THE PROGNOSIS

Saturday marked one year since Arizona Republican Sen. John McCain's now famous thumbs-down vote that upended the last GOP attempt to fully repeal the Affordable Care Act. 

In the leadup to that vote, Republicans faced intense political pressure from a grassroots campaign that focused on the often emotional stories of the tens of millions of Americans who would lose coverage if the ACA went away. The law had become increasingly popular, and individuals who didn't get insurance through their job and previously couldn't affordable quality care now had access to it. For many, the threat of losing their coverage was enough to make them activists. 

Now, Democrats are counting on them to also be voters. 

In these months before the November midterms, Democrats are again focusing on what would be lost without the ACA. They're hoping Americans' anxiety about health care will motivate them to go to the polls. But without a big, in-your-face- repeal effort by Republicans, it's unclear whether the issue has the same emotional heft it did a year ago. 

The Democrats have been testing out how Americans feel about health care through their opposition to Supreme Court nominee, Brett Kavanaugh. They've tried to make his confirmation a referendum on health care, or more specifically, the ACA. 

 

But our Post colleague Paul Kane spoke last week to the GOP caucus's most moderate members, Sens. Susan Collins and Lisa Murkowski, who both voted against ACA repeal, each of whom told him the pressure ahead of that vote came directly from their constituents. On the Supreme Court issue, there is plenty of intensity, but it's coming more from outside political groups, they said. 

That makes sense. With a Supreme Court nomination there's lots of hypotheticals and complicated legal jargon. The repeal vote was black and white; an "aye" meant the ACA would have been largely eliminated and "no" meant it mainly stayed. That's the biggest difference between last year's movement and this year's effort: Republicans are no longer trying to repeal the ACA in its entirety. Instead, they vote on small, more arcane changes while the White House issues regulations all intended to chip away at the law and render it unworkable.

But "STOP SHORT-TERM DURATION PLANS" is not quite as catchy on a bumper sticker. 

And yet, cheaper, leaner plans are one example of a way the Trump administration is taking real action to undermine the ACA. The short-term plans exist to provide Americans with temporary coverage for up to three months. They are exempt from ACA requirements, so insurers can offer skimpy plans at a low premium. But the Trump administration is going to allow insurers to offer the plans for a year, effectively allowing them to compete with plans on the ACA's individual market exchanges. What that means in practice is that younger, healthier people can buy those cheap plans, leaving older, less healthy Americans with more expensive coverage because insurers will raise premiums to afford a population that will lean on the system more heavily. 

The Office of Management and Budget concluded its review of that regulation on Friday, the last administrative hurdle, so a final rule is expected any day.

That's just one of several tactics pursued by the Trump administration.

But Democrats will have an opportunity to convince voters that Republican efforts have negatively affected the ACA's goal of affordable care. Open enrollment begins in October and many Americans on and off the exchanges will face higher monthly premiums due to a variety of factors. A July Quinnipiac University poll found that 22 percent of Americans ranked health care as the most important issue to them ahead of the election, just under the economy and immigration. Of those who said health care, 71 percent would support the Democratic candidate in the midterms.

So, even if tying Kavanaugh to the ACA is too abstract for most voters, the Democrats will continue to hammer the message that health care protections will continue to be at risk with him on the court and with a Republican-controlled Congress and White House.

In a preview of their campaign message, Senate Democrats at the end of last week brought several Americans with preexisting conditions to Capitol Hill to make the case against Kavanaugh and more broadly against rolling back the ACA. The senators' remarks were transparently political. 

"Republicans are running scared on health care," Sen. Ron Wyden (D-Ore.) said. "The fact is they are trying to defend the indefensible, rolling back protections for those with pre-existing conditions, this means you're taking health care back to the days when health care was for the healthy and wealthy. They're trying to defend junk insurance and this really takes my breath away."

AHH, OOF and OUCH

AHH: Incoming Veterans Affairs secretary Robert Wilkie plans to reassign several of the agency’s political appointees who are Trump loyalists in an effort to “form his own leadership team” and “ease lawmakers’ continued concern that VA, historically a nonpartisan corner of the government, has become highly politicized,” our Post colleague Lisa Rein reports.

Wilkie has discussed his plans with the president, and the announcements could come as early as this week.

“The changes would sideline much of VA’s interim leadership team under acting secretary Peter O’Rourke, who drew unfavorable reviews from lawmakers in both political parties following a dispute with the agency’s inspector general and a  Washington Post report that highlighted O’Rourke’s efforts to purge civil servants and some political appointees whom he and others installed by Trump deemed unsupportive of the president’s agenda,” Lisa writes.

“O’Rourke, a former Trump campaign worker, will be reassigned to a less visible role overseeing a new office focused on improving VA operations,” she adds.

Among the obstacles Wilkie faces are leadership vacancies, including a lack of a permanent deputy secretary, or an undersecretary for VA’s health system, an undersecretary for health, and an assistant secretary for information technology. “Additionally, dozens of senior-level staff have departed VA amid the turmoil that has marked the past six months, leaving numerous vacancies,” Lisa continues.

OOF: In the policy shop under the Trump administration’s Health and Human Services Department, Trump appointees have removed positive references to Obamacare, changed a report that undermined the administration’s stance on refugees, added language opposing abortion rights to a strategic plan and tailored “facts to fit Trump’s message,” according to a story from Politico’s Dan Diamond.

“Another report suggesting that millions more people would get health coverage if Obamacare were rolled back — a finding at odds with nearly every independent analysis — was widely mocked and produced over the objections of career staff at the office of the assistant secretary for planning and evaluation, known as ASPE, say several sources,” Dan writes.

One former official told Dan it was “just another example of how we’re moving to a post-fact era.”

But officials in the department deny that such adjustments are occurring. “I reject the premise of your question and allegation,” spokeswoman Caitlin Oakley told Politico. “Secretary [Alex] Azar has made very clear that HHS is a science- and evidence-based organization and it will operate accordingly.”

Another official said the policy shop was no more partisan than the one under the Obama administration. “I don’t believe the Trump administration ASPE has put out reports that are any less analytically or methodologically rigorous than those of the Obama administration ASPE,” Republican health policy analyst Lanhee Chen, who served in the George W. Bush administration, told Politico. “Those who express concerns regarding the quality of reports ‘falling off’ are probably using that argument as a cover for the fact that they disagree with the findings of the reports.”

OUCH: A new study reveals that a quarter of adults who went to the emergency room with sprained ankles were prescribed opioid painkillers, our Post colleague Lenny Bernstein reports.

The report was based on a state-by-state analysis of more than 30,800 private insurance claims from 2011 to 2015. The median prescription for adults was 15 tablets, or three days’ worth of hydrocodone, oxycodone, tramadol or other narcotics, Lenny reports. The study found patients who were prescribed the largest amount of the drugs were five times more likely to continue with prolonged opioid use, compared with adults given 10 or fewer pills.

“The state-by-state review revealed wide variation in the use of opioids for the sprains, from 40 percent in Arkansas to 2.8 percent in North Dakota,” Lenny writes. “All but one of the nine states that recorded above-average opioid prescribing are in the South or Southwest. None are in the parts of Appalachia or New England that have been hit hardest by the opioid epidemic.”

The study highlights how commonplace it is for physicians to prescribe opioids even for minor injuries, but Lenny notes ER doctors are responsible for prescribing just a small portion of the opioids patients consume every year. The analysis also followed a warning from the Centers for Disease Control to physicians to dole out the narcotics judiciously.

TRUMP TEMPERATURE

— Our Post colleagues Nick Miroff, Amy Goldstein and Maria Sacchetti describe some of the woes that plagued the Trump administration as it attempted to comply with a court order to reunify migrant families it had separated at the U.S.-Mexico border. Firstly, there was no distinct classification for the family units a federal judge had called on them to reunify. A term “deleted family units” was created, but it did not solve issues at the root of the process.

“The crucial tool for fixing the problem was crippled,” Nick, Amy and Maria write. “Caseworkers and government health officials had to sift by hand through the files of all the nearly 12,000 migrant children in HHS custody to figure out which ones had arrived with parents, where the adults were jailed and how to put the families back together.” There were issues with keeping track of the families’ records and there were communication and coordination issues among the agencies tasked with reunification.

The story from our colleagues detailing the efforts and subsequent complications is worth reading in full, and is based on interviews with 20 current and former government officials, advocates and contractors. “What was lost in the process was the family. The parents didn’t know where the children were, and the children didn’t know where the parents were. And the government didn’t know either,” U.S. District Judge Dana M. Sabraw, the judge overseeing the process, said in a hearing on Friday.

Here’s a breakdown of the status of the 2,600 children who were at one point in the custody of the administration via our Post colleague Philip Bump:

  • 1,500 children have been reunited with their parents, including 1,442 kids 5 and older and 58 under 5.
  • 378 kids have been otherwise discharged, meaning they were moved to sponsor households, reunited with family members released into the United States, or they turned 18.
  • 23 children under 5 cannot yet be reunified because their parents are in criminal custody, or their parents have been already deported.
  • Another 711 children over 5 are awaiting reunification or cannot be reunified, either because their parents have waived reunification claims, their parents were released into the United States or have already been deported or are unable to be located. Other reasons include parents having been flagged because of a review or background check or some other court action.
  • Another 21 children under 5 cannot be released because parents have disqualifying criminal backgrounds, the adults cannot be confirmed as parents, the adults have been determined to be threats to the child and one parent is being treated for a communicable disease.
  • 26 children have been determined to be ineligible for reunification.
AGENCY ALERT

— HHS official Ximena Barreto, who had previously spread conspiracy theories on social media, has been pushed out, Politico’s Dan Diamond reports.

“Before joining HHS as a deputy communications director in December 2017, Barreto spread conspiracy theories on social media and through online videos — among them that Hillary Clinton was engaged in a child-sex ring at a Washington pizza shop, involved in the murder of Democratic National Committee aide,” Dan writes.

After her social media posts were made public, Barreto was placed “on review,” per the report, and moved from her role as a deputy communications director to the agency’s Administration for Children and Families office. She’s the third former member of the Trump campaign to be forced out of the agency this month alone, Dan points out.

HEALTH ON THE HILL

— Senate Minority Leader Charles E. Schumer (N.Y.) won’t be cracking down on red-state Democrats who vote in favor of Kavanaugh, Trump’s nominee for the Supreme Court, telling our Post colleague Sean Sullivan “punishment is not how this place works.”

“The Kavanaugh fight is a potential defining battle for Schumer, after an up-and-down 18 months,” Sean writes. “The Democratic leader, who boasts of knowing the personal phone numbers of his caucus by heart, held them together last year against the failed GOP push to repeal the Affordable Care Act and the successful Republican revamp of tax laws. But divisions this year over a banking bill and the confirmation of Gina Haspel to head the CIA left a bitter taste in the mouths of some Democrats.”

Immediately after the president announced that he had picked Kavanaugh, Schumer tweeted his intentions:

But he has since tempered his resistance, acknowledging the “uphill fight” to not only unite all Democrats in voting against the nominee, but to pull a Republican into the fight as well, Sean writes.

Schumer, who has expressed concern with how Kavanaugh could vote on critical health care and abortion rights' issues, “summed up his message to the red-state Democrats this way,” Sean writes: “Let’s see who this nominee is and let’s see where he stands on these important issues.” 

— In a letter to the Federal Trade Commission, House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) called for a review of recent pharmacy benefit manager mergers to determine whether the middlemen’s moves could hike the cost of drugs.

Consolidation in the PBM industry is part of a larger trend of centralization in the health-care market more generally,” Walden writes in the letter. “There is conflicting information, however, on the impact of PBMs on health care costs for patients… Because some mergers may benefit patients while other mergers may harm patients, we believe it is important to closely monitor these trends.”

The PBMs, which have been increasingly targeted as one reason for skyrocketing prescription drug costs, act as a negotiator between drug manufacturers and insurers. (The Health 202 has written about state efforts to target the middleman, as well as legislation in both chambers of Congress that ais  to block some of the players’ obscure actions.)

Walden’s letter refers to the three largest of the middlemen, CVS Caremark, Express Scripts and OptumRx, all of which have participated in mergers and now make up more than two-thirds of the market.

STATE SCAN

The Centers for Medicare and Medicaid Services announced Sunday night that it had approved a Wisconsin proposal aimed at lowering insurance premiums. 

Wisconsin filed a waiver request to create a reinsurance program where the state can use federal money to help insurers offset the costs of expensive claims, thus freeing them up to charge less for monthly premiums. The state projects premiums could go down 3.5 percent for individuals getting their insurance on the exchanges.The state is committing $200 million to the program, with $34 million coming from the state budget and the rest from federal taxpayers, according to Milwaukee Journal Sentinel. Wisconsin's was the first such waiver approved this year, and fourth overall. 

In a letter to Walker on Sunday, CMS told Walker the "reinsurance program will lower individual market premiums in the state and the premium tax credits (PTC) to which Wisconsin residents would have been entitled absent the waiver.”

Republican Gov. Scott Walker, who is up for reelection this year, celebrated the win on Twitter, while his Democrat opponents were quick to call it a political stunt:

CMS administrator Seema Verma tweeted following the announcement: 

— And here are a few more good reads: 

The Fix
A year ago today, Republican Sen. John McCain shocked fellow lawmakers by casting the decisive vote against repealing the Affordable Care Act.
Peter W. Stevenson
Almost as soon as President Trump took office, he began rolling back health care rules that had angered religious groups for much of the last decade.
FiveThirtyEight
MEDICAL MISSIVES
1,387 facilities got only one out of five stars for staffing because they failed to maintain the required nursing coverage or to provide data proving they did.
The New York Times
A growing chorus, including the Trump administration, is calling for a rethinking of after-the-fact drug discounts that some say contribute to rising prices.
The New York Times
Wonkblog
Identical shooters with identical intent would kill fewer people if they had access to less powerful firearms.
Christopher Ingraham
REPRODUCTIVE WARS
Telemedicine prescriptions could undercut state abortion restrictions.
Politico
DAYBOOK

Today

  • The House Veterans Affairs Subcommittee on Health holds a field hearing on “VA Long-term Care.”

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on health care costs on Tuesday.
  • The Senate Veterans Committee holds a legislative hearing on Wednesday.
  • The U.S. Food and Drug administration holds a joint meeting of the “Drug Safety and Risk Management Advisory Committee and the Anesthetic and Analgesic Drug Products Advisory Committee” on Friday.  
SUGAR RUSH

From the Fact Checker: When President Trump's "fake news" isn't fake:

A look at leaders who have called the press "enemies of the people:"