THE PROGNOSIS

Some top Trump appointees have learned the hard way that serving at the pleasure of the president is no easy task (read: Rex). But newly installed Health and Human Services Secretary Alex Azar is casting his boss’s bigly persona as a refreshing chance for sweeping reform. 

Azar told employees yesterday that President Trump’s marching orders are essentially this: Do “very big and bold things.” That's what he loves about working with the president, Azar said in a live-streamed, all-staff meeting at the Centers for Medicare and Medicaid Services.

“In areas in the past where traditional political operatives said this is untouchable, Seema and I don’t get that kind of guidance,” Azar added, referring to CMS Administrator Seema Verma. “It’s ‘do the right things, solve big problems and come up with big solutions.' ”

It was the first time since his February confirmation that Azar had directly addressed the employees of CMS, the part of HHS that oversees the government’s big insurance programs with a whopping $1 trillion budget that makes up one-quarter of all federal spending.

While CMS keeps a low public profile, the agency exerts huge pull over how states can run their Medicaid programs, which Medicare benefits seniors can access and, perhaps most controversially, how the Obamacare marketplaces operate.

Stakeholders are watching closely for how Azar might alter precedent set out by the Obama administration, especially in contrast to his predecessor Tom Price, who was viewed by many as more politically driven than policy-focused. Azar has been trying to create the opposite reputation, engaging in many more public appearances and speaking in greater detail about payment and other changes he’d like to take on.

At yesterday’s staff meeting — which lasted about half an hour and involved a short question-and-answer period at the end led by Verma — Azar laid out four areas where he wants HHS to focus: lowering drug prices, making private insurance more affordable and accessible, restructuring payments so they’re based on care quality and not quantity, and addressing the opioid epidemic.

Trump weighed in on these four aims, Azar told staff. “These four areas really need the power of the office of the secretary and the presidency to direct the transformational changes we need,” he said.

Azar is walking quite the political tightrope, overseeing the health-care law Trump has bashed repeatedly. It could be tricky for him to remain in the president’s good graces, given early indicators that he’s unwilling to ignore the law to fit political aims (such as CMS’s recent disapproval of Idaho for trying to let insurers duck ACA requirements).

When he talks about the president, Azar characterizes Trump’s unfiltered style as courageous and one that aligns nicely with a dramatic change agenda. “It’s nice to know when leadership has your back on demonstrating that kind of courage,” Azar said.

It was also one of the first times Azar has publicly interacted with Verma, although the two know each other well because they’re both from Indiana. There has been some speculation about how well they’re working together, but Azar described their interactions as a “mind meld.”

“The administrator and I are in a mind meld on the direction of everything you’re doing here,” Azar told staff, saying he’s pleased with the direction the agency is going and how it’s planning to achieve goals.

The two appeared to be congenial on stage. At the meeting’s conclusion, Verma presented Azar with a ball cap labeled “CMS,” saying it completed his outfit after he’d been given a lab coat by the Food and Drug Administration and some scrubs from the National Institutes of Health, two other major agencies that are part of HHS.

Azar also spent much of the meeting praising the 4,100 employees of CMS and speaking fondly of the years he spent at the agency from 2001 to 2007, first as general counsel and then as a deputy under HHS Secretary Mike Leavitt.

“I feel a bit like Rip van Winkle,” Azar said. “I had a 10-year nap and I woke up again.”

Azar tweeted this afterwards:

AHH, OOF and OUCH

AHH: While Trump has told advisers he wants to oust VA Secretary David Shulkin, the White House has sent mixed messages publicly and it remains unclear to what extent the secretary still has the president's full trust -- basically leaving Shulkin in what The Post's Lisa Rein, Josh Dawsey and Emily Wax-Thibod​​eaux describe as a "presidential purgatory."

As recently as Monday, one White House aide declined to discuss Shulkin’s future while another told Fox News the president had confidence in him “at this point in time.” "The uncertainty has left the leader of the federal government’s second-largest agency, its employees, and even senior White House officials wondering if Shulkin still officially speaks for VA. It has raised questions, too, about what’s being done to restore order at the agency after weeks of turmoil have left little doubt that Shulkin, the lone Obama administration holdover in Trump’s Cabinet, is next to go in what’s become a pronounced leadership shake-up," Lisa, Josh and Emily write.

"What’s befallen Shulkin is a favorite tactic of Trump’s, who followed a similar approach with Secretary of State Rex Tillerson and, to a lesser degree, national security adviser H.R. McMaster," they continue. "The president emasculates those who fall from favor, humiliating them through media leaks and in disparaging comments to friends. The mixed signals often leave even senior White House officials guessing who will be fired and when."

OOF: Larry Nassar’s former boss, who led Michigan State University’s medical school from 2002 until last year, sexually assaulted and harassed four female students and mishandled a 2014 complaint against Nassar, according to criminal charges unsealed yesterday. William Strampel, 70, was arrested on Monday and taken to jail on four charges, our colleague Will Hobson reports. The charges stem from the ongoing investigation of the role individuals at Michigan State played in crimes committed by Nassar, the former Michigan State and USA Gymnastics physician who sentenced to 40 to 175 years for sexually assaulting former gymnasts in his care.

“Two of the charges announced Tuesday — both misdemeanor counts of willful neglect of public duty — relate to Strampel’s handling of an April 2014 complaint by a 24-year-old woman that Nassar massaged her breast and vaginal area in a sexual manner at a campus clinic when he was supposed to be providing treatment for hip pain,” Will explains. “Strampel initially prohibited Nassar from seeing patients while Michigan State’s Title IX office conducted an investigation, but in June 2014 he allowed to Nassar to resume working at the clinic...Strampel’s other charges stem from a pattern of discriminatory behavior described by four former female students.”

OUCH: The loss of eggs and embryos at an Ohio fertility clinic earlier this month is double what the clinic initially thought, the Associated Press reports. An alarm system was shut off on one of the clinic's embryo tanks when it failed. More than 4,000 eggs and embryos were ruined, affecting about 950 patients.

In a letter sent to its patients yesterday, the University Hospitals Ahuja Medical Center said it remains unclear who may have shut off the alarm or why it was turned off. Had the alarm been on, it may have alerted clinic staff when the embryo tank’s temperatures started to rise to dangerous levels. The clinic also doesn’t know how long the alarm had been off. Clinic officials wrote they're “heartbroken to tell you that it’s unlikely” any of the eggs and embryos are viable.

The liquid nitrogen storage tank at the Cleveland-area clinic heated up unexpectedly earlier this month. Initially, the clinic said more than 2,000 eggs and embryos were potentially damaged. 

OPIOID OPTICS

— Nearly 1 million people weren't working because of opioid addiction in 2015, per a new study from the American Action Forum that underscores the profound effect of drug use on the U.S. economy. The study finds that 919,400 people between the ages of 25 to 54 were out of the workforce in 2015 because they were dependent on opioid drugs, my colleague Katie Zezima reports. Between 1999 and 2015, the loss of employees and their productivity because of opioid addiction cost the U.S. economy $702.1 billion, or just under $44 billion per year.

The share of Americans who aren't working because they're dependent on opioids has gotten worse every year since 1999. AAF researcher Ben Gitis found the loss of work hours caused the economic growth rate to slow by 0.2 percentage points over the 16-year period. The average growth rate was 2 percent during that time, but may have been 2.2 percent had those workers been in the labor force and not addicted to opioids, Gitis told Katie.

— Katie also reports authorities have indicted a suspected Mexican drug kingpin they say was responsible for trafficking enough fentanyl to kill 10 million people. Officials with New York’s Special Narcotics Prosecutor have indicted Francisco Quiroz-Zamora, alleging he arranged for 44 pounds, or nearly 20 kilograms, of fentanyl to be shipped to New York.

“Authorities say the arrest of Francisco Quiroz-Zamora provides a window into how the powerful Sinaloa cartel moves drugs from Mexico to the United States,” Katie writes. “Quiroz-Zamora, a 41-year-old known as 'Gordo,' or the Fat One, has been charged with operating as a major trafficker, first-degree sale of a controlled substance and second-degree conspiracy.”

“For a high-level dealer, Quiroz-Zamora was involved in every aspect of the process that gets drugs from creators to users,” Katie continues. “He organized a pipeline that sent drugs from Mexico to Arizona and California through trucks, cars and drug couriers and authorized transactions between customers and dealers, according to authorities.”

—The National Safety Council is partnering with the president's executive office, the Department of the Interior and the National Park Service to set up a memorial to victims of opioid abuse on the ellipse in front of the White House from April 12 to 18. The exhibit will feature a wall of 22,000 engraved white pills, each representing the face of someone lost to a prescription opioid overdose in 2015. It will also display some of the victims' personal effects and provide "Opioids: Warn Me" labels for patients' insurance cards and prepaid mail envelopes to help them easily get rid of unused medications.

Trump announced the exhibit yesterday, in a tweet:

INDUSTRY RX

— Aetna announced Tuesday it will become the latest health insurer to pass on to consumers the savings from rebates it negotiates with drug manufacturers. Starting in 2019, company will automatically pass on the rebates on prescription drugs directly to the members enrolled in its fully insured plan, CNBC’s Angelica LaVito reports. The change could affect about 3 million people.

Aetna’s announcement comes just weeks after UnitedHealthcare announced it would do the same. (The Health 202 wrote about the move earlier this month.) It also shows a growing effort from health insurers to respond to consumer worries about high costs and a call for transparency around drug prices overall. “Aetna said most rebates are already shared, but greater transparency is needed in the pharmaceutical supply chain in response to drug prices rising nearly 25 percent between 2012 and 2016,” Angelica writes.  

Aetna CEO Mark Bertolini said in a statement he hopes “this additional transparency will encourage these companies to rationalize their pricing and end the practice of annual double-digit price increases."

HHS Secretary Azar applauded the news:

AGENCY ALERT

—Several major public-health groups sued the FDA yesterday for delaying certain rules for electronic cigarettes and cigars, saying consumers as a result will be exposed for years to “lethal and addictive components” in tobacco products, The Washington Post's Laurie McGinley writes.

The lawsuit filed by the American Academy of Pediatrics, American Cancer Society Cancer Action Network, American Heart Association and other groups challenges an FDA decision last summer to grant lengthy deadline extensions to manufacturers seeking approval for their products, giving cigar makers until August 2021 and e-cigarette makers until August 2022.

“The extensions have been embraced by the e-cigarette industry, which feared that many of its products would be banned under the original schedule,” Laurie writes. “In the suit filed Tuesday, health groups argue that the delay allows flavored tobacco products that target children and teenagers to remain on the market.”

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

On Leadership
"I think of those people from the early days all the time," says Tedd Ellerbrock, of the Centers for Disease Control and Prevention
Tom Fox
TRUMP TEMPERATURE
MEDICAL MISSIVES
To Your Health
Just 13 percent of the generation was tested for the infection in 2015, a new study found.
Laurie McGinley
To Your Health
The new mom, Emily Dial, described it as “one of the happiest moments of my life.”
Amy B Wang
STATE SCAN
Public Safety
Canabis advocates rallied for law reform Tuesday morning
Lauren Lumpkin
"We believe that our judge, our county, our juries in Harris County ... should be the ones to decide the fate of this lawsuit," said a local prosecutor. "This is where it happened."
Stat News
SECOND OPINION
Post Partisan
New evidence suggests a paper co-authored by Elizabeth Warren overstated the scale of the problem.
Megan McArdle
DAYBOOK

Today

  • The Center for Strategic and International Studies holds an event on “Celebrating Women and Girls: Change Agents or Food and Nutrition Security in Conflict Settings.”
  • The National Food Policy Conference begins.

Coming Up

  • FDA Commissioner Scott Gottlieb is scheduled to speak at the National Food Policy Conference on Thursday.
  • The Atlantic hosts “Cancer and the Community” in Pittsburgh, Pa. on Thursday.
  • The American Enterprise Institute holds an event title “What happened to compassionate conservatism — and can it return?” on Thursday.
SUGAR RUSH

A midwife in Frankfort, Ky. delivered her own baby via C-section with the help of her family and medical team:

The Fix’s Eugene Scott explores how white evangelicals, who have shown strong support for Trump, could react to allegations of infidelity against him:

Here's where Americans stand on gun control