I'm Dan Diamond, a POLITICO reporter tracking the health care fight. AMA away.

What are some of the major issues with healthcare in the US that neither Obamacare (ACA) or Don.T. Care (AHCA) do not address but should?

Drug pricing is probably the biggest one. The Obama administration tried really, really, REALLY hard to get something done last year. It collapsed.

I wouldn't be shocked if Democrats eventually helped President Trump on some drug price fix.

How much money are healthcare industry lobbyists currently spending to influence the outcome?

Great question. There’s no reliable roll-up number, but certainly in the tens of millions and probably more than $100 million. Advocacy groups are doing everything from buying ads on “Morning Joe” and “Saturday Night Live” to sending direct mail and holding rallies.

At the same time, there’s a lot more money being spent on non-Affordable Care Act issues, which makes sense — the ACA is just one corner of health care. The pharmaceutical industry recently launched a gigantic campaign to try and repair their reputation (and hold off pressure on drug prices).

I think it would be a great benefit to everyone, public and those involved in the process and even the media as a whole, if the media stopped ignoring, or not talking specifically about, how much lobbying money is invested into the processes that govern this country.

What I mean is; every story about major issues should include a section that talks, in specifics, about how much money is being injected into the process. When various special interests open their checkbooks, media should track that money as best they can and talk about it. In detail. Not generalities.

"The X, Y, and Z special interests have been heavily opposing this bill..." is forgettable. "X, Y, and Z have spent tens of millions of dollars in the last ten days hosting fundraisers, buying advertising, making donations, etc... to oppose this issue" is specific and makes people specifically think about how their voice is being overridden by money.

"Everyone knows" special interests put their fingers on the scale. That's a generality. The media should make it a specific issue, and attach it to every story. Stop letting the interests hide in the background noise and call them out, constantly. If nothing else, it might make them divert some of their scale altering funds into protecting their own images.

Now, obviously I know the interests don't copy their expenditures to you or anyone else. But you can make estimates. Public records, campaign donations, hotel and catering expenses, how many ads in which markets/time slots at how much average cost, etc... Yes it requires some work. But media is supposed to be doing that kind of work, tracking information and sorting it for the public.

You're absolutely right on the value — and need — for transparency.

POLITICO's pretty good at this:

• We have a dedicated team on the lobbying beat; here's their morning newsletter

• My colleagues and I break a lot of health care-specific news in our own morning newsletters about advocacy groups' spending.

• And when we write a relevant feature, we always try and include context on why a group is supporting or opposing and when $$ are in play

I wish we had some ongoing, interactive database, though. That's a great idea.

I don't know if you're in a position to comment on the media side of things, but a quick look at Brietbart will tell you that over the last few days, stories increasingly critical of the bill have been on its frontpage. Do you think this indicates some type of pivot meaning that the "Trump wing" doesn't think this thing is going to pass and wants to preemptively do a sour grapes kinda thing/distance themselves from it? Or do you think there's no particular insight to be gleaned from the observation?

It's a good observation.

I read Breitbart every day now — which isn't something I would've said a few weeks ago — and it's amazing how critical the site has been of Republicans' health plan and specifically Paul Ryan's role.

I don't think it's been a recent pivot because the bill's odds have plunged, though. They've hated the bill since it was first being drafted, because in the eyes of Breitbart (and conservatives) it doesn't do enough to repeal the ACA right away. And Breitbart has always looked for ways to zing Ryan, who they don't trust.

In what ways do you read Breitbart and what recommendations about it would you give to others? I understand the need for differing perspectives to get a fuller picture, but is Breitbart the answer for the everyday person or are there better options?

I read them for a few reasons.

1) To see a conservative reaction to the news 2) To see their specific scoops — i.e., Rand Paul gave them a newsy interview where he said Paul Ryan was trying to "pull the wool over the eyes" of Trump on this health bill

I can't comment on all of Breitbart — I'm usually just parachuting in quickly to read their health care coverage.

But given all of the criticism I'd heard, one thing that's surprised me is that small details of their health care policy and politics coverage aren't so different from what you might read in the Associated Press. Senator X said this thing, Governor Y said another — they report a lot of things that are factually true.

The big difference is how they spin and frame the news. Their headlines can be especially provocative. That's not so dissimilar from their liberal counterparts, I think.

So if your media diet is overwhelmingly left-leaning news, I do think reading Breitbart can be a useful corrective. Also, their site is much cleaner and easier to use than some of their competitors.

Why all the brinkmanship right now?

With Senate passage looking increasingly unlikely (both for lack of vote count and by running afoul of reconciliation restrictions), the House 'victory' would be hollow at best. And even then, there's another 1 1/2 years before the midterms to hammer out more details and do some deal-making, maybe even (gasp!) across the aisle. Instead, it feels like everyone's painted themselves in a corner.

The brinkmanship is because of one person: Trump.

He's pulling power moves straight out of "The Art of the Deal." Those moves may work on Wall Street; the U.S. Congress is really, really, REALLY not designed for "take it, or leave it" deals that are dropped on them like this — especially when the bill has this much impact.

Thanks. I hadn't realized how heavy a hand he had in establishing the speed of the legislation, as well as the current now-or-never approach.

It felt like he had 'outsourced' the healthcare plan to Ryan and was only coming in to make sure that he 'wins' with something getting passed.

You're right — the bill's language is being driven by Ryan. But the "take it or leave it" approach today is all Trump. Ryan doesn't want to get embarrassed on the floor.

Honest question: Does Trump understand that legislation needs to pass both the House and the Senate?

Ha! The DC joke is that he doesn't know what's in the bill, but yes, he gets the process.

What Trump may be fully realizing is that he's not the CEO of America — Congress is its own branch, with its own workings, and they can push back. Like the House GOP is doing right now.

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You know, this is my first AMA, and I'm just glad to be here and appreciate questions from anyone who has them.

I can't speak for my colleagues, but I don't think I've ever interviewed or spoken to anyone at the DNC since coming to POLITICO.

Meanwhile, I host a weekly podcast for POLITICO and book my own guests — this month alone, 60% of my guests have been conservatives. (Including two CEOs of Koch brothers-affiliated groups and a former White House official in the Bush administration.)

If the AHCA is passed as currently drafted, who is the biggest winner and who is the biggest loser?

(For bonus points, same question if bill is brought to a vote and not passed.)

So many ways to answer this question!

Republicans, in some ways, could be short-term winners and long-term losers. They get the credit for passing a bill ... that will reduce coverage for lots of people and shake up the insurance market yet again. So they could get punished in upcoming elections.

But the insurance industry and certain businesses (i.e., restaurants) are probably best positioned to be the winners — the AHCA relaxes taxes and regulations that they hate.

Loser: Poor, unhealthy Americans who depend on various Affordable Care Act expansions and protections.

Hi dan. I'm from the UK so I know very little about the US health system. As you know, we have access to 'free' healthcare, paid for by taxes. It has always struck me as odd that the same system has not been implemented in the US. Can you explain why a tax funded health care system has not been implemented in the US?

Just to set context: Almost no expert thinks the U.S. health system is well-constructed, and our reliance on getting health care through our employers is a historic accident. (Based on a decision to make health benefits tax-exempt decades ago.)

The problem is the sheer inertia — this is the system that the health care industry, politicians, even patients have come to know, so it's very hard to shift away. Even if many Americans don't like the way that things work.

Meanwhile, the first political lobbyists helped come up with the idea of government health care = socialism. This is a great article on that. What’s odd is that many Americans who hate the concept of government-run health care ... get their health care through Medicare or the VA health system.

What are the political implications of this bill either failing of passing in the House? To what extent will this hurt President Trump, or confirm his status as the leader of the Republican party?

Bonus question: if this vote fails, will Ryan still be Speaker?

One of the big questions of the day around the Capitol... here's one way to think about implications of failure.

Meet a president who failed to pass health reform in his first year, despite big talk: Bill Clinton. He went on to serve two terms and strike tons of deals with the Republicans.

Meet a president who kept asking Congress to do health reform, but they wouldn't agree to his timeline: Barack Obama. Not only did he eventually get it done, ditto on the two terms yadda yadda

Now if the bill somehow passes in current form, we're in a new ballgame where the Senate parliamentarian will determine if the bill can even comply with budget reconciliation rules. Given state of play today, not sure it's worth going into political implications on that yet.

Re the bonus Q — NO IDEA. But the conservatives — who made the most trouble for Boehner, and are now agitating against AHCA — may be happy if Ryan finds a way to spin a dead bill as respecting their wishes.

Do we know how this is going to impact on women's rights to safe contraception and abortions?

The health bill defunds Planned Parenthood for a year, which would be a big hit to the poor, sometimes rural women who depend on PP for access to contraception and reproductive health care. Here's CBO's projection.

One of the most striking estimates from that CBO report: thousands more babies would be born, because those women wouldn't have access to contraception and abortions. For anti-abortion-rights groups, that was hailed as great news — and a major reason to support the bill.

But groups like NARAL and Planned Parenthood are furious and say that the bill will result in many unplanned pregnancies for women who aren't ready to be moms, with the various social and public health challenges that can go along with that.

Was there a driving force behind the massive turnover of House Republicans? (I think I saw that only 25% of the current reps, we're actually around for the ACA fight.)

That number's not quite right, unfortunately. To clarify — only 25% of GOP reps were around when they were in the majority, under a Republican president, to work on Medicare Part D in 2003. Link.

But you're right: There's been a fair amount of turnover since 2009, for a few reasons. First, there's natural shifting from retirements, or job shifts, or even challenges from other Republicans — like Dave Brat taking Eric Cantor's seat. Second and more importantly, the GOP has gotten bigger — they've taken dozens of seats away from Democrats.

Hi Dan,

Thank you for doing this AMA. I realize that you are probably here to discuss the repeal and replacement of Obamacare but I feel like when these things come up, other areas of healthcare get pushed to the shadows and not discussed.

One example is the healthcare of veterans. As a vet, I have an obvious bias but in my opinion, this is just as important as whether ACA is passed or not. I say that because we are losing veterans at an alarming rate due to the injuries they sustained while fighting to protect our liberties as US citizens; often time due to suicide. However, the VA’s efforts to treat these problems are severely lacking. If you don’t believe me, take a look at what some veterans are saying about their treatment and tell me this doesn’t seem like an issue to you.

What are your thoughts on how the Veterans Affairs is operating and what can we as a society do to improve it? Also, how, if any does the proposed AHCA impact the healthcare of veterans?

I'm happy to talk about anything! I'm not the world's greatest Redditor, but I know that much :)

I just talked to a ton of people about the VA health system and what's working and what isn't. Check the story out here.

The bigger question for vets right now isn't the AHCA — it's how many $$ the Trump admin is going to shovel, or not, into the VA to patch up its various systems. The budget that the White House proposed last week was fairly generous, though Congress doesn't have to go along with it.

Dan what is your daily routine? You seemingly never sleep.

It varies by the day, but there are a few constants.

• My number one job is to write the daily PULSE newsletter, which comes out at 5:45 a.m. For everyone's sanity, I usually start collecting "string" (a newsroom term for notes, quotes, thoughts, etc.) the afternoon before and try to have PULSE mostly done by 9 p.m. that night. I then dip back in around midnight to make sure nothing's missing.

• For the weekly podcast, there’s an ongoing mix of scheduling with guests, doing as much prep as possible, conducting the interview, and then helping produce it.

• I also do other things for POLITICO — like write feature stories and quick hits or moderate panels — and try and work those in when possible.

• I probably spend too much time on Twitter. But I learn so much and have so much fun doing it.

What I can't get in the whole discussion is who is checking on the health insurance prices? The same insurance offers less benefits with higher deductibles for ACA versus employer plans. Is there proof that the ACA insured are more sick than the others? and why in heaven prices went up in certain states and not in others? are those states much more sick?

There've been various reports that found the patient mix of people buying ACA plans is sicker than expected.

The reason why insurance premiums go up at different rates in different states is all about local market dynamics and political decisions. If there are more insurers in a given market, that can sometimes drive the price of premiums lower through competition. If there's a market like Alaska or Wyoming, where there aren't that many doctors around, the prices might be high for reasons that have little to do with the ACA.

And if governors decided not to expand Medicaid or fight the ACA, that can be a factor in driving up prices too. Link

Think the Wizards have a chance at winning it all this year?

I think the odds of the Republican health bill passing are roughly equivalent to the Wizards winning the title — probably not going to happen, but there’s a chance.

And they’re going to make it interesting.

P.S. One of my favorite days as a writer was covering the Supreme Court in the morning and the Wizards at night. Not as impressive as John Wall going coast-to-coast, but I can't think of too many reporters who get to pull off the court-to-court move.

Of the congressmen that you've interviewed that are undecided, what have been their typical reasons for and against supporting AHCA, and what solutions have they proposed?

Why they're FOR the bill - They campaigned to get rid of the ACA and they're worried about the consequences if they don't - They say that the government is spending too much money on Medicaid and other programs - "Freedom," or basically that the ACA's regulations are bad and need to go ASAP

Why they're AGAINST - Moderates are worried about the CBO projection that millions will lose their health coverage - Conservatives are worried that the bill keeps too many of the Affordable Care Act's regulations and coverage expansion and would amount to them voting to keep an entitlement program

We're not really in a solutions space right now, as leaders are whipping votes, but a few lawmakers say they wished there was more time to craft a better bill.

What do you think the implications of their struggles on healthcare are on tax reform, infrastructure spending, and other Trump initiatives? How do you see the rest of his legislative agenda going?

I mean, it's clearly bad news.

1) If the health bill collapses and there's a ton of finger-pointing, it gets a lot harder to win deals when trust is broken between the White House and Congress.

2) There's also a real impact on the calendar, with all kinds of Congress-only priorities looming — Gorsuch confirmation and budget battles, for instance.

3) The stumbles may also have broader impact on consumer confidence and investing — Wall Street already is getting nervous.

who are the least well-known congressmen who hold more power than would be expected on this issue?

Depends on how you define "least well-known" — there are big names like Greg Walden (chairman of the Energy & Commerce Committee, who played a key role in drafting the bill) who aren't known nationally.

Usually, folks who are in leadership or chairing subcommittees are the ones to watch — they often get those positions because of the perceived ability to bring others along.

On health care specifically, folks like Michael Burgess and Phil Roe are outspoken and have played big roles.

How long did it take you to compose your virtuoso tweetstorm comparing the healthcare vote to an episode of Arrested Development?

Not that long! Maybe 10 minutes?

I'd had this clip in my head all week — for obvious reasons — and when I had a few minutes after filing a story last night, I thought of a setup joke and then tweeted both of them out.

After a long week, folks seemed to enjoy the laugh, so I kept going. I think by the fourth or fifth tweet I had a general structure in my mind.

A twitter user joked that I kept pausing because I was thinking of new tweets. But it was mostly because I was working on other things — and it was taking a while for the videos to upload.

Does anyone ever try to tell the politicians voting for this bill the lives that will be lost by approving it? You mentioned in another question that those voting for it see it from the view of politics rather than the people, but has anybody ever confronted those politicians when they say something like that?

He's not a politician, but you can hear what happens when I asked the CEO of FreedomWorks — the influential conservative advocacy group, which wants to fully repeal the Affordable Care Act — what happens if one American dies as a result. Skip to 55:45.

Could I ask a non-healthcare question?

You mentioned the local joke that Trump doesn't know what's in the bill, and it brought up a question.

How do D.C. Reporters feel about Trump, the man? Is he the buffoon that everyone says? I live states away and will never meet him. I'd like an opinion of someone who actually has met him and/or his team. I'm wondering if the jokes are just exaggerations or is he really clueless? I mean it can't be that bad, right?

Also, I'm getting very worried that the press is being taken for granted. Vaya Con Dias. You have my support.

I've never interviewed Trump or talked to him off the record. But colleagues and friends who have say he can be personally charming and charismatic — but has very little grasp of policy and how the government works, and seems generally disinterested.

I have spoken to members of his team / White House staffers, and some of them are incredibly competent and smart. Though stretched very thin in many cases, given lack of staffing.

I think it's clear — and today's fiasco proves it — that Trump badly miscalculated how to work with Congress.

What would be the best way to end Princeton's Men's Basketball dominance in the Ivy League?

Do what Harvard did, when they started to conquer the league five years ago.

Do most of them care about the projections showing 24 million to be kicked off health care or are they afraid of they don't "repeal Obamacare" they'll stunt the new administration? Are they worried about midterm backlash if it passes or are democrats likely to lose more seats instead?

Some GOPers do care about the CBO numbers — it's cost them key support.

I wrote a story for POLITICO (behind the firewall) about what I called the Cold-Feet Caucus. In several significant cases, Republicans who voted for the bill in committee before the CBO score came out later said they couldn't vote for the bill on the floor.

But there's also a general mistrust of CBO and polls among many rank-and-filers. That's not new; Democrats have taken shots at the agency over the years too. But some of it, frankly, is that a lot of the relatively new GOP congressmen just don't understand health care. It's not a core issue for Republicans. And if you have a conversation that goes beyond talking points, that comes out pretty quickly.

One more factor: Many in the House GOP have little faith in analysts' projections ... and after Trump's surprise victory, some of that cynicism is understandable.

Given that it's the first midterm under a very unpopular president, I think Dems are likely to gain seats almost no matter what if Trump stays this controversial.

Presuming we take Trump at his word and Congress passes the AHCA in some form or we're 'stuck' with ACA/ObamaCare, --should AHCA fail-- what tools are available to Congress/POTUS to do as much 'damage' as possible to ACA/ObamaCare to hasten its demise/unpalatableness without extraordinary legislative action? In other words, if ACHA fails what could be realistically accomplished through executive action, regulations, red tape, budgeting, et cetera that could damage the ACA/OCare/Exchanges and therefore healthcare access for millions of Americans?

WorldsOkayestDad, I can't imagine you're my dad, but thanks for asking a question that's perfectly timed for me.

I just wrote a big story for POLITICO yesterday on how the White House is already weakening the ACA and its exchanges. You can read that story here!

Will the GOP try again if this bill fails?

Taking my reply with the giant salt shaker that all political reporters should carry with them after last year's embarrassing predictions... I think so, eventually. You can't promise for seven years to repeal the ACA and then not do something.

The most interesting scenario, in my mind, is some smaller compromise that cuts out conservatives and brings in some Democrats to "repair" the Affordable Care Act's known problems while "repealing" a few small parts of it that nobody likes. We're a long way away from that scenario, though.

FAKE NEWS!!!

WAIT, do we yell that first or are we supposed to read something first? Stuff is hard!

You know, I interviewed Zeke Emanuel this week and even he yelled that at me first. I think that's just how you greet reporters in 2017.

What is Trump's relationship with the Freedom Caucus and what role will the Caucus play in the Trump Administration?

Because of the Freedom Caucus's hardline brand of conservatism, does this put them in opposition to the Trump presidency? Will that mean they will play a bigger role in today's politics as "anti-Trump" Republicans, or can the House pass legislation without them altogether?

Your user name totally threw me for a moment. Is this answer going to be on air tomorrow???

No one knows what happens next. Freedom Caucus members have been key Trump allies for a long time — they seemed simpatico on some big conservative ideas. And as caucus chairman Mark Meadows noted, he was Trump's lone supporter in North Carolina for a while. Caucus co-founder Mick Mulvaney is Trump's budget director.

But if this bill dies because of the Freedom Caucus and Trump remains famously vindictive ... sheesh.

There are lots of ways the health bill, and the Trump presidency, could go. There's a world where he somehow works out a deal with the caucus on health care and tacks further to the right. There's also a world where Trump ends up closer to the middle, just for the sheer ability to get stuff done. Since there are only ~35 members of that caucus, and if you can get Dems or centrists on board, it's not impossible to get legislation through.

How do you get a job as a reporter? They seem like an endangered species. But I'd so love to do it more than anything else's on earth.

It's a great job.

Yes, you're stressed by deadlines all the time; the daily routine is almost never glamorous; it sometimes seems like your work has no impact and is pointless; and sources (at least in politics) yell at you in private and attack you in public. (The Internet isn't always forgiving, either :)

And yet it's so much fun. Especially when your journalism shifts the world, even just a smidgen — some small problem gets fixed, some lawmaker is forced to answer a key question, something changes for the better. Those moments are amazing.

So how to get a job as a reporter? I'll share a bit about how I got my job — and my path is atypical. I worked in the private sector for years as a health care analyst, fell into writing on the side and ended up as a regular contributor for FORBES and later Vox. POLITICO recruited me almost two years ago, and I decided to take a risk and become a full-time journalist.

Most of my colleagues had a more traditional career arc: They worked on the school paper or went to journalism school, interned at various news organizations, and worked their way up.

What that tells me is that there are lots of ways to do this, if you want to! And no path is perfect.

Because I came to this later, I sometimes need a translator in the newsroom because I'm still learning techniques and lingo that everyone else takes for granted. But I also bring a very different skill set / knowledge base that comes in handy, too — all those years in the private sector gave me good contacts, for instance.

If you want to be a reporter and not a pundit, I'd recommend four must-dos.

1) Get the reps. The more you write and report, the better you get. It's just that simple. And if you can't get a paying job at first, start your own blog, write on the side for free, whatever it takes. Find a topic that you're passionate about, too.

2) Get out there and ask questions. There's a lot of writing on the Internet that's just personal opinion or analysis of other peoples' reporting. Which is fine! But it's not reporting.

So if you want to know why your local lawmakers don't support an idea, or why the Golden State Warriors are moving from Oakland, whatever it is — try asking them directly. You might be surprised but many folks will respond.

Then ask their colleagues and critics and people affected — get the most complete picture you can — and write it up. Congratulations, you're a reporter.

3) Find an outlet and editor who will make you better. At some point, just writing into the void isn't helpful. Reporters need feedback and suggestions to hone their articles and focus their ideas.

4) Learn to promote your own work, in a non-annoying way. I wouldn't have gotten my job at POLITICO if I wasn't so active on Twitter. That's how my future editor got to know and like my work.

But most of my tweets aren't about my own writing — the key to remember is that social media is about having a conversation, not doing commercials. The professional opportunities will come, but if not if you're a walking billboard.

CMS is delaying bundled payment programs. Can you further elaborate on how AHCA would affect bundled payments? What can potentially change and what will remain same?

I haven't responded to this question because I'm not our team's reporter tracking bundled payment news (and he's busy with a story) and I wanted to be sure I get this right. But my understanding is that AHCA wouldn't directly touch bundles.

CMS still seems pretty keen on testing pilot bundles — Pat Conway just spoke out about their value. The question is what happens to mandatory bundles under Tom Price and Seema Verma, and everyone I talk to is convinced those programs are DOA.

But aren't you fake news?

I get that lots of folks don't trust the media.

But I believe so, so strongly in the importance of a free, independent press — so much so that I quit my cushy private sector job to become a full-time journalist.

One reason I wanted to do a Reddit AMA, or tweet so much about policy, is to try to be as open and accessible as possible. I also don't block anyone on social media (unless someone's just so relentless racist or something) because I'd rather know what my critics are saying.

Do they even care that they're killing people while arguing about re-electing Trump?

As a reporter, I can't comment on the (emotional) thrust of your question.

But I do have an observation, having talked to so many lawmakers, lobbyists and others in recent weeks.

And maybe I'm naive — but I'm shocked that so many of their comments focused on the optics and politics and ignored the patient impact.