THE PROGNOSIS

At the center of the Trump administration's decision to separate children from their parents at the border is a small federal agency designed to unify families, not rip them apart. 

Under normal circumstances, the Office of Refugee Resettlement takes in minors who crossed the U.S.-Mexico border alone and provides them government-run shelter while trying to reunite the children with a parent or family member who is living in the United States. 

But now, the agency, housed within the Department of Health and Human Services, is charged with the opposite task: taking custody of children while their parents await trial in jail for coming into the country illegally. 

As our colleague Nick Miroff reported: Homeland Security officials said they separated 2,342 children from their parents along the border between May 5 and June 9, reclassifying them as “Unaccompanied Alien Children” and placing them in foster care with HHS.

“The people who do this work are by and large people working hard to help kids make it to their families, which is a fundamentally different role than serving as a detention facility for kids who have been involuntarily separated from their families. It is not an appropriate role for HHS,” said Maria Cancian, who served as deputy assistant secretary for policy in HHS's Administration for Children and Families during the Obama administration. 

When Health and Human Services Secretary Alex Azar testified in the Senate two weeks ago on an unrelated issue, Sen. Patty Murray (D-Wash.) asked him what HHS was doing “to make sure that the parents know where their children are, whether they're safe, and when they will see them again.” 

“We take our obligation to take care of these minor children very seriously,” Azar said. “Actually, 50 percent of the out placements from the Office of Refugee Resettlement of these minor children that we receive, who are separated only because their parents have crossed the border illegally and have been arrested, as any American who gets arrested, your child is taken away... we do keep in touch with the parents, because if they are released from detention, 50 percent of the children do end up with their parents as sponsors.”

Trump officials have not said how many kids that are part of the current "zero tolerance" policy to prosecute those who cross the border illegally have been reunited with their parents. 

 

Murray, the ranking Democrat on the Health, Education, Labor and Pensions Committee, also pressed the secretary on what the White House would do when the HHS shelters that house unaccompanied minors reach capacity. The agency had 11,785 children in its care as of Monday, with its shelters at 94 percent capacity, Miroff wrote. 

HHS has not responded to Murray, according to the senator's office. 

But with public outrage mounting over the treatment of migrant children, Sen. Lamar Alexander (R-Tenn.), who chairs the HELP committee, said during a hearing Tuesday morning that the Trump administration “should end that new policy immediately,” and he signed on to a letter signed by 11 Republicans to Attorney General Jeff Sessions asking him to halt the practice of separating children from their parents. 

The minors who previously crossed the border and ended up in HHS's care were typically teenagers who can make the harrowing journey alone. When they arrived, the shelters were a safe haven compared to what they'd just endured, Cancian said. The kids often experienced trauma from what they were escaping, but in these cases the social workers at the shelters were equipped to support them. 

But now, some babies and young children are being held in these facilities and medical professionals say they are likely being traumatized from the separation from their parents. There is concern that HHS staff isn't prepared to meet the very different social, emotional and physical needs of the youngest kids, particularly when they're experiencing severe separation anxiety with no telling when they'll see their parents again. 

"They are enormously vulnerable and we're concerned, is the staff there trained in trauma?" said Megan McKenna, spokeswoman for the nonprofit, Kids in Need of Defense. "Trauma is long lasting and it often doesn't go away and for a child to lose a parent like that, it's really a damaging sociological effect."

The youngest children are being sent to "tender age" shelters described by some as orphanages or institutional settings, the Associated Press reported. The AP said HHS is seeking job applicants who know how to care for children of all ages.

But can they train and screen people fast enough to keep up with the growing number of small children in the government's custody? 

Compounding the issue is concern that the rhetoric and policies of the Trump White House have scared adult undocumented immigrants living in the United States from sponsoring a child relative for fear of being deported. In April, HHS agreed to share information with DHS about children's potential sponsors, including their immigration status. So the result is kids staying in these government-run shelters longer. 

Mark Greenberg, who ran HHS's Administration of Family and Children under Obama, called the family separation policy "cruel and inhumane" and said "it’s deeply disturbing that the HHS is now being used to facilitate and support that policy."

The 200 or so people working for ORR are largely well-intentioned, career civil servants who do the work to help kids. So Cancian, who has worked in child welfare most of her career, said the officials currently working at the agency and at the shelters are in an untenable situation -- one that would leave her in quandary if she were still working at the agency, she said.

Cancian wonders if these workers should leave in protest -- or stay in their jobs and try to help make the situation for the children separated from their parents as humane as possible?

"The problem is it's changing from this mission of a family serving organization to a program that is a detention program," Cancian said. "It’s not clear to me if you were trying to make the right decision, but I would say, the responsibility rests in the people who put those providers in that situation."

Correction: An earlier version referred to Michael Greenberg. His name is Mark. 

POST PROGRAMMING ALERT: Today, The Post will host HHS Secretary Alex Azar and other key policymakers as well as health-care industry leaders at a Health 202 live event starting at 3:30 p.m. today. Paige will interview Azar and I'll be talking to some key lawmakers. Watch the event streamed live here.

AHH, OOF and OUCH

AHH: Sen. Ron Johnson (R-Wis.), who was a major force in passing the "Right to Try" measure this spring, met yesterday with FDA Commissioner Scott Gottlieb about implementing the new law -- which opens more doorways for seriously ill patients to try experimental treatments not yet fully approved by the FDA. In a statement provided to The Health 202, Johnson said Gottlieb offered him a commitment that the FDA will prioritize access to treatment as it puts the new law in place.

Johnson said the two also discussed the complexity of the development, study, and production of new therapies, especially for rare and severe diseases. "There are many risks facing the sponsor of a therapy under study and review, as well as legitimate reasons some sponsors may choose not to participate in Right to Try or the legacy Expanded Access program," Johnson said. "These realities are why it is crucial that implementation encourages participation by assuring parties that the Right to Try law and the FDA’s interpretation of the law does not impose additional risk to drug development and approval."

OOF: Smoking among U.S. adults has hit an all-time low. About 14 percent said they were smokers last year, down from 16 percent the previous year, according to a national health survey by the Centers for Disease Control and Prevention. There are still more than 30 million people in the country who are smoking, the Associated Press reports.  

The numbers reflect a significant shift -- about 42 percent of U.S. adults were smokers in the 1960s, according to the CDC. The decline is a result of better understanding about the health risks associated with smoke, cigarette taxes and smoking bans and the recent launch and popularity of electronic cigarettes.

OUCH: Child psychologists and experts who study human development are warning about how the Trump administration’s policy that leads to separating migrant families will affect children.

“It is not clear how long the administration plans to hold onto the 2,000 children in detention centers near the border, nor how long before they are returned to their families,” the New York Times’s Benedict Carey reports. “But psychologists have learned a great deal about what happens to institutionalized children over time, and in that research there are clues to the potential emotional harms faced by migrant children severed from their parents.”

Longer-term consequences of separation and institutionalization are hard to pinpoint, and Benedict notes it can depend on the age of the child and the characteristics of the holding facility. “Institutions — even the best and most humane — by their nature warp the attachments children long for, the visceral and concentrated exchange of love, tough and otherwise, that comforts, supports and shapes a child’s heart and mind,” he writes.

Benedict also notes that medical organizations have issued statements urging against the administration’s actions, “citing an increased risk of anxiety and depression in the children, as well as post-traumatic stress and attention-deficit disorder.”

AGENCY ALERT

— As The Health 202 previewed yesterday, the Trump administration issued new rules for small businesses and self-employed people to get health insurance that costs less via health associations. The rules accomplish through executive power what congressional Republicans have tried and failed to write into law over the past two decades, The Post's Amy Goldstein reports.

Announced Tuesday morning by Labor Secretary Alex Acosta, the final association plan rules come eight months after Trump directed the government to foster alternatives to the Affordable Care Act's insurance provisions and five months after the Labor Department proposed a draft version, Amy notes. Acosta’s central message was that the expansion of these plans will “level the playing field” between health insurance rules that apply to large companies and ones that pertain to small businesses.

“The new rules allow plans to exclude coverage for maternity care, prescription drugs, mental health services and other 'essential health benefits' the ACA requires of coverage sold to individuals and small businesses,” Amy writes. “Acosta emphasized that the rules keep the same 'consumer protection and health-care anti-discrimination that currently apply to large companies.' "

Trump praised the rule with his trademark hyperbole, yesterday telling the National Federation of Independent Businesses, “You are going to save massive amounts of money and have much better health care. It’s going to be fantastic . . . You are going to save a fortune.”

Trump continues to attack McCain for Obamacare vote 

— But congressional Democrats and an array of critics across the health-care industry said the availability of cheaper, skimpier coverage will leave some patients stranded when they get sick. “Finalizing this rule is simply the latest act of sabotage of our health care system by the Trump administration and a back door to expanding junk insurance plans,” Senate Minority Leader Chuck Schumer (D-N.Y.) said in a statement.

HEALTH ON THE HILL

— Some conservatives are not giving up their dream of repealing Obamacare. Yesterday, The Heritage Foundation, the American Enterprise Institute, the Galen Institute, the Manhattan Institute and other conservative groups and individuals released details of their proposal to repeal and replace the ACA.

Offering some similar provisions as last fall's health-care bill from Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), the proposal is the result of nine months of weekly meetings. It includes provisions includes calling on lawmakers to repeal ACA coverage requirements, turning over some spending to states through block grants, and expanding health savings accounts. (The Health 202 wrote about the proposal last month.)

But any movement on the proposal is a longshot. “The proposal risks irking centrist Republicans who want to focus on other subjects,” the Wall Street Journal’s Stephanie Armour writes. “Republican leaders have said they have no appetite for another push to repeal the ACA before the November midterm elections unless such a bill clearly has the votes to pass...But right-leaning groups are already at odds over the proposal, which drew swift condemnation from some organizations that said it retains too much of the health law’s spending.”

— The House GOP offered a 2019 budget proposal yesterday that would cut Medicare by $537 billion and Medicaid and other health programs by $1.5 trillion as part of $5.4 billion in cuts to mandatory spending over a decade. The savings would be achieved by moving Medicare to what is known as a “premium support” system involving more private plans and by imposing new caps on federal Medicaid payments to states. The plan includes reconciliation instructions requiring $302 billion in savings over a decade — nearly 50 percent more than the savings required in last year's budget reconciliation bill.

"The House Budget Committee is aiming to pass the blueprint this week, but that may be as far as it goes this midterm election year," The Post's Erica Werner reports. "It is not clear that GOP leaders will put the document on the House floor for a vote, and even if it were to pass the House, the budget would have little impact on actual spending levels...Nonetheless the budget serves as an expression of Republicans’ priorities at a time of rapidly rising deficits and debt."

Do the words “budget reconciliation bill” sound familiar? They should. Republicans tried to use the 2018 budget reconciliation measure to repeal and replace the ACA, without any Democratic support, to no avail. Hypothetically, they could try again using the 2019 budget bill, although that's unlikely given the political stakes in an election year.

— Lawmakers want to make the national suicide helpline a number as simple as 911. Sen. Orrin Hatch (R-Utah) has introduced the National Suicide Hotline Improvement Act, which would task the Federal Communications Commission, the Substance and Mental Health Services Administration, and the Department of Veterans Affairs with figuring out whether it would be feasible to set up a three-digit number for this purpose, determining the number, and assessing how well the current system works, the Washington Examiner’s Kimberly Leonard reports.

The bill is headed to the House Energy and Commerce Committee after passing the Senate unanimously in November and passing the House communications and technology subcommittee. The Congressional Budget Office says implementing the bill’s proposals would cost less than $500,000 over five years, Kimberly notes.

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

MEDICAL MISSIVES
STATE SCAN
World
The vote puts Canada on road to becoming the first advanced industrialized nation to legalize the drug nationwide.
Amanda Coletta
OPIOID OPTICS
DAYBOOK

Today

  • The House Energy and Commerce Subcommittee on Oversight and Investigations holds a hearing on “Examination of the GAO Audit Series of HHS Cybersecurity."
  • The House Armed Services Subcommittee on Military Personnel holds a hearing on “Military Health System Reform: Pain Management."
  • Sen. Shelley Moore Capito (R-W.Va.) and Rep. Linda Sánchez (D-Calif.) will host a briefing with UsAgainstAlzheimer's on the CHANGE Act.
  • AHIP’s institute and expo begins.
  • The American Medical Association holds a webinar on health literacy.

Coming Up

  • The House Veterans Affairs Subcommittee on Health holds a hearing on VA hiring authorities, recruiting and retention on Thursday.
SUGAR RUSH

Democrats reject GOP call for legislation, say immigration fix is within Trump's power:

Sen. John Cornyn (R-Tex.) seeks to fix immigration problem by the end of the week:

The Fix’s Aaron Blake analyzes Homeland Security secretary Kirstjen Nielsen’s defense of family separation: