THE PROGNOSIS

The government's response to Hurricane Maria in Puerto Rico — and how Americans perceive it — perfectly illustrates how President Trump puts his administration on the defense by failing to tame his tweets.

The United States has dispatched to Puerto Rico and the U.S. Virgin Islands more than 19,000 military and civilian personnel who are working around the clock to restore electricity, distribute supplies and care for the injured, according to the Federal Emergency Management Agency. That adds up to a pretty strong response to an extremely challenging situation, relief experts say.

But you wouldn’t know that if you just listened to Trump talk about the island and its inhabitants, millions of whom remain without electricity and telephone communications in the wake of Hurricane Maria.

The president has blundered his way through his response to the widespread wreckage crippling the territory, alternating between playing down the disaster, portraying it as an inconvenience and, last week, even threatening that federal assistance can’t continue to the island forever.

Trump, on the defensive about seeming to not do enough for the American citizens on the island, appeared to place the blame on them last Thursday:

And in a tweet that sparked intense backlash:

Under fire, the president then appeared to shift gears on Friday:

But Trump’s reassurances of support came only after several federal agencies scrambled Thursday to clarify that they’re as devoted to Puerto Rico’s relief effort as they were in Texas, Louisiana and Florida after Hurricanes Harvey and Irma. 

FEMA spokeswoman Eileen Lainez tweeted this:

Within a few hours of Trump’s Thursday morning tweetstorm, the Department of Health and Human Services, Veterans Affairs and the Defense Department gave short notice of a media call to discuss their efforts on the island, where they outlined steps taken to help medical centers there transfer the worst-injured patients to military hospitals, and bring in medical supplies.

HHS sent more than 600 on-site medical personnel who have provided care to 3,000 patients, Robert Kadlec, the agency’s assistant secretary for preparedness and response, told reporters. He insisted the “scope and scale” of the agency’s response in Puerto Rico was comparable to its efforts in Texas.

The agency also detailed its three-tiered system of providing care, in coordination with Puerto Rico’s Department of Health, which involves supporting its top trauma center in San Juan, supplying regional hospitals and working with Defense to help other affected hospitals across the island get what they need.

“We’re committed to assist the government of Puerto Rico to save lives,” Kadlec said. “I think the one thing you need to understand is the level of effort we’ll bring.”

That is not how many Americans perceive the administration’s response to Puerto Rico, which has been mostly framed around Trump’s seemingly halfhearted support of the U.S. territory in one of its darkest hours.

Polling shows a majority of the public — 52 percent,  according to a Quinnipiac University survey — doesn't think that the president cares about the heavily Hispanic island. And although Trump generally got good reviews for his handling Harvey and Irma, Americans don’t feel that way about his response to Puerto Rico. Just 36 percent said the federal government has done enough there, while 55 percent said it hasn’t, according to the Quinnipiac poll.

But it’s hard to identify exactly what more the federal government could be doing. Indeed, former FEMA director James Lee Witt told me he’d give the Trump administration an A-plus for how it’s responding to all the hurricanes' aftermath – including in Puerto Rico.

“They’ve maxed out probably how many people they could put there,” said Witt, a Democrat who ran the agency under President Clinton. “I know they’re all working frantically, but sometimes that’s not enough.”

Trump pointed to Witt's shining marks for his post-hurricane performance at a press conference Monday with Senate GOP leader Mitch McConnell (Ky.) and praised the former FEMA administrator for looking beyond partisan politics.

It’s just plain harder to get Puerto Rico up and running again than in Texas, Louisiana and Florida (read my colleague Dino Grandoni at The Energy 202 on the issue). For one thing, restoring electricity is a lot harder because of the island's aging infrastructure. When you don’t have power, it’s hard to identify where the problems are and recruit volunteers to respond. And responders can’t drive in supplies; they have to ship or fly them in.

“We were dependent on basically clearing the ports and airfields,” Kadlec said. “Those were challenges we encountered that we didn’t in Harvey or Irma.”

To top it off, Maria hit Puerto Rico and surrounding islands after Hurricanes Harvey and Irma had wreaked havoc in large portions of the southern United States, straining FEMA’s surge capacity to respond to multiple disasters at the same time.

“Puerto Rico is just a tougher situation for FEMA,” said Tevi Troy, a former HHS deputy secretary under George W. Bush and author of the book “Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office.”

Indeed, the island remains in crisis mode three weeks after Maria made landfall. As of yesterday, about 85 percent of residents remained without electricity. Their governor, Ricardo Rosselló, said during a news conference Saturday that he plans to restore power to 95 percent of the energy grid by Dec.15.

“Our goal as government is to give Puerto Ricans access to electricity with speed and efficiency,” he tweeted.

Rosselló has been careful not to criticize Trump’s tweets. But they dismayed some Republicans who were frustrated at how often and bluntly the president expresses his thoughts via the medium. Yesterday, Sen. Susan Collins (R-Maine) counseled the president to choose his words more carefully.

“The president needs to remember that his every word he speaks matters now that he is president of the United States,” she said on CNN’s “State of the Union.”

Puerto Ricans and the thousands of federal workers trying to help them in Maria’s aftermath may feel similarly.

“I think [FEMA’s] done a really good job so far,” Witt said. “I just wish President Trump hadn’t put out that tweet.”

AHH, OOF and OUCH

AHH: Make time to read this investigation from The Washington Post's Scott Higham and Lenny Bernstein, who detail how Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets at the height of the deadliest drug epidemic in U.S. history.

By April 2016, the opioid crisis had claimed 200,000 lives, more than three times the number of U.S. military deaths in the Vietnam War. Yet a handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills — an effort the DEA had opposed for years.

“With a few words, the new law changed four decades of DEA practice,” Scott and Lenny write. “Previously, the DEA could freeze drug shipments that posed an 'imminent danger' to the community, giving the agency broad authority. Now, the DEA must demonstrate that a company’s actions represent 'a substantial likelihood of an immediate threat,' a much higher bar.”

“The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market,” they write. “The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns.”

—Rep. Tom Marino, a Pennsylvania Republican who is now Trump’s nominee to be the nation’s next drug czar, was the chief advocate for the law. Political action committees representing the industry contributed at least $1.5 million to the 23 lawmakers who sponsored or co-sponsored four versions of the bill, including nearly $100,000 to Marino. Overall, the drug industry spent $106 million lobbying Congress on the bill and other legislation between 2014 and 2016, according to lobbying reports.

“The drug industry, the manufacturers, wholesalers, distributors and chain drugstores, have an influence over Congress that has never been seen before,” said Joseph Rannazzisi, who ran the DEA’s division that is responsible for regulating the drug industry. “I mean, to get Congress to pass a bill to protect their interests in the height of an opioid epidemic just shows me how much influence they have.”

OOF: The first $1 million medication is on the way, Stat News reports. On Thursday, Spark Therapeutics won unanimous support from an FDA advisory panel for its gene therapy drug, Luxturna, which has been shown to restore vision in children with an inherited form of blindness but could cost $1 million per patient.

Gene therapy has the potential to be a one-shot treatment that could reverse blindness, restore blood-clotting function to hemophiliacs, or even cure rare diseases outright. But the expense -- an the potential that such treatments won't work in every patient who tries them -- raised big financing questions. Will private insurers pay for them? Or taxpayers, via Medicare and Medicaid?

"These one-shot cases are potentially transformative — but not every patient responds to the same extent with gene therapy,” said Dr. Mark McClellan, a former FDA commissioner who now leads the Duke-Margolis Center for Health Policy. “We’re definitely not all the way there yet.”

OUCH: Wealthy conservative donors and influential Republican lawmakers say they increasingly fear a historic backlash at the ballot box next year if the GOP fails to rewrite the nation's tax laws just as lawmakers failed to overhaul Obamacare, my colleague Sean Sullivan reports from New York.

"At a two-day midtown Manhattan summit of the billionaire industrialist Koch brothers’ powerful donor network, GOP patrons, senators and strategists spoke in cataclysmic terms about the price they expect to pay in the midterm elections if their tax reform effort does not win passage," Sean writes. "They voiced concerns a demoralized Republican base would stay home, financiers would stop writing campaign donation checks to incumbents and the congressional majorities the party has built in the House and Senate could evaporate overnight.

Their hope is if Republicans succeed in revamping the tax code, some of the disappointment over the failure to pass a health-care bill earlier this year will evaporate. But the GOP discord that decimated that effort is already threatening to undermine the tax push, Sean reports.

--Sen. Ted Cruz (R-Tex.) warned that Republicans could face a “Watergate-level blowout” in the midterm elections if they don’t make major legislative strides on taxes and health care, invoking the political scandal that brought down Nixon’s presidency and set back the GOP considerably in subsequent elections.

“If tax reform crashes and burns, if [on] Obamacare, nothing happens, we could face a bloodbath,” the Texas Republican said in a moderated discussion.

TRUMP TEMPERATURE

--President Trump shook up the health-care world late Thursday night, when the Department of Health and Human Services announced that insurers discounting cost-sharing payments for the lowest-income marketplace customers will no longer get payments from the federal government to make up the difference.

The health-care industry, Democrats and other ACA supporters charged the administration was destabilizing the marketplaces just two and a half weeks before Healthcare.gov and other state-run marketplaces open for enrollment. Nearly 20 state attorneys general filed lawsuits to halt the administration from cutting off the payments. The discounts, known as cost-sharing reductions (or CSRs) are available to marketplace enrollees earning 250 percent or less of federal poverty and insurers must provide them, regardless of whether the government pays them back.

“The timing couldn’t be worse,” Allison O’Toole, chief executive officer of ­Minnesota's marketplace MNsure, told my colleague Amy Goldstein, adding that hundreds more consumers than usual have phoned its call center in recent days, uncertain whether they can still get and afford health plans.

"The administration’s move, which officials formalized through a filing in a federal appeals court, could throw the ACA sign-up season that begins Nov. 1 into disarray. Some insurers and state regulators are scrambling to reconsider rates for next year, and the uncertainty is sure to make an already challenging enrollment period even more so," The Post's Juliet Eilperin, Amy and Carolyn Y. Johnson write. "Yet it is unclear whether either the litigation or vehement opposition by a broad swath of the health-care industry has any chance of stopping what the president and his top aides portrayed as integral to their broader effort to dismantle the 2010 health law."

Trump tweeted this on Friday:

Trump also tried to shift the pressure to Democrats to act instead of Republicans:

--But Democrats, publicly expressing fury at Trump's move to cut off the subsidies, may be even more wary of striking a bipartisan deal for Congress to fund them. Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) have been in negotiations over ways to stabilize the ACA markets. They'd signaled that they are close to a deal, but Republicans have been demanding some reforms to Obamacare and conservatives in the House have grown very wary of the talks, vowing to oppose anything that they view as a bailout.

Today Trump heads to a potentially pivotal meeting with Senate Majority Leader Mitch McConnell (R-Ky._, with whom the president has publicly clashed. Advisers say the one-on-one talk is meant to get both sides on the same page heading into the critical fall and early winter legislative session as they tackle issues on healthcare, immigration and federal spending, among others, my colleague Paul Kane reports.

--Former Trump White House aide Steve Bannon seemingly exposed the logic behind the move at his appearance at the Values Voter summit over the weekend. Here's what Bannon said, per my colleague Aaron Blake: "'Then you had Obamacare,' Bannon said. Trump is 'not gonna make the [cost-sharing reduction] payments. Gonna blow that thing up. Gonna blow those exchanges up, right?'"

"If the underside of the bus outside the White House weren't already so conspicuously crowded, you might say Bannon was tossing his old boss under it."

Watch Bannon's full remarks below:

HEALTH ON THE HILL

--Trump's decision to halt the subsidies increases the potential for a government shutdown in December and makes the issue central to next year’s midterm elections, The Post's Mike DeBonis and Ed O'Keefe report. "Trump and Republican allies defended the move as removing a giveaway for insurance companies, and they blame rising premiums on fundamental flaws in then-President Obama’s signature health-care reform law. But Democrats called it an act of sabotage against the ACA for which the GOP will be held responsible at the polls," Mike and Ed write.

"The dispute sets the stage for another wave of political battles over the nation’s health-care system, as Republican lawmakers will need to decide whether to authorize the subsidies through legislation as well as whether to once again attempt a broader repeal of the ACA," they write. "Democrats could also use a Dec. 8 appropriations deadline to threaten a government shutdown if the subsidies are not restored. The party’s leaders stopped short of such a threat Friday. But Democrats warned more broadly that escalating Republican efforts to undermine the ACA — which also included an order by Trump on Thursday loosening insurance requirements — would be used against the GOP in the 2018 elections."

“Republicans in the House and Senate now own the health-care system in this country from top to bottom, and their destructive actions, and the actions of the president, are going to fall on their backs,” Senate Minority Leader Chuck Schumer told reporters Friday. “The American people will know exactly where to place the blame when their premiums shoot up and when millions lose coverage.”

Some more good reads:

The political hostage-taking carries risks for the president and for Republicans, who have struggled to enact his agenda.
John Wagner and David Nakamura
President Donald Trump’s decision to end a provision of the Affordable Care Act that was benefiting roughly 6 million Americans helps fulfill a campaign promise, but it also risks harming some of the very people who helped him win the presidency.
AP
"That’s my fight, that’s my mission,” the House minority leader said amid calls for her and other senior Democrats to quit their leadership roles and make way for a new generation.
Paul Kane
Even before his decision to undercut Obamacare, people saw Trump as responsible for the law's fate.
Philip Bump
MEDICAL MISSIVES
Two weeks after the shooting, Tina Frost has continued to defy the odds.
Amy B Wang
DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions holds a hearing on “How the Drug Delivery System Affects What Patients Pay” on Tuesday.
  • The Washington Post holds an event on America’s opioid epidemic on Wednesday.
  • The Center for Global Development holds an event on “Allocation Rules to Guide Aid Spending in Global Health” on Wednesday.
  • Axios hosts an event on what's next for health care with Sens. Lamar Alexander (R-Tenn.), Bill Cassidy (R-La.), and Tim Kaine (D-Va.) on Wednesday.
  • The U.S. Chamber of Commerce holds an event on “Advancing Priorities and Innovative Solutions Aid Uncertainty” on Wednesday.
  • The Senate Health, Education, Labor and Pensions Committee will hold a hearing on “Examining How Healthy Choices Can Improve Health Outcomes and Reduce Costs” on Thursday.
SUGAR RUSH

Trump: ‘We’ve done a great job in Puerto Rico:’

How SNL took on Harvey Weinstein:

Three times people have taken to Twitter to describe their sexual abuse experiences:

Watch a Baltimore school choir’s spine-tingling performance of 'Rise Up:'

The moment a California family discovered their dog survived the wildfires:

Kellyanne Conway is a terrifyingly quotable Pennywise the Clown in SNL’s biting sketch, writes The Post's Aaron Blake: