From hospitals, doctors and patients, a last gasp of opposition to the Senate health-care bill

Just four days after Senate GOP leaders revealed their health bill this summer, Tucson Medical Center hosted a town hall thousands of miles away drawing roughly 700 people in person and 1,900 online. In its aftermath, hospital employees, doctors and members of the public sent nearly 2,900 emails to the state's two Republican senators, John McCain and Jeff Flake, urging them to reject any legislation that would jeopardize patient health care.

The move was like nothing the hospital had done before, said Julia Strange, the center's vice president for community benefit. While they had sponsored educational sessions on issues such as cardiac arrest and opioid abuse, "this was clearly different," she said - and when triple the number of expected attendees showed up, "We had to order extra cookies."

Most corners of the U.S. health-care industry have stood steadfastly opposed for months to Republican efforts to revise the Affordable Care Act. Patient advocate groups and Democratic organizers have crowded town halls since February to grill lawmakers. But in recent weeks, a last gasp of advocacy has come from an even wider range of groups and individuals trying to block the Senate health bill. Community hospitals have held information sessions. Pediatricians have starred in videos. Patient associations have flown in hundreds of Americans with chronic illnesses to meet with lawmakers and their aides.

These events, in turn, have generated tremendous public pressure on the senators who will decide over the next week whether their health bill will succeed or fail. The measure remained in trouble this week, with conservatives angling for a more dramatic repeal of the ACA and centrists saying the bill jeopardized coverage for too many Americans. President Trump even weighed in publicly Wednesday, telling senators he will be "very angry" if they don't pass a bill.

"It does make a big impact," Sen. Shelley Moore Capito, R-W.Va., said of the advocacy across the country. Capito is weighing whether she can accept phasing out Medicaid coverage for nearly 180,000 West Virginians, along with other changes. Last year nearly 18 percent of those Medicaid dollars paid for substance-abuse treatment; in recent days Capito has met with state officials as well as leaders of community centers and nursing homes who have warned about the impact of limiting Medicaid funding.

The push has touched other senators, too. Sen. John Hoeven, R-N.D., said in a statement that he has met with health-care leaders and particularly officials with rural hospitals, who "stressed the importance of stabilizing the health insurance market and also ensuring that low-income individuals have access to health care coverage either through Medicaid or refundable tax credits." Hoeven said over the July Fourth recess that he opposes the bill in its current form.

Senate Majority Leader Mitch McConnell, R-Ky., has spent days reworking portions of the legislation, diverting money from a planned tax cut to insurance premium subsidies and exploring whether to let insurers offer bare-bones plans on the ACA market. But he has done little to alter the proposed cuts to Medicaid or other provisions that have alarmed health-care providers and people with costly medical conditions. The new draft's details are expected to emerge Thursday when leaders disclose a revamped package.

The plan to phase out Medicaid expansion programs that were added under the ACA in 31 states and the District of Columbia - and to restrict government spending for the program starting in 2025 - has prompted pushback not just from liberal activists but virtually every influential player in the health industry, along with several Republican governors including Arizona Gov. Doug Ducey.

"We're a Medicaid expansion state," McCain told reporters Wednesday, adding that the bill would have to change to earn his vote. "I'm happy with the way it is in Arizona."

Several Senate Republicans said in interviews this week that they were committed to pressing ahead with their plan to revise the 2010 law known as Obamacare because they want to curb entitlement spending and address the needs of Americans whose premiums have soared since the law's enactment.

"It's a guaranteed financial crisis if we don't do something about our entitlement programs," said Sen. Patrick J. Toomey, R-Penn., who has pushed for indexing Medicaid to a lower inflation rate. "It's not a question of whether that happens, it's just a question of when, and how devastating that is."

John Thune, S.D., the Senate's third-ranking Republican, said Wednesday that when it comes to the bevy of interest groups weighing in, "Everybody's kind of getting numb to it."

But the opposition inside and outside the Senate remained formidable.

Hospitals who gave up some federal payments under the ACA in exchange for the promise of more insured patients have made a particularly impassioned case against the measure. Strange noted that Arizona froze Medicaid enrollment in 2009, and expanded the program at the end of 2013. The hospital's bill for bad debt and charity care dropped from $25.9 million in 2014 to $8 million in 2016: even though it paid $11.1 million to help pay for Medicaid expansion last year, it still ended up ahead.

Meanwhile, Valley Health CEO Mark Merrill, who runs two hospitals in West Virginia and another two in Virginia, just sent his third memo to employees Tuesday on how congressional Republicans' plans to rewrite the health care law could hurt both their patients and their business.

Twenty-five percent of his 5,500 employees live in West Virginia; he urged "those who are so inclined" to contact Capito and Sen. Joe Manchin, D-W.Va., "to advise them of your concerns and your objections to the BCRA."

"I wanted them to act armed with facts, so they could understand what this really means," Merrill said in an interview.

Still, these arguments have not swayed all the Republican holdouts: Sen. Ron Johnson, Wis., said in an interview that now that he has had more time to analyze the bill he is open to bringing it to the floor for a vote.

The idea that funding for Medicaid could be curtailed in the future is not a problem for him, he said: "It's really Medicaid expansion states that will have a problem," he said.

Capito, for her part, said her most influential conversations have been with parents who have lost children to drug overdoses who didn't get access to treatment. While she appreciates the fact that the revised bill will give more federal funding for opioids treatment, she noted that having a new facility won't matter if someone loses their health coverage.

"You're not going to access it," she said.

In contrast to the original fight to pass the ACA, the coalition of organizations pushing to preserve the law are broader than they were in the past. "Protect Patients First" encompasses most of the nation's most influential provider and disease advocacy groups: AARP, American Cancer Society Cancer Action Network, American Diabetes Association, American Heart Association, American Hospital Association, American Medical Association, Federation of American Hospitals, March of Dimes and American Nurses Association.

The coalition has already sponsored events in Ohio, Nevada, and Colorado and has another set for Thursday at a cancer-treatment center in Charleston, W.Va. AARP has launched a seven-figure ad campaign, with new radio and television ads targeting GOP Sens. Lisa Murkowski, Alaska, Cory Gardner, Colo., Dean Heller, Nev., Rob Portman, Ohio, and Capito this week.

The American Academy of Pediatrics held a call last month with more than 220 pediatricians, kicking off two days of action on June 15 and June 22 in which hundreds of doctors called their members of Congress to urged against passing the health-care bill. Nearly 100 doctors have posted videos on social media opposing the Senate bill and urging lawmakers to protect Medicaid. And more than 30 pediatricians wrote op-eds and letters to the editor that have been published in newspapers across the country.

Sue Nelson, vice president for federal advocacy at the American Heart Association, said the fact that more Americans are insured now has added an urgency to groups' efforts compared to the pre-ACA days.

"We also have so much more to lose now," Nelson said, citing a recent finding that the incidence of cardiac arrest significantly declined among middle-aged adults who got covered after the law's passage.

The country's biggest doctor groups, for their part, started plotting strategy just days after Donald Trump was elected president, when it was clear the ACA could be repealed. At a November AMA meeting, the presidents of four groups - the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists and the American College of Physicians - asked their staff to devise a legislative strategy. The American Osteopathic Association and the American Psychiatric Association joined them as well.

On Wednesday, leaders from the six groups shuffled from Senate office to Senate office, meeting with nine Republicans they hope could be influenced to vote against the Senate health-care bill.

They didn't meet with McConnell or his leadership team. Nor did they didn't get any solid promises from the rank-and-file to oppose the bill. But the senators generally listened and indicated they at least understood the concerns, said Jack Ende, president of the American College of Physicians.

"They didn't all say we're definitely voting no, but I think they listened and realized we have real concerns," Ende said. "I don't think we convinced everybody we talked to, but hopefully they know it will not be an easy vote."

Many of these advocates have been shut out from the start of the process. Former president Barack Obama and congressional Democrats spent much of 2009 seeking to cut deals with different segments of the health care industry - to deflect the kind of attacks that torpedoed the party's health-reform effort in 1994 and may do the same this year.

While McConnell had been pressing for a vote on the measure before the end of June, the delay gave opponents more time to marshal their arguments and make their case to lawmakers. This final lobbying push represents opponents' best chance of derailing McConnell's final drive to passage, which continues to look uncertain.