THE PROGNOSIS

Health and Human Services Secretary Alex Azar didn't lay out a specific plan or timeframe for handling the cases of roughly 2,300 migrant children in his department's custody in a Health 202 interview that took place just minutes after President Trump signed an executive order ending family separations at the U.S.-Mexico border.

Azar said only that his department is always “working aggressively” to get detained children turned over to their parents or other sponsors when I pressed him on how long it will take HHS’s Office of Refugee Resettlement to handle the enormous caseload Trump’s “zero tolerance” policy placed upon the agency.

“Well, we are always working aggressively,” he told me at our Health 202 Live event. “We need to get the children out of our care as expeditiously as possible … I said the average is about 58 days and so we want to get them with appropriate sponsors as quickly as we can.”

It remains unclear exactly what will happen next for these kids since Trump's order affects only detained families going forward. An HHS spokesperson initially said the sponsorship process would continue as usual, but the agency quickly walked back those comments, issuing a statement last night saying an official "misspoke" about Trump's order but not articulating a clear plan for reuniting children with their parents.

"It is still very early and we are awaiting further guidance on the matter," Brian Marriott, a spokesman at HHS's Administration for Children and Families, wrote. "Our focus is on continuing to provide quality services and care to the minors in HHS/ORR funded facilities and reunifying minors with a relative or appropriate sponsor as we have done since HHS inherited the program." 

The agency Azar runs finds itself in a quandary after Trump abruptly reversed course yesterday on an immigration crackdown that resulted in thousands of children being separated from their parents and placed in shelters run by ORR. Trump's policy of prosecuting everyone who illegally crossed the border -- including parents with children -- effectively forced the separation of parents and children because those parents were sent to detention facilities in which children aren't allowed to be held. They were instead transferred to HHS custody -- alone. The problem now is how to reunite families in which the parents of children in HHS custody are being detained in different facilities -- some parents have been deported without their children.

“Now the president is ordering the kids remain together, [that] they don’t come over to our facilities,” Azar said, when I asked him to clarify the order.

HHS officials had been laying out plans to expand capacity and staffing at centers where unaccompanied minors were held after being pressed to the limit under the approach the administration started in early April.

Under normal circumstances, HHS would only be responsible for providing government-run shelter to minors who crossed the border alone. But over the past six weeks, the agency found itself taking custody of many more children — some of them very young — while their parents awaited trial for coming into the country illegally.

Homeland Security officials had said Tuesday that 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 with HHS.

The Associated Press reported that the agency had set up at least three “tender age” shelters to house the influx of babies, toddlers and young children and planned to open a fourth shelter in Houston. Last week, HHS announced it was opening a temporary tent shelter in Tornillo, Tex., and was seeking to house children on military bases.

But those plans might be moot under Trump’s order, which would keep families together in federal custody while they await prosecution for illegal border crossings (although that opens up another can of worms by potentially violating a 1997 court settlement limiting the duration of child detentions).

Azar didn’t offer specific details on that front, either, saying only that the agency “will be working on that to determine what our needs are” going forward.

“We have a regular flow,” he said. “The vast majority of kids that we get are children who come to the country unaccompanied — totally unaccompanied, and we have to take care of them and we need the capacity, so we’ll have to assess what our needs are there.”

Trump’s switch is another sign of the White House’s chaotic policymaking that has plagued members of his Cabinet, who at times have had to change course on a dime, defend unpopular policy positions or operate with less-than-full intel.

The president repeatedly defended his immigration crackdown, including forcibly separating immigrant children from their parents after they crossed the border, our colleagues John Wagner, Nick Miroff and Mike DeBonis report.

“But images of young children in tears, housed in metal cages, set off an international outcry,” they wrote yesterday. “Trump’s action came shortly after House Republican leaders vowed to bring broader immigration legislation up for votes Thursday to address the crisis, despite widespread skepticism that a bill could pass.”

“So we're going to have strong, very strong borders, but we’re going to keep the families together,” Trump said as he signed the order in the Oval Office yesterday. “I didn't like the sight or the feeling of families being separated.”

It’s unclear whether Azar advised the president on the policy reversal or alerted him to the heavy burden on HHS should the zero-tolerance approach continue. When I pressed Azar on whether he had communicated with the White House, Azar said that his agency plays a role only in caring for detained children — not in prosecuting their parents.

“What we do is if we get kids — the unaccompanied children — we work to take care of them,” Azar said.

There has been lots of speculation over the past few weeks over the care HHS and its contractors running shelters are able to provide to so many children, many of them young. Azar ardently defended the agency and its contractors, saying the children are provided with education, medical attention and psychological care and counseling.

He also said he has personally visited such a center, although he wouldn’t disclose when or which one. “I have in fact recently been to a facility, and as I said, the children are — these grantees who take care of these children have a deep passion and sense of mission for caring for these kids,” he said.

There’s a concurrent issue to the question of how to house migrant children — that is, what happens to them after they’re released to sponsors. These sponsors are usually parents or family members, but not always (and whether they can be released to parents who are being detained is a real question). McClatchy reported on Tuesday that HHS has lost track of 6,000 unaccompanied children who didn’t keep in touch with federal officials.

But Azar challenged the idea that HHS could lose track of kids, saying that once they’re placed it’s no longer the agency’s responsibility to oversee them. He said the agency typically calls sponsors at the 30-day mark to check in, but can do little if the sponsor doesn’t answer the phone and doesn’t call back.

“At that point they are subject to local and state child welfare protection procedures; we aren’t running a national child welfare system,” he said.

Read on for more toplines from our discussion with Azar about health-care costs in America.

AGENCY ALERT

On lowering drug prices:

— Azar wouldn't say whether he has personally met with any drug executives about moves to lower the list price of certain medications, although Trump claimed earlier this month that industry announcements along that vein are on the way.

"So obviously I’m not going to preempt any announcement by the president or otherwise," Azar said. "I did mention to you already that there are many drug companies who would like to lower list prices and do so rather quickly, and they’re working through, frankly, the difficulties of the system and the channel. I remain hopeful that the players in the drug pricing channel will all work together to make this happen because it is an undeniable good for patients."

— When I asked whether Azar was going too easy on drug companies in the president's drug plan -- considering pharmaceutical stocks rose following the rollout -- the secretary dismissed the criticisms. “Listen, judging your success or failure on the stock market daily and hourly price variations would be a foolish enterprise,” he said.

“The core of our policies are strong," he added. "They’re actually revolutionary. We are seeking nothing short of the complete rewiring of the drug pricing and drug reimbursement system in the United States — nothing short of that. Those who actually know, this is rocket science. This is a very complex are...and that’s why, frankly, your average stock analyst or other — it’s going to be very hard to see the importance.”

— Azar said his agency is still looking into banning the drug rebates that drive up drug list prices through the Anti-Kickback Statute, which would apply primarily to Medicare Part D plans but could affect the private sector as well. “I don’t want to conclusively state the full reach of our regulatory authority,” Azar said, adding he wanted to be “deliberately ambiguous there.”

“We need to look at that, there are complexities there,” he added, saying the administration would want to get public input because it would require “restructuring an entire segment of the economy and how that works. “

On handling the next open enrollment season: 

— When I asked his aims for the 2019 marketplace enrollment period (starting in November), Azar started by reiterating his objection to the ACA. "I don’t think it’s working for people," he said. "I think we need a different system that is both sustainable and offers affordable options for individuals."

But he said he'd "faithfully operate" the marketplaces as long as they remain "on the books." "I’m going to do so in a way that delivers as good of care as we humanly can for people and as affordable insurance as we can, and we will work to get people enrolled, make sure that they know the options and get them enrolled if it’s an offering of interest to them,” he said.

When I asked whether he'd try to increase marketplace enrollment, he said he'd define success as helping people find an insurance option that is “affordable, available, and they want to use,” either through the marketplace or “through the other alternatives that we’re able to offer, whether its association health plans or if we have additional short-term limited duration plans, or any other offerings.”

— Azar didn't deny that the health-care industry has overwhelmingly criticized his agency's final rule on Tuesday to expand association health plans, calling the concerns "well-founded" and "well-meaning." 

"But our concerns are also well founded and well meaning,” he added. “We’re not only concerned about the people that are in the individual insurance markets and are they getting quality insurance and insurance that’s affordable and not just affordable to acquire but affordable to use.”

On the Justice Department’s decision not to defend the ACA in court:

While Azar said he'll carry out the health-care law, he said he also agrees with DOJ's position that its protections for people with preexisting conditions can't stand without the individual mandate penalty. “That’s a constitutional, and then followed by statutory argument of just interpretation around whether you sever these other provisions along with—are these other provisions inextricably connected to the individual manatee?,” he said.

Azar noted that the Trump administration’s position is similar to the arguments the Obama administration made to the Supreme Court back in 2012 (although Congress has since repealed the penalty while leaving the consumer protections in place, thus indicating these protections can stand on their own). “It is the same position they took in the Supreme Court litigation around the individual mandate that if you were to strike down the individual mandate, the guaranteed issue and community rating are inextricably connected to the individual mandate and must fall as a matter of statutory interpretation,” Azar said.

AHH, OOF and OUCH

AHH: Yesterday, the House passed a bill partially lifting the so-called "IMD exclusion," allowing Medicaid to start paying for opioid and cocaine addiction treatment in inpatient facilities with more than 16 beds. Passed in a 261-155 vote, the bill from Rep. Mimi Walters (R-Calif.) was one of the more controversial of the dozens of opioids measures the House has been approved in the last two weeks, as Democrats complained it didn't go far enough.

“We are helping to ensure that people get the care that they need in the midst of this crisis, and most importantly, it will save lives,” Walters said on the House floor. Read Colby Itkowitz's recent explainer on the issue here.

OOF: Tempers flared on cable news after former Trump campaign-manager Corey Lewandowski seemed to dismiss a report that a 10-year-old girl with Down syndrome was separated from her parents. After Democratic strategist Zac Petkanas told the story on Fox News Tuesday night, Lewandowski interjected with a seemingly mocking “womp womp" (like the noise made on a game show when a contestant's fortunes have taken a bad turn, as The Post's Aaron Blake describes).

“Did you just say ‘womp womp’ to a 10-year-old with Down syndrome?” Petkanas fired back. “How dare you… how absolutely dare you, sir.”

Our colleagues Kyle Swenson and Amy Wang report that by Wednesday, Lewandowski’s reaction had gone viral but he'd doubled down. “An apology?!” Lewandowski responded when asked by a Fox News host if he felt he should apologize for his remarks. “I owe an apology to the children whose parents are putting them in a position that is forcing them to be separated.”

OUCH: There’s one piece of unfortunate news from this month’s report from the Centers for Disease Control and Prevention on youth risk behavior: Many of today’s teens are not eating their veggies. The report found 7.2 percent of high school students reported eating no vegetables in the prior week, compared with 4.2 percent in 1999. It also found the percent of high-school students eating vegetable last year was 59.4 percent, down from 64.5 percent in 1999.

But our colleague Chris Ingraham notes that veggies aside, the report using 2017 data is basically just full of good news for teens (shown in the table above). “The survey finds that risky behavior — drinking, using drugs, having sex — is down nearly across the board among America's high school students, relative to either a few years or a few decades ago," he writes. "Marijuana use continues to drop, defying legalization opponents' predictions of what would happen after states began legalizing the drug.”

TRUMP TEMPERATURE

— Prior to the president’s new executive order on migrant families, the American Medical Association joined a chorus of medical groups and corporate leaders urging the administration to stop separating parents and their kids at the border. The AMA warned in a letter that the practice will “do great harm to children and their parents and caregivers, who felt compelled to make a dangerous and uncertain journey because of safety concerns in their own countries."

AMA's chief executive officer Dr. James Madara write that the policy was discussed at the group’s annual meeting earlier this month. “Families seeking refuge in the U.S. already endure emotional and physical stress, which is only exacerbated when they are separated from one another,” Madara wrote. “It is well known that childhood trauma and adverse childhood experiences created by inhumane treatment often create negative health impacts that can last an individual’s entire lifespan. Therefore, the AMA believes strongly that, in the absence of immediate physical or emotional threats to the child’s well-being, migrating children should not be separated from their parents or caregivers.”

HEALTH ON THE HILL

— The Senate voted yesterday to reject the administration’s proposed plan to claw back about $15 billion in spending that had been previously approved by Congress. Two Republicans joined all their Democrats in voting no in a narrow 48-50 vote on a rescissions package the House approved earlier this month, our colleague Erica Werner reports.

The cuts in the rescissions package included $7 billion from the Children’s Health Insurance Program, mostly from an expired account that can no longer be used," Erica notes. "Democrats had accused Republicans and the Trump administration of targeting important programs with the rescission cuts, but Republicans countered that most of the money was sitting unspent, in some cases in expired accounts that couldn’t be tapped."

Yesterday’s vote was startling because one of the opposing votes came from Sen. Richard Burr (R-N.C.), who does not normally buck the White House or GOP leadership, Erica writes. The other GOP vote came from moderate GOP Sen. Susan Collins (R-Maine).

"Independent analyses said that since most of the money would not have been spent anyway, the actual spending reduction in the package was closer to $1 billion," she reports. "That’s a tiny fraction of the federal budget. But in a midterm election year conservative lawmakers saw the rescissions package as a way to show Congress’ commitment to reining in spending at a time of drastically rising deficits and debt."

INDUSTRY RX

— Renowned surgeon and best-selling author Atul Gawande will lead the independent health-care initiative being advanced by Amazon, JPMorgan Chase and Berkshire Hathaway. The unnamed Boston-based company will be focused on using technology to make health care more transparent, affordable and simple for the more than 1 million employees who work for the three companies, our colleague Carolyn Y. Johnson reports.

"Choosing Gawande, a practicing surgeon at Brigham and Women's Hospital in Boston and a writer for the New Yorker magazine, suggests that the company will be focused on innovation that could ripple broadly," Carolyn writes. "Gawande was praised Wednesday by colleagues as a creative, visionary leader who has devoted his career to devising health-care solutions that can be widely adopted to improve surgery, childbirth and end-of-life care around the world. He is best known for making surgery safer through the implementation of a simple checklist."

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

MEDICAL MISSIVES
To Your Health
Demand has soared for the Shingrix vaccine and order limits will be in effect through 2018.
Lena H. Sun
STATE SCAN
DAYBOOK

Today

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Trump's rally in Minnesota, in 3 minutes
President Trump signed an executive order to end family separations at the border, saying he and his family felt "strongly" about the matter

Senators react to Trump executive order on family separation