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The Senate voted narrowly on Tuesday to begin debate on a bill to repeal major provisions of the Affordable Care Act, but hours later, Republican leaders suffered a setback when their most comprehensive plan to replace President Barack Obama’s health law fell far short of the votes it needed. The Tuesday night tally needed to reach 60 votes to overcome a parliamentary objection. Instead, it fell 43-57. (Kaplan and Pear, 7/25)

Nine senators on the right and center rejected the first version of the Better Care Reconciliation Act brought to a vote after the chamber began debate on a path forward earlier that afternoon. Tuesday evening's vote was the first of many expected in the next several days as senators shape a final bill on how to reform the individual insurance market and change federal Medicaid funding. (Lee, 7/25)

The first casualty was an amended version of the “Better Care” plan from GOP leaders – along with additions from Sen. Rob Portman (R-OH), who wanted to add back $100 billion in Medicaid funding, and Sen. Ted Cruz (R-TX), who pressed for his ‘Consumer Freedom Amendment,’ which would let insurance companies that sell regular Obamacare plans also offer lower-cost plans with less health coverage. (Dupree, 7/25)

Senate Democrats pledged to fight against all of the GOP’s repeal efforts. “We will do everything we can inside this building,” Senate Minority Leader Chuck Schumer of New York said at a news conference, adding that people outside Washington should organize too. “We are going to fight and fight and fight until this bill is dead.” (Litvan and Dennis, 7/25)

Senate Republicans fell short Tuesday of their effort to advance a health care proposal they’ve worked on for several weeks. The Senate voted 43-57 against the amendment to the health care bill, which would roll back part of the 2010 health care law and replace it. Nine Republicans joined Democrats and independents in opposing the amendment. The Republicans who voted against the amendment on a procedural motion were Sens. Susan Collins, R-Maine; Bob Corker, R-Tenn.; Tom Cotton, R-Ark.; Lindsey Graham, R-S.C.; Dean Heller, R-Nev.; Mike Lee, R-Utah; Jerry Moran, R-Kan.; Lisa Murkowski, R-Alaska; and Rand Paul, R-Ky. An earlier version of the measure would result in 22 million fewer Americans having insurance in 2026, according to the Congressional Budget Office. (McIntire, 7/25)

“We knew this wasn’t going to be easy, and there’s a lot of work ahead of us,” said Sen. John Thune of South Dakota, a member of the Senate GOP leadership. (Armour, Peterson and Hackman, 7/25)

“The endgame is to be able to move something at the end of this process across the Senate floor that can get 50 votes and then to get into conference with the House,” said Sen. John Thune (R-S.D.), a top McConnell lieutenant. (Sullivan, Eilperin and Snell, 7/25)

Tuesday night's vote doesn't prevent GOP leadership from offering another repeal and replace amendment, or another version of BCRA. It could also help GOP leadership get rank-and-file senators on the record, as they try to figure out a path forward. (Carney, 7/25)

Prodded by President Donald Trump, a bitterly divided Senate voted, at last, Tuesday to move forward with the Republicans' long-promised legislation to repeal and replace "Obamacare." There was high drama as Sen. John McCain returned to the Capitol for the first time after being diagnosed with brain cancer to cast a decisive "yes" vote. The final tally was 51-50, with Vice President Mike Pence, exercising his constitutional prerogative, breaking the tie after two Republicans joined all 48 Democrats in voting "no." (Werner, 7/25)

As Mitch McConnell strode to the Senate floor on Tuesday, with no votes to spare to keep the GOP’s Obamacare repeal campaign alive, he knew where everyone in his conference stood. Everyone, that is, except for Ron Johnson. (Everett, Kim and Haberkorn, 7/25)

To get to this point, McConnell had to abandon the customary legislative process, forgoing public hearings and committee debate in a way almost never seen for major legislative proposals. And he left Republican lawmakers with a series of legislative options — which polls show are deeply unpopular with Americans — that would leave as many as 32 million more people without health coverage and weaken health protections for tens of millions more. (Levey, 7/25)

Two Republican senators — Susan Collins of Maine and Lisa Murkowski of Alaska — broke with their party and opposed the Senate vote to move ahead on a health care overhaul. The votes by the two women drew criticism from President Donald Trump, who said, "So we had two Republicans that went against us, which is very sad, I think. It's very, very sad for them." (Daly, 7/25)

The Senate faces several days of heated debate and tough votes, with the final outcome in doubt. Can Republicans actually repeal and replace Obamacare? Or simply repeal it? Can they roll back the expansion of Medicaid under the Affordable Care Act, which resulted in millions of more enrollees? What about eliminating Obamacare taxes? And defunding Planned Parenthood? What about a “skinny repeal” bill that would get rid of the employer and individual mandates under Obamacare while leaving almost all the rest of the legislation in place? All this is still up in the air. (Bresnahan, 7/25)

The Senate on Tuesday began debate on healthcare legislation, taking a big step forward in its effort to repeal ObamaCare, after Vice President Pence broke a 50-50 tie to cast the deciding vote. Two Republicans, Sens. Lisa Murkowski (Alaska) and Susan Collins (Maine), voted with Senate Democrats against the procedural measure, highlighting the narrow margin of error the White House and GOP leaders face in getting a repeal bill to President Trump. (Sullivan, 7/25)

Reviving their touch-and-go effort to repeal the Affordable Care Act, Senate Republicans narrowly agreed Tuesday to begin debate on an undefined health care bill that could change how millions of Americans obtain insurance. In a dramatic showdown that required Vice President Mike Pence to break a tie vote and that prompted Republican Sen. John McCain to return to Washington days after a cancer diagnosis, the Senate agreed to start an unusual and grueling process of drafting legislation — amendment by amendment — on the Senate floor. (Fritze, 7/25)

You had to be there. After days of uncertainty about whether Senate Republicans would vote to begin debating a bill to repeal the Affordable Care Act, it boiled down to a few tense minutes on the Senate floor. As the vote started shortly after 2 p.m. ET, 30 reporters crammed into the small hallway in front of the chamber, waiting for Arizona Republican Sen. John McCain’s dramatic arrival on the elevator. (Bluth, 7/25)

The maverick stood with his party on Tuesday, casting a crucial vote in the Republican drive to repeal "Obamacare." But then, like an angry prophet, Sen. John McCain condemned the tribal politics besetting the nation. Confronting an aggressive brain cancer, the 80-year-old Arizonan served notice he would not vote for the GOP legislation as it stands now. McCain's impassioned speech held the rapt attention of his colleagues in the Senate chamber. (Alonso-Zaldivar, 7/26)

He said that although he had voted to begin debate on repealing the Affordable Care Act, he would definitely not vote for a Senate health care bill without major changes. As it turned out, however, Mr. McCain did side late Tuesday with most Senate Republicans who voted — unsuccessfully — to replace the health care law with the most comprehensive plan his party has offered so far. (Steinhauer, 7/25)

Standing in the well of the Senate with the surgical scar over his left eyebrow clearly visible, McCain urged his colleagues to "stop listening to the bombastic loudmouths" on radio, television and the Internet who rail against compromise. "To hell with them!" McCain said. (Gaudiano, 7/25)

“Let’s trust each other. Let’s return to regular order. We’ve been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle,” McCain told his colleagues, who gave him the floor for an unusual address usually reserved for a retiring senator. “We’re getting nothing done, my friends. We’re getting nothing done.” (Kane, 7/25)

The senator spared no one—not himself, not Senate Majority Leader Mitch McConnell (R., Ky.). “Sometimes I made it harder to find common ground because of something harsh I said to a colleague,” Mr. McCain said. “Sometimes I wanted to win more for the sake of winning than to achieve a contested policy.” (Hughes, 7/25)

Trump hailed McCain in not one but two Tuesday tweets. The president called McCain an "American hero," apparently changing his mind two years after declaring on the campaign trail that "he's not a war hero" and "I like people who weren't captured." McCain spent more than five years as a prisoner of war in Vietnam, earning several medals for valor. (Schor, 7/25)

Sen. John McCain (R-Ariz.) voted in favor of a procedural hurdle Tuesday evening that would have advanced the GOP's ObamaCare repeal and replace bill to a vote. The vote to advance the proposal to a vote failed 43-57, with McCain voting yes. (Hellmann, 7/25)

Sen. John McCain’s decision to return to Washington for Tuesday’s vote on health care legislation came less than two weeks after surgery to remove a blood clot in his head — and shortly after he was diagnosed with an aggressive form of brain cancer. His quick return came as a surprise to much of Washington. When he received his diagnosis of glioblastoma on July 14, he announced that he would stay in Arizona for a week to recover. And in a speech after Tuesday’s vote, McCain announced that he’ll be returning to Arizona to continue treatment after a few days in D.C. (Sheridan and Ross, 7/25)

Despite misgivings about the closed-door process used to write a bill to repeal and replace the Affordable Care Act and its potential impact on rural health care providers, Republican U.S. Sen. Jerry Moran joined his Kansas counterpart, Pat Roberts, in voting to begin debate on the legislation. In a statement released Tuesday, Moran said he has for years been “committed to repealing and replacing Obamacare.” (Mclean, 7/25)

Despite his sharp criticisms of nearly every health-care bill pushed by Republican leadership this year, Ohio Sen. Rob Portman sided with party leaders Tuesday to keep alive the GOP effort to dismantle and replace Obamacare. By joining 49 other Republicans and Vice President Mike Pence, the Ohioan cleared the way for the Senate to launch a floor debate and provide lawmakers with an opportunity to amend a bill Republicans have promised for years. (Torry and Wehrman, 7/26)

With Ohio Republican Rob Portman's support, the U.S. Senate has voted to start debate on sweeping changes to the nation's health insurance rules, including billions in cuts to programs that cover the poor and low-income Americans. No one, including 50 senators who voted to proceed and Vice President Mike Pence, who provided the necessary 51st vote, knows how this will end. (Koff, 7/25)

U.S. Sen. Cory Gardner gave his first hint on where he stands on his chamber’s initiative to undo the Affordable Care Act, voting yes Tuesday on a procedural vote that passed after going down to the wire. ...Even a few hours earlier, Gardner aides said the Colorado Republican still hadn’t decided whether he would back it — an approach that tracks with Gardner’s weekslong avoidance of a definitive position. His Democratic counterpart from Colorado, U.S. Michael Bennet, voted no. (Matthews, 7/25)

Republican lawmakers are likely to find a consensus to overturning former President Barack Obama’s U.S. health plan, partly because the cost of inaction would be too high, ex-House Majority Leader Eric Cantor said. “The political implications are pretty severe if the party can’t deliver on seven, eight years of promises to repeal and replace Obamacare,” the former congressman, who became a banker at Moelis & Co., said Tuesday in an interview on Bloomberg Television. (Rausch and Basak, 7/25)

Both of Iowa’s U.S. senators on Tuesday voted in favor of opening debate on reforms to the health care law known as Obamacare. U.S. Sens. Chuck Grassley and Joni Ernst were among the 50 Republicans voting for the motion to proceed, a procedural step that did not commit lawmakers to specific changes to the law but will allow further debate and amendments. (Noble, 7/25)

Sens. Lamar Alexander and Bob Corker sided with other Senate Republicans on Tuesday and voted to move forward with a plan to repeal and replace the Affordable Care Act, even though no one is certain what the final bill will look like. ...The Senate failed late Tuesday night to pass a comprehensive bill to repeal and replace Obamacare. The bill needed 60 votes to overcome a parliamentary hurdle, but fell short after a number of Republicans rejected the plan. The vote was 43-57. Corker voted against the proposal. Alexander supported it. (Collins, 7/25)

Perdue was on the late shift Monday night as Democrat after Democrat took to the floor in a last-ditch effort to defend Obamacare and trash the GOP’s uncertain repeal plans. Their comments incensed the typically measured Perdue, who has positioned himself as an unwavering supporter of the Trump White House and its agenda. (Hallerman, 7/25)

Just after Republicans voted Tuesday to advance the GOP’s health care bill, Senator Elizabeth Warren took to the steps of the Capitol to denounce the effort to repeal the Affordable Care Act. ...The Senate, by a hair, voted Tuesday to start debating Republican legislation to tear down much of the Obama health care law. (Prignano, 7/25)

Minnesota’s two U.S. senators voted with all other Democrats against the Senate debating a federal health care law rewrite Tuesday, July 25, pleading to allow the two parties to work together, and a former Republican senator agreed with them. “We can still stop this,” Sen. Amy Klobuchar declared shortly after the vote. “We can still put aside partisanship and instead work together on bipartisan solutions, like lowering the cost of prescription drugs and strengthening the exchanges.” (Davis, 7/25)

Celebrating a slim but symbolic health-care win in Washington, President Donald Trump told supporters in Ohio that the nation was one step closer to liberation from the "Obamacare nightmare." (Salama, 7/26)

Mr. Trump, in a 45-minute interview with The Wall Street Journal, said he has been working to secure the 50 votes needed to pass the measure, which he described as a difficult but crucial step toward ultimately putting in place a health-care system that would replace former President Barack Obama’s Affordable Care Act. “I think we’re doing pretty well on health care,” the president said in the Oval Office interview. “We’ll see.” (Nicholas, 7/25)

The Senate's days-long debate on health care features a dynamic that's relatively rare on Capitol Hill. Genuine suspense. Debate kicked off Tuesday without an obvious endgame. Several Republicans voted to start debate but said the bill will have to be changed for them to vote to actually pass the legislation later this week. The amendment process promises to be extensive and freewheeling. And victory for Republicans and President Donald Trump is not guaranteed. (Ohlemacher, 7/26)

Once the Senate burns through its 20 hours of debate, split among Republicans and Democrats, it goes to a vote-a-rama, which at this point looks like it will be late Thursday. Theoretically that allows for unlimited amendments as long as they are relevant. But probably a few dozen will be voted on. (Demko, 7/25)

The Senate is expected to vote midday Wednesday on an amendment that would create a clean repeal of the Affordable Care Act that wouldn’t take effect for two years. The delay is intended to give lawmakers time to come together on a replacement plan before people lose their health care. But even with conservative support, the clean repeal is not likely to pass because at least three Republican senators — Susan Collins of Maine, Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia — have all said they wouldn’t vote for a repeal without a replacement. Other lawmakers have also expressed concern. (Collins and Shesgreen, 7/25)

Based on what senators were saying on Tuesday, here are some of the plans and amendment likely to come up for debate or a vote — potentially in different combinations — in coming days. (Goldstein and Winfield Cunningham, 7/25)

Under the procedural rules Senate Republicans have adopted to pass health-care legislation with a simple majority, rather than the 60 votes usually needed, they are limited in how much of the ACA they can repeal. Any measure must be generally related to taxes or spending. So only parts of the ACA can be knocked down, and only certain kinds of replacements can be proposed. (Armour, 7/26)

Senate Republicans are working to adapt two key anti-abortion provisions in the Senate health care bill in an effort to salvage the language and please conservative groups. On Friday, Parliamentarian Elizabeth MacDonough said the language that blocks Medicaid reimbursements for Planned Parenthood and prevents tax credits from being used for insurance that covers abortion would violate budget reconciliation rules as currently written. (Raman, 7/25)

Senate Republicans have embarked on an unpredictable and potentially chaotic floor debate aimed at repealing Obamacare amid significant doubts that they can muster 50 votes to pass any kind of health bill. GOP leaders will hold votes on a slew of different health bills to see how close they can get to passing something. The debate -- which will be punctuated with skirmishes over obscure rules and parliamentary challenges -- will culminate in an all-night "vote-a-rama" later this week that could feature dozens, or even hundreds, of amendment votes. (Edney, Litvan and Tracer, 7/26)

The Senate voted Tuesday to begin debate on repealing the Affordable Care Act. On Tuesday night, the Senate failed to pass one of three proposals, a revised version of its plan to repeal and replace the current law. Here are the next steps. (Park, Parlapiano and Sanger-Katz, 7/25)

So the Senate has voted to start debate on a bill to replace the Affordable Care Act. Now what? Well, it gets wonky. The rules for budget reconciliation, the process the Senate is using that limits debate and allows a bill to pass with only a simple majority, comes with a set of very specific rules. Here are some of the big ones that could shape whatever final bill emerges. (Rovner, 7/25)

If the current options for overhauling the health care system can’t get a majority of Senate votes, the majority leader, Mitch McConnell, has a new backup plan, according to senators and lobbyists: a simple bill that eliminates three of Obamacare’s least popular provisions. The plan, which has been nicknamed “skinny repeal,” would eliminate the Affordable Care Act’s individual mandate, the employer mandate and a tax on medical devices, at least for a few years. (Sanger-Katz, 7/25)

In substance, this plan would repeal just three parts of the ACA, according to several sources familiar with the approach. It would eliminate the requirement that most Americans carry health insurance as well as the requirement that employers with at least 50 full-time employees offer coverage to their workers. Both are central elements of the 2010 health-care law and its least popular aspects with the public. The “skinny” plan also would rescind the tax on medical devices, one of several taxes the ACA created to help pay for other elements of the law. A close variant of this surfaced two years ago in the House, as part of the GOP’s strategy back then to lower federal deficits. Congressional budget analysts estimated at the time that 15 million fewer Americans would have insurance coverage “most years” as a result. (Goldstein, 7/25)

Experts warn, though, that repealing the individual mandate without any replacement measures would destabilize the insurance market and spike premiums. (Sullivan, 7/25)

The plan wouldn't touch Obamacare's Medicaid expansion, making it more palatable to Senate moderates. But it could trigger significant resistance by preserving the ACA's insurance regulations, which senators like Mike Lee of Utah and Rand Paul of Kentucky have insisted need to be struck down. "How do the ultra-conservatives vote for it?" asked one former Senate Republican aide. (Diamond, 7/25)

Moderates may be concerned the “death spiral” would hurt too many people in the individual market. (Soffen and Schaul, 7/25)

Senate Republicans would likely go for a bare-minimum “skinny repeal” only if other approaches ... cannot win approval. (Abutaleb, 7/25)

There aren’t a lot of Colorado-specific numbers yet on the impacts of a repeal of the individual mandate, but there are two areas of concern in addition to rising costs. First, with more people uninsured, hospitals could be on the hook for providing more care that they don’t get paid for. That could threaten some hospitals’ ability to remain open. Second, if insurers are spooked by federal policy changes, they could bolt from the state as early as this year, leaving people shopping on their own for health insurance with fewer — or no — choices. (Ingold, 7/25)

Obamacare had been unpopular for at least the past four years, opinion surveys shows, suggesting that their move to change the law would draw public support. But the Senate action comes amid increased public backing for the 2010 health law—as well as for the idea that the government should play a role in helping people obtain health insurance. That is one reason that moving an overhaul of the law through Congress has been so balky for the GOP. (Chinni, 7/25)

Ahead of a Senate vote to begin debate over health care, President Trump pressed Republicans on Monday afternoon to fulfill their seven-year promise to repeal and replace the Affordable Care Act, surrounded by families whom he characterized as “victims” of the law.“ For 17 years, Obamacare has wreaked havoc on the lives of innocent, hard-working Americans,” he mistakenly said of the law, passed in 2010, before listing “terrific reforms” in the Senate bill. Here’s an assessment. (Qui, 7/25)

Senate efforts have failed so far for a variety of reasons. But here’s one that hasn’t yet been explored: local television news. That drumbeat of coverage in their home districts during Senate debates may have made some GOP senators think twice about angering constituents — including those of their own party. (Fowler and Gollust, 7/26)

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. (Long, 7/25)

Projections that the Obama administration’s signature health-care legislation would drive workers out of the labor force have proved wrong, according to a new paper by researchers at Stanford University. (Derby, 7/25)

Just hours before Senate Republicans are expected to take a crucial first vote on repealing Obamacare, one health insurer is saying that its big bet on the health insurance law has been paying off. Centene Corp. beat Wall Street’s earnings estimates for the second quarter, and said that much of its strength came from the company’s Affordable Care Act marketplace health plans, where the insurer has about 1.1 million of its 12.2 million customers. (Tracer, 7/25)

One of the biggest insurers in the Affordable Care Act's marketplaces is warning the federal government that it must preserve cost-sharing payments for low-income customers to avoid hurting millions of people. Centene Corp. said Tuesday that a better-than-expected performance in those individual insurance markets prompted it to beat Wall Street expectations in the second quarter and raise its forecast for 2017. (7/25)

Dr. Ann McKee, a neuropathologist, has examined the brains of 202 deceased football players. A broad survey of her findings was published on Tuesday in The Journal of the American Medical Association. (Joe Ward, Josh Williams and Sam Manchester, 7/25)

In the 202 total brains belonging to men who played football on all levels, researchers found CTE in 177. Out of the 14 brains of men who only reached the high school football level, three brains were diagnosed with CTE. Forty-eight of 53 brains belonging to men who stopped playing football after the college level also were also diagnosed with CTE. (Culpepper, 7/25)

"While we still don't know what the incidence is in the general population or in the general population of football players," [Dr. Ann McKee] says, "the fact that we were able to gather this many cases [in that time frame] says this disease is much more common than we previously realized." (Goldman, 7/25)

Even those with mild CTE had suffered from disabling mental problems, including agitation, impulsivity, explosive tempers, and memory loss. More than half contemplated suicide. Suicide, in fact, was the leading cause of death among those with mild CTE. (Freyer, 7/25)

The quality of sperm from men in North America, Europe and Australia has declined dramatically over the past 40 years, with a 52.4 percent drop in sperm concentration, according to a study published Tuesday. The research — the largest and most comprehensive look at the topic, involving data from 185 studies and 42,000 men around the world between 1973 and 2011 — appears to confirm fears that male reproductive health may be declining. (Cha, 7/25)

Last month, a few minor blisters turned into a flesh-eating nightmare for hiker Wayne Atkins, who developed a dangerous bacterial infection after climbing Mount Garfield, a 4,500-foot peak in New Hampshire. Atkins survived, but barely: He spent 2 1/2 weeks in a medically induced coma while doctors pumped him full of antibiotics and removed chunks of his flesh to get rid of the infection. And Atkins was lucky, relatively speaking: Infection with flesh-eating bacteria is considered a surgical emergency, and can require limb amputation. One in four people with necrotizing fasciitis dies. (Caruso, 7/25)

The tragic spectacle of the legal battle over Charlie Gard, the 11-month-old British baby whose genetic disease has inflicted catastrophic and irreversible brain damage, appears to be drawing to a close. ... But perhaps most troubling of all for me is the abuse of the nurses and other medical staff caring for Charlie, who has lived nearly his all his days on life support and mechanical ventilation. (McLean, 7/25)

Much of the scientific research on resilience — our ability to bounce back from adversity — has focused on how to build resilience in children. But what about the grown-ups? (Parker-Pope, 7/25)

If you're involved in high school athletics, you know the scene. There's increasing pressure to specialize in a single sport and play it year-round. The upside? Focusing on one sport can help give kids the edge they need to compete on elite club teams — or travel teams. Many athletes hope to attract the attention of college recruiters, or be offered a sports scholarship. This emphasis on competitive success has become widespread throughout the U.S., according to a consensus statement from the American Medical Society for Sports Medicine. (Aubrey, 7/25)

The company that manufactured experimental stem cell medicine for several aging sports heroes is facing several complaints in court for large unpaid bills, as well as a complaint by an investor who accuses the company of misusing funds and fraud. (Schrotenboer, 7/25)

Missouri lawmakers on Tuesday delivered Republican Gov. Eric Greitens a political win by sending him a wide-ranging bill tightening abortion regulations that would give the attorney general power to prosecute violations, prompting critics to say the changes are aimed at limiting access to abortion in a state that already has tough restrictions. (Ballentine, 7/25)

Physicians will have to meet with women seeking abortions three days before the procedure and Missouri’s attorney general will have the ability to enforce abortion laws under the bill headed to Gov. Eric Greitens on Tuesday. ... Supporters say the legislation, sponsored by Sen. Andrew Koenig, R-Manchester, will make clinics safer, while critics contend it will make it harder for women to obtain abortions. (Rosenbaum, 7/25)

The Texas Senate gaveled in around 10 a.m. Tuesday, but it wasn't until past midnight that lawmakers turned their attention to Senate Bill 4, an anti-abortion measure that was initially approved over objections from Democrats. Passed in a 21-10 vote, the measure prohibits local and state government agencies from contracting with abortion providers and their affiliates. (Smith and Najmabadi, 7/26)

Colorado’s health insurance exchange has made progress in addressing repeated accounting troubles but still fails to always follow its own policies when it comes to contracts and purchases, according to a state audit released Tuesday. The audit of the exchange, known as Connect for Health Colorado, found that 11 percent of payments analyzed — which came out to about $50,000 — did not have the proper documentation. The same was true for nearly $4 million in contract costs. In one instance, the audit found that Connect for Health’s general counsel signed off on a nearly $3 million database contract despite not having the authority to do so for contracts that big. (Ingold, 7/25)

A rampant heroin and opiate epidemic on the Red Lake Indian Reservation has prompted tribal leaders to declare a public health emergency, seek outside help in addressing the crisis and consider the extraordinary step of banishing tribal members involved in drug dealing. ... Overdoses on the northern Minnesota reservation have increased significantly in the past few months, tribal leaders said, adding that the problem has worsened with the arrival of more heroin and more of it laced with deadly fentanyl. (Smith, 7/26)

The police officer who last year questioned the then-dean of USC’s medical school about his role in the drug overdose of a young woman expressed skepticism at Dr. Carmen Puliafito’s account, according to an audio recording that was made by the officer and released Tuesday. Puliafito told the officer he was at the Pasadena hotel room where the overdose occurred as a family friend to help the woman, who was later rushed to Huntington Memorial Hospital. (Elmahrek, Pringle, Parvini and Hamilton, 7/25)

Jackson Health System is counting on growth in its core operations — plus an estimated $442 million from Miami-Dade taxpayers — to break even on a proposed $1.9 billion spending plan for 2018 approved by hospital trustees on Tuesday. Salaries and benefits for Jackson’s 12,000 full-time employees, who will receive an average 2 percent pay raise next year, tops the hospital system’s list of expenses for next year at about $1.1 billion or 59 percent of the total. (Chang, 7/25)

Opponents of restricting menthol tobacco sales in Minneapolis claimed victory Tuesday after a City Council committee failed to vote on the ordinance and send it to the full council, though members will vote on the proposal Aug. 2. An already-depleted Health, Environment and Community Engagement Committee fell to three members and lost its quorum when Council Member Alondra Cano stepped out near the end of a lengthy public hearing, delaying the vote. (Belz, 7/25)

Twice as many United States women are dying in childbirth today as in 1990, even though all other wealthy nations have seen declines in maternal mortality rates. ...Dr. Shilpa Babbar, who specializes in high-risk pregnancies at SSM Health St. Mary’s Hospital in St. Louis County, said that rising rates of obesity and women having children later in life may help explain these figures. (Bouscaren, 7/26)

Boston Children’s Hospital plans to make complex heart treatment for children available to more patients through a new collaboration with the Cleveland Clinic, the hospitals announced Wednesday. In its latest move to grow out of state, Children’s will become a part of the Cleveland Clinic’s national network of cardiovascular care providers. (Feiner, 7/26)

A nonprofit that serves Central Florida residents with HIV and AIDS says the rates are going up. ...[Joshua] Meyers said the Ryan White figures show 600 new HIV infections in Orlando last year, which made Orlando the city with the sixth highest infection rate in the country – up from No. 8. (Aboraya, 7/25)

The State Water Resources Control Board on July 18 adopted the strictest possible standard (5 parts per trillion or less) for the contaminant in public drinking water. ...Statewide, the tap water of about a million Californians is known to contain TCP at levels higher than that, according to data from the state water board. (O'Neill, 7/25)

Minnesota's public drinking water supplies are in good shape, according the state's Department of Health, but a new report also warns agencies should remain prepared for that to change. ...Minnesota also needs to be prepared to address other pollution in the water supply, including nitrate contamination, which the report states is an ongoing concern for a several areas of the state. (Richert, 7/25)

Facing changing demographics and a steep dropoff in demand, the state’s oldest hospital will discontinue maternity care this year. HealthEast Care System’s St. Joseph’s Hospital made the move because fewer women are choosing the St. Paul facility for their baby deliveries. Health system leaders announced the decision Tuesday, noting that women will still be admitted for maternity care through Sept. 7 and that babies will still be delivered until Sept. 10 at HealthEast’s flagship hospital — Minnesota’s first hospital when it was founded in 1853. (Olson, 7/25)

The Texas Senate on Tuesday approved legislation to give teachers bonuses and to improve retired teachers' health benefits — but only after the bill's author removed a controversial provision requiring school districts to cover the cost of teacher pay raises. The upper chamber voted 28-3 to give initial approval to Senate Bill 19, authored by Sen. Jane Nelson, R-Flower Mound, which would borrow money from the Texas Health and Human Services Commission to pay for $193 million in statewide teacher bonuses and inject $212 million into a faltering state-run health insurance program for retired teachers. (Swaby, 7/25)

Minnesota’s oldest hospital will no longer be a destination to deliver babies. St. Joseph’s Hospital in downtown St. Paul will close its maternity ward Sept. 10, according to Fairview HealthEast, which operates the 164-year-old downtown hospital. The decision comes after HealthEast merged with Fairview Health Services earlier this year and is the result of mothers choosing to give birth in the suburbs, according to a Fairview HealthEast statement Tuesday. (Orrick, 7/25)

A Kansas City team this week won an award from the Robert Wood Johnson Foundation for developing a robotic chat app that could steer you to a place where that prescription won’t break your budget. Project Helix — a collaboration of KC Digital Drive and two consulting outfits — aimed to help patients navigate the dizzying worlds where prescriptions, pharmacy prices and often inscrutable insurance plans overlap. (Canon, 7/25)

Three Milwaukee-area industrial barrel refurbishing plants have been cited by state regulators for violating 19 environmental laws, including misrepresenting information and sending hazardous ash to a landfill not permitted to handle such waste. Inspectors found that the plants handled, stored and shipped hazardous waste without permits, failed to keep numerous required records, and continued to spew putrid odors over neighborhoods three years after similar smells were noted by inspectors. (Diedrich and Barrett, 7/25)

Democrats are going straight at one of the top concerns of voters, using the rising cost of drugs to strike a more populist tone and counter President Donald Trump, who campaigned hard against the power of the drug industry, but took a friendlier stance after taking office. Congressional Democrats [on Monday] laid out a three-pronged approach to lower the cost of prescription drugs in the United States that aims to stop large price increases and give the federal government more power to influence what Medicare pays for medicines. (Karlin-Smith, 7/24)

Democrats are proposing an independent agency to tackle the high cost of prescription drugs. The director would be appointed by the president and confirmed by the Senate, charged with investigating drug manufacturers and able to slap fines on companies with exorbitant rate hikes. Pharmaceutical companies would also be required to notify the government of substantial price increases. (Mui, 7/23)

Awhopping $450 billion was spent in the United States on prescription drugs last year. Topping the list, perhaps unsurprisingly, are medications whose patents were still in force or had recently expired. When a patent expires, generic versions — or biosimilar versions of biologic drugs — can become available, driving down costs that in turn make them accessible to more patients. (Blau, 7/25)

The idea is to break a logjam caused by an FDA program that is designed to boost safety. Typically such a program, known as a Risk Evaluation and Mitigation Strategy, requires drug makers to develop a plan to educate doctors and monitor distribution. But generic companies claim they have been denied samples of brand-name drugs needed to conduct product testing in order to win FDA approval. Brand-name companies argue that REMS programs do not permit such sharing. (Silverman, 7/19)

As part of their newly unveiled “Better Deal” agenda, congressional Democrats are pledging to tackle one of healthcare’s thorniest issues—the high cost of prescription drugs. “Right now, there’s nothing to stop vulture capitalists from egregiously raising the price of life-saving drugs without any justification,” Senate Minority Leader Chuck Schumer, D-N.Y., said during a press conference Monday. (Small, 7/25)

In a blow to the pharmaceutical industry, Ohio state officials have approved a controversial initiative designed to lower drug prices for the November ballot. Known as the Ohio Drug Price Relief Act, the ballot measure would require state agencies to pay no more for medicines than the Department of Veterans Affairs. The agency currently gets a 24 percent federally mandated discount off average manufacturer prices. (Silverman, 7/21)

The conflicting claims in the prescription drug issue that will be on the Ohio ballot in November are enough to cause a headache. Or even something requiring a prescription. The most recent flurry of ads last week on broadcast television attacked the previous flurry of TV ads, each accusing the other of deceptive tactics to manipulate Ohio voters. What to believe? (Troy, 7/24)

“Pharma Bro” Martin Shkreli has kept up his trademark trolling on social media during his securities fraud trial — calling the case “bogus” — but the jury won’t hear him defend himself in court. The government’s last witness testified on Tuesday, a day after a lawyer for the former biotech CEO told the court that his client had chosen not to take the witness stand. Closing arguments are expected later this week. (Hays, 7/26)

Once again, a controversial rule for updating generic drug labeling is being postponed, but this time, its chances of being implemented appear slimmer than ever, according to consumer advocates. The rule was proposed four years ago by the Food and Drug Administration in an effort to bolster patient safety. Specifically, the rule would allow generic drug makers to independently update safety warnings, something only brand-name drug makers can currently do before receiving FDA permission. (Silverman, 7/24)

For a time, high drug prices made headlines, and it looked like the issue could be tackled by the Trump administration. But as we all know, efforts to repeal Obamacare have consumed Republicans much of this year. The drug problem hasn’t gone away; it’s just lingering in the background. Even the cost of some generic drugs are rising. (Gornstein, 7/25)

The Food and Drug Administration will delay issuing furlough notices to employees whose salaries depend on congressional action renewing the agency’s fee-collection authority, FDA Commissioner Scott Gottlieb announced Monday in an email obtained by CQ. Gottlieb’s announcement effectively gives Congress until Sept. 30 to pass a bill that would provide the agency with about $1.4 billion in annual funding through fiscal 2022 from the prescription drug and medical device industries. That money mostly goes to the salaries of employees who review medical product applications. Lawmakers previously believed the agency would begin issuing furlough notices 60 days before funding lapsed on Sept. 30, and were aiming to finish work on the bill by late July. (Siddons, 7/24)

U.S. Food and Drug Administration Commissioner Scott Gottlieb spoke with Bloomberg News about drug pricing, new medicine and regulations. This transcript of the interview has been edited for clarity and length. (Edney and Mattingly, 7/24)

At a swanky hotel in the Theatre District, about a dozen health policy experts and drug development academics gathered Wednesday to talk drug pricing. Speakers on the Manhattan Institute-curated panel see a future where the amount of money people pay for pharmaceuticals has something to do with how much “value” they provide — but seemed to have more questions than answers about what that actually means. (Swetlitz, 7/19)

The pharmaceutical company Celgene has agreed to pay $280 million to settle claims that it marketed the cancer drugs Thalomid and Revlimid for unapproved uses, the company said on Tuesday. Under the terms of the settlement, which resulted from a lawsuit filed by a whistle-blower — a former sales representative at Celgene — the company will pay $259.3 million to the United States and $20.7 million to 28 states and the District of Columbia. (Thomas, 7/25)

An experimental HIV pill from Gilead Sciences suppressed the virus in newly diagnosed patients at a rate statistically equivalent to that of a similar, rival drug from GlaxoSmithKline, according to results from a late-stage clinical trial presented Monday. The positive data supporting Gilead’s new HIV pill, a second-generation integrase inhibitor called bictegravir, are vitally important to the Foster City, Calif.-based biotech company. Sales of Gilead’s hepatitis C drugs are falling and its oncology pipeline has largely disappointed, so the company is once again reliant on its HIV business for the majority of its profits. (Feuerstein, 7/24)

In a split decision, a federal jury in Chicago ordered AbbVie to pay $150 million in punitive damages for fraudulently misrepresenting the risks of its AndroGel testosterone replacement drug. But at the same time, the jury decided the drug maker was not liable for a heart attack that the plaintiff, Jesse Mitchell, suffered after taking the medication. The trial was the first in an estimated 6,000 lawsuits that the drug maker faces over its controversial marketing, which warned that low testosterone can interfere with sex drive, moods, and energy levels. However, the increased usage was accompanied by dueling medical studies — and subsequent debate — over the extent to which AndroGel and other such drugs could increase cardiovascular risks. (Silverman, 7/24)

Vertex Pharmaceuticals Inc. on Tuesday released clinical findings showing its new approach to combating cystic fibrosis substantially improved lung function in patients, lifting hopes for a treatment that could be used by about 68,000 people worldwide — including 24,000 who don’t respond to any existing medicines. The results prompted Boston-based Vertex to say it plans to launch one or two late-stage clinical trials of the biotech’s three-drug combination in the first half of next year. (Weisman, 7/18)

Merck’s checkpoint inhibitor Keytruda doesn’t help patients with advanced head and neck cancer live longer, but the failed phase 3 clinical trial, announced Monday night, won’t compel the FDA to rescind the drug’s conditional approval, the company said. And with that, the pile of evidence pointing towards FDA’s extreme flexibility when it comes to easy drug approvals grows even larger. (Feuerstein, 7/24)

Scott Gottlieb, head of the Food and Drug Administration, wasted no time in his opening remarks at a forum last week on high drug prices. “The fact is that too many people can’t afford the medicines that they need,” he declared. On that, I hope, we can all agree. (David Lazarus, 7/25)

In 2014, when Greg Jefferys’s urine started smelling like dead meat, he knew there was something seriously wrong. For weeks, Jefferys, an Australian then 60 years old, had felt fatigued and noticed that just a slight bump would leave a dark purple bruise on his skin. Blood tests revealed to Jefferys that he had chronic hepatitis C – a disease he’d never heard of. (Sophie Cousins, 7/25)

Back in Sacramento, drug companies fight to kill Senate Bill 17, which would force some transparency in drug pricing. ... It would apply to drugs that cost more than $40 a month and would require drug companies to issue 60-day notices when they intend to raise prices by more than 10 percent over a two-year period. (7/24)

Drug pricing is a topic commanding a lot of attention these days, particularly as healthcare in the U.S. is a national focus. The debate isn’t simple. The ways that drugs are distributed and paid for in this country can be best described as convoluted. Froma Harrop, a nationally syndicated, award-winning columnist who focuses on the financial world, has recently weighed in on this discussion with her op-ed “America’s addiction to abusive drug pricing.” Given her reputation, one would expect that her views would add substance to the debate. Instead, her op-ed is fraught with inaccuracies. (John LaMattina, 7/19)

After years of failed efforts, the California Legislature may finally pass a bill that responds to the problem of rising prescription drug costs. But temper your enthusiasm: Though this measure (SB 17) has been fiercely resisted by the pharmaceutical industry, it wouldn’t actually stop manufacturers from raising their prices as high as they think the market will bear. It would just make them reveal more about the cost and value of their drugs as they do so. (7/24)

Anyone who's attempted to read the tea leaves on this bill has long since smashed their cup against the wall. The Senate voted to debate a bill; we just don't know what will be in it. There's no full text. There's been no Congressional Budget Office score of a final proposal. There hasn't been a single public hearing. And there's no certainty Senate Majority Leader Mitch McConnell can get 50 votes together on anything other than a discussion of an intentionally amorphous bill. We're in the health-care twilight zone. (Max Nisen, 7/25)

In January 1988, in Ronald Reagan’s final State of the Union address, he noisily dropped on a table next to the lectern in the House chamber three recent continuing resolutions, each more than a thousand pages long. Each was evidence of Congress’s disregard of the 1974 Budget Act. (George F. Will, 7/25)

Ignoring overwhelming public opposition to legislation that would destroy the Affordable Care Act, Senate Republicans voted on Tuesday to begin repealing that law without having any workable plan to replace it. The majority leader, Mitch McConnell, browbeat and cajoled 50 members of his caucus to vote to begin a debate on health care without even telling the country which of several competing bills he wanted to pass. Vice President Mike Pence provided the tiebreaking vote. (7/25)

Mitch McConnell, the Senate Republican leader, proved an old adage wrong on Tuesday. Sometimes, it turns out, you can beat something with nothing. After weeks of negotiations toward a Senate bill to repeal Obamacare, Kentucky Sen. McConnell was at an impasse. He couldn’t amass a majority for any of several competing proposals to replace Obamacare. Nor could he attract a majority for “repeal and delay,” a punt that would declare the program dead, but leave it in place for two years. (Doyle McManus, &/25)

In 2009 and 2010, Republicans complained bitterly that a major health care overhaul was being rammed through Congress without their input. Their objections were somewhat off base. The Affordable Care Act, which came to be known as Obamacare, borrowed heavily from a 1990s Republican bill, included multiple GOP amendments, and sprang initially in the Senate from a bipartisan group of six. (7/25)

We recognize that securing Americans’ health care future is absolutely paramount. The Senate can now vote on a variety of bipartisan proposals and amendments to ensure that every American has access to quality, affordable care. The process of repealing the Affordable Care Act began in November 2010, when voters across the country rejected the bill and sent the largest freshman class since World War II to the House of Representatives. (Sen. Tim Scott, R-S.C., 7/25)

Louisiana Republican John Kennedy cracked to Politico this week that “the sight of the gallows focuses the mind,” and perhaps that explains why after months of group therapy Senate Republicans finally voted Tuesday to open debate on repealing ObamaCare. Whatever the impetus, the vote kept GOP reform hopes alive and may have saved the GOP Congress. (7/25)

Yesterday, Senate Majority Leader Mitch McConnell did the seemingly impossible and got the votes he needed to proceed to consideration of the House-passed plan for repealing and replacing the Affordable Care Act (ACA). At this point, it’s hard to tell what exactly will happen in the coming days, but there is one thing that is fairly certain: if the current Republican effort succeeds in passing a bill, the legislation will make the individual insurance market less stable than it is under current law. (James C. Capretts, 7/26)

It’s hard to ignore the irony of Sen. John McCain returning to Washington from cranial surgery at the Mayo Clinic just to keep alive a bill that would make health insurance unaffordable to millions of Americans. Had McCain (R-Ariz.) considered the symbolism of his actions more carefully, he might have lingered longer at the hospital. (7/25)

Americans are divided on what to do about health care, but they should be united in this conclusion: Senate Republicans’ manic approach to reforming a sector that represents one-sixth of the U.S. economy and determines life or death for millions of people is utterly craven and irresponsible. ...This is how Republicans are going to determine how Americans get their health care? (7/25)

It was always predictable Obamacare would collapse of its own weight because it centralizes health care in America, empowering the bureaucracy instead of doctors and patients. It has not controlled health care costs as promised. (Rick Perry, 7/25)

President Donald Trump raged against what he called “Obamacare lies” Monday, urging Senators to move forward on a repeal and replace plan for the Affordable Care Act. ...But the proposals put forth so far by Republicans, and backed by Trump, are estimated to leave tens of millions of Americans without health care and put tens of millions more with very limited coverage and at risk for bankruptcy should anyone in the family contract a major illness. (EJ Montini, 7/25)

As Sen. Susan Collins, a Maine Republican, said Sunday, if the Senate does open floor debate, it's unclear whether senators would be dealing with Paul Ryan's House-passed bill, Mitch McConnell's first, second or (unseen) third plan - or an ACA repeal, with a Senate promise to replace the law, eventually. ...That's also why Sen. Rob Portman, a suburban Cincinnati Republican who has spelled out his own careful stance on protecting Ohioans that he says will guide his vote, must vote "no" on moves by McConnell to force Senate action on an ill-considered, narrowly partisan package that would devastate health care in Ohio. (7/25)

Sen. Rob Portman cast the wrong vote Tuesday in supporting a hasty, politically motivated effort to allow Senate debate and, presumably, a vote on one or a series of ill-considered, narrowly partisan measures likely to devastate health care in Ohio. ...As Sen. Susan Collins, a Maine Republican who cast one of only two Republican "nos" on the Senate floor, said before the vote, no one even knew exactly what senators were being asked to debate and maybe vote on. (7/25)

My husband is a professor at Rutgers University in New Jersey, so I have a gold-plated health care plan that's similar in many respects to the insurance enjoyed by people who work for the federal government. In their case, no matter what plan they choose from the insurance smorgasbord, the feds subsidize 72% of the premium cost. (Jennifer Anne Moses, 7/26)

For seven and a half years, Republicans have campaigned and voted to replace the Affordable Health Care Act. When given a real chance at success, with governing control, they were impeded by a president who's ignorant on the issue. Then, after Republican senators slipped behind closed doors to come up with their own plans, they provided products that voters, even some Trump supporters, overwhelmingly spotted as frauds. (Albert R. Hunt, 7/25)

Republicans on the House Appropriations Committee offered some promising phrases when describing their fiscal year 2018 Labor-HHS budget: “Invest in essential health,” “focus investments in programs our people need the most,” and “targeting investments in … public health. ”House LHHS Subcommittee Chair Tom Cole concluded, “This bill is one that reflects the priorities that Americans value, and will continue to support the well-being of Americans through funding these vital programs.” (Clare Coleman, 7/24)

All eyes are on the Senate as it debates what to do about ObamaCare. But the House has a last chance this week to abolish one of the law’s most dangerous creations: a board with sweeping, unchecked power to ration care. The Independent Payment Advisory Board—what critics call the death panel—would be an unelected, unaccountable body with broad powers to slash Medicare spending. But the law contains a living will for IPAB. If the president signs a congressional resolution extinguishing the panel by Aug. 15, it will never come into existence. (Grace-Marie Turner and Doug Badger, 7/25)

Unfortunately, a federal advisory panel is urging lawmakers to cut Medicare Part B, the program that covers chemotherapies, immunotherapies and other advanced drugs that must be administered by doctors. If Congress implements this recommendation, these trends could reverse, as Wisconsin seniors would lose access to life-saving medications. (Sandra Gines and Carrie Riccobono, 7/25)

Kudos to those Democratic Missouri lawmakers who still have not given up on trying to stop Gov. Eric Greitens from single-handedly taking in-home and nursing care away from 8,300 seniors and disabled people. On Monday, several legislators asked the state to drop plans to request a federal waiver from the Centers for Medicare and Medicaid Services that would allow them to cut the program. (7/25)

The need for what we are calling medical “quality” is acute, yet the strategies employed to obtain it are destroying medicine. Patient outcomes are inconsistent, care varies depending on many factors outside of disease state, and the cost of our medical system is not sustainable. But to fix this, most health systems employ non-clinicians to audit charts while checking boxes such as “A1C<8%?” and “DVT prophylaxis ordered within 24 hours?” These non-providers then send threatening letters and cut salaries with “pay-for-performance.” Unsurprisingly, such efforts are not working, and only end up creating distorted physician-patient relationships. Yet, obtaining improved quality requires only a few key steps. (Kjell Benson, 7/25)

Despite its benevolent intention to help patients without approved treatment options gain access to drugs in development, right-to-try legislation threatens the integrity of clinical trials, which remain the safest way for patients to try experimental drugs. (Kelly McBride Folkers, 7/25)

StreetCred’s formula is simple. It takes advantage of the trusting relationships that families have with their pediatricians and makes productive use of the time typically wasted in doctors’ waiting rooms. In partnership with the IRS-sponsored Volunteer Income Tax Assistance program and other government agencies, StreetCred uses trained volunteers and staff to help families file taxes, attain tax refunds, and apply for anti-poverty government programs. (Andrea Levere, 7/25)

Early this week, nearly 100 people were found trapped in a sweltering tractor-trailer in San Antonio, Texas. Ten have died and others are in critical condition. Many were sent to local hospitals for treatment of severe dehydration and shock, medical conditions that are common in the emergency department. What may not be as obvious to emergency physicians is that these people are possibly victims of human trafficking. As physicians who have treated victims of human trafficking and research this scourge, we believe that this form of severe exploitation is under-recognized in health care settings and live are being lost because of that. (Abraar Karan and Hanni Stoklosa, 7/25)

TV personality Maria Menounos stunned fans when she announced this month that she was in recovery from surgery for a nonmalignant brain tumor, which she discovered while her mother was battling brain cancer. Perhaps most surprising was how quickly Menounos was treated. She explained to People magazine that when she told her mother’s doctor about her symptoms — headaches, dizziness, slurred speech — he immediately investigated what was wrong. (Emily Dwass, 7/26)

Attorney General Jeff Sessions has apparently learned nothing regarding the War on Drugs. He wants to re-escalate this failed policy at a time when many states are realizing its futility and trying to move in different directions. Drug treatment doesn't work 100 percent of the time, but it is certainly more effective (and less costly) than incarcerating people with this illness. And as long as there are addicts, there will always be dealers, so incarcerating dealers has little long-term impact on the drug problem. (Allen Hays, 7/25)

Representative David P. Linsky, a Natick Democrat, has filed legislation that would allow family and household members, police, district attorneys, and health care providers to go to court and seek “extreme risk protective orders” for individuals who pose a significant danger to themselves or others. The bill, which has raised the hackles of gun rights groups, stands up to constitutional scrutiny and builds in an important hearing mechanism before long-term restrictions can be imposed. (7/26)