THE PROGNOSIS

It's not a secret that among President Trump's chief desires is to see the Affordable Care Act fail. Every chance he gets he chastises Sen. John McCain (R-Ariz.) on his thumbs-down “no” vote that helped kill GOP efforts to repeal the law. The majority of actions the White House has taken as it pertains to the ACA have been to undermine it. 

So it should be of little surprise the administration has removed entire sections about the ACA from the official Medicaid.gov site, its hub for the Center for Medicaid and CHIP Services. Of the 13 pages dedicated to the ACA that were overhauled, eight redirect to another page with similar information, but on only two do the words “Affordable Care Act” appear, according to an analysis released this morning from the Sunlight Foundation. Additionally, another page that explained the coordination between Medicaid and the ACA exchanges was also removed and now redirects to an “Error: Page Not Found” note. (The report can be read in full here.)

Here is what a sample page at Medicaid.gov used to look like:

It's hard to say how consequential it is that these pages no longer exist. Who knows how many Americans have sought out ACA information on the Medicaid.gov site? But it certainly is symbolic of the Trump White House's systematic efforts to make Obamacare disappear. 

Sunlight, a nonpartisan government watchdog group, is tracking the Health and Human Services Department website for unannounced changes. In May, its researchers found a reference to the ACA had been removed from Medicare.gov. A spokesman for the Center for Medicare and Medicaid Services could not respond to our questions about this by this morning, but Sunlight's Toly Rinberg shared with me that in May a CMS representative gave this explanation on background: “CMS performs routine updates and maintenance to our websites, which includes the revision and removal of content that is not current or underutilized.  In this instance, there was a period of time when people with Medicare coverage had questions and interest in the ACA and its impact on Medicare.  However, the ACA has now been law for over eight years and both HealthCare.gov and www.cms.gov/cciio [cms.gov] are well-established sites for Healthcare Exchange information.” 

It's a tough argument to buy especially given that Medicaid recipients and people receiving subsidies to buy on the ACA exchanges frequently bounce between the two based on their fluctuating income levels (the government allowed states to expand their Medicaid programs after the passage of Obamacare, though not all states have done so). Sunlight notes that among the information removed are details about "eligibility requirements."

“There has been a change in how information about ACA is being presented or made accessible to the public,” said Sunlight researcher Rachel Bergman. “It’s now multiple centers within the agency removing their ACA information.” 

For transparency advocates such as Sunlight, changing the contents of a government website without notice is cause enough to raise the issue. But for health-policy experts, the vanishing language is nothing compared to the Trump administration chipping away at the law itself. 

Just this week, the Trump administration announced it was cutting funding for the navigators program, groups trained to help individuals sign up for insurance on the federal ACA marketplace. Last fall I visited one of those navigator sites in Maryland on open enrollment day and watched as people waited for hours for the chance for one-on-one help navigating Healthcare.gov. This anecdote didn't make it into The Post's final story that day, so I share it now:

Raphael Ernest, 43, of Silver Spring, said he received daily emails reminding him to come in and update his pay stub information in the system. 

For the last year, he and his wife have been uninsured, but he’s had both his 9-year-old and 1-year-old daughters on Medicaid. Alma Luna, the certified navigator who worked with him Wednesday, suspected he didn’t realize he and his wife were also eligible for Medicaid under the expansion so he never requested it.

Ernest could get insurance through his employer, but he couldn't afford the more than $100 monthly premium, he said. 

He came in simply to update his documents to ensure his daughters remained covered, but Luna offered to check on his status as well. He walked out fully insured under Medicaid. 

After the navigator rule was announced Tuesday, HuffPost's health-care reporter, Jonathan Cohn, offered on Twitter a smart explanation of why it matters: “The program costs less than $40 million last year. In the context of federal spending on health care, that is nothing. Not even a rounding error. And the point of the navigators isn't to run up huge enrollment numbers. It's to provide assistance to people who need it.” 

But that's just one of the significant ways the Trump administration has gotten around congressional inaction to weaken Obamacare. The New York Times on Wednesday began tracking the changes Trump is making to the ACA. So far it has listed 14 ways

“The administration has been able to do a meaningful amount, the largest change is Congress repealing the individual mandate, but some of the regulatory changes that they've proposed or are moving forward with now will have significant effects as well,” said Matt Fiedler, a health-policy expert at the Brookings Institution.

Most damaging, he told me, is the White House's plan to expand “short-term limited-duration policies,” which do not have to comply with the basic benefit standards mandated by the ACA, and typically don't accept people with preexisting conditions. Under the ACA, people are limited to staying on those plans for up to three months, but the Trump rule would extend that timeline to a year. These cheaper plans will probably attract younger, healthier enrollees, which leaves sicker Americans buying the ACA-approved plans, thus driving up prices, which is what the individual mandate was created to avoid. 

“This will allow a full parallel market that doesn't meet the benefit standards,” Fiedler said. “That's going to change the structure, and departs from the intent, of the Affordable Care Act.”

Then there's the announcement last week that the administration was delaying promised “risk adjustment” payments to insurers. Edwin Park, a Georgetown University professor of public policy, wrote Wednesday that it was another way the Trump administration was trying to “sabotage” the ACA. Without knowing whether they'll receive the payments they were expecting, insurers could raise premiums in 2019 or even decide to pull out of the marketplaces altogether, he explained. 

There's also Medicaid, which grew tremendously under the ACA both because of the states that expanded eligibility and because many low-income individuals who never bothered to shop for health insurance before found out they were entitled to coverage. But the Trump administration is offering waivers to states that want to add work requirements to the safety-net program, which critics say adds an unnecessary barrier to care.

But for supporters of the ACA, there is one silver lining, Fiedler said. No matter how hard the Trump White House tries to dismantle the law or create confusion or erase it from government sites, it would still require an act of Congress (or the Supreme Court) to repeal and replace Obamacare entirely.

The ultimate goal of the ACA was to provide more people with affordable coverage, and for now, the subsidies many people receive to help them pay for their plans are still in place as is the Medicaid expansion in 23 states and D.C., which gave millions more Americans free government health-care coverage. 

Opponents, however, argue the law is a mess, driving up costs as insurers flee from marketplaces. They're not giving up the fight to eliminate it, even if their available tools as of now are mostly in the hands of the Trump administration and not Congress.

AHH, OOF and OUCH

AHH: North Dakotans could get a chance to vote on whether to legalize marijuana after supporters of the movement submitted more than 18,000 signatures to the secretary of state supporting deciding on the measure, more than the 13,452 required get it on the November ballot.

“Like a recent successful medical-marijuana measure in Oklahoma, the effort has largely flown under the radar, with no financial backing from national drug policy groups such as the Drug Policy Alliance and the Marijuana Policy Project,” The Post’s Christopher Ingraham reports. “And like Oklahoma, North Dakota is a deep-red state that hasn’t voted for a Democratic presidential candidate since 1964.”

The secretary of state still needs to certify the petition signatures to qualify the measure for November’s ballot. The bill would legalize the possession, sale and use of marijuana for people 21 and older in North Dakota and would expunge marijuana convictions from North Dakotans’ criminal records, Christopher reports.

The state has one of the lowest rates of marijuana use, but one of the highest arrest rates for use of the drug. Fewer than 10 percent of North Dakota residents used the drug in 2016, per the federal National Survey on Drug Use and Health, but in the same year, 2,513 of the 61,000 residents who used marijuana were arrested for simple marijuana possession, according to FBI data compiled by pro-legalization group NORML. That rate of 41 arrests per 1,000 users is the second highest in the nation.

OOF: The Centers for Medicare and Medicaid Services is threatening to close LiveOnNy, one of the nation’s largest “organ procurement organizations” (OPOs) after warning that it had failed to meet minimum standards of success in organ collection, our Post colleagues Lenny Bernstein and Kimberly Kindy report.

The letter from CMS last month warned the agency would not renew LiveOnNy’s contract set to expire on Jan. 31. But a spokesman for the agency noted there are plans to make sure organ procurement and transplantation would not be disrupted, Lenny and Kimberly report.

The organization has begun an appeal that could take up to seven months. It has been one of the poorest-performing procurement organizations in the country, our colleagues report, and last ranked as the second-worst OPO nationally.

The letter from CMS also comes at a “time of upheaval in the transplant industry, which faces a perennial shortage of donor organs,” Lenny and Kimberly write.

OUCH: When marijuana becomes legal to buy and smoke in Canada come October, don’t expect Americans to be able to hurry across the border and return with the drugs. Plenty of legal and physical barriers will prevent U.S. citizens from bringing pot purchased legally in Canada back into the states, The Post’s Katie Zezima and Lornet Turnball report.

“Though marijuana will be legal for medical or recreational use in many places on either side of the roughly 6,000-mile border — including Alaska, Maine and Vermont — the U.S. government routinely bars Canadians who admit to having used the drug from entering the country,” they write. “And U.S. citizens who try to cross back into the United States carrying marijuana bought legally in Canada to states where it is legal to have it could be arrested at the border crossings for possession — or drug smuggling — and face stiff fines or years in jail.”

Even though marijuana is legal for recreational use in nine states and the District, and allowed for medical use in 31 states, it’s still illegal under federal law. “Federal law is applicable at the U.S.-Canada border, meaning the possession, distribution, sale and production of marijuana is illegal there,” Katie and Lornet report.

“Crossing the border with marijuana is prohibited and could potentially result in seizure, fines, and apprehension,” U.S. Customs and Border Protection said in a statement.

TRUMP TEMPERATURE

— The Trump administration is set to announce today that it will expedite the process of reunifying families, the New York Times’s Miriam Jordan reports. “The government will stop requiring a litany of steps before a child can be released from a shelter, the American Civil Liberties Union confirmed. It has sued the government over the family separations,” Miriam writes. “To speed up the reunions, the government will no longer insist on fingerprinting all adults in a household where a child will live, or require home visits by a social worker.”

Instead, officials will just need to prove the family connection, and that the parent or guardian does not have a criminal record, before releasing the child to them, per the report.

— Some of the youngest children who were separated at the U.S.-Mexico border no longer recognize their parents after months or weeks of separation, the New York Times reports. During tearful reunions, some children tried to “wiggle free” from their parents and others called out for the social workers they had been in contact with since separation. One 3-year-old pointed to other children he had been with, thinking they were his siblings, reporters Miriam Jordan, Katie Benner, Ron Nixon and Caitlin Dickerson describe.

The Los Angeles Times’s Esmeralda Bermudez reports on the heart-wrenching story of Hermelindo Che Coc, a man from Guatemala whose son was taken at the border, and whose case file has been misplaced. “His case underscores the confusion and heartbreak that has marked the Trump administration’s efforts to reunite families this week,” Esmeralda writes. “While some children were placed with parents Tuesday, many more families remain separated, not knowing when they would see one another again.”

Che Coc’s 6-year-old son Jefferson called him from a New York shelter: “Papa, I thought they killed you,” Jefferson said to his father. “You separated from me. You don’t love me anymore?”

— Before Pfizer announced that it would delay its drug price increases, Trump contacted the chief executive to say the July 1 hikes “complicated the administration’s drug pricing plans,” Reuters’s Michael Erman and Yasmeen Abutaleb report. HHS Secretary Alex Azar had initially called Ian Read but the CEO requested to speak directly with Trump, per the report. “The conversation took place around 4:30 p.m. ET on Tuesday and lasted about 10 to 15 minutes,” Michael and Yasmeen report. Trump tweeted about the call just over 2 hours later.

— Stat’s Erin Mershon and Ike Swetlitz have a list of key takeaways from Pfizer’s announcement Tuesday that it would delay the price increases. It’s worth reading what the announcement does and doesn’t say in full, but here are some highlights:

  • Pfizer isn’t actually dropping drug prices, just returning to pre-July 1 prices and only temporarily. The company said it would hike prices after the end of the year, or when the administration’s drug blueprint “goes into effect,” whichever is first.
  • As The Post’s Damian Paletta also noted, the announcement was an example of Trump’s successful use of the presidential bully pulpit. “This is not an industry that compromises,” Rachel Sachs, an associate professor at Washington University School of Law, told Stat. “This industry will always push for the maximum that it is able to get, and it is surprising to me to see Pfizer appear to back down on this question, because that’s not [this] industry’s style.”
  • The effort to push Pfizer to adjust prices is a sign that the administration is focusing on drug list prices, which Azar has mentioned is a priority.
  • It’s still unclear how much further the deal goes between the president and Pfizer. “Already, Sen. Ron Wyden (D-Ore.) is raising questions about whether the administration brokered an actual deal with the drug manufacturer — an act that could violate laws that prevent the Health and Human Services Department from negotiating lower prices with drug companies,” Erin and Ike report.
HEALTH ON THE HILL

— The House Appropriations Committee voted, 30 to 22, Wednesday to approve a more than $177 billion in funding for the Labor, Education and HHS departments after debating for more than 12 hours. For the first few hours of the markup, the Trump administration’s family separation policy was a main discussion point, CQ News’s Kellie Mejdrich and Andrew Siddons report, but they noted the debate also included gun-research funding, abstinence-only sex education and thorny political issues around religious adoption agencies.

Here are a few highlights from the marathon markup:

  • Among the amendments adopted Wednesday was language to overturn the 1997 legal settlement known as the Flores agreement that prevents undocumented children from being held together with their parents in detention for more than 20 days while awaiting immigration court proceedings,” Andrew and Kellie write. “The amendment from [Rep. Tom Cole (R-Okla.)] faced partisan debate before being adopted, 31-21. …While the amendment would allow families to stay together, it would also allow them to keep children in detention indefinitely.”
  • The panel also approved an amendment that would protect adoption agencies from being denied federal funding if they choose not to place children with LGBTQ couples, The Hill's Juliegrace Brufke reports. “The measure, introduced by Rep. Robert Aderholt, drew swift condemnation from Democrats, but the Alabama Republican defended it as necessary for allowing social-services agencies to exercise their religious freedom,” per the report.
  • House Republican appropriators blocked a proposal to designate funding for gun-violence research through the Centers for Disease Control and Prevention, Politico reports. “The party-line vote marked Democrats’ latest failed bid to spur studies into preventing firearm-related injuries and deaths — and comes despite a bipartisan agreement earlier this year that the CDC is permitted to conduct such research,” per Politico’s Adam Cancryn.

— A social media highlight for the day: When Republican Rep. Mike Bost (Ill.) congratulated a constituent on winning Jeopardy, she used her newfound platform as an opportunity to blast Bost’s vote to overhaul the ACA:

REPRODUCTIVE WARS

— Supreme Court nominee Brett M. Kavanaugh has ruled on one major abortion case in his dozen years on the federal bench, a ruling that could “define the coming debate on what his elevation to the Supreme Court would mean for a woman’s constitutional right to the procedure,” our colleagues Robert Barnes and Ann E. Marimow report.

Abortion-rights advocates and antiabortion activists alike believe Kavanaugh will be able push the majority toward allowing for more abortion restrictions, and potentially overturning Roe v. Wade. And they point to his strongly worded dissent on a case involving a pregnant immigrant teenager in federal custody as a signal of what’s to come.

Kavanaugh charged his colleagues in his dissent with creating “a new right for unlawful immigrant minors in U.S. government detention to obtain immediate abortion on demand,” borrowing the phrase from the antiabortion vocabulary, Robert and Ann write.

Fatima Goss Graves, president of the National Women’s Law Center, which supports abortion, said the case was “Kavanaugh’s audition for the Supreme Court,” adding that “after showing his hostility to abortion, he was added to Trump’s shortlist.”

— Last month, the last abortion provider in Guam retired, leaving the island without a single abortion provider.

Guam allows abortions within the first 13 weeks of pregnancy without restriction, up to 26 weeks of pregnancy on the condition that the fetus has a physical or mental defect or on the condition of rape or incest, and at any point in the pregnancy if there is a risk to the mother’s health, the Pacific Daily News reports.

Guam Memorial Hospital does not offer abortions as an elective procedure, nor does it refer clients to other locations who offer the service.

Attorney Anita Arriola, an abortion rights advocate, told the publication that without an abortion provider, women may be left without options except to travel outside of Guam for legal or illegal abortions. “Regionally, there aren’t many options available for women seeking abortions. Abortions are outlawed in the Philippines and the Commonwealth of the Northern Mariana Islands,” per the report. “Arriola said abortions in Japan can be done under limited circumstances.”

OPIOID OPTICS

— Pharmaceutical companies Cardinal Health, McKesson Corp. and Amerisource Bergen shipped about 1.6 billion doses of prescription opioids to pharmacies in Missouri from 2012 to 2017, a report released by the office of Sen. Claire McCaskill (D-Mo.) reveals.

The three companies moved an estimated equivalent of 260 opioid pills for every person in the state during that time, as the state and nation struggled with the growing opioid crisis, our colleague Katie Zezima reports.

Katie notes the report also indicates the number of pills moved and the number of suspicious orders the companies reported to the Drug Enforcement Administration, a requirement under the Controlled Substances Act to report suspicious orders as a way to prevent pills moving into the black market.

McKesson and AmerisourceBergen each shipped about 650 million opioids to the state, according to data the companies provided to the Senate Committee on Homeland Security and Governmental Affairs. McKesson reported 16,714 suspicious orders from 2013 to 2017. AmerisourceBergen reported 224 from 2012 to 2017 and Cardinal Health reported 5,125 suspicious orders to the DEA after shipping about 325 million pills.

The companies were fined millions of dollars over the years over various allegations related to the failure to report suspicious orders, Katie reports. But despite such fines, the committee report indicated DEA enforcement has been on the decline since 2011.

“This report confirms what many of us believe, that we have a welcome mat out for drug dealers from surrounding states,” McCaskill said. “That’s the only thing that would explain this type of density of opioids being shipped” to border counties.

BRAIN WAVES

— Think about the people you surround yourself with. Do they influence a healthier lifestyle or bring you down? “Researchers have found that certain health behaviors appear to be contagious and that our social networks — in person and online — can influence obesity, anxiety and overall happiness,” Tara Parker-Pope writes in the New York Times. “A recent report found that a person’s exercise routine was strongly influenced by his or her social network.”

Tara describes the “moai,” a social network concept from Japan where a group of five friends are connected for life as a source of social, logistic, emotional and financial support. National Geographic fellow and author Dan Buettner is working with federal and state health officials, as well as former Surgeon General Vivek Murthy, to bring the concept to two dozen cities in the United States, as Tara writes. “We’re finding that in some of these cities, you can just put people together who want to change health behaviors and organize them around walking or a plant-based potluck,” Buettner said. “We nudge them into hanging out together for 10 weeks. We have created moais that are now several years old, and they are still exerting a healthy influence on members’ lives.”

MEDICAL MISSIVES

— Here’s one troubling way a Texas family is trying to afford health care. A Texas couple, Maria and Jake Grey, is considering a divorce to pay for health expenses for their daughter who has a rare chromosomal disorder, Lauren Zakalik reports for local ABC affiliate WFAA.

One of the couples’ two daughters has Wolf-Hirschorn Syndrome, and her hearing and vision issues, seizures, heart and kidney complications require round-the-clock care. The family estimates they spend $15,000 out of pocket each year, more than 30 percent of their income. Jake, who is an Army veteran, makes $40,000 so the family does not qualify for Medicaid. And there’s a 14-year-waiting list for state aid. A divorce would mean Maria could qualify for Medicaid as a single, unemployed mother of two, Lauren reports.

“For someone to kind of make you choose between your marriage and your child is just — it's just a really weird spot to be in,” Jake said. “It's morally wrong I feel like, and I think it's conflicting for me too, because I feel like what's happening to us is morally wrong.”

—And here are a few more good reads from The Post and beyond: 

Speaking of Science
“It is a game-changer in the field,” one cancer researcher said, “and I'm sure that this technology has legs.”
Ben Guarino
Business
Ochsner Medical Center’s remote monitoring program is gaining popularity.
Carolyn Y. Johnson
The centrist Senate Republicans suggested other Supreme Court contenders would have been harder to support.
Politico
AGENCY ALERT
U.S. officials are still investigating health problems at the U.S. embassy in Cuba, and do not know who or what was behind the mysterious illnesses, which began in 2016 and have affected 26 Americans.
Reuters
INDUSTRY RX
Scientists reported that metastatic cancer cells that had been CRISPR’d to attack the original tumor improved survival in lab mice with brain cancer.
Stat News
Pfizer Inc announced plans on Wednesday to reorganize into three units, separating its consumer healthcare business that the U.S. drugmaker has been trying to sell since last year.
Reuters
STATE SCAN
Post Nation
Nevada and Nebraska have both announced unprecedented plans to use fentanyl in executions.
Mark Berman
 Mike DeWine long had labeled Ohio's expansion of Medicaid health coverage to 664,439 adults — largely the working poor — as financially
The Columbus Dispatch
DAYBOOK

Today

  • The American Hospital Association holds a webinar on “An Innovative Way to Manage Radiation Dose Compliance Across Your Enterprise."
  • AHIP holds a webinar on value-based care.

Coming Up

  • The Brookings Institution holds an event on “(De)stabilizing the ACA’s individual market: A view from the states” on Friday.
SUGAR RUSH
Vice President Pence was heckled by protesters over President Trump's immigration policies:

Democrats hone in on health-care concerns with D.C. Circuit Judge Brett Kavanaugh.:

From the Fact Checker: The winding tale of Justice Kennedy and President Trump: