with Paulina Firozi


If disgraced Health and Human Services Secretary Tom Price is remembered for what he opposed — namely, Obamacare — his successor Alex Azar appears eager to be known for what he supports.

In a notable nod to the tenets of the Affordable Care Act, HHS’s Centers for Medicare and Medicaid Services indicated yesterday the agency feels Idaho is out of line with the state's recent, daring move to allow insurers to duck the health-care law’s coverage requirements.

“The Affordable Care Act remains the law,” CMS Administrator Seema Verma wrote in a notice, adding that based on the agency’s review of Idaho’s actions, there’s “reason to believe that Idaho would be failing to substantially enforce the provisions” laid out in the ACA.

Idaho’s move, which I explained in more detail in this Health 202, presents a major test of whether Azar will prioritize upholding the ACA as written or give in to political pressures within his own party to undermine it. It appears, at least for now, that Azar is not willing to enter potentially dangerous legal territory by condoning Idaho’s actions, which experts agree would have been a clear violation of the ACA. My colleague Amy Goldstein has more on yesterday's Idaho letter here.

Azar is also aiming to score some big goals by creating a U.S. health-care system rewarding good care, an area where Price was deeply reticent. He and several lower-ranking HHS officials, including Verma and FDA Commissioner Scott Gottlieb, made several major public speeches laying out their priorities, suggesting a more transparent and future-oriented approach than under Price's management.

“I like to describe it as a hockey stick moment,” Azar told reporters yesterday. “We are at a critical point where, with enough energy and commitment, we can drive seriously toward a value-based system.”

In his two speeches — one to community hospitals on Monday and another to insurers on Thursday — Azar laid out the clearest picture yet of the legacy he hopes to leave behind as head of the sprawling federal agency overseeing the government’s biggest health insurance programs as well as drug safety, public health and medical research.

The Association of American Physicians and Surgeons:

Politico's Dan Diamond:

He wants to make major inroads on a problem that has long plagued the country’s health-care system, which spends more per patient than any other country. The U.S. health system boasts an arcane pricing web that leaves patients in the dark about the costs of their own care and leads to massive inefficiencies, duplications and misplaced incentives.

Azar was careful not to criticize the work of the Obama administration, which had laid out — and accomplished — some major goals in restructuring Medicare payments so they incentivize doctors, hospitals and clinics to coordinate and streamline care instead of just paying them for performing more services (I detailed that effort in this Health 202).

But he’s trying hard to reverse the perception left by Price that HHS is backtracking on the limited progress made under Obama.

“Under President Trump, this is the direction we’re going,” Azar told several dozen reporters gathered at the Humphrey Building, adding that he had spoken with the president earlier that day. “He’s deeply committed to these changes in the system."

The health-care system makes it extremely difficult for consumers to discover how much services cost because opaque prices are typically negotiated between insurers and providers and can vary dramatically based on which plan a patient has or where they receive care. That results is a system filled with waste, where care is delivered and consumed with little regard for cost or value.

And it shows in the aggregate. While the United States has the third-highest costs for medical care — outranked by only Norway and Switzerland — it’s ranked near the bottom of all developed nations on health-care efficiency as measured by life expectancy, costs per capita and costs as a percentage of GDP.

Azar outlined four key ways he wants HHS to get at the problem: by improving data-sharing among providers and patients, making prices more transparent for consumers, driving change in the system through Medicare and Medicaid, and removing government barriers to change.

“This is the agenda, this is the direction,” Azar said. “This is the destination, and now our job is to mobilize the 80,000 great people of this department to make this a reality in our programs.”


AHH: Cigna announced it will buy pharmacy benefit giant Express Scripts in yet another major health-care industry merger. The $67 billion deal brings Express Scripts, the last major standalone pharmacy benefit manager (PBM), under the umbrella of an insurer, our colleague Carolyn Y. Johnson reports. “The companies say the deals reflect an evolution in health care, toward a payment system that is linked to people's health outcomes and keeping people well."

In an interview, Cigna CEO David Cordani gave the example of a woman who becomes injured at work and is prescribed painkillers. Separately, the patient may become depressed and be prescribed psychotropic medications, unbeknown to her primary care doctor. The combined company, he said, would be able to use real-time data to flag such cases and "complete a picture of the whole person -- and help that primary care physician more actively treat the mind and body, potentially modify her pain management," Cordani told Carolyn.

The deal comes at a time of upheaval among PBMs. In December, major PBM CVS Health announced it would acquire health insurer Aetna. Earlier this week, FDA commissioner Gottlieb criticized pharmacy benefit managers, as well as other players in the health care industry, for contributing to higher drug costs.

OOF: Premiums in the Obamacare marketplaces will probably jump 35 to 94 percent across the country in the next three years, according to a new nationwide report by California's marketplace. The analysis released yesterday finds wide variations state to state, with a broad swath of the South and parts of the Midwest in danger of what the report calls “catastrophic” average rate increases by 2021, The Washington Post's Amy Goldstein reports.

According to the report, the largest single impact will come from eliminating the ACA’s penalty for lacking health coverage. That change alone, part of the tax overhaul passed in December, can be expected to increase premiums by 7 to 15 percent next year and by as much as 10 percent each of the following two years. Analysts said the rising cost of medical care and new efforts by the administration to expand the availability of leaner health plans will also drive up average premiums.

“The effect is going to be: The individual market will be poor people who get subsidies and sick people who buy no matter what,” said Peter Lee, executive director of Covered California, the state-run marketplace that sponsored the analysis. “And the middle class will be priced out of insurance in about a third of America.”

OUCH: A battle over Medicaid will keep Virginia’s House and Senate from passing the state's budget on time, The Post's Laura Vozzella reports. House and Senate negotiators have been trying to hash out differences between two vastly different two-year state spending plans, but after meeting late Wednesday to discuss a compromise proposed they didn't break the impasse, Laura reports.

The House version calls for expanding Medicaid under the ACA while the Senate’s does not. "As a result, the House plan is much more flush, with more than $370 million in extra spending for schools, state employee raises and other priorities because of projected savings due to Medicaid expansion," Laura reports.

Democratic Gov. Ralph Northam won office last year promising to expand Medicaid after Republicans in the House and Senate steadfastly blocked expansion for four years under Northam’s predecessor, Terry McAuliffe. Opposition in the House softened after Republicans nearly lost control of the chamber in November elections, but there's been no visible shift in the state Senate. The GOP controls both chambers by two seats.


—It's been a bad news week for the opioid epidemic, with the release of new CDC data showing abuse appears to still be on the rise. The crisis is spiking nationwide among African Americans, with deaths rising 41 percent in 2016 among black people in urban counties, NPR's Marisa Peñaloza reports.

“This epidemic started in white suburban and rural areas where people are overdosing mostly with prescription medicine like Percocet and OxyContin,” Marisa reports. Dr. Edwin Chapman, who specializes in drug addiction in D.C., said black people are prescribed painkillers less often than white people, possibly a factor in why fewer initially fell victim to opioid abuse. But as deaths rise among African Americans, experts suggest the culprit is fentanyl. 

"African Americans are falling victim to fentanyl and carfentanyl because they are so much more potent than heroin," Dr. Melissa Clarke, who works with Chapman, told Marisa. Fentanyl is a powerful synthetic opioid that is often laced in heroin and other street drugs.

—As the opioid crisis appears to get worse, at least it's not being ignored. In a sweeping show of concern about the epidemic, lawmakers and state leaders from both sides of the aisle are calling for an increase in efforts to address abuse and overdose. “Every single governor has it at the top of his or her list, even more than Congress because they’re seeing it,” Sen. Lamar Alexander (R-Tenn.) told the Wall Street Journal ahead of another hearing yesterday by the Senate Health, Education and Labor Committee.

Former New Jersey Republican governor Chris Christie, who led Trump's opioid commission, told WSJ the efforts to fight the rampant crisis has been slowed by a delay in filling administration roles that would help with the effort. “Congress has fallen short on the funding, the administration has fallen short in getting the personnel to make it happen,” he said. But he noted that governors, at least the Republican ones, aren't going to call attention to this. “If you’re a Republican governor, you’re always going to be cautious about being critical," Christie said.

Maryland Gov. Larry Hogan, also a Republican, urged lawmakers to “make increased funding for the opioid crisis a top priority,” and added “we simply can’t stop it without the federal government stepping up,” per the Baltimore Sun. Oregon Gov. Kate Brown, a Democrat, is calling on the federal government to focus on prevention over punishment.

"Right now, the federal government recognizes the problem, but is overly focused on punishment,” she said during the Senate hearing, according to KTVZ. “That leaves us, the states, to right the wrongs of a war on drugs that has done nothing to address the issues that drive this health crisis, while our prisons and our foster care systems are filled to capacity with its victims."

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


Coming Up

  • The National Coalition on Health Care holds an event on alternative payment models on March 16.

Here's a look at President Trump's cabinet meeting on Thursday: 

President Trump congratulates Florida for "very good" gun legislation:

House Minority Leader Nancy Pelosi (D-Calif.) said she's "more concerned with the president's policies" than the Stormy Daniels payout: