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Former Obama Aides Lead Opposition to Health Care Repeal

Andrew M. Slavitt, the former head of the Centers for Medicare and Medicaid Services, has been trolling Republicans over health care on Twitter, posting hundreds of tweets each week that attack their proposals as meanspirited and wrong.

Kathleen Sebelius, Mr. Obama’s first secretary of health and human services, will soon embark on a monthlong bus tour designed to pressure members of Congress to oppose the health care law’s repeal.


Kathleen Sebelius, Mr. Obama’s first secretary of Health and Human Services, will soon embark on a monthlong bus tour designed to pressure members of Congress to oppose the repeal of the Affordable Care Act.

Gabriella Demczuk for The New York Times

And a few blocks from the Capitol, a political war room run by Leslie Dach, one of Mr. Obama’s top health care officials, is coordinating a nationwide anti-repeal campaign by liberal think tanks, local “resistance” groups, sympathetic governors, medical and insurance lobbyists, Democratic activists, polling experts and academics.

Conceived in the hours after Mr. Trump was elected in November, the group, called Protect Our Care, is at the heart of the effort to oppose a repeal. It hosts strategy calls at 8:30 and 9:45 every morning to develop talking points, plan TV ads and discuss the latest vote counts from the House and Senate.

“The most important thing is that people understand what repeal means for them,” Mr. Dach said. “And what repeal means is millions losing their insurance, costs going up, not down, and anxiety coming back in their lives.”

The Obama aides have helped direct about $6 million toward television ads by Save My Care, a separate group in Washington.

The aides insist they are just one part of a broader liberal network that has been organically animated by anger about the Republican efforts to repeal the health care law. But they bring years of experience to the political fight, and their efforts have not gone unnoticed.


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In late February, Mr. Trump accused his predecessor of being the hidden hand behind town hall meetings where angry citizens accused lawmakers of trying to take away their health care. “I think that President Obama is probably behind it, because his people are certainly behind it,” Mr. Trump told Fox News at the time.

In fact, the former president has made only a few public comments on the repeal effort, once using Facebook to denounce “the fundamental meanness at the core of this legislation.” His current advisers say Mr. Obama has had little direct involvement in managing the day-to-day campaign, though he is regularly briefed on the subject.


Andrew M. Slavitt, the former head of the Centers for Medicare and Medicaid Services, testified on Capitol Hill in 2013. Mr. Slavitt has used Twitter as a weapon against repeal efforts.

Evan Vucci/Associated Press

His former aides have taken a more active role.

Anita Dunn, Mr. Obama’s onetime communications director, is helping to spread the anti-repeal message, placing opinion articles in newspapers and distributing letters, including one from a group representing 7,000 Catholic nuns who oppose repealing the health law.

Meaghan R. Smith, who served as the communications director at the Department of Health and Human Services under Mr. Obama, and Lori Lodes, who was the spokeswoman at the Centers for Medicare and Medicaid Services, have become the de facto press secretaries for the effort, working to influence stories written by political and health care reporters.

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And Kristie Canegallo, who was Mr. Obama’s deputy chief of staff for policy implementation, is directing frequent strategy sessions with the opposition leadership. She has essentially reprised her White House role as the logistics person responsible for ensuring that a sprawling bureaucracy stayed on task as the health care law went into effect.

Ms. Canegallo’s conference calls have continued almost nonstop, even while she was on vacation in Australia, according to one participant.

“We’ve had a simple goal from the beginning, which is to stop the repeal of the Affordable Care Act, to protect Medicaid,” Mr. Dach said in an interview this week.

Part of that strategy involved a public effort to broadly portray the Republican repeal effort as a threat to people’s existing health care choices.

Mr. Slavitt’s tweets are revered among Obama alumni for their sharp edges. Last week, when the Congressional Budget Office released its latest estimate of the effects of the Republican bill, Mr. Slavitt did not mince words.


How Many People Across America Are at Risk of Losing Their Health Insurance?

A state-by-state look at who could lose insurance under the proposed Republican health care plans.

“NEW CBO is out a disaster,” he tweeted. “22 million people lose coverage insurance markets die.”


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Dan Pfeiffer, a former senior adviser to Mr. Obama; Tommy Vietor, one of his national security spokesmen; and Jon Favreau and Jon Lovett, his speechwriters; have used their popular podcast, “Pod Save America,” to regularly rail against the Republican repeal effort.

Among the episode titles: “Kill Bill Vol. 2.”

But the campaign against repeal is also more targeted, aimed directly at a handful of Republican senators who have expressed concern about the effects that scrapping the Affordable Care Act could have on their poorest constituents.

In an opinion article about the Republican repeal effort, former Vice President Joseph R. Biden Jr. warned that it would lead to “a massive cut in Medicaid” and have a “dramatic impact” on budgets. Aimed at Senator Dean Heller, a Nevada Republican, the article appeared in The Reno Gazette-Journal.

After Mr. Heller and Senator Shelley Moore Capito, Republican of West Virginia, voted on Tuesday to open debate on repealing the health law, Save My Care released television ads on Wednesday chiding both of them.

“Senator Capito just broke her promise by casting the deciding vote to repeal our health care,” the narrator says. “Because of Capito, over 100,000 West Virginians could lose their insurance.”

That vote marked a setback in the battle to save Mr. Obama’s legacy. But in the hours since, the opposition campaign has celebrated a bit. Votes on several variations of repeal legislation failed to pass the Republican-controlled Senate on Tuesday and Wednesday.

Still, the former aides to Mr. Obama said they did not intend to drop their guard. When a repeal bill failed to pass in the House in March, they relaxed their efforts, only to see the legislation roar back to life a few weeks later.

“The lesson here is eternal vigilance,” Ms. Dunn said. “We all prematurely celebrated after the first House vote. Until we can control one body, we can’t afford to walk away.”

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As Cost Of US Health Care Skyrockets, So Does Pay Of Health Care CEOs

Vicki Reid, right, holds a likeness of John Martin, who was then CEO of the pharmaceutical company Gilead Sciences. Reid and others were protesting high drug prices in front of the conference on retroviruses and opportunistic infections — a meeting held at the World Congress Center in Atlanta in March 2013.

John Amis/AP Images for AIDS Healthcare Foundation

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John Amis/AP Images for AIDS Healthcare Foundation

Vicki Reid, right, holds a likeness of John Martin, who was then CEO of the pharmaceutical company Gilead Sciences. Reid and others were protesting high drug prices in front of the conference on retroviruses and opportunistic infections — a meeting held at the World Congress Center in Atlanta in March 2013.

John Amis/AP Images for AIDS Healthcare Foundation

In the seven years since the Affordable Care Act was passed, CEOs of U.S. health care companies have made a lot of money.

Their compensation far outstrips the wage growth of nearly all Americans, according to reporter Bob Herman, who published an analysis this week of “the sky-high pay of health care CEOs” for the online news site, Axios.

Based on corporate financial filings with the Securities and Exchange Commission, Herman did research on 113 heads of 70 of the largest U.S. health care companies in the last seven years. Cumulatively, he says, these CEOs have earned $9.8 billion since the ACA was first enacted. Only four of the 113 CEOs were women, he notes, and only two are right now in charge of major health care companies.

The top earner was John Martin, the former CEO of the pharmaceutical company Gilead Sciences, who took home nearly $900 million, Herman says. Gilead makes, among other things, medicines to treat HIV and AIDS, as well as two leading drugs to treat hepatitis C.

Several other executives topped $250 million.

Robert Siegel, host of NPR’s All Things Considered, spoke with Herman about his analysis. Excerpts of the interview follow, edited for length and clarity.

Interview Highlights

Who are these CEOs and why are they earning so much money — on average, $20 million per year, you say?

We looked at a wide array of different companies. They include pharmaceutical companies, health insurers, hospitals, pharmacies — it really spans the gamut. And we found that since the Affordable Care Act went into effect in 2010, their pay has really gone up. So the ACA hasn’t really hurt their earnings, per se. And a lot of the money that they’re earning is coming in the form of vested stocks.

Of course, an underlying issue behind all the talk about Obamacare is not just how we pay for health care and who gets insurance (and in what form) to pay for health care, but how much we pay for health care. What do these CEOs’ earnings say about health care costs in the United States?

For the longest time, health care inflation has really blown away the rate at which the rest of the economy is growing. And a big reason why is because health care executives are not paid to slow spending. Because so much of their pay comes in the form of stock, their incentive is to do whatever it takes to make that stock go up. So that means selling more drugs; raising prices above inflation; performing more procedures; getting more people into the hospital. And those are the exact opposite things that health policy experts believe would benefit the broader system: lower prices; eliminating unnecessary care and drugs; coordinating better care.

But from 2010 (when the Affordable Care Act was signed) through 2015, the Dow Jones went up from under 11,000 to almost 18,000. Wouldn’t executives in most sectors of the economy be making huge gains on stocks and stock options during the period that is also the lifetime of Obamacare?

The stock market really has been doing quite well since the Affordable Care Act has gone into effect, but the reason why this matters even more for health care is a sixth of our economy is devoted to health care. And that continues to grow more every year. So if the most influential executives of these companies are being paid to keep that trajectory up, that’s money that’s being taken away from education or infrastructure or other parts of the economy that may not be growing as quickly, and maybe that we’d want to grow more quickly.

Can a health care executive argue that the Affordable Care Act brought a lot of people into coverage who haven’t had it before? We’ve heard this anecdotally — that lots of people are getting treatment for things that they were skipping when they couldn’t afford it. So, more people are going to the doctor; they’re getting more prescriptions.

There is some effect there, but that doesn’t account for everything. The underlying incentives still really push these companies to do more — even if it’s unnecessary. There’s still this big issue of all these services that people are getting, are they necessary? And I think that’s one of the questions that still need to be answered.

Are there any proposals on the table now — either in Republican bills or in Democratic proposals — that would actually reduce health care costs significantly and reverse this trend?

In the health care debate right now, none of the proposals in Congress address this whatsoever. A lot of what’s being proposed merely tinkers with the financing of health care and who gets health insurance. Nothing is being addressed about drug prices, for example. Nothing’s being addressed about the actual costs of the system. The debate right now is still bickering over how to finance the system — not around how much the system itself costs, which I think is a big issue.

NPR editors Renita Jablonski and Gisele Grayson, and producer Ian Stewart contributed to this story.

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Senate Soundly Rejects Repeal-Only Health Plan

But even that narrow bill could have a significant impact on the nation’s health care system. Democrats on Wednesday night released a Congressional Budget Office analysis of the effects of repealing several provisions that could be part of a “skinny” repeal measure. The analysis found that the number of uninsured people would increase by 15 million next year compared with current law, and Democrats said they were told that premiums would be roughly 20 percent higher.


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But the point of the narrow repeal measure would not be to enact it. Instead, Republicans are simply trying to get some measure to bring to negotiations with the House.

“I think people would look at it not necessarily based on its content, but as a forcing mechanism to cause the two sides of the building to try to solve it together,” said Senator Bob Corker, Republican of Tennessee.


Senator Chuck Schumer of New York and Senator Claire McCaskill of Missouri on Wednesday after the Senate rejected a measure that would repeal major parts of the Affordable Care Act.

Stephen Crowley/The New York Times

Senator Chuck Schumer of New York, the Democratic leader, called that “a ruse to get to full repeal” and warned that hard-line Republicans in the House would apply pressure to reluctant moderate Republicans in the Senate.

A scaled-down bill would fall far short of what Senate leaders had aspired to pass. But if 50 senators could agree, with Vice President Mike Pence breaking any tie, such a bill would keep alive the effort to repeal the Affordable Care Act, under which about 20 million people have gained coverage.

“What we need to do in the Senate is figure out what the lowest common denominator is — what gets us to 50 votes so that we can move forward on a health care reform legislation,” Tom Price, the secretary of health and human services, said on CNBC.

That strategy would require conservative senators like Rand Paul of Kentucky, Ted Cruz of Texas and Mike Lee of Utah to vote for a measure that leaves the basic structure of the Affordable Care Act in place, hoping that House-Senate negotiations could produce a more ambitious repeal. Such senators have argued that far broader replacement legislation did too little to eradicate the health law.


How Many People Across America Are at Risk of Losing Their Health Insurance?

A state-by-state look at who could lose insurance under the proposed Republican health care plans.

And cracks are already showing.

“The skinny plan is not a replacement of Obamacare,” Senator Lindsey Graham, Republican of South Carolina, said. “Would it be better than Obamacare? Yeah. But that’s not the goal. The goal is to replace Obamacare.”

In a letter on Wednesday, 10 governors — five Republicans and five Democrats — urged the Senate to reject a “skinny” repeal measure. The Blue Cross Blue Shield Association, a major insurance trade group, warned senators about the consequences of repealing the mandate that most people have health coverage without otherwise incentivizing people to get and maintain coverage.


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“A system that allows people to purchase coverage only when they need it drives up costs for everyone,” the association said.

With two legislative approaches having been rejected by Republicans — the comprehensive measure and then the repeal-only measure — Democrats were left wondering what exactly Republican leaders were cooking up, and how they could reasonably expect senators to vote on that legislation in just a day or two. Republican leaders have been plotting strategy and drafting legislation largely behind closed doors, with a final vote likely by Friday.


The G.O.P.’s Health Care Hail Mary: ‘Skinny Repeal’

Margot Sanger-Katz, a New York Times correspondent, explains the implications of a new, more modest health care bill Republicans are working on.

By ROBIN STEIN, NATALIE RENEAU and ROBIN LINDSAY on Publish Date July 26, 2017.

Photo by Gabriella Demczuk for The New York Times.

Watch in Times Video »

Republicans are seeking to pass a repeal bill under special budget rules that limit debate to 20 hours and preclude a Democratic filibuster.

Senate Republican leaders, including the majority leader, Mitch McConnell of Kentucky, have emphasized that senators would be free to offer any amendments they see fit. But Senator Ben Cardin, Democrat of Maryland, highlighted a major challenge that he and other senators face: How can they prepare amendments to legislation without knowing what they are amending?

“What is the bill that we are considering?” he asked. “It’s not the bill that Senator McConnell brought forward because that bill was defeated. It’s not the ‘repeal and we’re starting from a blank slate’ because that was defeated.”

Just a week ago, Mr. McConnell seemed to have failed in putting together a health bill that could pass the Senate. But he managed to persuade enough of his reluctant members to agree on Tuesday to vote for a procedural motion to take up the repeal bill that passed the House in May, and on Wednesday, he vowed to press forward with the repeal effort.

How Each Senator Voted on Obamacare Repeal Proposals

A plan to repeal and replace the Affordable Care Act and a partial repeal plan failed in the Senate.

The vote on the repeal-only measure showed the changing political dynamics that Republicans have grappled with this year on health care. With Mr. Obama in the White House, they could pummel his health law, with their words and with their votes, but his veto pen still loomed.

The Senate passed a similar repeal-only bill in 2015, and only one current Republican senator, Susan Collins of Maine, voted against it at the time. But that measure was vetoed by Mr. Obama, while senators are now trying to pass a bill that will actually become law.


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But the Congressional Budget Office said last week that the repeal-only legislation would increase the number of people who are uninsured by 17 million next year and by 32 million in 2026 compared with current law.

Senator Lamar Alexander of Tennessee, the chairman of the Senate health committee, was among the Republican senators who voted against the measure on Wednesday. He said he did not believe his constituents would like the idea of “canceling insurance” for millions of Americans and then “trusting Congress to find a replacement in two years.”

“Pilots like to know where they’re going to land when they take off,” Mr. Alexander said, “and we should too.”

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Trump calls out Murkowski over health care vote

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Senate Health Care Vote: Where the Debate Left Off and What Happens Next

The vote underscored the bind that Republican leaders have found themselves in. Repealing the health law without an immediate replacement lacks crucial support among Republicans, but a more comprehensive measure that would have repealed major parts of the law with a ready replacement also came up short on Tuesday night.


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With neither approach viable, Senate Republican leaders may have no choice but to fall back on a third choice: Push a far more limited measure that repeals parts of the Affordable Care Act, such as its mandate that most people have insurance and a tax on medical devices, but leaves most of President Barack Obama’s signature health law in place. Senators would then take their narrow bill into negotiations with the House, which passed a comprehensive measure to repeal and replace the Affordable Care Act.

Where did everything leave off Tuesday night?

Understandably, confusion is rife over what the heck is happening on the Senate floor: What was that vote Tuesday night? Why did Senator John McCain, Republican of Arizona, give that impassioned speech saying he would not vote for the Senate health care bill as it stands, then turn around and cast a yes vote on Tuesday night?

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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.


Republicans Are Voting This Week to Repeal or Replace Obamacare. Here Are Their Proposals.

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 party’s ideological spectrum.


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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.


John McCain to Senate: ‘We’re Getting Nothing Done’

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.


Photo by Gabriella Demczuk for The New York Times.

Watch in Times Video »

And what does McCain actually want?

On Wednesday, the Arizona Republican let his leaders know what he wants. Mr. McCain’s office said that he had filed three amendments meant to address concerns from leaders in his home state of Arizona, including the governor, Doug Ducey, a Republican.

Arizona is one of 31 states that expanded Medicaid under the Affordable Care Act, and the amendments would all address Medicaid. One of them would extend the phase out of the Medicaid expansion to 10 years, considerably longer than the bills under consideration. Another would increase the growth rate for Medicaid payments to states to better reflect health care inflation.


The G.O.P.’s Health Care Hail Mary: ‘Skinny Repeal’

Margot Sanger-Katz, a New York Times correspondent, explains the implications of a new, more modest health care bill Republicans are working on.

By ROBIN STEIN, NATALIE RENEAU and ROBIN LINDSAY on Publish Date July 26, 2017.

Photo by Gabriella Demczuk for The New York Times.

Watch in Times Video »

“Any reform to our health care system must reward states like Arizona that are responsibly managing their health care services and controlling costs – not penalize them,” Mr. McCain said in a statement, adding that the amendments would “ensure our citizens who are most in need do not have the rug pulled out from under them.”

What’s happened so far on Wednesday?

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

But Mr. Trump’s 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 Alaska’s 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.

Blue Cross Blue Shield warns the Senate

The Blue Cross Blue Shield Association warned senators on Wednesday that repealing the Affordable Care Act’s mandate that nearly everyone have health insurance would be disastrous if Congress fails to replace it with another measure that ensures that people get and maintain insurance coverage.

“If there is no longer a requirement for everyone to purchase coverage, it is critical that any legislation include strong incentives for people to obtain health insurance and keep it year-round. A system that allows people to purchase coverage only when they need it drives up costs for everyone. Immediate funding for the cost-sharing reduction program also is essential to help those individuals most in need with their out-of-pocket costs, so they can access medical services. And dedicated funds must be provided to help pay for the care of those with significant medical conditions.

In order to ensure a stable individual insurance marketplace, any final legislation must include these crucial elements to avoid steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.”

The association appeared to be worried about a so-called “skinny repeal” bill that would do away with the Affordable Care Act’s individual mandate and mandate that most employers offer insurance to their workers, but would include little else. Republican leaders believe that such a narrow bill may be the only measure that can get through the Senate.

Now what happens in the Senate?


The Senate majority leader, Mitch McConnell of Kentucky, on Tuesday at the Capitol.

Gabriella Demczuk for The New York Times

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.


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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.

Then what happens?

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.

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The Latest: Doctors, insurer criticize GOP health care bill

The Latest on the effort by congressional Republicans to pass a health care bill (all times local):

3:10 p.m.

Doctors and a major health insurer group are criticizing the latest GOP health care proposal in the Senate.

That idea is called a “skinny repeal,” because it would only get rid of the most unpopular parts of “Obamacare,” such as the requirement that individuals carry health insurance or face fines.

The American Medical Association said in a statement that invites healthy people to opt out of the health insurance market, forcing premiums up for everyone else.

“Eliminating the mandate … only exacerbates the affordability problem,” said the AMA.

That criticism was joined by the BlueCross BlueShield Association. The insurer group also said Congress has to provide money now to help stabilize shaky state markets for individual policies. Insurers want a guarantee that subsidies to help low-income people with their deductibles will continue.


7:20 a.m.

President Donald Trump is attacking a Republican senator who opposed moving forward with long-promised legislation to repeal and replace “Obamacare.”

Trump says on Twitter Wednesday that Sen. Lisa Murkowski, of Alaska, “really let the Republicans, and our country, down yesterday. Too bad!”

Murkowski was one of two Republicans who on Tuesday voted against allowing debate of GOP legislation to repeal much of the Affordable Care Act.

The final tally was 51-50, with Vice President Mike Pence breaking the tie.

Trump has been pushing lawmakers to deliver on their promises to repeal and replace. Whether Republicans can find consensus remains unclear.


3:46 a.m.

Where the Senate Republican effort to demolish the Obama health care law ends up is anyone’s guess. But early indications are the GOP will have a hard time replacing that statute with any sweeping changes.

Senators planned to vote Wednesday on a Republican amendment repealing much of President Barack Obama’s law and giving Congress two years to concoct a replacement. Solid Democratic opposition and Republicans unwilling to erase the law without a replacement in hand were expected to defeat that plan.

Late Tuesday, the Senate voted 57-43 to block a wide-ranging proposal by Majority Leader Mitch McConnell replacing Obama’s law with a far more restrictive GOP substitute. Those voting no included nine Republicans.

That roll call raised questions about what splintered Republicans can achieve in terms of reshaping Obama’s law.

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1 million jobs on the line as Senate votes on health care

America could lose more than a million jobs if the Senate votes to repeal the Affordable Care Act on Tuesday.

That’s according to a report from George Washington University’s Milken Institute School of Public Health and the Commonwealth Fund.

“This legislation could single-handedly put a big dent in health care job growth,” said Leighton Ku, the lead author of the report and the director of the Center for Health Policy Research at George Washington University.

Repealing the law, also known as Obamacare, would dramatically scale back federal funding for health care, especially Medicaid. That translates into job losses as hospitals, retirement homes and other health facilities get fewer dollars.

“We’re talking about one out of every 20 health care jobs disappearing by 2026. That’s a lot,” Ku said.

Much of the debate over the “repeal and replace” of Obamacare has centered on how many Americans would lose insurance. The bill that Senate Republicans proposed would lead to 22 million fewer Americans with health insurance in the next decade, according to the nonpartisan Congressional Budget Office. The House Republican bill would leave 23 million fewer people covered, and a straight repeal of Obamacare would bring the most losses of all: 32 million off insurance, according to the CBO.

Job losses, however, get much less attention, despite the fact that health care has been a booming field for job growth. Even during the Great Recession, health care jobs continued to grow. A third of all jobs created in the United States in the past decade have been in health care.

According to the Labor Department, 15.7 million Americans have jobs in health care today — roughly 1 in 9 workers. And a lot of the job growth Trump has heralded so far in his tenure has also come from health care.

Kaiser Health News.

Trump says the Senate is “very close” to having the votes to pass, but it’s clear the job impact is one of the concerns weighing on some Republican senators’ minds. These senators are worried about what their home states would lose if they repeal Obamacare and enact the alternatives under consideration. Federal health dollars would drop, more people would lose insurance and many good-paying jobs would go away.

Since Obamacare went into full effect in 2014, 1.2 million people have gained employment in health care. Most of the jobs have come in hospitals and outpatient care where people are treated for non-emergencies. Many hospitals, such as Harris Medical Center in Newport, Ark., have seen their “bad debts” drop substantially since more patients have been able to pay since Obamacare was enacted. At Harris, bad debt has been cut in half. That has allowed hospitals to expand services — and jobs.

Sen. Susan Collins of Maine is one of the GOP senators who has come out strongly against the Senate’s Better Care Reconciliation Act (BCRA). BCRA “would also jeopardize the very existence of our rural hospitals and our nursing homes, which not only provide essential care to people in rural America, but also are major employers in the small communities in which they are located,” Collins said on ABC’s “This Week.”

The CBO didn’t calculate job losses, but the health experts at George Washington University did, using a similar economic model to the CBO’s. “Our analyses shows that almost every state ends up being a loser on jobs,” Ku said.

The report finds that every state would lose health care jobs almost immediately as federal health care funding is cut, especially for Medicaid. The 31 states that expanded Medicaid funding, including West Virginia and Ohio, would be especially hard hit.

In total, nearly a million jobs in health care would be lost by 2026 under BCRA, as well as another half a million jobs in other sectors from the cutbacks in spending by health organizations and employees who are laid off.

The job losses under the House bill are similar, although slightly less (924,000 in total). Ku and his team didn’t look at what would happen if the Senate just does a straight repeal of Obamacare without replacing it with anything, but Ku told The Washington Post the job reductions would likely be similar to the 1.45 million under BCRA.

As with any study, these are estimates. Assumptions had to be made and no one knows what the future will hold, especially in a field like health care that is experiencing innovative technological advances. Still, there’s widespread agreement among economists that health jobs would likely decline in coming years under the GOP plans. The disagreement is over whether other sectors would gain or lose jobs.

“Congress definitely should be considering the impact of the Obamacare repeal on job growth in health care,” said Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research. “The question is does the repeal have a positive impact on job growth in other sectors of the economy?”

Young hasn’t run his own models, but he points out that President Barack Obama helped sell his health reform by telling the business community that his plan would reduce health costs overall and thus spur growth in other industries. Job growth did pick up in Obama’s second term, although it’s debatable how much of a role health care costs played in that. Health care costs still grew, albeit at a slower pace.

For senators weighing whether to vote yes on Tuesday, a key factor is what Collins said: Many of the job losses would hurt communities that can least afford them.

“The groups that will get hit the most are rural hospitals and inner city teaching hospitals,” said Stuart Altman, a professor of national health policy at Brandeis University.

Many of those rural areas voted heavily for Trump. The president has said he wants to be the “greatest jobs producer that God ever created,” but the bills he is supporting in the Senate would likely slash jobs.

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Senate Braces for Health Showdown With McCain on Hand but a Plan Unclear

The remarks from Mr. Trump, who has been largely absent from the policy debate, had the ring of a threat by a president who has grown frustrated watching Republicans repeatedly try, and fail, to reach consensus on his campaign promise to immediately roll back the health law and enact a better system.


The Outcomes of the Many Republican Health Plans Are Not So Different

Comparing how the plans would affect key measures like the number of uninsured and the deficit.

He said their constituents would exact a price for inaction — “you’ll see that at the voter booth, believe me” — and hinted that any Republican who did not support the bid to open debate on an as-yet-determined health bill would be painted as complicit in preserving a health law passed on the basis of “a big, fat, ugly lie.”

“For Senate Republicans, this is their chance to keep their promise,” Mr. Trump said, repeating the “repeal and replace” mantra on which Republicans campaigned last fall. “There’s been enough talk and no action; now is the time for action.”

After months of planning, debating and legislating, much of it behind closed doors, the Senate this week has reached the moment when votes will have to be cast. The big question Monday was what exactly the Senate will be voting on.

The fight on the Senate floor will unfold in stages.

First, the Senate majority leader, Mitch McConnell of Kentucky, said he would move ahead with a procedural vote on Tuesday to take up the health bill that narrowly passed the House in May. He urged his colleagues to do so.

“Many of us have waited literally years for this moment to finally arrive, and at long last, it has,” Mr. McConnell said on the Senate floor.

If that vote succeeds, the Senate would then be able to consider numerous amendments, including complete substitutes for the House bill. But it remains unclear what would take its place, and Senate Republican leaders have not said which substitute measure would be considered first.


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Under one possible series of events, Mr. McConnell could quickly move to replace the House bill with an entirely new measure to repeal the Affordable Care Act without a replacement.


Senator John McCain in May. The Arizona Republican said on Monday that he would be in Washington on Tuesday for a health care vote despite his brain cancer diagnosis.

Al Drago/The New York Times

If that amendment vote fails, as it most likely would, he could move to replace the House bill with a version of the proposal he has been refining for weeks: to repeal the health law while also replacing it.

Senator John Cornyn of Texas, the No. 2 Senate Republican, said there would be “endless amendments” if the procedural hurdle were cleared. He played down the significance of which substitute measure would come first.

“Everybody will get a vote on everything they want to vote on,” Mr. Cornyn said. He added, “What we’re trying to do is convince everybody that if they’d like to get a vote on their amendment, then they need to vote to proceed to the House bill.”

Democrats were incredulous.

“We are potentially one or two days away from a vote on a bill that would reorganize one-sixth of the American economy, impacting tens of millions of American lives, and no one knows what it is,” said Senator Chuck Schumer of New York, the Democratic leader. “It’s sort of like Alice in Wonderland around here.”

What they will vote on will not matter if senators oppose beginning debate. Mr. McConnell can lose only two Senate Republicans, now that Mr. McCain intends to be in the chamber.

Senator Susan Collins, Republican of Maine, is all but certain to vote no on the procedural vote, no matter what legislation Mr. McConnell promises to put before the chamber if the initial hurdle is cleared.

At least two other Republicans, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska, have indicated they will not vote to proceed if Senate leaders plan to then put forth a measure to repeal the health law without providing a replacement.

While in West Virginia later on Monday, addressing the National Scout Jamboree, Mr. Trump teased the health and human services secretary, Tom Price, about whether he would be able to wrangle support from Ms. Capito and other Republicans. “He better get them,” Mr. Trump said, smiling at Mr. Price to indicate he was joking — or at least seemed to be. “Otherwise, I’ll say, ‘Tom, you’re fired.’”


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He then added, “You better get Senator Capito to vote for it.”

Republican leaders are pressuring senators to go along at least with the procedural step, to bring them closer to delivering on their longtime promise of repealing the Affordable Care Act, which was adopted without any Republican votes.

“While disagreements remain on the best way to repeal and replace Obamacare, one thing is certain: The American people rightfully expect us to keep our promises and get the job done,” said Senator Ted Cruz, Republican of Texas, who said he would vote to begin debate.

Another complication is whether the more comprehensive of the different repeal measures that could go before the Senate — Mr. McConnell’s bill, which would also replace the health law — could be pared down because of parliamentary rules.

The repeal bill is being considered under special expedited procedures that apply to certain budget-related legislation. These rules limit debate, preclude a filibuster and allow passage with a simple majority vote. However, the rules stipulate that provisions of the bill can be removed if they would not change federal spending or revenue, or if the budgetary effects are “merely incidental” to a policy objective.

The Senate parliamentarian, Elizabeth MacDonough, who serves as a sort of referee, has made a preliminary finding that a number of provisions of Mr. McConnell’s repeal-and-replace bill appear to violate Senate rules.

These provisions would, for example, cut off federal funds to Planned Parenthood for one year; prohibit the use of federal subsidies to buy insurance that includes coverage for abortions; and require people who have experienced a gap in insurance to wait six months before obtaining coverage in the individual market.

If a senator objects to any of these provisions, the presiding officer could sustain the objection, following the parliamentarian’s advice. Republicans would then need 60 votes to keep that provision in the bill — a nearly impossible threshold for any significant issue.

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Health Bill, Boy Scouts, Jimmy Choo: Your Tuesday Briefing

The party is unfurling proposals aimed squarely at voters who see a gap between President Trump’s populist message and the reality of his tenure.


Senator Chuck Schumer of New York, flanked by fellow Democrats, helped introduce the party’s new economic message on Monday in Berryville, Va.

Justin T. Gellerson for The New York Times

After six months in office, Mr. Trump has moved the bar for outrage, shifting the understanding of what is standard, our chief White House correspondent writes.

The president addressed the National Scout Jamboree on Monday. “Who the hell wants to speak about politics when I’m in front of the Boy Scouts?” he asked. As it turns out, he did.

• A door closed out the light, and life.

Details of one of the deadliest instances of human trafficking in the U.S. were revealed after the driver of a tractor-trailer carrying dozens of migrants was charged.

The truck was found in San Antonio on Sunday. Ten people have died.

• Standoff eases in Israel.

The government began removing metal detectors at a major Jerusalem mosque compound after days of bloodshed and a diplomatic crisis with Jordan.


Israeli security forces dismantled metal detectors at the entrances to the Aqsa Mosque compound in Jerusalem’s Old City today.

Ammar Awad/Reuters

• Guilty plea in kayaker’s death.

A woman accused of killing her fiancé in 2015 by tampering with his kayak near New York City pleaded guilty to a reduced charge.


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• “The Daily,” your audio news report.

In today’s show, we discuss what we learned from Jared Kushner.

Listen on a computer, an iOS device or an Android device.


• Employers say they are having trouble filling jobs because too many applicants can’t pass drug tests.

• EmCare is one of the largest physician-staffing companies for U.S. emergency rooms.

Yale researchers found that customers of one big insurer were charged more when EmCare entered a hospital.

Michael Kors has found some new shoes to go with its handbags, agreeing today to buy Jimmy Choo for about $1.2 billion.

• Prompted by the debate over sleeveless clothing for women in Congress, we asked readers about “appropriate” business attire. Here’s what they said.

• U.S. stocks were mixed on Monday. Here’s a snapshot of global markets.

Smarter Living

Tips, both new and old, for a more fulfilling life.

• Cutting carbs? Here’s why it’s so tough.

• Finding the source of a stomach bug can reduce future risk.

• Recipe of the day: Good tomatoes and bread are a summer delight.


• Shakespeare, under the sky.

In today’s 360 video, experience the playwright’s works in outdoor venues around the world.


Shakespeare, Under the Sky and Around the Globe

Experience Shakespeare in 360 degrees and the way the Bard intended — in the great outdoors.


Photo by T Charles Erickson for The New York Times. Technology by Samsung..

Watch in Times Video »

• Partisan writing you shouldn’t miss.

Writers from across the political spectrum react to the news on the Russia investigation and more.


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• Fears for safety in a crowded Arctic.

A decline in sea ice is allowing more marine travel, but experts say the remote region is unprepared to face an emergency at sea.

• “We have decided to let our son go.”

The parents of Charlie Gard, the chronically ill British infant who drew attention from Pope Francis and President Trump, abandoned efforts to prolong his life.


Charlie Gard’s parents, Chris Gard and Connie Yates, outside the High Court in London on Monday.

Will Oliver/European Pressphoto Agency

The Evening Briefing by Email

Get a nightly rundown of the day’s top stories delivered to your inbox every Monday through Friday.

Best of late-night TV.

The comedy hosts got in some last cracks at Sean Spicer after he resigned as White House press secretary.

• Quotation of the day.

“Of course it’s a great honor that the central government would pay attention to us here in Baiyangdian. We just don’t know what to expect — except that we’re going to have to move.”

Chen Dazheng, a boatman along the canals in a wetland region that the Chinese government is planning to transform into a satellite city of Beijing.

Back Story

Long before a Masters champion first put on a green jacket, young men in London were competing to wear Doggett’s Coat and Badge, an athletic honor that will be awarded today for the 303rd time.


A previous winner of the Doggett’s Coat and Badge race, wearing the victor’s livery, before the 2012 edition.

Luke Wolagiewicz for The New York Times

The coat is red, and the badge is large and silver. Under the will of Thomas Doggett, an actor, they go to the fastest young waterman in an annual race along the River Thames.


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Watermen were the taxi drivers of Doggett’s time, rowing passenger boats that were often the quickest way around a city that until 1750 had only one bridge. As today’s London taxis fight Uber, watermen fought horse-drawn cabs in a long, losing battle. In 1622, one waterman put his complaints into verse:

Against the ground we stand and knock our heels,

Whilst all our profit runs away on wheels.

By 1873, watermen were rare enough that Doggett’s race had to be made easier, using light skiffs rowed with the tide, rather than four-passenger wherries rowed against it.

But it has gone on, pausing only for World War II. (Races were held later to pick the missing winners.) A Times reporter covered the 2012 edition.

Peter Robins contributed reporting.


Photographs may appear out of order for some readers. Viewing this version of the briefing should help.

Your Morning Briefing is published weekdays at 6 a.m. Eastern and updated on the web all morning. You can browse through past briefings here.

What would you like to see here? Contact us at

You can sign up here to get the briefing delivered to your inbox. Check out our full range of free newsletters here, including our new guide to “Game of Thrones.”

Correction: July 25, 2017

An earlier version of this briefing misstated how many times Doggett’s Coat and Badge has been awarded. Today’s award was the 303rd, not the 302nd.

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They Voted Trump and Need Health Care. A Democrat-Doctor Volunteers

WISE, Va. — For Whitney Smith Castle, the health care debate in Washington felt even further away than the 400 miles this corner of Virginia’s coal county is from Congress.

Her daughter was having health problems and she didn’t know what to do.

“You have no idea how many times we’ve been to doctors,” she told the specialist at a free clinic set up at the county fairgrounds here that treats some 2,500 patients in a single weekend each year.

Image: Lt. Governor Ralph Northam arrives at the Wise County Fairgrounds to volunteer during the Remote Area Medical clinic, July 22, 2017, in Wise, Virginia.

Image: Lt. Governor Ralph Northam arrives at the Wise County Fairgrounds to volunteer during the Remote Area Medical clinic, July 22, 2017, in Wise, Virginia.

Her 8-year-old daughter, Miranda Smith, looked up through blonde bangs at the pediatric neurologist — who also happens to be the state’s lieutenant governor and a physician — as he put a stethoscope to her chest. He provided a diagnosis and his cell phone number, assuring Castle that everything should be fine.

Lt. Gov. Ralph Northam, running for governor as a Democrat, had just come from his first debate against Republican Ed Gillespie that morning. The two had argued about the GOP plan to repeal and replace the Affordable Care Act — and now Northam was treating those who had fallen through its cracks.

“Just another day at work,” Northam said in the drawl of Virginia’s rural Eastern Shore.

Wise County voted 80 percent for Donald Trump, but with unemployment, poverty and disability rates all above the national average, most of the patients here didn’t care about whether the White House would prevail in the health care debate raging in D.C. or what version of the GOP plan would be voted on. They just wanted care.

“I don’t have insurance enough to have an opinion on that,” said William Doss of repealing Obamacare as he waited to see a dentist.

For his part, Northam said Obamacare is working and that he hopes to get Virginia to finally accept the law’s Medicaid expansion if he wins, which might help people like those at the clinic.

“I’m a big believer that health care should be a right, just like education is a right,” he said. “In the richest county in the world, people should be able to not be one medical issue away from financial demise or death.”

He added, “I think everybody that is in policy-making should come out and see what’s going on out here.”

Stan Brock founded Remote Area Medical, which has run this pop-up clinic for 18 years, to send doctors to developing countries. But he found the need was so great in Appalachia and other parts of the U.S. that the non-profit now runs dozens of free clinics each year right at home.

Hundreds of people travel from all over southwest Virginia to spend the night in their cars and line up in the pre-dawn hours to see a doctor, get their teeth fixed, or leave with a new pair of glasses.

Brock knows it can be a photo opportunity for politicians. Democratic Gov. Terry McAuliffe visited Friday and almost didn’t recognize Sen. Tim Kaine, D-Va., who was volunteering at patient registration.

Image: Lt. Governor Ralph Northam gives, Ashton Gardner, from Coborn, Virginia, a neurological examination during Remote Area Medical clinic, July 22, 2017, in Wise, Virgina.

Image: Lt. Governor Ralph Northam gives, Ashton Gardner, from Coborn, Virginia, a neurological examination during Remote Area Medical clinic, July 22, 2017, in Wise, Virgina.

But Brock, a former TV star as co-host of “Wild Kingdom” who at 80 still looks camera-ready, wants every politician to see the failures of the country’s healthcare system with their own eyes.

“I’m actually convinced that if President Trump were to come to one of these big events, he would say to himself, ‘Wow, I should do something about this,’ ” Brock said. “They’re all cheering for him now, but they’re all expecting something to change for the better. And it’s not, for now, at least.”

This was Northam’s fifth time volunteering at a free clinic, which he said gives him a chance to practice the field medicine skills he honed in the Army during the first Gulf War.

As he wound his way between open-air dentist chairs where people were getting their teeth pulled, doctors and nurses in scrubs kept coming up to greet “Dr. Northam.” The patients didn’t seem to notice or care about the VIP in their midst.

It’s a two-and-half hour drive in any direction to the nearest county that went for Hillary Clinton last year. She didn’t even crack 18 percent of the vote in Wise County, even though her husband won it twice 20 years ago.

Trump is still popular among many at the clinic, but there’s also a deep cynicism about all of politics.

“Everyone says they’ll help this area. No one ever does,” said Aaron Breedlove, who recently moved over the border to Tennessee where the economy is a bit better.

“There’s no jobs, all the stores are shut down,” said Crystal Phillips, pointing to the decline of the coal industry. “And they wonder why all the kids wind up on drugs or stealing.”

Northam doesn’t need southwest Virginia to win the state next year, but as a veteran from Virginia’s rural Eastern Shore who admitted to voting for George W. Bush, he thinks he can improve Democrats’ margins outside the state’s population centers.

“I feel like if anybody can get out and listen to these folks and let them know we’re here to help them, I can do that,” he said. “Most people, especially parents, trust their pediatrician.”

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