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The Health 202: Some Republicans blame Medicaid for opioid epidemic

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with Paulina Firozi


Senate Republicans will push a new line of attack on the Medicaid program at a hearing this morning: that expanding the federal insurance program for low-income Americans has contributed to the country’s opioid overdose epidemic.

It’s an argument that Homeland Security and Governmental Affairs Committee Chair Ron Johnson (R-Wis.) began airing last summer, as the Senate worked on a health-care bill to roll back the Affordable Care Act’s Medicaid expansion and enact even deeper spending cuts to Medicaid.

“The Medicaid expansion may be fueling the opioid epidemic in communities across the country,” Johnson wrote to the Health and Human Services inspector general in July. “Because opioids are so available and inexpensive through Medicaid, it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

Today, the Wisconsin Republican has invited several conservative policy wonks and officials from GOP-led states to testify about what he and some other Republicans view as these unintended consequences of Medicaid — that by enveloping more Americans in coverage, it’s potentially giving them access to opioid painkillers, which they’re then distributing on the streets.

Louisiana Attorney General Jeff Landry has advanced the same argument, per the AP's Melinda Deslatte: . @AGJeffLandry at the BR Rotary Club criticizes Medicaid expansion as worsening opioid abuse, criminal justice overhaul as harming public safety. Hits on @LouisianaGov programs, without naming Edwards. #lalege #lagov," she tweeted on Jan. 10.

From the Times-Picayune's Julia O'Donoghue: 

The hearing should be a lively one, because with it, Republicans are directly challenging one of Democrats’ top strategies for combating opioid abuse: expanding Medicaid so more patients can get access to the treatment they need to overcome their addictions.

Esther Choo, a doctor at Oregon Health and Science University:

Ranking Democrat Claire McCaskill (Mo.) plans to push back hard, according to prepared remarks shared in advance with The Health 202.

“This idea that Medicaid expansion is fueling the rise in opioid deaths is total hogwash,” according to her testimony. “It is not supported by the facts. And I am concerned that this committee is using taxpayer dollars to push out this misinformation to advance a political agenda.”

So, who’s right here? There’s little data to draw from, since Medicaid was expanded only recently under the ACA. But while conservatives have noted that overdose deaths are much higher among people inside the program than those outside it, according to the Centers for Disease Control and Prevention, they’ve not been able to prove Medicaid actually leads to opioid abuse.

On the contrary, as Medicaid advocates note, expanding the program to include childless adults earning up to 133 percent of the federal poverty level has given more Americans access to addiction treatment. The program, which provided coverage to 3 in 10 people dealing with opioid addiction in 2015, covers outpatient treatment and inpatient detoxification, among other services, for substance use disorder.

“Medicaid expansion helps address the opioid problem — it did not create it,” McCaskill plans to say.

It's true that enrolling in Medicaid makes it easier for patients to see a doctor, who could then prescribe them an opioid for pain. But as with those insured under Medicare or private plans, Medicaid recipients must first obtain a prescription — they can’t just go seize it off a shelf — and a provider must say it’s medically necessary before Medicaid will pay for it.

When I asked Johnson’s office for comment, staffers pointed me to the letter the senator sent the HHS inspector general last summer. In that letter, Johnson said he’d identified 261 people convicted of using their Medicaid cards to obtain opioids and then reselling the drugs at “enormous profit.”

Johnson also pointed to HHS data showing drug overdose deaths rose twice as fast per 1 million people in Medicaid expansion states versus non-expansion states under the ACA. Johnson used Centers for Disease Control and census data to argue that drug overdose deaths increased 22 percent in expansion states but just 15 percent in non-expansion states between 2013 and 2015.

Since the ACA was passed in 2010, 32 states plus the District of Columbia have chosen to expand the program while the rest of the states — all of them Republican-led — have opted out. Experts told me the problem with comparing expansion states to non-expansion states is that they all have different characteristics. Some expansion states were hit particularly hard by the opioid crisis, which may have been partly why they chose to expand Medicaid to begin with.

“It’s kind of like a chicken-versus-the-egg problem,” the Kaiser Family Foundation’s Mary Beth Musumeci said.

And here’s another counterpoint: Opioid abuse began spiking in the late 1990s, well before states began expanding Medicaid. Plus, there’s strong evidence that recent increases in opioid mortality stem not from prescription opioids, but from the illegal drugs fentanyl and heroin, which Medicaid doesn’t pay for.

Let’s assume for a moment that Republicans are right — that Medicaid is contributing to opioid abuse. But if they argue against Medicaid based on the idea that it potentially allows more patients to get prescriptions for opioids, they could use that same reasoning to oppose expansion of private health insurance.

Expanding health insurance of any variety increases people’s access to health care. Much of that care is beneficial; some may not be, Katherine Baicker, dean of the University of Chicago’s Harris School of Public Policy, told me.

“I don’t think anybody would suggest because overprescribing of opioids poses a series health risk, people shouldn’t go see the doctor,” Baicker said.

Over in the House, Rep. Lynn Jenkins (R-Kan.) is also holding an opioid-focused hearing this morning at the Ways and Means Oversight Subcommittee. See this panel on how the Centers for Medicare and Medicaid Services is addressing abuse in the Medicare Part D prescription-drug program.

"More than 42 million beneficiaries rely on the program for prescription drugs, including opioids," Jenkins plans to say, according to her prepared remarks shared with The Health 202. "It is critical that Medicare, and private Part D plan sponsors have the tools they need to ensure that opioids are provided only when medically necessary."

Navy Rear Adm. Ronny L. Jackson, the lead White House doctor, said on Jan. 16 that President Trump’s “overall health is excellent.” (Video: Bastien Inzaurralde/The Washington Post)

-- Yesterday, reporters and TV viewers were treated to an extraordinary and wide-ranging presentation by the White House physician on the state of President Trump's physical and mental fitness.

Navy Rear Adm. Ronny L. Jackson, who examined the 71-year-old Trump in the president's first physical exam on Friday, spent nearly an hour detailing many of the president's vitals, and characterized the president's health as “excellent" overall.

Here are some of the physical data points Jackson shared, per our colleagues Jenna Johnson and Lenny Bernstein:

  • The president is 6-foot-3 and weighs 239 pounds. Jackson said Trump does not get enough exercise, something he discussed with his patient. “He would like to lose 10 to 15 pounds. We talked about diet and exercise a lot. He’s more enthusiastic about the diet part than the exercise part, but we’re going to do both,” he said.
  •  Given his height, Trump’s BMI is 29.9. A BMI of 30 would be obese, according to the National Institutes of Health.
  • Trump’s blood pressure is 122/74, which Jackson said is in the normal range.
  • Trump has a fasting blood glucose of 89, which is normal, with no signs of diabetes.
  • Trump’s cholesterol of 223 is in the elevated range and his low-density lipoprotein of 143 is borderline high. Jackson said the president’s cholesterol is elevated, and so he is increasing Trump’s medication to control 
Navy Rear Adm. Ronny L. Jackson, the White House lead doctor, says he has “absolutely no concerns” about President Trump’s “cognitive ability.” (Video: The Washington Post)

A lot of questions at the press conference revolved around Trump’s mental fitness.

Trump inflamed the ongoing debate over his psyche this month when he tweeted he was a “very stable genius.” Wanting to put the issue to rest, the president requested a cognitive exam from Jackson, Jenna and Lenny report. Jackson said the president “did exceedingly well" on the Montreal Cognitive Assessment, saying there was “no indication whatsoever that he has any cognitive issues.” In fact, Jackson said Trump received a score of 30 out of 30 on the test.

What exactly does that mean?

Here’s what that test looks like. The Atlantic’s James Hamblin describes the test’s components this way: “Six points for knowing the date and where you are. Two points if you can identify what a banana and an orange have in common. Three points for correctly identifying pictures of a lion, camel, and rhinoceros. Another point if you can repeat the phrase ‘I only know that John is the one to help today.’ Another point if you can read the following letters: FBACMNAAJKLBAFAKDEAAAJAMOFAAB. Three points if you can draw a clock that indicates the time ‘ten past eleven.’”

In other words, it would be extremely concerning if the president (or basically any other adult) did poorly on this exam. Still, Donald Trump Jr. was quick to boast about his father’s top score: 

“It’s not the SAT; it’s a screening device:” Our colleague Philip Bump explains why people may be misunderstanding the cognitive assessment. “If you look at the test, it’s pretty hard to see how you could not score a 30," he writes. "You see a picture of a lion and have to identify it as a lion? That old joke about how the elderly and toddlers are subject to the same indignities seems pertinent here: Is this really the bar that needs to be met to demonstrate full mental capabilities? Well, according to those who study dementia and other mental deterioration, yes.”

Here’s how Jackson responded when asked about Trump’s health despite his inadequate physical activity, via CBS News's Mark Knoller:

Watch that exchange, via Think Progress's Aaron Rupar:

Jackson said the president does not have a dedicated exercise routine:

Jackson also signaled he was not worried about the president’s stress levels, from Bloomberg News’s Jennifer Jacobs:

As MSNBC's Chris Hayes points out, some people did not quite believe the president's reported weight: 

Cartoonist Ben Ward poked some fun with a clearly ridiculous tweet:

So who is Ronny Jackson, who has been a White House doctor since 2013? Newsweek wrote a debrief on the physician’s background last week. Jackson attended Texas A&M University at Galveston for his undergraduate degree studying marine biology before attending medical school at the University of Texas Medical Branch. He began active duty in the Navy in 1995 and was later deployed as the emergency medicine physician in charge of resuscitative medicine at Iraq's Taqaddum air base, per Newsweek.

Jackson has served in the White House since the George W. Bush administration, first under Air Force Brig. Gen. Richard Tubb. He was named to the top post under President Barack Obama. A former Obama administration official praised Jackson on Twitter following the briefing:

From former top Obama adviser Dan Pfeiffer:

Also from journalist Yashar Ali:

Our colleague Derek Hawkins writes on the Lebanese Canadian doctor, Ziad Nasreddine, who created the Montreal Cognitive Assessment, which he reports “has proved so effective over the past two decades that it has been translated into dozens of languages and is used by physicians in well more than 100 countries.”


AHH: The Department of Health and Human Services is preparing new protections for health-care professionals who refuse to perform abortions, treat transgender patients based on their gender identity and provide other services to which they morally object, Politico reports. The White House is reviewing a proposed rule allowing the HHS office in charge of civil rights to offer additional protections to these workers and enact penalties on organizations that get in their way.

"The pending rule, which could be released as soon as this week, has been described to Politico as establishing a new 'division' of the HHS civil rights office that would conduct compliance reviews, audits and other enforcement actions to ensure that health care providers are allowing workers to opt out of procedures when they have religious or moral objections," Dan Diamond and Jennifer Haberkorn report.

"The office would also conduct outreach and technical support to help others who are seeking to strengthen protections for these workers," they write. "The new rules — a priority for anti-abortion groups and supporters — could come just days before Friday’s March for Life, the annual gathering in Washington marking the anniversary of the Supreme Court’s Roe v. Wade decision."

OOF: The Department of Veterans Affairs says it won't conduct research into whether medical marijuana could help veterans suffering from post-traumatic stress disorder and chronic pain. In response to a letter from House Democrats, who asked the agency to research pot as an alternative to opioids and anti-depressants many veterans use, VA Secretary David Shulkin said his department's ability to research medical marijuana is hampered by the fact the drug is still illegal under federal law.

“VA is committed to researching and developing effective ways to help Veterans cope with post-traumatic stress disorder and chronic pain conditions,” Shulkin wrote in a response to a letter from members of Congress. “However, federal law restricts VA’s ability to conduct research involving medical marijuana, or to refer veterans to such projects.”

"The response comes as at least 29 states, plus the District of Columbia, Guam and Puerto Rico, have legalized the use of medical marijuana in some form," the Post's Katie Zezima reports. "Veterans groups, including the American Legion, have been pushing for the drug to be studied and used to help ease the effects of PTSD, chronic pain and other disorders."

“What America’s veterans need prioritized right now is for cannabis to be treated as a health policy issue,” said Nick Etten, founder and executive director of the Veterans Cannabis Project. “We’re desperate for solutions for the conditions we’re dealing with.”

OUCH: More than 3 million fewer people had health insurance at the end of 2017 relative to the year prior, a Gallup poll finds. A recent estimate of the connection between a lack of insurance and mortality suggests that for every 800 people without insurance for a year, one will die — meaning that 4,000 more people may have died during the year than would have had they been covered, The Post's Philip Bump reports.

In the fourth quarter of 2016, the percentage of uninsured adults in the United States was 10.9 percent — a low after three years of declines following the passage of Obamacare. In 2013, before the law went into effect, nearly 1 in 5 adults lacked insurance. But over the course of last year, that figure rose again to 12.2 percent.

The biggest increases in the uninsured rate were among those age 25 and under, low-income Americans and minorities, Philip reports. Among those earning less than $36,000 a year, the percent without insurance jumped from 20.8 to 22.8 percent. Among black Americans, the rate jumped from 12.5 to 14.8 percent — and among Hispanics, the percentage of uninsured is now nearly 30 percent.


--House Republican leaders have presented their rank-and-file with a one-month spending bill aimed at keeping the government open ahead of the Friday night deadline, as hopes for a bipartisan deal on young undocumented immigrants fade. The bill to extend existing spending levels through Feb. 16 includes a six-year extension of the Children's Health Insurance Program — aimed at winning Democratic votes — and delays a trio of ACA taxes. The tax on medical devices and high-cost "Cadillac" plans would be delayed for two years, while the health-insurance tax (known as the "HIT") would be delayed for one year.

Few lawmakers were enthusiastic about the legislation, but several described it as a necessary evil to avoid the first government shutdown since 2013, The Post's Erica Werner and Mike DeBonis report. Leaders plan to test support today for the measure and bring it to a vote Thursday, but it wasn't immediately clear whether they would succeed. Remember that Democrats have leverage here because their votes are needed to keep the government open — definitely in the Senate but possibly also in the House unless Republicans can unify behind the short-term proposal.

White House legislative director Marc Short played down the chance of a shutdown to reporters last night, but he dismissed Democratic demands that any must-pass spending bill include a fix for the young immigrants who are losing deportation protections granted by the Obama administration.

“We think we will avoid a shutdown. It’s important to avoid a shutdown. You’ve seen the president’s messaging about the need to make sure that our troops are funded. I think you’ll see him continue to make that case,” Short said after meeting with top congressional aides of both parties in the office of House Majority Leader Kevin McCarthy (R-Calif.). “I’m not sure why funding our troops is tied to a deal for illegal aliens,” he added.

--This morning, Sen. Patty Murray (D-Wash.) is sending a letter asking the Trump appointees leading HHS to explain what she views as their pattern of undermining evidence-based practices. Murray is pointing to several recent moves by HHS -- including suspending a database of the National Registry of Evidence-based Programs and Practices (The Post's Lena Sun and Juliet Eilperin broke that story here.), making changes to the Teen Pregnancy Prevention Program and discouraging CDC and broader HHS officials from using phrases like ‘evidence-based’ and ‘science-based’ in budget request documents.

"The emerging pattern at HHS of undermining efforts to ensure policy decisions are driven by data and research is especially dangerous in a department that impacts the health and well-being of every person and family in our country," Murray writes. "I ask that you provide detailed information on the department’s failure to prioritize evidence-based work, as well as an explanation for how you believe such rollbacks are consistent with the mission of the department."


— Remember Tom Price? Yeah, the former HHS secretary who resigned amid a private jet scandal last fall. He's got a new gig on the advisory board of Jackson Healthcare, a Georgia-based provider of health-care staffing and technology services, per Bloomberg News's Ivan Levingston.

Price will bring unparalleled knowledge of the U.S. health-care system to the new post, Jackson Healthcare CEO Richard Jackson said in a news release. The company's director of corporate communications said Price will “provide feedback on our business plan and advice on business strategy overall” but declined to provide information about his compensation.

--A few more good reads from The Post and beyond:

Trump's first-year report card: Voters say he's no genius (Politico)


There were over 12,000 poison control calls for people eating laundry pods last year (Christopher Ingraham)

The Parasite on the Playground (New York Times)


UnitedHealth stock jumps after insurer's profit more than doubles on a one-time tax gain (CNBC)


'Safety Net' Hospitals Face Federal Budget Cuts (Stateline)

After a Debacle, How California Became a Role Model on Measles (New York Times)



  • The Senate Finance Committee holds an open executive session to consider the nomination of Alex Azar to lead the Department of Health and Human Services.
  • The Senate Homeland Security and Governmental Affairs Committee holds a hearing on “Unintended Consequences: Medicaid and the Opioid Epidemic."
  • The Senate Judiciary Subcommittee on Crime and Terrorism holds a hearing on the “long-term care needs of first responders injured in the line of duty.”
  • The Senate Health, Education Labor and Pensions Committee holds a hearing on “Facing 21st Century Public Health Threats: Our Nation’s Preparedness and Response Capabilities, Part I.”
  • The House Ways and Means Oversight Subcommittee holds a hearing on the opioid crisis.
  • The Bipartisan Policy Center holds an event on “Reinventing Rural Health Care."

Coming Up

  • The House Veterans’ Affairs Subcommittees on Health and on Economic Opportunity hold a joint hearing on addressing veteran homelessness on Thursday.
  • The Cato Institute Policy Perspectives 2018, including a keynote address on “Misdiagnosing the Opioid Crisis”, takes place on Thursday.
  • Kaiser Health News holds an event on what’s in store for health care in 2018 on Thursday.

The many defenses and dodges to Trump's 'shithole countries' remark:

From categorizing it as "tough language" to saying they "don't recall that specific phrase," Trump supporters are downplaying his "shithole countries" remarks. (Video: Jenny Starrs/The Washington Post)

Watch the powerful testimonies from victims of sports doctor Larry Nassar:

Several victims delivered emotional testimonies during the sentencing hearings of Michigan sports doctor Larry Nassar. Here's some of what they said. (Video: Amber Ferguson, Monica Akhtar/The Washington Post)

Watch The Daily Show's Trevor Noah on the White House physician's report on Trump's health: 

Seth Meyers checks in on the hurricane recovery effort in Puerto Rico: