THE PROGNOSIS

Republicans haven’t succeeded in stripping Medicaid dollars from Planned Parenthood. But the Trump administration could soon go after abortion providers in another way — with new restrictions on the federal family planning program.

In the next week or so, the Department of Health and Human Services is expected to release a notice of funding for what’s known as the Title X program, which annually awards $280 million in grants to clinics around the country for providing birth control and other family planning services to about 4 million Americans, most of them low-income.

Some Title X recipients — especially clinics that provide abortions — are nervously awaiting the notice, which could contain new rules for applicants. It could bar them from using non-taxpayer dollars to offer abortions, restrict the types of contraception Title X will cover or shift the program’s focus from birth control to abstinence, for example.

“It will be the administration’s first opportunity to say how they want the Title X program to look,” said Jessica Marcella, vice president of advocacy and communications at the National Family Planning and Reproductive Health Association, told me.

In other words, Title X could be next on the list for Republicans -- now holding the reins in both Congress and the White House --  seeking to restrict the controversial procedure. In their quest to roll back the rights to abortions, House Republicans have already passed a bill banning the procedure after 20 weeks. And yesterday, the House Judiciary Committee held a hearing on a bill banning abortions once the fetus has a discernible heartbeat, which typically occurs very early on in pregnancy around the eight-week point.

Federal law already prohibits both Title X and Medicaid funds from being used for abortions. But conservatives, who now serve at high levels in the Department of Health and Human Services and hold broad powers to reshape federal programs, don't want any abortion providers to receive taxpayer dollars, period.

Had Congress passed either chamber’s version of an Obamacare overhaul into law, Planned Parenthood would have been stripped of the Medicaid dollars it uses for all sorts of other health-care services. In the same way, new rules around Title X could prevent funding to any providers as long as they offer abortions.

It’s still unclear exactly what changes — if any — the administration will propose in the upcoming funding notice. And any proposals could require further rulemaking, a process which typically takes months. But HHS has dropped a few clues so far about how it might put a more conservative stamp on Title X.

A strategic plan HHS released last month defines life as beginning at conception, a shift from how the Obama administration spoke about the agency’s goals. “HHS accomplishes its mission through programs and initiatives that cover a wide spectrum of activities, serving and protecting Americans at every stage of life, beginning at conception,” the statement says.

HHS also signaled over the summer that it wants to get new standards in place right away instead of waiting until some of the longer-term Title X grants expire. In July, the agency sent notices to recipients that they’d have to reapply for funding in 2018, even if they had a three-year grant.

One can also consider the views of Teresa Manning, who now administers Title X as deputy assistant secretary for HHS’s Office of Population Affairs. Manning, a former lobbyist for prominent antiabortion group National Right to Life and, more recently, a legislative analyst for the Family Research Council, has often objected to the use of emergency contraception, equating it to an abortion in the earliest stages of pregnancy.

If HHS tries to entirely ban abortion providers from receiving Title X funding, it could affect a sizable number of recipients. Out of 535 clinics surveyed in 2015 by the Guttmacher Institute, an abortion-rights group founded by Planned Parenthood that is now a separate entity, about 10 percent of them said they offer abortions separately from any Title X funding.

Such a move wouldn't be unprecedented. President Ronald Reagan's administration added some abortion-related restrictions to the program back in the 1980s.

Reagan barred recipients from referring patients to abortion providers, counseling patients that abortion is available or sharing finances or a physical location with a provider. The rule reversed a prior requirement for Title X recipients to provide counseling about abortion. Although the Supreme Court upheld the Reagan-era rule in 1991, President Bill Clinton then suspended it in 1993.

All will become clearer once HHS actually releases the funding notice, which stakeholders say they expect soon. Of course, we’ve already had one big contraception-related mandate from the department, which in October issued rules that pared back a requirement via the Affordable Care Act that employers cover no-cost contraception for employees.

In that rule, HHS pointed to the Title X program as a possible source of birth control for women who may no longer access it through their employer-sponsored health plans. If the agency then restricts the types of contraception Title X covers, reproductive-rights advocates will be shaking the finger.

“I think broadly it’s clear women’s access to reproductive health care is very much in this administration’s sights,” said Kinsey Hasstedt, a senior policy manager for Guttmacher.

Guttmacher is sounding an alarm, even before the guidance lands:

STATE SCAN

--OPEN ENROLLMENT kicked off yesterday with little fanfare from the Trump administration. It's the fifth annual open enrollment season under the Affordable Care Act, and also the shortest one, lasting just 45 days this year. Healthcare.gov and the federal-run marketplaces will be open until Dec. 15 for better or for worse, without the marketing effort the Obama administration conducted in years past to direct people there.

“Unlike the past four years, when the previous administration marked the arrival of each ACA enrollment period with considerable hoopla from the White House on down, the Health and Human Services Department limited its statements to two low-wattage tweets Tuesday afternoon and Wednesday morning,” our colleagues Amy Goldstein, Juliet Eilperin and Colby Itkowitz write.

Neither acting HHS Secretary Eric Hargan nor CMS Administrator Seema Verma held events on enrollment yesterday. President Trump himself seemed to ignore the milestone altogether. His only reference to the health-care law on Wednesday were two tweets calling on Congress to include a repeal of the individual mandate as part of the tax revamp:

The notices and messaging that did come from federal officials was limited and different in tone. Amy reports that advance emails sent late last week went only to people who already had Obamacare coverage, and not all 20 million customers in HHS's database who had bought marketplace plans at one time or another. And the tone of the messages that did go out was different from years past. Where emails previously underlined health-plan affordability -- an element that focus groups and research under the Obama administration found particularly motivatin --  this year’s notes removed any mention of cost.

“The emails encourage potential consumers to shop around for the plan that best meets their needs,” an agency spokesman said.

With sign-ups officially underway, emails now will be sent to all former marketplace customers. But those notices will also be sparser and not targeted at specific niches of consumers, Amy reports. For example, lower-income customers won't be informed that they are probably eligible for the ACA’s cost-sharing subsidies to help pay their deductibles and other out-of-pocket costs.

But in pockets across the country, people seemed eager to enroll, Juliet, Amy and Colby report. In Missouri, in Maryland, in Colorado, in Connecticut, people gathered at locations still offering in-person assistance. And lawmakers and activist groups took to social media to spread the word. 

Democrats did their own marketing effort. From Sen. Patty Murray (D-Wash.):

Rep. Beto O'Rourke (D-Tex.), who has entered the 2018 Texas Senate race:

From Hillary Clinton:

Liberal group Indivisible:

From the Kaiser Family Foundation:

And former President Barack Obama himself shared a video Wednesday to mark the start of the enrollment season and urge people to sign up:

"It's November 1, which means today is the first day to get covered for 2018," Obama says in the clip:

From The Daily Beast’s Sam Stein:

--And in California and New York, which have the biggest state-run exchanges in the country, officials say they're going "all out" to promote enrollment, Politico reported yesterday.

From Sen. Kamala Harris (D-Calif.):

“Covered California is going out in a big way for open enrollment this year," Peter Lee, executive director of the state’s exchange, told Politico. That includes a major advertising push and 19-city bus tour to encourage people to enroll.

And New York Mayor Bill de Blasio offered a counter message to the Trump administration. “When you can’t trust the federal government to protect your constituents, you have no choice but to do it yourself," he said, per Politico. "In NYC, we have an entire team dedicated to the cause." The mayor said they've done targeted outreach to 300,000 families already this year, and another push gets underway now that the sign-up season is starting.”

AHH, OOF and OUCH

AHH: In its final report released yesterday, Trump's commission on the opioid crisis called for a nationwide system of drug courts and easier access to alternatives for people in pain, part of a wide-ranging menu of improvements it said are needed to curb the epidemic, my colleague Lenny Bernstein reports. The commission, headed by New Jersey Gov. Chris Christie (R), made more than 50 recommendations:

--It said the government should expand drug courts into all 94 federal jurisdictions instead of fewer than half.

--Doctors and others who prescribe opioids should show they have received training in the safe prescribing o opioids before they can renew their licenses to handle controlled substances with the Drug Enforcement Administration.

--The panel also wants to mandate that providers check prescription-drug-monitoring databases to ensure  users aren't “doctor shopping."

But it's also notable what the commission didn't recommend. It specifically declined to endorse the use of marijuana for pain, despite some studies suggesting that may decrease opioid deaths, Lenny writes. Christie that research has “found that marijuana use led to a 2½ times greater chance that the marijuana user would become an opioid user and abuser.” 

Nor did the commission endorse establishing safe-injection sites like those in Canada, where intravenous drug users can use drugs under the supervision of trained personnel who prevent them from overdosing. The report also didn't identify new funding for combating the crisis.

"Like Trump, who declared the opioid crisis a 'public health emergency' six days ago, the President's Commission on Combating Drug Addiction and the Opioid Crisis identified no new funding for the drug crisis, which claims the lives of an estimated 175 people every day," Lenny writes. "But it called for block grants of substance abuse aid that would consolidate federal funding from a variety of sources and send it to cities and states that are fighting the battle on their streets."

OOF: The Post's Juliet Eilperin scoops this morning that Sam Clovis, who has been nominated as chief scientist for the Department of Agriculture, has no academic credentials in either science or agriculture. The agency confirmed in an Oct. 17 letter, obtained by Juliet, that Clovis has no such credentials. 

"The post for which President Trump has nominated his campaign co-chair — USDA undersecretary for research, education and economics — has traditionally been held by individuals with advanced degrees in science or medicine," Juliet writes. "The 2008 farm bill specifies that appointees to the position should be chosen 'from among distinguished scientists with specialized training or significant experience in agricultural research, education, and economics,' given that the official is 'responsible for the coordination of the research, education, and extension activities of the Department.'"

Clovis had told the Senate Agriculture, Nutrition and Forestry Committee’s top Democrat, Debbie Stabenow that his time teaching and running for political office in the Hawkeye State steeped him in the field of agriculture.

OUCH: Even as it deals with fallout from Hurricane Maria, Puerto Rico is facing a huge dropoff in its Medicaid funding. It's asking the Trump administration and Congress for help in filling the funding hole that has put a quarter of the island’s residents at risk of losing medical care.

"The territory, which has grappled for years with shortfalls in funding of its Medicaid healthcare program, is on track to run out of money to pay doctors and hospitals by early next year, leaving as many as 900,000 low-income Puerto Ricans without care," Reuters reports. "Puerto Rico Governor Ricardo Rosselló has asked Washington to waive the territory's share of Medicaid costs - a step that could cost hundreds of millions. Last week, Rossello returned with another request: an infusion of $1.6 billion per year for at least five years."

A dozen Democratic senators have sounded the alarm, as has Republican Sen. Marco Rubio (R-Fla.), who said the Medicaid funding losses could drive people away from the island.

"If you take the storm and you add already all the inconveniences, obstructions that it's created - and combine that with a Medicaid collapse - then you're really going to accelerate the number of people coming to the mainland," Rubio told Reuters.

And here are a few more good reads: 

Enrollment starts Wednesday and runs through Dec. 15 — half the window as in past years.
Chicago Sun Times
HEALTH ON THE HILL
Price resigned at the end of September amid controversy over his use of charter aircraft.
The Hill
MEDICAL MISSIVES
The popularity of online crowdfunding for medical expenses makes it easy for the beneficiary to be an acquaintance and a fraudster at the same time.
Stat News
INDUSTRY RX
The president’s idea for advertising could backfire if we don’t learn from past antidrug campaigns.
The New York Times
DAYBOOK

DON'T MISS THIS: The Post and Live Nation will bring the “Can He Do That?” podcast to a live audience at the Warner Theatre on Tuesday, Nov. 7. In this live taping, political reporters Bob Woodward, David Fahrenthold and Karen Tumulty will join host Allison Michaels to review the past year in President Trump’s White House and the biggest moments that made people wonder “Can He Do That?” Tickets can be purchased now at Live Nation. Attendees will also receive a free 30-day digital subscription to The Washington Post. 

Today

  • The Edward M. Kennedy Institute holds an event on the national opioid epidemic with Sens. Rob Portman (R-Ohio), Sheldon Whitehouse (D-R.I.) and Jeanne Shaheen (D-N.H.).
  • Politico holds a live event on next steps in the opioid crisis.

Coming Up

  • The Brookings Institution holds an event on policy approaches to the opioid crisis on Friday.
  • The American Enterprise Institute hosts an event on Puerto Rico after Hurricane Maria on November 6.

  • Axios hosts an event on a new era in cancer innovation with former Vice President Joe Biden and former first lady Jill Biden on November 8.

  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on November 13.

  • STAT holds an event on the FDA on November 13.

SUGAR RUSH

After the New York attack, Sen. Chuck Schumer (D-N.Y.) asks President Trump, "Where is your leadership?:"

Donald Trump Jr.’s Halloween socialism lesson, according to the Internet:

Hillary Clinton chats with Trevor Noah on The Daily Show: 

Samantha Bee says Chief of Staff John Kelly is not the adult in the White House: