with Paulina Firozi


Outgoing Secretary of State Rex Tillerson spoke to reporters at the State Department March 13, after President Trump said he was ousting him earlier that day. (Reuters)

As Rex Tillerson exits the State Department, he leaves behind a confusing trail of mixed messages about whether the Trump administration wants to support or undermine U.S. funding for global health.

President Trump’s tweet yesterday morning that he’d fired Tillerson was sudden yet not surprising given the former oil executive’s fraught year as the country’s top diplomat. Tillerson's tenure was marked by repeated clashes with the White House, a massive exit of talent from the agency he leads and an extreme reticence to interacting with the media.

Trump didn’t specifically cite Tillerson's health-care policies as a reason for giving him the boot — the president instead pointed to disagreements in key areas of foreign policy such as the 2015 Iran nuclear deal and the approach to North Korea. But it’s easy to see why the two men were not on the same page when you look at how they approached major U.S. funding streams for priorities such as HIV/AIDS, maternal health and more.

Trump and Tillerson's rhetoric did at times sounded quite positive toward funding major global-health initiatives. Trump used his first address to the United Nations to brag about U.S. investments in programs to take on AIDS, infectious diseases and human trafficking. And Tillerson occasionally expressed public support for global health programs, for example praising the Bush-era PEPFAR program in a major speech in October.

“PEPFAR has empowered people around the world to take their lives and their counties back,” Tillerson said at the time. “The Trump administration is committed to building on the progress we have already made by accelerating our approach that focuses on the hardest-hit populations.”

But the picture looks different when you consider Trump’s budget requests. The president called for sweeping cuts to virtually every funding stream in his 2018 budget plan last year and in the 2019 version the White House released last month.

The president's most recent budget requested cuts of 18 percent for PEPFAR, which distributes medical supplies to combat HIV/AIDS in the developing world. The budget document seeks a 32 percent reduction for the Global Fund to Fight AIDS, Tuberculosis and Malaria; a cut of 24 percent for maternal and child health; and a whopping 50 percent slash for family planning and reproductive health.

“There was this rhetorical support, but the proposed cuts were so significant there seemed to be a disconnect,” said Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation.

It’s unclear precisely why the administration has called for such deep cuts to global health aid. For one thing, it’s one area Republicans in Congress are typically eager to fund. Congress routinely allocated even more dollars for global aid than President Barack Obama requested during his two terms. A major hallmark of George W. Bush’s presidency was dramatically expanding AIDS funding through both PEPFAR and the global fund — now the two biggest funding streams for global health initiatives.

There’s another reason the proposed cuts were puzzling. Foreign assistance makes up less than 1 percent of the federal budget, and less than one-fourth of that goes to global health. So trying to trim these programs would do next to nothing to move the needle on U.S. spending, regardless of deficit concerns.

Tillerson didn’t publicly push back against the Trump budget, which would have been unusual for a Cabinet member, anyway. But he provided little evidence that he was making global health any kind of priority for the State Department. Instead, he’ll be best remembered for his effort to reorganize the agency, for which he received much criticism as key positions remained unfilled for months.

“I don’t know that global health was a particular focus for Secretary Tillerson at all,” Thomas Bollyky, senior fellow for global health at the Council on Foreign Relations, told me. “He tended to focus pretty heavily on institutional issues, a big departure from the past.”

The Onion poked fun yesterday:

Sen. Chris Murphy (D-Conn.) questioned whether Tillerson's successor, CIA Director Mike Pompeo, will continue the restructuring: 

There is one way global health programs appeared to be sheltered from the staffing upheaval in Foggy Bottom. Experts say Tillerson left in place or brought on top administrators with strong backgrounds in global health, including Deborah Birx, who oversees PEPFAR, and Mark Green, head of USAID.

But, as with many other areas of Trump's administration, it’s often hard to figure out the direction or priorities for top Trump appointees. That is how many global health experts said they’ll remember Tillerson.

“Part of the problem is this administration has been inconstant in its support,” said Jeff Sturchio, president of Rabin Martin, a global health consulting firm. “You never know if it’s going to change its tune overnight.”

The president discussing Rex's departure:

President Trump spoke March 13, after it was announced he ousted Secretary of State Rex Tillerson and planned to tap CIA Director Mike Pompeo to replace him. (The Washington Post)

This story, tweeted by the Post's Ashley Parker, is a good illustration of how Trump treated Tillerson:

Abortion rights groups weren't pleased Tillerson had enacted new bans on funding for organizations that provide abortions. Planned Parenthood tweeted that CIA Director Mike Pompeo, Trump's choice to replace Tillerson, likely won't be any better.


AHH: The panel that advises the White House on cancer policy is calling for immediate action to curb high costs for medications. The President’s Cancer Panel released a report yesterday outlining a series of recommendations  to ensure cancer drugs, which can at times run more than $100,000 per year, are priced according to value. The panel also sought to push cheaper, generic versions of drugs to the market.

“Cancer patients should not have to choose between paying for their medications or paying their mortgages. For so many, it is truly a matter of life and death,” panel chairwoman Barbara Rimer said in a statement. “This is a national imperative that will not be solved by any one sector working alone.”

The report says the complex process that goes into getting a drug to the patient “has resulted in drug prices that often do not reflect the benefits experienced by patients.” “Achieving better alignment could improve the quality of cancer care; create incentives for development of innovative, effective new drugs; and help address increases in drug spending that are threatening to put high-value drugs out of reach for some patients,” it says.

OOF: So exactly why does the United States spend twice as much on health care as other wealthy countries? A new study suggests Americans are using health care at similar rates to other rich countries, and the real difference is in the exorbitant prices of procedures and treatments, The Washington Post's Carolyn Y. Johnson reports. The finding doesn't mean Americans aren't overusing health care -- it just means that we aren't alone in doing so, Carolyn explains.

The sweeping study of health-care expenditures, published in the Journal of the American Medical Association, found higher spending in the United States isn't driven by overuse but by high prices — including doctors' and nurses' salaries, hospital charges, pharmaceuticals and administrative overhead. That finding contradicts conventional wisdom. “The thinking goes that the American health care system is uniquely set up to incentivize wasteful imaging scans, oodles of unnecessary prescriptions and procedures that could have been prevented,” Carolyn writes.

The study compared the United States with the United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland and Denmark from 2013 to 2016 on nearly 100 different measures of care. It found the United States spent about twice as much per person on health care, an investment that produced the shortest life spans and the highest rate of infant deaths. 

OUCH: Will David Shulkin be the next secretary to get fired? Trump is souring on his embattled VA secretary and telling aides he might replace him as part of a broader shakeup of his Cabinet, The Post's Lisa Rein and Josh Dawsey report. Senior White House officials said Shulkin could be forced out within days and the New York Times has reported the president is considering Energy Secretary Rick Perry, an Air Force veteran, to replace Shulkin. Trump invited Perry to the White House for lunch on Monday but did not formally offer him the job.

"A physician and former hospital executive who won unanimous confirmation by the Senate last year, Shulkin has been a favorite of Trump’s, racking up legislative victories and fast changes at an agency the president railed against on the campaign trail," Lisa and Josh write. "But months of turmoil in VA’s senior ranks have roiled the ­second-largest federal bureaucracy, which employs 360,000 people. Shulkin has said publicly that high-level political appointees installed by the White House are scheming to oust him over personality and policy differences."


—Yesterday, House lawmakers rejected a “Right to Try” bill that would have allowed seriously ill patients to bypass the FDA to access to experimental treatments. Our colleague Laurie McGInley reports the 259-to-140 vote followed a “spirited debate in which GOP lawmakers portrayed the measure, which was strongly backed by President Trump and Vice President Pence, as a last chance at survival for desperately ill patients.” They also noted dozens of states have passed or introduced similar measures.

But Democrats argued the legislation would weaken critical FDA protections without addressing the fundamental obstacles to experimental drugs. On Monday, more than 75 patient groups sent a letter to House leaders calling for them to reject the bill. The groups, which included the American Cancer Society, Cancer Action Network and the American Lung Association, said it “would not increase access to promising therapies.” The letter said the proposed model would be “less safe” for patients than the existing program, called expanded access.

“The FDA's expanded-access program, which receives about 1,000 requests a year for experimental drugs, already approves 99 percent of the appeals,” Laurie explained. “But drug companies often balk at providing experimental drugs outside of clinical trials. The right-to-try legislation does not compel pharmaceutical firms to provide sought-after therapies.”


—CVS Health and Aetna shareholders have voted to approve the merger between the pharmacy benefits manager and major health insurer. CVS first announced the deal to buy Aetna for $69 billion in December. Yesterday, the two companies held meetings where more than 98 percent of CVS shareholders' ballots and 97 percent of Aetna shareholders' ballots were in favor of the deal, CNBC reported. Now it’s up to the Justice Department to approve it.

"When this merger is complete, the combined company will be well-positioned to reshape the consumer health care experience, putting people at the center of health care delivery to ensure they have access to high-quality, more affordable care where they are, when they need it," CVS Health chief executive Larry Merlo said in a statement.


—It appears former HHS Secretary Tom Price has paid back the government for the costs of his jet travel that resulted in his resignation last fall. In a letter raising new questions about travel costs associated with flights White House senior adviser Kellyanne Conway took with Price, Rep. Elijah Cummings (D-Md.) noted Price had paid the Treasury $60,000 to reimburse costs of his travel.

In his letter to House Oversight Chairman Trey Gowdy (R-S.C.), Cummings urged Gowdy to subpoena White House documents on Cabinet officials’ pricey travel that includes information on Conway. He wrote that Conway’s travel, as well as costs from another White House official cost taxpayers “tens of thousands of additional dollars.” Cummings's letter details four trips, including travel in May 2017 for Price, Conway and several staffers totaling more than $44,530, another trip in July totaling more than $14,569 for all passengers and a trip in September.

“To date, the White House has refused to provide any documents at all, including those relating to Ms. Conway’s participation in these trips, whether she intends to repay the taxpayers for the cost of her travel, or whether the President is considering any disciplinary action against her in light of his decision to fire Secretary Price for participating in the same trips,” Cummings writes.

The White House dismissed the letter, saying the “partisan attack on Kellyanne is ridiculous," per ABC News. Deputy White House press secretary Hogan Gidley added: “Members of the President’s Cabinet invite relevant White House staff for official travel to events advancing the President’s agenda. When White House staff accompany Cabinet Members their travel plans are arranged, secured and financed by the inviting agency.”

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



  • The Senate Indian Affairs Committee holds an oversight hearing on opioids in the Indian community.
  • The Patient-Centered Outcomes Research Institute and the American Heart Association hold a briefing on cardiovascular disease.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the 340B Drug Discount Program on Thursday.
  • VA Secretary David Shulkin testifies before the House Appropriations Subcommittee on Military Construction, Veterans Affairs and Related Agencies on Thursday.
  • HHS Secretary Alex Azar testifies before the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies on Thursday.

Activists laid 7,000 pairs of shoes on the lawn of the U.S. Capitol to represent every young person killed by a gun since the Sandy Hook massacre:

Activists laid 7,000 pairs of shoes on the lawn of the U.S. Capitol on March 13 to represent every young person killed by a gun since the Sandy Hook massacre. (Reuters)

Education Secretary Betsy DeVos calls onCongress to pass gun control legislation "without delay:"

Education Secretary Betsy DeVos urges Congress to pass gun control legislation "without delay." (Reuters)

Here's Stephen Colbert's take on Trump ousting Secretary of State Rex Tillerson: