THE PROGNOSIS

A new law allowing veterans to use public money to seek private health care has broad bipartisan support. But lawmakers and the White House are divided over how to pay for it, creating a stalemate that is now holding up funding for the entire federal government. 

As is so often the case in Washington, bipartisan agreement over policy can easily be sidelined by spending woes. Every stakeholder wants this program paid for in full, yet Democrats want to lift previously set budget caps to pay for it, while some Republicans and the White House say the funding should be offset. The fight is one of the first that is likely to mar agreement before Sept. 30, when the government must be funded or shut down.

The spending standoff comes as the Senate prepares to vote Monday to confirm a new Veterans Affairs secretary after the Washington Post's Lisa Rein reported the department's interim leadership was firing employees seen as disloyal to President Trump. It will be up to nominee Robert Wilkie, after he's confirmed, to set the parameters for when a veteran can see a private doctor, Lisa previously wrote. 

“It is of utmost importance that any policy changes that impact the future of the department be made by a confirmed VA secretary who can be held accountable by Congress and the American people,” Veterans Affairs Committee Chairman Sen. Johnny Isakson (R-Ga.) said in a statement.

For years now, dating back to the Obama administration, the VA has been embroiled in scandals and missteps. Most notably were the long delays veterans faced waiting for care at VA hospitals across the country that in some cases were blamed for deaths. In response, Congress passed a law in 2014 allowing veterans to see a private doctor if they'd have to wait more than 30 days to see a VA doctor or lived more than 40 miles from a VA clinic or hospital.

Then, just last month, President Trump signed into law an updated version called the "VA Mission Act" that took away those specific parameters and made seeing a doctor in the private sector easier for veterans. It was considered a major victory for the president who campaigned on giving veterans more choice in their health care. 

But funding it is becoming a major roadblock.

Earlier this week, Trump's acting VA Secretary Peter O'Rourke and Office of Management and Budget Mick Mulvaney sent a letter to the chairs and ranking members of the Senate and House appropriations committees voicing opposition to any increased spending for fiscal 2019 beyond what has already been budgeted.  

"We have a responsibility to provide our veterans with the care they deserve, while also being good stewards of the taxpayer dollar," they wrote. "The best way to serve our veterans is by ensuring congressional oversight in the same way other programs are subjected to oversight, including by asking the Congress to make difficult tradeoffs between competing priorities within the statutory spending limits that the Congress itself sets. Such oversight justifies every taxpayer dollar spent and encourages the program to serve veterans with innovative, streamlined, and efficient quality of care."

Last week, lawmakers from both chambers were scheduled to meet to hammer out differences in their appropriations spending bills before the fiscal year ends on Sept. 30. Absent a deal, they'd have to pass incremental continuing resolutions or risk a government shutdown. But the conference was canceled at the last minute, as Politico reported, over the veterans' issue. 

The impasse comes down to somewhere between $1 to $2 billion in additional funds to shore up the veterans program for next year, which as of now only has enough money to get through May 2019. The program will then need close to $10 billion for each of the next two years to keep running.

Veterans advocacy groups' sent a joint letter urging Congress to fulfill the promises in the new law. 

"We are very concerned that without assurance of sufficient funding, reform and modernization of the VA health care system – which millions of ill and injured veterans rely on – could be delayed or endangered," the groups wrote. 

But this week, the debate continued with no end in sight. Senate and House Budget Chairs Sen. Mike Enzi (R-Wyo.) and Rep. Steve Womack (R- Ark.) wrote to appropriators saying they should be able to find the extra billion dollars or two within the existing budget to prioritize veterans' health. 

"Providing America's veterans with access to quality healthcare and serving as responsible stewards of taxpayer dollars is not an either-or proposition," they wrote. "Congress can -- and should -- do both."

Ranking Democrat on the House spending panel Rep. Nita Lowey (NY) responded, challenging Republicans that they should have considered the funding shortfall before passing the new veterans' bill, adding that the measure was not yet passed when budget caps were first set. For that reason, she writes, unless the caps are lifted, fully funding the new program won't be possible "without cutting funding for other vital domestic programs, including other veteran’s services."

"Republican Leadership, and President Trump, should have prioritized fully funding the VA MISSION Act before it was signed into law," Lowey wrote. "Instead, Republicans chose to ignore the well-being of our veterans to play political budget games."

It's been years since Congress actually passed increased spending for all of the government. Because they often can't agree on spending levels — typically due to infighting among Republicans — they've kept funding limping along at current levels. To do so again, would also mean the veterans' health program they just green-lighted wouldn't get the money it needs.

Carlos Fuentes, legislative director for Veterans of Foreign Wars, said his organization is not taking sides over which approach is best -- busting the caps or borrowing money from other programs. They just want it funded. 

"Overall it is a great bill and would make a huge difference for veterans the only thing that would prevent its success is inadequate resources," Fuentes told me. "These are earned benefits and received bipartisan support and must be properly funded or we will go back to what happened in 2014 when we had a crisis of access around the country."

AHH, OOF and OUCH

AHH: The Trump administration said yesterday it will consider importing certain drugs from overseas as a way to tame the rising prescription drug costs in the United States.

The Food and Drug Administration said it would create a working group to explore how to safely import drugs in the case that there’s a sharp price hike on a manufacturer’s off-patent drug, our Post colleague Laurie McGinley reports. FDA Commissioner Scott Gottlieb said the working group would look at whether imports would help patients afford cheaper medications in the case of a drug shortage until there was a new supplier in the United States.

HHS Secretary Alex Azar said such a move “could help address price hikes and supply disruptions that are harming American patients.”

“Generally, the importation of drugs from other countries is illegal,” Laurie writes. “But the FDA doesn't enforce the ban against individuals bringing in small amounts of drugs for personal use. And it occasionally allows the importation of foreign-approved drugs into the United States by manufacturers and suppliers to ease supply shortages, such as ones that occurred as a result of the hurricane in Puerto Rico.”

Laurie also notes that rather than examining the reimportation of drugs that were manufactured in the United States and exported elsewhere, the working group will look at importing drugs approved in other countries that could offer an alternative to FDA-approved drugs.

OOF: Attorneys representing the families suing University Hospitals in Cleveland over the destruction of thousands of eggs and embryos at its fertility clinic called for information about the case to continue to be publicly shared, criticizing the medical center for requesting a gag order in the case.

Our Post colleague Ariana Eunjung Cha reports attorney Joseph Peiffer, who is representing 75 of the 1,000 impacted families, told reporters that one woman was told in a July 13 letter that her embryos were among those destroyed when a freezer malfunctioned in March, after the center initially told the woman she had not been affected. Peiffer said the woman had begun treatment to prepare for embryo transfer.

“University Hospitals Cleveland Medical Center said in a response to questions Thursday evening that no additional eggs or embryos were impacted beyond the 4,000 they reported earlier, and that only two patients who had eggs or embryos donated to them were in this situation,” Ariana reports.

Peiffer suggested the medical center’s gag order request could be an “intentional attempt” to prevent further communication to inform people about additional issues, Ariana writes. “Frankly I just don’t have a synonym for outrage that expresses this enough,” Peiffer said.

OUCH: The U.S. Government Accountability Office released a report yesterday that found the whistleblowers in VA were 10 times more likely to face disciplinary action or removal compared with their colleagues.

NPR’s Eric Westervelt reports the GAO also found 66 percent of VA employees who filed formal complaints did not work in the department the next year, that senior VA managers were sometimes “not held accountable,” and officials found guilty of misconduct received less punishment than was suggested. The report also noted the department doesn’t always document the dispute and resolution, which Eric notes suggests “employees may not have received due process.”

“The GAO report underscores what VA whistleblowers have been saying for years: that too many of those who speak up about mismanagement, fraud or abuse are quickly silenced,” Eric writes. “And that sometimes they're even investigated by the very managers they're blowing the whistle on.”

TRUMP TEMPERATURE

— The Trump administration appears to be making some strides to bring down drug prices, launching a series of moves following the announcement from major drugmakers that they would delay some of their prescription price hikes, Bloomberg’s Anna Edney reports.

HHS late Wednesday sent a proposed regulation to OMB on the rebate that drugmakers offer to insurers and pharmacy-benefit managers that critics believe is one of the reasons drug prices are so high. The FDA on Wednesday also released a proposal to ease the approval of biosimilars, or generic copies of brand name drugs. “Both moves were part of President Donald Trump’s blueprint for lowering drug prices released in May,” Anna writes.

“The blueprint is very real, it’s definitely the president’s blueprint and the sweeping reforms contemplated in it are on the way,” HHS Deputy Secretary Eric Hargan said Thursday during remarks in front of leaders of the lobbying group Pharmaceutical Research and Manufacturers of America, Anna reports. “When this president talks about fundamental change to drug markets, he follows through.”

OMB will have to review any proposed regulation before it is publicly released.

— Pharmaceutical giant Merck became the latest drugmaker to buckle amid pressure from the president over increasing prescription drug prices, announcing yesterday it would not only halt increases but lower the price of several of its medications.

The New Jersey-based company said in a statement it would “commit to not increase the average net price across our portfolio of products by more than inflation annually.” The company also said it would lower the price of certain drugs, including a hepatitis C medication by 60 percent and “several other medicines” by 10 percent.  

Back in August, Trump criticized company for being a contributor to high drug costs.

HHS Secretary Azar thanked the company on Twitter:

Earlier in the day, Trump tweeted to thank two of the latest drugmakers for shifting plans to increase prices amid taunting from Trump, our Post colleague John Wagner reports.

Politico's Sarah Karlin-Smith and Andrew Restuccia report Pfizer's CEO met with the president at the White House on Thursday amid the ongoing pressure. "Ian Read's appearance followed a Trump tweet this morning that thanked Pfizer and the Swiss manufacturer Novartis for pledging not to raise drug prices further this year," they write. "Top pharmaceutical industry CEOs are in Washington for an annual planning meeting of the major drug lobby PhRMA."

Novartis announced Wednesday that it did not plan to increase its U.S. prices for the rest of 2018. A day earlier, Pfizer had said it would delay increases that were set to take effect at the beginning of the month.

But some Democrats pushed back on Trump's declared success. 

The Health 202 wrote about Trump's drug pricing efforts this week and how little significant change had yet been realized. On Wednesday, HHS posted a blog on its website pushing back on media coverage.

Following the news of delays from Pfizer and Novartis, Dan Best, senior adviser to the secretary for drug pricing  writes: “It is hard to imagine, in light of this news, that some in the media are still claiming that the Trump Administration’s plan for reforming drug pricing isn’t delivering. Yet that’s the tired story many are sticking to, and they’re leaving out crucial facts in the process.”

But he insists “HHS has responded, implementing changes and reforming regulatory pathways to lower the price of prescription drugs.”

AGENCY ALERT

— Homeland Security Secretary Kirstjen Nielsen would not say yesterday whether the Trump administration would be able to meet the court-ordered July 26 deadline to reunify children ages five to 17 with their parents after being separated at the U.S.-Mexico border.

"We will do our best, but we will not cut corners," Nielsen said at the Aspen Security Forum in Colorado, Politico’s Connor O’Brien reports, adding Nielsen said the reunification process are “about the protection of the child.”

"A good portion of these adults showing up are not their family,” she said.

— Meanwhile, at an emergency command center in Washington, federal workers are trying to make the deadline.

“The room on the sixth floor of the Department of Health and Human Services’ Hubert H. Humphrey Building, with banks of computer terminals and wraparound television screens, is typically used to handle public health epidemics or hurricanes,” our Post colleagues Nick Miroff, Maria Sacchetti and Amy Goldstein report. But now the space is being used to look through migrant children’s case files to match them to their parents.

By Wednesday, our colleagues write the administration had reunited 364 of the 2,500 older children with their parents, according to a Thursday court filing. Officials say there are 1,600 adults eligible to be reunited with their children, but half of those still need to be interviewed and cleared, and another 90 have been determined to be ineligible over criminal records or other concerns.

“HHS officials in charge of the operation say they are doing everything they can to give the children back quickly and safely, working round-the-clock to meet U.S. District Judge Dana M. Sabraw’s deadline, or least demonstrate enough progress to keep him convinced it’s a good-faith effort,” Amy, Maria and Nick write.

Amy, Maria and Nick report that HHS software complicated the reunification process as the case workers “started the process with no clear way of knowing who among the nearly 12,000 migrant children in federal custody after crossing the border were those taken from their parents,” which was “plain to see in the HHS software shown to reporters, which lacks a data-entry field to label children who are separated minors.”

— The Centers for Medicare and Medicaid Services on Wednesday sent the OMB a proposed regulation that would allow the administration to resume making billions of dollars of payments to health insurers under Obamacare, Bloomberg’s Zachary Tracer reports.

“An administration official said the rule is an option being considered to resolve the legal dispute that has held up the payments,” Zachary reports. “Health-insurance industry groups had pushed the Trump administration to issue an interim final rule for the risk-adjustment program to resolve a legal dispute that had threatened to halt payments under the program.”

The risk-adjustment payments are meant to even out costs for insurers for sicker and thus costlier patients. CMS announced earlier this month it would halt $10.4 billion in payments that are due to insurers for 2017 expenses.

Zachary writes insurers had “warned they might have to raise Obamacare premiums for 2019 if the dispute wasn’t resolved quickly.”

— Meanwhile, Republican lawmakers continue to want to find a way to restore the payments. Rep. Greg Walden (R-Ore.), chairman of the Energy and Commerce Committee, told Axios: "We want this fixed, whether we have to legislate or do it by rule. It needs to happen.”

HEALTH ON THE HILL

— A group of Senate Democrats yesterday introduced a resolution that would allow the Senate to intervene in an ongoing lawsuit brought by 20 states over whether the Affordable Care Act is constitutional.

The lawsuit contends that without the individual mandate, which will be repealed next year, the health-care law would no longer be constitutional, thus invalidating consumer protections for people with preexisting conditions.

In a news conference, the senators, led by Sens. Joe Manchin (W.Va.), Bob Casey (Pa.), Claire McCaskill (Mo.), Heidi Heitkamp (N.D.), Joe Donnelly (Ind.) Jon Tester (Mont.) Sherrod Brown (Ohio) and Catherine Cortez Masto (Nev.) called on their Republican colleagues to sign onto the resolution.

“Protections for those with pre-existing conditions are vital, yet this administration, aided by Congressional Republicans, is doing all it can to end them,” Casey said during the news conference. “We will defend the pre-existing condition protections in court. If Senate Republicans support protections for people with pre-existing conditions as they claim, then they should support this resolution.”

— To push back against Republican efforts to dismantle the ACA, several states and D.C. passed their own versions of an individual mandate requiring all residents to have health insurance. But, because Congress, has say over D.C.'s budget, the House GOP moved Thursday to block the District from doing so, report our Post colleagues Jenna Portnoy and Peter Jamison. The lawmakers also voted to restrict D.C. from funding that helps low-income women obtain abortions, commercializes recreational marijuana and allows terminally ill patients to end their lives, they write. The moves are the most aggressive ways that federal lawmakers have tried to rein in D.C. local elected officials in at least a decade.

INDUSTRY RX

— Laboratory Corp. of America was hit with a cyberattack, leaving potentially vulnerable the sensitive information maintained by the medical-testing giant.

“LabCorp processes millions of blood, urine and other diagnostic tests each week,” the Wall Street Journal’s Rob Copeland and Melanie Evans report. “It is one of the world’s largest domestic commercial lab-testing companies and maintains a database containing health information on roughly half the U.S. population.”

LabCorp said it’s investigating the “ransomware” attack, Rob and Melanie report, adding the attack first affected one of its genetic-testing units over the weekend. A company spokeswoman said there was no indication any data was breached.

MEDICAL MISSIVES

— And here are a few more good reads: 

Would you want to know if you harbor a gene linked to Alzheimer's or another incurable disease? A new poll finds most Americans would.
Associated Press
Auditor General Eugene DePasquale proposes levying a 35 percent tax on recreational marijuana sold in state-sanctioned retail stores. Marijuana advocates, however, warn that DePasquale may be overreaching because he assumes the state will capture all of the underground market.
Philadelphia Inquirer
Local
The person came into contact with Vibrio, a waterborne, flesh-eating bacteria.
Dana Hedgpeth
STATE SCAN
Public Safety
Fire medics are treating patients for symptoms related to K2 or similar synthetic drugs.
Clarence Williams
REPRODUCTIVE WARS
With a new Supreme Court Justice on the way, anti-abortion groups sense a unique moment to achieve their goal, and they’re mobilizing forces at the local level.
New York Times
The ruling protecting abortion rights may not be overturned entirely, but instead chipped away at slowly. Even if it is, abortion won’t suddenly be illegal nationwide.
BuzzFeed
The study, published in April, falsely claimed to have gotten ethical approval for human research.
BuzzFeed News
DAYBOOK

Today

  • The Alliance for Health Policy holds an event on “State Responses to the Evolving Individual Health Insurance Market."
SUGAR RUSH

Trump asks businesses to increase apprenticeships:

Late-night laughs: Trump backtracks on his Russia comments: