisa.Mascaro@latimes.com

@LisaMascaro

noam.levey@latimes.com

@noamlevey

UPDATES:

6:45 p.m.: This story was updated after Sen. John McCain announced he would return to Washington for the vote.

This story was originally published at 3:40 p.m.

Read the original:

Senate healthcare vote presents critical test for GOP and Trump - Los Angeles Times

Superintendents are concerned cuts to Medicaid will threaten crucial medical services.

Edwin RiosJul. 24, 2017 3:15 PM

FatCamera/GettyImages

On the eastern end of Michigans Upper Peninsula, Rachel Fuerers school district depends on more than $870,000 in Medicaid funds each year. About 5 percent ofits overall annualbudget, the money goestowardprovidingmedical services for more than 1,000 special education students in 19 public schools across 4,000 square miles.

Those dollars, though, will be at risk if Republicans in Washington get their way.

Lastweek, Senate Republicans effortsto repeal and replaceand then just repealObamacare appeared to be dead. But now, at President Trumps urging,senators are again poisedfor avote on some sort of health care overhaul thisweek, though it remains to be seenwhether theyll vote ona partial repeal of the Affordable Care Act (ACA)or a full repeal and replace effort.

What is clear is thatpassing either bill would greatly endanger the future of Medicaid.Therepeal and replace bill, the Better Care Reconciliation Act (BCRA), imposes a cap on Medicaid spending that would sharplyreduce funds in future years. The alternative, a bill introduced by Senate Majority Leader Mitch McConnell (R-Ky.) lastweek that mirrors a 2015 effort to mostly repeal Obamacare, would shrink Medicaid spending over the next decade, especially for people who were newly eligible to receive Medicaid through the ACA.

Though McConnell currently lacks the votes to ensure either bills passage, school officials and advocates are keeping their eyes trainedon theSenate.

Were being told that special education is being spared,says Fuerer,who works as special education director at MichigansEastern Upper Peninsula Intermediate School District, but thats not true at all if there are cuts to Medicaid.

Fuerer joined hundreds of school superintendents from across the country in recentweeks indescending uponWashington to lobbyCongress, meeting with their states representatives to convince them to leave Medicaid alone.Theyre lumping everything together in this repeal and replace, Fuerer says. In doing so, they are trying to fix something thats not broken. Medicaid isnt broken.

ToFuerers surprise, even just the fewHouse members she met with the otherweek didnt fully understand the extent of just how much schools rely on Medicaid dollars.While the programis primarily used to fund health insurance for low-income families,italso doles out billions of dollars each year directly to school districts to fund special education services that are mandated by federal law and to supportservices for poor students.Nowschool superintendents, from both red and blue states, are expressingconcern that the GOPs health care plans would forcedistricts to struggle to provide crucialservices for their most vulnerablestudents.

Intalking about the bill as a repeal of Obamacare, Republican rhetoric can be misleading. BCRAwould fundamentally remake Medicaid, a program that has operated since 1965,slicingspending by$772 billion over the next decade andleaving 15 million morepeople uninsured.It does this by turning Medicaid from an open-ended promise from the government to fund state needsinto a block grant or per capita programstarting in2020 that will limit the amount of money each state receives.

Currently,John Hill, executive director of the National Alliance for Medicaid in Education, estimates thatalmost half the children in this country are on Medicaid. So any cut is going to have an adverse effect on kids, no matter how much theyll assure us its not going to happen,Hill tellsMother Jones.

As mandated by the Individuals with Disabilities EducationAct (IDEA) from 1975, schools must provide a free and appropriate public education to students with disabilities. But Congress has historically fallen short on covering the cost of educating special-needs students under IDEA, so states and local agencies have turned toMedicaid tohelp offset the difference and paythe cost for medical services and equipment. Starting in 1988, schools, like hospitals and insurance providers, have been able to request reimbursements from the Department of Health and Human Services for such expenditures.

In 2015, schools received nearly $4 billion in Medicaid funding, according to the Center on Budget and Policy Priorities, less than a third of whats doled out for special education spending under IDEA.

That $4 billion has been essential to schools covering the costs of speech and physical therapy, behavioral services, and medical equipment, such as wheelchairs and walkers. For low-income students, districts use such funds to pay for vision, hearing, and other healthscreenings, as well asforschool nurses and mental health services. Its also important to note thatschool districts dont just offer services to poor and disabled students during school hours; they act as a connecting point to enrolleligible low-income families in Medicaid and in the Childrens Health Insurance Program and help families find health care providers. In turn, schools get reimbursed for their outreach efforts.

Sherri Smith, thesuperintendent of Lower Dauphin, a suburban Pennsylvaniaschool district of just 4,000 students, was also in D.C. recentlyto meet with representatives. She says the small but targeted $50,000 in Medicaid funding her district receives each yearhelps pay for more medical-related services, such as occupational and physical therapy, along with mental health services to serve a growing need for students in the district. The money also allows the district to pay for additional nurses and personal care aides for students with disabilities and low-income students.

Schools are doing more outside the peripheral of just teaching and educating, Smith says. So actually getting Medicaid dollars for medical services for our students, which they need, allows us the opportunity to do so. Im afraid that without those kinds of dollars, that will go away.

In the broader Medicaid landscape, funding for school districts is just onetiny line item. The National Alliance for Medicaid in Education projects that school districts receive less than 1 percent of all Medicaid reimbursements.

Whileneither the House nor Senate repeal-and-replacebill specifically targets funding for schooldistricts, with lessmoneycoming from Washington, states would be forced to make cuts elsewhere in their budgets, which could impactthe entire community. Districts might be pushedto raise taxes, reduce spending on general education programs, or cutstaff.

If schools opted to diminish services for special education students, they could be at risk of falling out of compliance withfederal law, opening districts up to lawsuits and a potential furtherloss of federal dollars. This is all the more complicated due toa recent Supreme Court ruling that raisesthe standard for what schools mustoffer and expands students rights.

We would have to be stringent on services if Medicaidfunding went away, Smith, of Pennsylvania, says. Depending on what types of services, if that child needs it, and its mandated in their individualized education plan under IDEA, then we would have to provide those services. Wed have to find our money, which means we would have to go back to our taxpayers in Pennsylvania, or we would have to look to cut from our regular programs to make up the difference.

Similarly, for Fuerer in Michigan, the cuts to Medicaid funding in the proposedhealth care billswould mean that her district might need to slashitsoverall budget just so the same level of services can be provided. The reality is, [the loss of Medicaid funding is]probably not cutting a speech provider. Its probably cutting a gen ed teacher, she says. If you weaken the general education services, you are weakening the entire school community.

Sasha Pudelski, assistant director of policy and advocacy for the School Superintendents Association, says that changes to Medicaid could put schools in competition with hospitals and insurance providers for Medicaid dollars. Schools cant compete with other frontline healthcare providers for those dollars, Pudelski says. From our perspective, it could end Medicaid as we know it in schools.

Fuerer attended three meetings with Michigan representatives when she was in Washington this month, at least one of which really surprised her.When she sat downwith freshmanRepublicanRep. Jack Bergman,she says,he had never heard about the Medicaid billing in schools and he listened very intently. He didnt commit to changing his position, she says. He voted for the House bill. But he was interested and asked us for more information. It was better than the other ones.

Fuerer also met with an aide toRepublican Rep. Justin Amash, whovotedyes onthe House bill that includedcuts to Medicaid spending similar to those in the Senate proposals. In themeeting, Fuerer recallsthe staffer saying that Amash believed that responsibility for funding education and healthcare should be left to states. Fuerer says she finds that response a little frustrating.

Chris Kjolhede, co-director of the school-based health program at Bassett Healthcare Network, which runs in-school health clinics across 15 school districts in rural upstate New York,says that though its still tooearly to know the extent of damage on schools in the GOPs legislation, it is terrifying to think about major cuts to Medicaid. He says roughly half of children who work with his program receive care as a result of Medicaidfunding andNew Yorks Child Health Plus program.

Kjolhedes program relies on the federalfunds to provide dental, physical, and mental health services for more than 7,500 kids. He adds that Bassett has advocatedwith elected officials to let them know that the group was concerned about the loss of Medicaid reimbursements in his red district. If the funding goes away, theoretically, I have to figure out how to pay for the services or the services go away, Kjolhede tells Mother Jones. Theres a lot of pressure on those of us trying to make it happen.

Edwin Rios is a reporter at Mother Jones. Reach him at erios@motherjones.com.

Mother Jones is a nonprofit, and stories like this are made possible by readers like you. Donate or subscribe to help fund independent journalism.

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Students With Disabilities Are the Overlooked Victims of GOP Health Care Repeal - Mother Jones

President Donald Trump is scheduled to visit Ohio on Tuesday as the U.S. Senate will vote on whether to open debate on legislation to repeal and replace former President Barack Obama's health care law.

Ohioans have mixed feelings about Republicans' efforts.

Some who rely on government assistance say they're having trouble sleeping at night because they're worried about their medical expenses. Others are hopeful the Republican plan will make things more affordable for them.

Trump, who is scheduled to hold a rally in Youngstown Tuesday night, has been urging Republicans to support an effort to repeal and replace Obama's statute.

Republican Ohio Sen. Rob Portman could be a key swing vote on the GOP legislation and is facing immense pressure from both sides.

On Saturday, Vice President Mike Pence attended the Ohio Republican Party's annual fundraising dinner in Columbus and urged GOP senators to get rid of Obama's health care policies. Then on Monday, Republican Gov. John Kasich, said the Senate should not try to "force a one-sided deal that the American people are clearly against."

Here's a look at some residents' concerns.

FIGHTING FROM A WHEELCHAIR

Darrell Price, 50, was born with cerebral palsy and had his left hip replaced in 2009. He lives in subsidized housing in Cleveland, gets around with a power wheelchair and relies on a Medicaid-funded assistant to wash him, dress him and cook his meals, six hours a day, six days a week.

"If those Medicaid cuts go through, I'm scared to death," said Price, who voted for Hillary Clinton in November. "If I don't have enough funding to go into a nursing home, what happens then? Do I go on the street?"

Price has been jumping on activist conference calls, emailing Portman's office every week and drove two hours to Columbus on Saturday to protest when Pence came to visit.

"Every week, they're saying 'oh, we're going to have a vote in a week,' and then it fails," Price said. "There's no certainty at all. I'll go down fighting if that's what I have to do."

STUCK IN YOUNGSTOWN, HOPEFUL FOR TRUMP

Judy Martin, 72, of McDonald, Ohio, "tosses and turns" in bed at night, wracked with leg pain and worried about her medical bills.

Martin, a factory worker for 51 years, said she burned through her $20,000 in life savings on medical expenses a year after her retirement. She now relies on a monthly $1,500 social security check and Medicare subsidies, but still has to pay roughly $400 a month for medication and supplemental insurance.

"It feels like we're getting punished as we're getting older," Martin said. "I earned my time out there. Here we are, stuck."

Martin, who voted for Trump, "has faith" that Trump will make things more affordable for her, and is excited to hear what Trump has to say about health care when he comes to Youngstown, a 15 minute drive from her home. Though she won't be there in person, she plans to watch his speech online and hear about it from her son who plans to attend.

"I believe that Trump can do it, and that he will take care of the little people," Martin said.

CONSIDERING MOVING OUT OF STATE

Jeni and Kevin Potter's 13-year-old daughter, Erin, has battled leukemia three times and received bone marrow transplants twice. Over the years, their medical bills ran into the millions, mostly paid for by company insurance after the Affordable Care Act removed lifetime caps on insurance payouts.

So when the Potters heard that Congress was trying to repeal the Affordable Care Act, they looked at each other and thought, "What are we going to do?"

"You've got to think out of the box," said Jeni Potter, who voted for Clinton. "Where can we go to get her health care?"

The Potters, who live east of Cleveland, jumped online and scouted houses in Canada. Jeni Potter emailed every single representative in the Massachusetts House, seeing if they would be covered by that state's near-universal health system.

They've relaxed a little in the past month as Republican plans have stalled, but worries still loom large in the back of their minds.

"What does this mean for her?" Jeni Potter asked. "I have no idea. That unknown is terrifying."

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Trump to rally in Ohio as residents worry about health care - ABC News

Bart Stupak didnt seek out the role he played in the fight over ObamaCare more than seven years ago, but he has no regrets over how it all played out.

Stupak, a Democrat who opposes abortion and represented Michigans 1st Congressional District for 18 years, became a thorn in his partys side over demands in the debate on the Affordable Care Act (ACA) against funding for abortion. Now, hes telling his side of the drama during former President Obamas first term that resulted in the passage of the massive healthcare overhaul, just as Republicans struggle in their multi-year push to repeal it.

Stupak eventually voted to pass the final legislation, after securing a promise from Obama that reinforced the governments commitment to the Hyde Amendment.

The book is not about me. The important part is the small group of folks who pushed healthcare over the finish line, Stupak said in a recent interview in his Washington office at law firm Venable, where he now works.

Stupak sees his role in the ObamaCare debate as successful, though it didnt come without sacrifices. Threats were made on his life, and he continues to describe the experience as his personal healthcare hell.

Now, Stupak has a unique perspective watching Republicans wage their own war to dismantle Obamas signature healthcare law.

A months-long push by lawmakers to repeal and replace ObamaCare was left in shambles last week when several Senate Republicans came out against the legislation. The defeat was compounded less than 24 hours later, when certain GOP senators also refused to back a repeal-only plan.

The developments have left Republicans frustrated and with no clear path forward, though Senate Majority Leader Mitch McConnellMitch McConnellMcConnell to pin down colleagues on healthcare Looking back on healthcare hell McCain returning to Senate in time for health vote MORE (R-Ky.) has pledged to hold a vote this week.

The problem, Stupak says, is that lawmakers are focused on politics over policy.

If they want to repeal the Affordable Care Act, every Congress has that right. All I ask is you do it based on policy reasons and not based on political reasons, Stupak said. The policy decisions are no longer debated. Its all politics.

President Trump campaigned on repealing and replacing ObamaCare and has shown growing frustration with GOP lawmakers failure to get the job done. Following the efforts collapse last week, Trump hosted Republican senators at the White House, scolding them over the stalled push and demanding they revive it.

Stupak sees the healthcare fight as indicative of the growing partisanship in Washington, which festered when he was in Congress.

His book lays out a dramatic 2009 scene in which a staffer on the House Energy and Commerce Committee ripped into him privately for voting in favor of a Republican amendment aimed at boosting disclosure of medical costs offered to eventually unsuccessful healthcare legislation.

What are you doing voting with the Republicans? the staffer said, according to Stupaks account.

Stupak says that the divide has gotten worse since, blaming it partially on the increase of money in politics.

Its hard to get to know some of the Republicans. Ive tried, he said. And even some of the Democrats.

The White House, he says, is also a big part of the problem.

Weve got political slogans, but we dont have any policy. Thats my objection with President Trump. I think he means well; he just doesnt know anything, Stupak said.

Stupak announced that he would not seek reelection in 2010, the same year the ACA was passed, a decision he says he made the night Obama was elected in 2008. Stupak, who had contemplated retiring multiple times before, says Obamas win gave him confidence that the Democrats would be able to pass comprehensive healthcare reform, allowing him to retire having fulfilled a major campaign promise he made when he first ran in the early 1990s.

The former police officer maintains he was never going to be a lifer in Congress. I told my wife, Im done. No more. She didnt believe me, but I kept that promise, he said. As things unfolded over those two years, it just reinforced my decisionmaking.

Since he stepped away, he has had more time to devote to law and his family, spending fewer hours on the road trying to span his 600-mile-wide district in Michigan.

Still, Stupak keeps in touch with his old colleagues when he is in Washington. He has served as a fellow at the Harvard Institute of Politics and hopes to keep writing books.

My life is just less complicated, he said.

Stupak has also continued to insert himself into the nexus of healthcare and law, filing Supreme Court briefs supporting Hobby Lobby and Little Sisters of the Poor in objection to the governments application of ObamaCares contraception mandate.

In the six years following his exit, Washington has undergone a tremendous shift the administration of a new, unexpected Republican president has taken over, and the GOP has claimed control of both chambers of Congress.

When asked for his opinion of Trump, Stupak made the unusual move of drawing a parallel between the president and his predecessor, whom he was reluctant to support for president because of his dearth of experience.

I always thought it was good to shake up Washington, but I also believe that experience comes in government. He has no experience, and it shows, Stupak said of Trump.

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Looking back on 'healthcare hell' - The Hill

Dont tell anyone, but American conservatives will soon be embracing single-payer healthcare, or some other form of socialized healthcare.

Yes, thats a bold claim given that a GOP-controlled Congress and Presidentare poised to un-socialize a great deal of healthcare, and may even pull it off. But within five years, plenty of Republicans will be loudly supporting or quietly assenting to universal Medicare.

And thats a good thing, because socializing healthcare is the only demonstrably effective way to control costs and cover everyone. It results in a healthier country and it saves a ton of money.

That may seem offensively counterintuitive. Its generally assumed that universal healthcare will by definition cost more.

In fact, in every first-world nation that has socialized medicinewhether it be a heavily regulated multi-insurer system like Germany, single-payer like Canada, or a purely socialized system like the United Kingdom-it costs less. A lot, lot less, in fact: While healthcare eats up nearly 18 percent of U.S. GDP, for other nations, from Australia and Canada to Germany and Japan, the figure hovers around 11 percent. (Its no wonder that smarter capitalists like Charlie Munger of Berkshire Hathaway are bemoaning the drag on U.S. firm competitiveness from high healthcare costs.) Nor are healthcare results in America anything to brag about: lower life expectancy, higher infant mortality and poor scores on a wide range of important public health indicators.

Why does socialized healthcare cost less? Getting rid of private insurers, which suck up a lot money without adding any value, would result in a huge savings, as much as 15percent by one academic estimate published in the American Journal of Public Health. When the government flexing its monopsony muscle as the overwhelmingly largest buyer of medical services, drugs and technology, it would also lower prices-thats what happens in nearly every other country.

So while its a commonly progressive meme to contrast the national expenditure of one F-35 with our inability to afford single-payer healthcareand I hesitate to say this lest word get out to our neocon friendsthere is no need for a tradeoff. If we switched to single payer or another form of socialized medicine, we would actuallyhave more money to spend on even more useless military hardware.

The barrier to universal healthcare is not economic but political. Is profligate spending on health care really a conservative value? And what kind of market incentives are working anywayits an odd kind of market transaction in which the buyer is stopped from negotiating the price, but that is exactly what Medicare Part D statutorily requires: The government is not allowed to haggle the prices of prescription drugs with major pharmaceutical companies, unlike in nearly every other rich country. (Both Hillary Clinton and Donald Trump pledged to end this masochism, but the 45th president has so far done nothing, and U.S. prescription drug prices remain the highest in the world.) Does anyone seriously think medical savings accounts with their obnoxious complexity and added paperwork are the right answer, and not some neoliberal joke?

The objections to socialized healthcare crumble upon impact with the reality. One beloved piece of folklore is that once people are given free healthcare theyll abuse it by going on weird medical joyrides, just because they can, or simply let themselves go because theyll have free doctor visits. I hate to ruin this gloating fantasy of lumpenproletariat irresponsibility,but people need take an honest look at the various health crises in the United States compared to other OECD(Organisation for Economic Cooperation and Development) countries. If readily available healthcare turns people hedonistic yahoos, why does Germany have less lethal drug overdoses than the U.S. Why does Canada have less obesity and type II diabetes? Why does the Netherlands have less teen pregnancy and less HIV? The evidence is appallingly clear: Among first-world countries, the U.S. is a public health disaster zone. We have reached the point where the rationalist santera of economistic incentives in our healthcare policies have nothing to do with people as they actually are.

If socialized medicine couldbe in conformity with conservative principles, what about Republican principles? This may seem a nonstarter given the pious market Calvinism of Paul Ryan and Congressmen like Reps. Scott Perry (R-Pa.) and Mo Brooks (R-Ala.), who seem opposed to the very idea of health insurance of any kind at all. But their fanaticism is surprisingly unpopular in the U.S. According to recent polling, less than 25 percent of Americans approve of the recent GOP healthcare bills. Other polls show even lower numbers. These Republicans arealso profoundly out of step with conservative parties in the rest of the world.

Strange as it may seem to American Right, $600 EpiPens are not the sought-after goal of conservatives in other countries. In Canada, the single-payer healthcare system is such a part of national identity that even hard-right insurgents like Stockwell Day have enthusiastically pledged to maintain it. None of these systems are perfect, and all are subject to constant adjustment, but they do offer a better set of problemsthe most any mature nation can ask forthan what we have in the U.S.

Andvirtually no one looks at our expensive American mess as a model.

I recently spoke with one German policy intellectual, Nico Lange, who runs the New York outpost of the German Christian Democrats main think tank, the Konrad Adenauer Stiftung, to get his thoughts on both American and German healthcare. Is socialized medicine the entering wedge of fascism and/or Stalinism? Are Germans less free than Americans because they all have healthcare (through a heavily regulated multi-payer system), and pay a hell of a lot less (11.3 percent of GDP) for it?

Mr. Lange paused, and took an audible breath; I felt like I had put him in the awkward spot of inviting him over and asking for his honest opinion of the drapes and upholstery. Yes, he said, we are less free but security versus freedom is a classic balance! National healthcare makes for a more stable society, its a basic service that needs to be provided to secure an equal chance for living standards all over the country. Even as Mr. Lange delineated the conservative pedigree of socialized medicine in GermanyYou can certainly argue that Bismarck was a conservative in founding this systemI had a hard time imagining many Democrats, let alone any Republican, making such arguments.

Indeed, the official GOP stance is perhaps best described as Shkrelism than conservatism, after the weasel-faced pharma entrepreneur Martin Shkreli, who infamously jacked up the price of one lifesaving drug and is now being prosecuted for fraud. (Though in fairness, this type of bloodsucking awfulness is quite bipartisan: Heather Bresch, CEO of Mylan corporation, which jacked up the price of EpiPens from $100 to $600, is the daughter of Senator Joe Manchin (D-WV), who defended his daughters choice.)

But GOP healthcare politics are at the moment spectacularly incoherent. Many GOP voters have told opinion polls that they hate Obamacare, but like the Affordable Care Act. And as the GOP healthcare bill continues to be massively unpopular, Donald Trump has lavished praise on Australias healthcare system (socialized, and eating up only 9.4 percent of the GDP there). Even in the GOP, this is where the votes are: Trumps move to the center on questions of social insuranceMedicare, Medicaid, Social Securitywas a big part of his appeal in the primaries. The rising alt-Right, not to hold them up as any moral authority, dont seem to have any problem with universal Medicare either.

It will fall on reform conservatives to convince themselves and others that single-payer or some kind of universal care is perfectly keeping with conservative principles, and, for the reasons outlined above, its really not much of a stretch. Lest this sound outlandish, consider how fully liberals have convinced themselves that the Affordable Care Acta plan hatched at the Heritage Foundation for heavens sake, and first implemented by a Republican governoris the every essence of liberal progressivism.

Trumps candidly favorable view of Australian-style socialized healthcare is less likely a blip than the future of the GOP. Republican governors who actually have to govern, like Brian Sandoval and John Kasich, and media personalities like Joe Scarborough, and the Rock, will be soon talking up single-payer out of both fiscal probity, communitarian decency, and the in-your-face evidence that, ideology aside, this is what works. Even the Harvard Business Review is now giving single-payer favorable coverage. Sean Hannity and his angry brigade may be foaming at the mouth this week about the GOP failure to disembowel Obamacare, but Seans a sufficiently prehensile fellow to grasp at single-payer if it seems opportunejust look at his about-face on WikiLeaks. And though that opportunity has not arisen yet, check again in two years.

The real obstacle may be the Democrats. As Max Fine, last surviving member of John F. Kennedys Medicare task force, recently toldthe Intercept, Single payer is the only real answer and some day I believe the Republicans will leap ahead of the Democrats and lead in its enactment, he speculated, just as did Bismarck in Germany and David Lloyd George and Churchill in the UK. For now, an invigorating civil war is raging within the Democrats with the National Nurses Union, the savvy practitioner-wonks of the Physicians for a National Health Program, and thousands of everyday Americans shouting at their congressional reps at town hall meetings are clamoring for single-payer against the partys donor base of horrified Big Pharma executives and affluent doctors. In a few years there might even be a left-right pincers movement against the neolib/neocon middle, whose unlovable professional-class technocrats are the main source of resistance to single payer.

I dont want to oversell the friction-free smoothness of the GOPs conversion to socialized healthcare. Our funny country will always have a cohort of InfoWars ooga-boogas, embittered anesthesiologists and Hayekian fundies for whom universal healthcare is a totalitarian jackboot. (But, and not to be a jerk, its worth remembering that Hayek himself supported the socialized healthcare of Western Europe in one of his most reasonable passages from the Road to Serfdom.)

So even if there is some banshee GOP resistance at first, universal Medicare will swiftly become about as controversial as our government-run fire departments. Such, after all, was the trajectory of Medicare half a century ago. You read it here first, people: Within five years, the American Right will happily embrace socialized medicine.

Chase Madar is an attorney in New York and the author of The Passion of Bradley Manning: The Story Behind the Wikileaks Whistleblower.

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The Conservative Case for Universal Healthcare - The American Conservative

It's coming down to the wire for the Republican health-care bill, with President Donald Trump's push for action on Monday almost sounding like a "Hail Mary," analyst Ipsita Smolinski told CNBC.

Trump on Monday stepped up pressure on Senate Republicans to come up with a plan to overhaul the U.S. health-care system, saying they have "not done their job in ending the Obamacare nightmare."

"If this doesn't get done before the August recess, then really the calendar is running out," said Smolinski, managing director and health-care analyst at Capitol Street.

"The budget resolution ends Oct. 1, so you could come back in September and get this done but the clock is really ticking," she said in an interview with "Closing Bell" on Monday.

Senate Republican leaders are pushing for a vote Tuesday on a motion to proceed with a health-care bill, which would allow it to go up for debate and possible amendments. However, they have not made clear which plan they want to move forward on once they proceed with the proposal.

The Senate GOP's bill to repeal and replace Obamacare stalled out after not garnering enough support for passage. And its plan to simply repeal Obamacare and replace it during a two-year transition period also lacks support.

Smolinski said it looks like changes will have to be made for a plan to gain traction.

"A deal would have to come through in the coming days, whether it's additional Medicaid dollars or something that would get some of those moderate senators who have expanded Medicaid to sign on."

CNBC's Jacob Pramuk contributed to this report.

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The 'clock is ticking' on Republican health-care legislation: Analyst - CNBC

The Senate returns to Washington on Monday with its GOP leaders determined to vote this week on their years-long quest to demolish the Affordable Care Act, even though the goal remains mired in political and substantive uncertainties.

Central questions include whether enough Senate Republicans will converge on any version of their leaders health-care plan and whether significant aspects of the legislation being considered can fit within arcane parliamentary rules.

Sen. John Barrasso (R-Wyo.) indicated on Sunday that the majority party may not have enough support to prevail on even a first step a routine vote to begin the floor debate.

Were continuing to work with all of the members. Were getting much closer to that, Barrasso, one of the chambers few physicians, said on CBSs Face the Nation.

Meanwhile, the two Republicans who have been the efforts most outspoken foes in the Senate relaunched complaints that their leaders are leaving them clueless as to what exactly will be put forward.

Late last week, Majority Leader Mitch McConnell (R-Ky.) adopted a strategy uncharacteristic for a tactician who usually spares his caucus needless difficult votes.

Several days earlier, McConnell had lacked enough support to call for a vote on a bill that would rescind parts of the ACA and replace them with a variety of conservative health policies. He quickly switched, saying the chamber would vote anew on a repeal-only measure passed in late 2015 by both the Senate and House and vetoed by then-President Barack Obama. Less than 24 hours later, that idea faltered, too.

So McConnell has resorted to a plan C: bringing to the floor an anti-ACA bill passed by the House this spring and allowing senators a sort of free-for-all for substituting in either of the Senate measures or new iterations.

We are still on track ... to have a vote early this week, a McConnell spokesman said on Sunday. The Senate will consider all types of proposals, Republican and Democrat.

But Sen. Susan Collins (R-Maine), a centrist who says the Senates Better Care Reconciliation Act would cut Medicaid in ways that would hurt rural and vulnerable Americans, derided that strategy during an appearance on Face the Nation.

Lawmakers dont know whether were going to be voting on the House bill, the first version of the Senate bill, the second version of the Senate bill, a new version of the Senate bill or a 2015 bill that would have repealed the Affordable Care Act now and then said that somehow well figure out a replacement over the next two years, Collins said.

I dont think thats a good approach to facing legislation that affects millions of people and one-sixth of our economy, she added.

Her sentiment was echoed by conservative Sen. Rand Paul (R-Ky.), who contends that the main GOP proposal the Senate has been considering does not go far enough to undermine the ACA. The real question is, what are we moving to? What are we opening debate to? Paul said on CNNs State of the Union. He reiterated that he only would support a bill that would remove large portions of the ACA and not legislation continuing federal subsidies that help millions of people afford their insurance premiums.

Such ideological crosscurrents within his own party are what McConnell has been trying to surmount. The GOP has a narrow majority of 52 senators, and Democrats are unified against the effort to dismantle Obamacare. Given this partisan terrain, Senate leaders are relying on a legislative process known as reconciliation, which allows a bill to be passed with a simple majority when it has budget implications, rather than the customary 60 votes needed to ward off a potential filibuster by opponents.

But the reconciliation strategy hit a roadblock late Friday as Senate Democrats released a set of guidance from the chambers parliamentarian, who concluded that aspects of a June26 version of the Better Care Reconciliation Act probably would not fit within the budget rules. The guidance says several parts of the proposal would require a full 60 votes for approval, including limits on funding for Planned Parenthood and health plans that provide coverage for abortion both restrictions conservatives have favored.

The parliamentarian also cautioned against a significant part of the GOP bill meant to encourage Americans to maintain health coverage: allowing health plans to freeze out for six months applicants who have allowed their coverage to lapse.

McConnells spokesman, Don Stewart, noted that the parliamentarian similarly cautioned against portions of the 2015 ACA repeal bill, but it still passed through the reconciliation process. Neither Stewart nor other Senate staffers said what changes could be contemplated to get around the parliamentary problem.

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Senate Republicans plan to plow ahead with health-care vote this week - Washington Post

If we learned anything from the bitter debate over the Affordable Care Act (Obamacare) which seems doubtful it is that we cannot discuss health care in a way that is at once compassionate and rational. This is a significant failure, because providing and financing health care have become, over the past half-century, the principal activity of the federal government.

If you go back to 1962, the earliest year with such data, federal health spending totaled $2.3 billion, which was 2.1 percent of the $107 billion budget. In 2016, the comparable figures were $1.2 trillion in health spending, which was 31 percent of the $3.85 trillion budget. To put this in perspective, federal health spending last year was twice defense spending ($593billion) and exceeded Social Security outlays ($916 billion) by a comfortable margin.

The total will grow, because 76 million baby boomers are retiring, and as everyone knows, older people have much higher medical costs than younger people. In 2014, according to the Kaiser Family Foundation, people 65 and over had average annual health costs of $10,494, about three times the $3,287 of people 35 to 44. Medicare and Medicaid, nonexistent in 1962, will bear the brunt of higher spending.

At a gut level, we know why health care defies logical discussion. We personalize it. We assume that whats good for us as individuals is also good for society. Unfortunately, this is not always true. What we want as individuals (unlimited care) may not be good for the larger society (overspending on health care).

Our goals are mutually inconsistent. We think that everyone should be covered by insurance for needed care; health care is a right. Doctors and patients should make medical choices, not meddlesome insurance companies or government bureaucrats; they might deny coverage as unneeded or unproven. Finally, soaring health spending should not squeeze wages or divert spending from important government programs.

The trouble is that, in practice, we cant meet all these worthy goals. If everyone is covered for everything, spending will skyrocket. Controlling costs inevitably requires someone to say no. The inconsistencies are obvious and would exist even if we had a single-payer system.

The ACA debate should have been about reaching a better balance among these competing goals and explaining the contradictions to the public. It wasnt.

The ACAs backers focused on how many Americans would lose coverage under various Republican proposals more than 20 million, the Congressional Budget Office has estimated. The ACAs entire gain in coverage would be wiped out, and then some. From 2013 to 2015, the number of insured Americans rose by 13 million, estimates Kaiser. But the ACAs advocates dont say much about stopping high insurance costs from eroding wage gains or strangling other government programs.

Meanwhile, congressional Republicans and the Trump White House proposed huge cuts in health spending $1trillion over 10 years for the ACAs repeal alone while implausibly suggesting that hardly anyone would be hurt or inconvenienced. There was no coherent strategy to reconcile better care with lower costs. Democrats kept arguing that the health cuts were intended to pay for big tax cuts that would go mainly to the rich and upper middle class. Sounds right.

Still, theres no moral high ground. Some Democrats have wrongly accused Obamacare opponents of murder. This is over-the-top rhetoric that discourages honest debate. Its also inconsistent with research. Kaiser reviewed 108 studies of the ACAs impact and found that, though beneficiaries used more health care, the effects on health outcomes are unclear.

We are left with a system in which medical costs are highly concentrated with the sickest patients. (The top 5percent account for half of all medical spending.) This creates a massive resource transfer, through insurance and taxes, from the young and middle-aged to the elderly. (Half of all health spending goes to those 55 and over, who represent just over one-quarter of the population).

And yet, we govern this massive health-care sector representing roughly a third of federal spending and nearly a fifth of the entire economy only haphazardly, because it responds to a baffling mixture of moral, economic and political imperatives. It will certainly strike future historians as curious that we tied our national fate to spending that is backward-looking, caring for people in their declining years, instead of spending that prepares us for the future.

We need a better allocation of burdens: higher eligibility ages for Social Security and Medicare; lower subsidies for affluent recipients; tougher restrictions on spending. But this future is impossible without a shift in public opinion that legitimizes imposing limits on health spending.

We didnt get that with the eight-year Obamacare debate. The compassionate impulse overwhelmed the rational instinct. The result is that health care is controlling us more than we are controlling it.

Read more from Robert Samuelsons archive.

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How health care controls us - Washington Post

The Republican Party spent Wednesday desperately trying to save its healthcare plan after the GOP's Senate leadership was forced to admit that it doesn't have the votes to repeal and replace Obamacare. Video provided by TheStreet Newslook

Seema Verma, administrator of the Centers for Medicare and Medicaid Services(Photo: Jack Gruber, USA TODAY)

WASHINGTON Several Hoosiers in key positions in the Trump administration,led by Vice President Mike Pence, are negotiating the future of federal health policy despite the states mixed reputation on health care.

Indiana spendsless on public health funding than any otherexcept Nevada, a handicap when Indiana was home to the nations first HIV outbreak linked to the injection of oral painkillers in 2015.

In addition, the state for years has ranked among the least healthy. Hoosiers smoke more, are less active and die sooner than most Americans.

Before Pence became vice president, however, he was among the minority of Republican governors who expanded their states Medicaid program a move which gave hundreds of thousands of Hoosiers access to health care and helped the state respond to the HIV outbreak.

Pence has been a leader of the Trump administrations so far unsuccessful efforts to repeal the Affordable Care Act Obamacare, including phasing out its Medicaid expansion a program Pences successor is using to fight the opioid addiction epidemic.Another former Pence health policy aide now helps Health and Human Services Secretary Tom Price a good friend of Pences work with Congress on the agencys legislative agenda.

Long-time Pence aide Matt Lloyd, the top HHS spokesman, is the sherpa to help guide the Trump administrations surgeon general nominee through Congress.

President Donald Trumps pick? Indianas state health commissioner, Dr. Jerome Adams, who was appointed to his position by Pence.

Its certainly significant, Eliot Fishman, the CMS official during the Obama administration who worked with Indiana on granting approval for its alternative Medicaid program, said of the concentration of Hoosiers in health policy positions. But, for myself, I was hopeful that having people who had successfully negotiated, and then implemented, an innovative Medicaid expansion in Indiana would have led to more support for Medicaid expansion nationally. I have not seen evidence of that yet.

Tom Miller, a health policy expert at the right-leaning American Enterprise Institute, said its understandable that so many Pence people ended up in key health care positions.

It didnt light up President Trump as the thing he was most deeply invested in, and had a range of experience in, Miller said. Mike has some experience, knowledge and engagement in this area of policy more so than most other folks close the issue in the White House. So its not surprising that he is taking the lead on this.

Read more:

With John McCain out, McConnell still plans a Senate health care vote next week

CBO'S score of the GOP 'repeal-only' health care bill is harshest yet

Trump is playing health care games with lives. Where are the grown-ups?

Indiana is home to some significant players in the health care industry. Anthem, one of the largest insurance companies, is headquartered in Indianapolis, as is drug maker Eli Lilly and Co.

Warsaw, Ind., is known as the Orthopedic Capital of the World because of the concentration of medical device makers.

And health savings accounts, the tool Republicans have championed as a way to make consumers more invested in their health care decisions, were pioneered by an Indiana insurance entrepreneur as an alternative to traditional health insurance. (The alternative Medicaid program Verma helped Pence create for Indianas Medicaid expansion mimics aspects of health savings accounts.)

Yet, despite Indianas leadership in sectors of the health care industry, the state ranks near the bottom on many health measures.

On the most recent overall ranking by the United Health Foundation, Indiana comes in at 39th healthiest. That scale takes into account behaviors, environmental health, policies, clinical care and outcomes.

Not surprisingly, the category that stands out the most to Paul Halverson, dean of Indiana Universitys Richard M. Fairbanks School of Public Health, is public health funding. Indiana ranks 49th on spending per capita on preventive and education programs that improve health.

We just have not prioritized public health funding in Indiana in a number of years, Halverson said. Thats despite the fact, he said, that studies show properly funded public health systems can reduce medical care expenditures and increase life expectancy.

The HIV outbreak in Southern Indiana put a spotlight on the weaknesses in the states health infrastructure.

Still, Halverson gives a lot of credit to Adams the state health commissioner poised to become the nations top doctor for how he worked with Pence to respond to the outbreak. The response included allowing needle exchangesdespite Pences initial reservations.

Pences successor, Indiana Gov. Eric Holcomb, has made reducing the number of opioid deaths one of his top goals as governor.

But Holcombs strategy to fight the opioid epidemic relies heavily on Medicaid, the jointly funded state and federal program which Pence is pushing hard to curtail.

Pences support, as governor, for expanding Medicaid in Indiana was a departure from his congressional record. He had voted against adding a prescription drug benefit to Medicare and against expanding the health care program for lower-income children whose families make too much to qualify them for Medicaid.

Still, Pence never completely closed to the door to finding a way to acceptthe federal funding made available through the Affordable Care Act to expand Medicaid eligibility.

Clearly, Governor Pence had policy concerns about expanding Medicaid, said Brian Tabor, executive vice president at the Indiana Hospital Association, which pushed hard for the expansion. But he never said `no.

The alternative Medicaid program Pence and Verma got the Obama administration to sign off on was one of Pences top achievements as governor.

Despite being a conservative state, they generally speaking overcame their conservative credentials to support policies that expanded coverage for people, even though they did it with a conservative flavor to it, said Andy Slavitt, who headed the Centers for Medicare and Medicaid Services under former President Barack Obama.

Whether Pences program, which requires participants to make monthly contributions if they want more comprehensive coverage, works better than traditional Medicaid is still being evaluated.

But Verma knows how crucial the ACA funding was to making the expansion possible, said Fishman.

There was just no way from a budgetary perspective that Indiana could have expanded coverage at the regular (federal reimbursement rate), Fishman said.

Thats not something Pence and Verma talk about as theyve tried to sell lawmakers and governors on replacing Obamacare with legislation that would phase out the ACAs extra federal funding for Medicaid while also reducing the federal governments financial support for regular Medicaid.

Governors who heard their pitch at this months National Governors Association summer meeting were skeptical.

He was selling ice beverages in the wintertime, Miller, the think tank expert, said of Pence. (Governors) wanted to know how they were keeping the money they already had, and they were trying to tell them theyd be better off, even though it seemed like they were getting less. Thats hard to pull off.

Pence who has been traveling the country and holding roundtable discussions at the White House to highlight the Obamacare disaster as well as courting lawmakers by phone and in private dinners at his residence has been more active than Trump in trying to pass repeal-and-replace legislation. He played a key role in getting changes to the House bill so it could pass that chamber in May. But the Senates version is stalled.

If Senate Majority Leader Mitch McConnell, R-Ky., cant round up enough GOP votes next week to bring any health care bill to the floor, legislation may be shelved for the foreseeable future. That will shift the focus to the changes the administration is able to make through agency action.

Pence and Verma have told governors the Trump administration will be more permissive and act faster on state requests to try new approaches.

It took our state more than two years for the federal government to approve our waiver, Pence told governors at the summer meeting. And even then, they frankly, rejected an awful lot of what we were trying to do.

Fishman, who called the negotiations he conducted with Verma on Indianas request intense but ultimately successful, said that experience likely contributed to Vermas commitment to letting states test their own approaches. But he suspects the administration will push the limits on the federal rules theyre allowed to waive under the law.

Its likely that there will be litigation, he predicted.

Slavitt, who like Fishman has been a vocal opponent of the repeal and replace efforts, said it would be a mistake to take too much of an ideological approach to policy changes.

If people come to the job and do what they did in Indiana, which is focus pragmatically on how to expand coverage, he said, that would be a good thing.

Contact Maureen Groppe at mgroppe@gannett.com. Follow her on Twitter: @mgroppe.

Mike Pence: As vice president, Pence has a lead role in the Trump administrations effort to undo the Affordable Care Act. Obamacare. Pence has been more active than Trump both publicly and privately in trying to get repeal and replace legislation through Congress. As governor, Pence was among a minority of Republicans who took federal funding made available under the Affordable Care Act to expand Medicaid.

Seema Verma: The administrator of the Centers for Medicare and Medicaid Services, Verma has been helping the administration explain to lawmakers and governors the Medicaid changes proposed in legislation. Shes also encouraged states to seek permission from her office for local approaches to running Medicaid. A former Indiana-based health care consultant, Verma helped create Indianas alternative Medicaid program and worked with other states on unique approaches.

Brady Brookes: Brookes is Vermas deputy chief of staff. She was legislative director for Pence when he was governor.

Brian Neale: Neale is a deputy CMS administrator, overseeing Medicaid and the health care program for low-income children whose families make too much to qualify for Medicaid. When Neale was Pences health care policy director in the governors office, he and Verma negotiated permission from the Obama administration to expand Indianas alternative Medicaid program.

Tyler Ann McGuffee: A former health care policy director for Pence, McGuffee works on Health and Human Services Secretary Tom Prices legislative agenda and is a liaison between Congress and the agency.

Matt Lloyd: Spokesman for the Health and Human Services Department, Lloyd was Pences deputy chief of staff in the governors office and worked for him for years on Capitol Hill. In addition to his spokesmans job, Lloyd is helping shepherd Trumps surgeon general nominee through the Senate confirmation process.

Dr. Jerome Adams: Indianas state health commission has been tapped by Trump to be the next surgeon general. Adams was appointed to his state position by Pence.

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Many of key players on Trump health care reform team are Hoosiers - USA TODAY