with Paulina Firozi


There’s one set of eyes that President Trump’s appointees absolutely cannot ignore as they set about trying to reshape Obamacare and enact sweeping new changes to the government’s health-care programs.

They belong to Joe Grogan, director of health programs at the White House’s Office of Management and Budget.

You’ve probably never heard of Grogan — but you should know who he is. Grogan, perhaps more than any other member of Trump’s administration, holds the power to nix or give the nod to hundreds of regulations shaping how the federal government runs Medicare, Medicaid, the Affordable Care Act marketplaces, the FDA, the CDC and all the other sub-agencies contained within the sprawl of the Department of Health and Human Services.

Without Grogan’s assent, for example, the Centers for Medicare and Medicaid Services wouldn’t have been able to essentially wipe out steep and long-term drug discounts received by charity and rural hospitals. Last month’s rule change to the 340B program — viewed by many as rather gutsy on the part of CMS because it infuriated hospitals — had to get past Grogan’s desk at OMB, just like every other regulation change the administration wants to make.

“If Joe didn’t want it to happen, it wouldn’t happen,” Tom Scully, former administrator of CMS, told me. “There’s no policy coming out of CMS that he doesn’t have the power to veto.”

Scully held Grogan’s position in the early 1990s under President George H.W. Bush. Grogan is one of four appointees under OMB Director Mick Mulvaney who oversee the federal government’s programs. These directors are the bridge between the agencies and the president, who of course has the final word on administrative changes.

It’s fair to say that virtually every rule change proposed or enacted by HHS — from easing reporting requirements for doctors to exempting more employers from paying for birth control to rolling back drug discounts — have Grogan’s mark on them in some way.

“Whether it’s a big home health regulations or nursing homes or hospitals, I can tell you it’s a 90 percent Joe call,” Scully said.

Acting as gatekeeper for regulations is just part of the job. The OMB’s chief responsibility is to produce the president’s budget. So, at the end of the year, when members of Congress go home for the holidays and staffers on Capitol Hill and the agencies are drinking eggnog, Grogan and his aides will be working overtime to prepare the next year’s budget proposal, which is typically rolled out in February.

It’s a hefty task, especially when you consider how much our government spends on health care. The programs under HHS consume more than one-third of the federal budget, leaving reams of line items for Grogan to review. It will be his responsibility to coordinate between the agency requests and Trump’s priorities to come up with a final proposal the president will present to Congress early next year.

This past year, before Grogan was in place, Trump proposed a spending blueprint often referred to as a “skinny budget” that would have dramatically whittled down federal spending, including cutting HHS by 17.9 percent.

“OMB is the super god of our society,” said Tommy Thompson, who served as HHS secretary under President George W. Bush. “They are the ones who have the power to say yes and no on so many items because they control the budget.”

During their overlap at HHS, Thompson oversaw Grogan as he headed the agency’s Presidential Advisory Council on HIV/AIDS, a group that provided advice as the President’s Emergency Plan on AIDS Relief (PEPFAR) was implemented.

The role was one in which Grogan’s rightward leanings could have been on display, as there were heated disputes at the time about the program. But those who worked with him — even people not necessarily ideologically aligned — describe Grogan as a good-government type who worried first and foremost about doing his job well.

Carl Schmid, deputy executive director at the AIDS Institute, said he coordinated closely with Grogan during his time leading the council. Schmid said he doesn’t recall any ideological debates; only that Grogan was devoted to policies making sure those with HIV got access to medication.

“He was very concerned about making sure the money followed the epidemic,” Schmid said.

The OMB didn’t respond to a request for an interview with Grogan.

Grogan joined HHS after graduating in 2000 with a law degree from the College of William & Mary. In 2006, he went to the FDA as a policy adviser, and from there joined the drug industry -- first at Amgen and then at Gilead Sciences. Those who know him say he brings those industry sensibilities to the OMB job.

“Philosophically, he’s very focused on making sure he understands the way that private industry operates and interacts with the government,” AdvaMed chief executive Scott Whitaker told me.

In the same way that Sen. John McCain’s (R-Ariz.) infamous thumbs-down helped kill the GOP effort to repeal and replace the ACA, it will be Grogan’s thumbs-up to administrative changes that will shape the way the Trump administration implements the law over the next few years.

That is, if Grogan stays in the position for any length of time. Scully told me he couldn’t recall anyone keeping the job for longer than three years because of the crushing workload.

“The downside is you don’t go to sleep,” Scully said. “I never put in more hours than I did in that job.”

But if anyone can handle the position, maybe it’s Grogan. Thompson called him “a complete star.”

“Joe Grogan is a self-starter, extremely intelligent, an extremely hard worker,” Thompson said. “You give him an assignment and he gets it done.”


AHH: You can already see that your Starbucks pumpkin spice latte is 380 calories and your glazed Krispy Kreme doughnut is 340 calories when you view these chains' menu boards. Several chain establishments complied early with menu-labeling requirements -- part of Obama-era legislation that was delayed for years. But starting in May 2018, all major food chains will be required to post information about calorie counts on menus, Vox reports.

Stemming from the ACA, chain restaurants with 20 or more locations must publicly display their calorie counts on menus and for items in their vending machines. In a rule released last Thursday, the administration mostly maintained the approach started by the Obama administration. FDA Commissioner Scott Gottlieb said in an interview with Politico that the calorie information is for the public good.

"We definitely believe that the availability of this information has public health importance," Gottlieb told Politico. "We have data to demonstrate that. We want to see the regulation finalized and implemented." He signaled that the information could lead to further research and policies as the administration is “looking at how we can use nutritional information as a way to prevent disease and death.”

OOF: First, the good news. Despite fears there would be "bare" counties in the ACA marketplaces without a single insurer to offer coverage, every American has at least one plan option.

But many counties have only that -- one plan option. For 2018, there will be an average of just 3.5 insurers per state, down from 4.3 this year and 5.6 the year prior, according to a new study released Friday by the Kaiser Family Foundation. More than one in four shoppers have just one plan to choose from, with the counties most afflicted with sparse plan options are rural and thinly populated.

OUCH: The Recovery Institute of South Florida, an inpatient mental-health facility, has been targeting New Jersey school teachers, custodians and social workers with generous union health plans, keeping them for longer stays than necessary and forcing them to undergo expensive treatments specifically to drain their benefits, STAT and the Boston Globe found. They interviewed 10 people treated at the institute, nearly all of whom said they were allowed only limited contact with family and complained about inadequate and cookie-cutter treatment. Several said they were forced to stay in the facility as a condition of their  employment.

Union members described receiving treatments that appeared to be designed to spike the insurance bills, Stat’s David Armstrong’s and Boston Globe’s Evan Allen reported. Many of the New Jersey teachers went to Florida after their union representatives put them in touch with a consultant named Terry Livorsi. Livorsi owns the Florida institute.

"In pursuit of union workers, treatment providers and brokers frequently wine and dine labor officials and those who work in union employee assistance programs, creating an environment where referrals can go to operators more interested in getting rich than helping workers get better," David and Evan write. "Brokers and consultants are also often paid to send union members to particular centers; and some treatment centers hire family members of union workers to ensure referrals."

“The main reason people want union members is strictly financial,” John Christian, chief executive of Modern Assistance Programs, a Massachusetts-based company that runs employee assistance programs for unions, told them. “Unions have good health and welfare plans; they have good benefits.”


--The Trump administration is siding with doctors by slowing or shrinking several Obama-era initiatives aimed at reducing health-care costs by paying doctors based on the quality of their care instead of compensating them for every appointment, service or procedure, the New York Times reports. The Health 202 also explored this topic last month, when we wrote about how former HHS Secretary Tom Price had moved federal regulations in a direction favorable to doctors.

Many doctors have chafed at the scope and speed of experiments by the Obama administration to transform the way Medicare -- which also tends to shape how private insurers operate -- pays for everything from primary care to cancer treatment, Abby Goodnough and Katie Zernike report. But now HHS is pulling back on many of those experiments, canceling or shrinking Medicare initiatives that required doctors to accept lump sums for cardiac care and joint replacements, two of Medicare’s biggest cost drivers. Most recently, HHS exempted more doctors from a new merit-based system set up by the bipartisan 2015 law, which did away with a faulty and widely hated payment formula that had long threatened massive cuts to doctors.

"The efforts to chip away at mandatory payment programs have attracted far less attention than attempts by President Trump and congressional Republicans to dismantle the Affordable Care Act, but they have the potential to affect far more people, because private insurers tend to follow what Medicare does," Abby and Katie write. "That in turn affects the country’s ability to deal with soaring health care costs that have pushed up insurance premiums and deductibles."


--Whither CHIP? Stuff's getting real for the Children's Health Insurance Program, whose funding has yet to be reauthorized by Congress even though it technically expired more than a month ago. States still have some dollars to run on, but that won't last forever. Last Thursday, the board that runs CHIP in West Virginia voted to end the program by Feb. 28 if lawmakers don't send along the federal dollars it relies on, the Washington Examiner reports.

Hillary Clinton termed it this way last week: Congress is playing "roulette" with the program, Clinton said at a health-care symposium in Pennsylvania.

"This is the first time where we're really playing roulette with these kids and their families," Clinton said, per the Hill. “Because states are going to start shutting down these programs because they don’t have a funding stream.”

The House has passed a CHIP funding bill mostly along partisan lines, but the Senate Finance Committee hasn't decided how to finance its own version. The general thought at the moment is that CHIP funding probably will be included in a year-end spending bill.


--Five Democrat-led states have filed a request to halt President Trump’s easing of the so-called birth control mandate under the ACA requiring employers to include no-cost birth control coverage in theirinsurance plans. Attorneys general for California, Maryland, New York, Delaware and Virginia filed a motion for a preliminary injunction late Thursday with a U.S. District Court in California.

“These backwards rules will deny millions of women across the U.S. access to healthcare, unconstitutionally permitting discrimination against women,” said California Attorney General Xavier Becerra, per the Washington Examiner. “The Affordable Care Act protects women’s access to healthcare. We will not stand by while the Trump Administration continues to disregard the rule of law.”

Last month, the Trump administration issued rules that significantly broadened the range of employers and insurers that can cite religious or moral beliefs to avoid the ACA requirement. The states’ injunction charges the federal government did not offer a comment period prior to issuing the rules and argues that they violate separation of church and state.

Some more good reads from The Post and beyond:



  • The Alliance for Health Policy holds an event on payment reform.
  • American Enterprise Institute holds an event on the opioid crisis.

Coming Up

  • NIHCM Foundation holds an event on stabilizing hte individual health insurance market on Tuesday.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on gene editing technology on Tuesday.
  • The House Oversight Subcommittee on healthcare, benefits, and administrative rules and subcommittee on intergovernmental affairs holds a hearing on Tuesday.
  • RealClearPolitics holds an event on examining the pharmaceutical supply chain on Tuesday.
  • Advocates for Opioid Recovery & Collaborative for Effective Prescription Opioid Policies hold an event on Wednesday.
  • The Cato Institute holds an event on liberating telemedicine with Sen. Brian Schatz (D-Hawaii) on Wednesday.
  • The Senate Health Education, Labor and Pensions Committee holds a hearing with Surgeon General Jerome Adams on Wednesday.

Republican lawmakers are split on whether Roy Moore, the embattled Alabama Republican, should continue his run for Senate given allegations against him:

Republican lawmakers are split on whether Roy Moore, the embattled Alabama Republican, should continue his run for Senate given allegations against him. (Meg Kelly/The Washington Post)

Former White House chief strategist Stephen K. Bannon compared the Roy Moore allegations to Trump's 'Access Hollywood' tape:

At a speech in Manchester, N.H. on Nov. 9, Stephen K. Bannon discussed claims about Roy Moore’s sexual misconduct. (Reuters)

All the times members of the Trump campaign interacted with Russians:

The Trump campaign and the White House have said there was no contact between anyone on their staff and Russia. This isn't true. (Meg Kelly/The Washington Post)

Watch Saturday Night Live's cold open featuring Roy Moore and Jeff Sessions: