with Paulina Firozi


Alex Azar is just two weeks into his new job, but he gave a few more hints this week about how he’ll lead the Department of Health and Human Services when he appeared before three Capitol Hill committees to testify about President Trump’s budget.

Some of the most consequential — and controversial — government policies and programs lie within Azar’s purview. Activists, those in the industry and lawmakers are watching anxiously to see how Trump’s second try at an HHS secretary approaches a wide range of responsibilities, from enforcing the Affordable Care Act to overseeing how states run their Medicaid programs to combating the opioid epidemic.

In the three hearings stretching over Wednesday and Thursday — held by the House Ways and Means Committee, the House Energy and Commerce Health subcommittee and the Senate Finance Committee — it was clear that Azar holds pretty traditional conservative views consistent with many of Trump’s top appointees. Yet he appeared to have a better rapport with some Democrats compared to his predecessor, Tom Price.

The former pharmaceutical executive firmly defended the major health-care spending cuts proposed by the White House and wouldn’t directly promise to enforce the ACA as the law of the land. But Azar also didn’t reject certain projects begun under the Obama administration, such as its push to peg more Medicare payments to value instead of quantity.

Here are the top five most interesting things Azar told members of Congress this week:

1. He wouldn’t commit to cracking down on Idaho, a Republican-led state that is allowing insurers to duck certain ACA requirements.

Azar said he would enforce ACA insurance mandates – such as banning higher premiums for those with preexisting conditions and requiring coverage in 10 categories of care – only if Idaho proactively asks the federal government for permission to exempt insurers from some of Obamacare's requirements.

“I have not yet seen the plan or have received any type of waiver request,” Azar told Sen. Ron Wyden (D-Ore.), who was questioning him about the move by Idaho's GOP Gov. C.L. “Butch” Otter. “I can assure you if we do receive that, and if it does progress forward, we’ll be looking at it very carefully and measuring it up against the standards of the law, as is our duty.”

But Otter doesn’t appear to have any intention of asking HHS for permission since he has invited insurers in his state to submit plans exempt from ACA mandates, Wyden noted. Blue Cross of Idaho is the single insurer to do so.

“This is the one that is going to determine whether states just on their own can say whether we are going back to yesteryear,” Wyden told Azar.

2. The new secretary is pretty stoked about slowing future growth in both Medicare and Medicaid spending.

Trump’s budget would stem federal Medicaid spending by $675 billion by 2028 by moving the program to the block-grant system envisioned by the health-care bill from Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) and using the lowest available growth rate.

The budget would also save Medicare nearly $6 billion over the same time period by pulling several levers, such as giving Medicare Part D plans more flexibility to set the list of drugs they cover and moving certain drugs from Medicare’s hospital program to its prescription drug program, where some price negotiations are allowed.

These are among the aspects of Trump’s budget that Democrats dislike the most. But Azar firmly defended the budget before lawmakers, saying Medicaid restrictions would allow states to create more sustainable insurance pools with cheaper options.

“That is one of the really constructive aspects of this budget,” Azar said. “It gives the states a real constructive tool to create risk pools for sustainable, affordable coverage in the future.”

Rep. Eliot Engel (D-N.Y.): 

The HIll's Peter Sullivan: 

3. Azar thinks HHS can help lower the list price of drugs overall by tweaking Medicare.

Rep. Jan Schakowsky (D-Ill.) was skeptical in questioning the former Eli Lilly exec about drug pricing proposed in the Trump budget deal that appeared to target only the “middle of the avalanche” for high drug prices rather than the “top.” Azar insisted that he could create incentives for drug makers to lower their drug prices overall by reducing the cost of Medicare drugs.

He listed several Medicare pricing changes suggested in the budget, including requiring private insurers to pay more for seniors’ drugs once they’ve hit $5,000 in out-of-pocket expenses, and changing the way such costs are calculated.

With these changes, private insurers selling Medicare Part D plans would have “even more incentive to fight against the branded drug companies to keep those list prices down,” Azar contended.

4. He's committed to gun violence research.

Several Democrats quizzed Azar on whether he's open to conducting federal health research on gun violence, something that's been limited since 1996 because of legislation preventing the Centers for Disease Control from carrying out research that could be used to advocate for gun control. Lawmakers pointed to the Wednesday shooting at a Florida high school that killed 17 people, putting it among the deadliest school shootings in U.S. history.

"We're in the science business and the evidence-generating business, and so I will have our agency certainly working in this field, as they do across the broad spectrum of disease control and prevention," Azar said, calling it a "priority" for HHS to research serious mental illness, the causes of violence and the causes of "tragedies like this."

5. He wouldn’t respond to questions about whether lawyers providing advice to immigrant children should be banned from discussing abortion access with pregnant detainees.

Azar was asked about a story The Washington Post’s Ann E. Marimow and Maria Sacchetti broke yesterday about how the nonprofit Vera Institute, a major legal services group for immigrant children, told its lawyers nationwide not to discuss abortion access, for fear of jeopardizing a multimillion-dollar contract with HHS.

Vera’s instruction to lawyers comes as the Trump administration has tried in court to block access to abortion procedures for undocumented teens in custody. Rep. Diana DeGette (D-Colo.) asked Azar whether he’d crack down on Scott Lloyd, director of the Office of Refugee Resettlement, for allowing the practice.

“We have with regard to these children who come into our custody a very important obligation, which is to look out for their health and welfare, as well as that of their unborn children,” Azar replied.

PROGRAMMING NOTE: The Health 202 will not publish on Monday, Feb. 19. Enjoy your weekend and we’ll be back in your inbox on Tuesday, Feb. 20.


AHH: Two of the nation’s biggest drug distributors shipped 12.3 million doses of powerful opioids to a single pharmacy in a tiny West Virginia town over an eight-year period, The Post's Lenny Bernstein and Katie Zezima report. The Family Discount Pharmacy in Mount Gay-Shamrock received the drugs from McKesson Corp. and Cardinal Health between 2006 and 2014, according to a report by the House Energy and Commerce Committee, which is investigating the sale of pills in West Virginia by wholesale drug distributors.

The new data is included in letters sent by the committee Thursday to the “Big Three” drug distributors — McKesson, Cardinal and AmerisourceBergen — demanding more information on the steps they took during those years to keep drugs off the black market. The committee said it has analyzed DEA data showing McKesson and Cardinal sent Family Discount millions of opioid painkiller pills, even though the town has only 1,779 residents.

“We need detailed answers and documents from these national distributors as to why large volumes of opioids were distributed to certain areas of the state,” the committee’s chairman, Rep. Greg Walden (R-Ore.), and ranking Democrat, Rep. Frank Pallone Jr. (D-N.J.) said in a statement. “West Virginians and families devastated by the opioid crisis all over the country deserve answers.”

The Centers for Disease Control and Prevention said the flu virus vaccine is only 36 percent effective this year for adults. (Reuters)

OOF: This season’s flu vaccine is only 25 percent effective against the most virulent and predominant strain of the virus -- and just 36 percent effective overall, our colleague Lena H. Sun reports.

Yesterday the CDC released a report confirming what federal health officials have feared: In especially bad flu seasons such as the current one, the flu vaccine is less effective. At a briefing for reporters, Azar likened getting a flu shot to wearing a seatbelt, “a sensible precaution” that Americans should take. "He said he, his wife and two children have all been vaccinated. So, too, has President Trump, according to Azar, who said he spoke to the president Wednesday about the continuing flu threat," Lena writes.

Even in a good year, the vaccine is never as effective as other vaccines. In comparison, the measles vaccine is 87 percent effective with two doses, Lena writes. But your doctor is still likely to recommend you get the vaccine, as it still offers some protection against H3N2, the predominant strain of the flu this season.

Here’s some positive news: In children younger than 9, the vaccine offers greater protection and decreases the risk of becoming sick enough to see a doctor by more than half. That’s especially important this season, as at least 63 children have died as a result of the flu since Oct. 1, a number that could top the 148 deaths reported for the 2014-2015 flu season. 

Lena also has a helpful flu explainer here.

OUCH: Planned Parenthood has joined forces with eight other local government, health care, and advocacy organizations to sue the Trump administration over the defunding of a national teen pregnancy program. The groups argue approximately $200 million in grants from the Obama-era Teen Pregnancy Prevention Program -- created by Congress to conduct scientific research into how best to lower teen pregnancy rates -- were wrongfully terminated.

It was designed as a five-year program, but grantees reported last summer they had received letters informing them the program would be terminated the following year, at the end of June 2018 — two years ahead of schedule, The Post's Ariana Eunjung Cha reports. Attorneys from Planned Parenthood, Democracy Forward and Public Citizen accused officials of attempting to illegally dismantle the program based on ideological beliefs rather than science.

Carrie Flaxman, deputy director for public policy litigation for Planned Parenthood Federation of America, told Ariana the programs have been widely praised as “models for kind of the best practices for teen pregnancy prevention across the country” and should be expanded, not cut back. “HHS has no authority to terminate the contracts" or the overall program, she said, calling the decision “arbitrary and capricious.” 

In remarks after the Florida high school shooting, President Trump said he is working with local officials to address school safety and mental health concerns. (The Washington Post)

—In his televised address at the White House yesterday, President Trump focused on tackling “the difficult issue of mental health” in response to the Florida school shooting. He earlier called the suspect who opened fire killing at least 17 people at a South Florida high school “mentally disturbed,” and also specifically addressed young people who feel isolated.

“I want you to know you are never alone and never will be,” he said, our colleague David Nakamura reported. Trump told young people to find a “a teacher, a family member, a local police officer or a faith leader” and to “answer hate with love.”

Trump tweeted this earlier Thursday:

Yet Trump steered clear of mentioning gun control laws. Our colleague Callum Borchers noted “the president's message fits a pattern in post-shooting remarks from his White House and Republicans more broadly." So did PBS NewsHour's Yamiche Alcindor:

After the October mass shooting in Las Vegas, and after a gunman opened fire in November on a church in Texas, and on the fifth anniversary of the Sandy Hook Elementary School massacre in December, the president, the White House press secretary and Republican leaders called for a discussion of mental-health issues, Callum explains.

Here’s some context for Trump’s response yesterday, via Bloomberg News's Jennifer Epstein: 

--Several medical associations called for stricter gun control laws and more gun violence research. The American Academy of Pediatrics called on lawmakers to take “meaningful action to protect our children, our families, and our communities,” with a ban on assault weapons, stronger background checks and solutions addressing firearm trafficking. "We will also continue to work to ensure that children and their families have access to appropriate mental health services, particularly to address the effects of exposure to violence," the group said in a statement.

The American Medical Association applauded Azar for saying he'd prioritize gun violence research. “We agree with Secretary Azar that the CDC has the authority to conduct this critical research into gun violence and they should begin their work immediately," the AMA said. "An epidemiological analysis of gun violence is vital to address this public health crisis so our society can take action and prevent injury, death and other harms resulting from firearms."

--Treasury Secretary Steven Mnuchin also broke with most of the Trump administration by calling on Congress to look into the issue of gun violence overall. “I will say, personally, I think the gun violence — it’s a tragedy what we’ve seen yesterday, and I urge Congress to look at these issues,” Mnuchin said. Our colleague Damian Paletta wrote Mnuchin's comments are notable because he was the first senior Trump administration official to call for a congressional review after the massacre. 

Many experts believe it is time to bring back a federal assault weapons ban or something similar, The Post’s Christopher Ingraham reports. The gunman behind Wednesday’s shooting, the man who shot more than 400 people in Las Vegas in October, the man who gunned down 26 people at the Texas church in November, and the man who gunned down 49 people in Orlando in 2016 all purchased military-style assault weapons legally.

When asked Thursday whether law enforcement should be able to confiscate weapons from people who have shown signs of mental illness, House Speaker Paul Ryan (R-Wis.) cautioned against drawing conclusions just yet. “This is not the time to jump to some conclusion not knowing the full facts. We've got a lot more information we need to know,” he said. “But if someone who is mentally ill is slipping through the cracks and getting a gun, because we have laws on the books — we have a system to prevent people who aren't supposed to get guns from getting guns — and if there are gaps there, then we need to look at those gaps."  

Our colleague Paul Kane wrote the positions lawmakers took following the shooting left "little chance of a legislative response to the continuing crisis of active shooters killing people with firearms in public places."

Yesterday, 19-year-old Nikolas Cruz confessed to police that he carried out the deadly shooting. And although police did not indicate a motive, our colleagues Lori Rozsa, Mark Berman and Renae Merle report "investigators continued to delve into his troubled, violent life and the red flags that littered his path back to Marjory Stoneman Douglas High School."

“This is an emotionally broken young man,” Gordon Weekes, the public defender, told reporters about Cruz, who made his first court appearance on Thursday. He added Cruz was on suicide watch and "has suffered significant mental illness, and significant mental trauma.”

You can read more about the 17 lives lost here, compiled by our Post colleagues. 

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



  • The USC-Brookings Schaeffer Initiative for Health Policy holds an event on patient cost sharing for prescription drugs.

Here's a timeline of the deadly Florida school shooting: 

At least 17 people were killed in a shooting at a high school in Parkland, Fla., on Feb. 14. According to officials, this is how and when the events occurred. (Melissa Macaya, Patrick Martin/The Washington Post)

A survivor of the Florida high school shooting asks: "Just, why?"

Olivia Prochilo, 16, a student at Marjory Stoneman Douglas High School in Parkland, Fla., managed to escape gunfire during the Feb. 14 shooting rampage. (The Washington Post)

Here's a look at how presidents have responded to school shootings: 

How presidents have responded to mass school shootings since Columbine High School. (Joyce Koh/The Washington Post)