The Washington PostDemocracy Dies in Darkness

The Health 202: Trump officials ignored HHS advice on two big issues

with Paulina Firozi


One Democratic senator later called it "the most powerful moment" of the Senate hearing on the reunification of migrant families. A career health official testified before lawmakers yesterday that he personally warned federal officials that separating children from their parents at the border could do serious psychological harm. 

During an exchange with Sen. Richard Blumenthal (D-Conn.), Jonathan White, a clinical social worker by trade who has worked for the Department of Health and Human Services under three presidents, said he'd told those deliberating the "zero tolerance" policy that "separation of children from parents entails significant potential for traumatic psychological injury to the child." But White said he was assured that wasn't the plan. 

White was tapped to oversee the reunification efforts at HHS after a federal judge demanded the more than 2,500 separated migrant children, some as young as infants, be given back to their parents. 

White's admission that his guidance went ignored is an example of the Trump White House's seeming disregard for career federal officials' expertise.

Notably, this was the second time this week we learned the Trump administration spurned HHS officials' advice. HHS Secretary Alex Azar and Centers for Medicare and Medicaid Services Administrator Seema Verma, both health-policy experts, tried to convince the White House to allow states to partially extend their Medicaid programs as a way to respond to public pressure without taking on the full expansion in the Affordable Care Act, the New York Times' Robert Pear reported. 

But Trump instead listened to conservative White House advisers like Larry Kudlow, the former CNBC talk show host turned Trump's National Economic Council director, and Mick Mulvaney, the Office of Management and Budget director, who, per the Times, took the position that expanding Medicaid even a little could be interpreted as supporting the growth of the ACA.  

When it came to family separations, it seems a similar dynamic was at play. White, a commander in the U.S. Public Health Service Commissioned Corps, suggested that not only were his warnings unheeded, but that he was also misled by the Trump administration who told him that separating families was not part of its "zero tolerance policy." At that time, he was working for the Office of Refugee Resettlement, the agency responsible for overseeing the care of unaccompanied minors, and said he was involved in discussions around the policy. White moved jobs within HHS on March 15 and the policy went into effect in early April. 

Here's the exchange between White and Blumenthal:

WHITE: "During the deliberative process over the previous year, we raised a number of concerns in the ORR program about any policy which would result in family separation, due to concerns we had about the best interest of the child, as well as about whether that would be operationally supportable with the bed capacity we have."

BLUMENTHAL: "Now I'm going to translate that into what I would call layman's language. You told the administration that kids would suffer as a result, that pain would be inflicted, correct?"

WHITE: "Separation of children from their parents entails significant risk of harm to children."

BLUMENTHAL: "Well it's traumatic for any child separated from his or her parents. Am I correct? I say that as a parent of four children."

WHITE: "There's no question; there's no question that separation of children from parents entails significant potential for traumatic psychological injury to the child."

White's testimony came on the same day the New York Times published a story about a five-year-old boy, now back with his parents, who is showing signs of post-traumatic stress. Experts told the Times that "many of the children released to their parents are exhibiting signs of anxiety, introversion, regression and other mental health issues." 

Last week, Jessica Henderson Daniel, president of the American Psychological Association, released a statement saying the longer the children were separated from their parents, the greater the risk of long-term cognitive effects. 

"Decades of psychological research have shown that children and parents may experience toxic stress as a result of lengthy separations," she said. "Toxic stress can cause irreparable harm to children’s cognitive development and can lead to a host of mental, social and physical health problems later in childhood and well into adulthood. These problems can include severe psychological distress, PTSD, sleep disturbances, social withdrawal, substance use, aggressive behavior and a decline in educational achievement."

White told Blumenthal he felt the children were receiving "sufficient care" from the shelters' mental-health clinicians. 

We've written here at The Health 202 many times about HHS's reluctant role in the separation crisis. After children were separated from their parents, they were designated as unaccompanied and put in the care of the department. When a federal judge said the government had to reunite those families by July 26, it fell on HHS to make that happen. 

Sen. Kamala Harris (D-Calif.) asked White what his agency was doing to complete that task. There remain hundreds of separated children still in HHS custody, mostly due to parents being deported.

"It is absolutely my heartfelt conviction that we must reunify those children with their parents," White told her. "I'm saying that if I could have reunified all those children with their parents by yesterday, it would be done."

Sen. Richard J. Durbin (D-Ill.) called on Homeland Security Secretary Kirstjen Nielsen to step down, amid immigrant families still separated July 31. (Video: Reuters)

AHH: A coalition of state attorneys general joined a chorus of opposition to the Trump administration’s proposal to block clinics that provide abortion services or make referrals from getting federal family-planning funding.

On Monday, 13 Democratic AGs joined governors from a growing group of states who have said they will sue the administration over the rule, or have said they will pull the state from the program over such policy changes, our Post colleague Ariana Eunjung Cha reports. Yesterday was the last day for the public comment period on the proposal rule.  

The proposal is an “effort to create what officials described as a ‘bright line’ of physical and financial separation in the $260 million Title X program, designed to provide basic primary and preventive services for low-income women and families, so that taxpayers do not ‘indirectly fund abortions,” Ariana explains.

In a letter to HHS Secretary Azar, the attorneys general questioned the constitutionality of the proposal, and charged that if adopted, the rule would “result in the invasion of the physician-patient relationship, the trampling of the constitutional rights of patients and providers, the transmission of incomplete, misleading, and medically dangerous information to women, and the frustration of the right to make an informed, independent decision as to whether to terminate a pregnancy.”

The letter was signed by the attorneys general of California, Connecticut, Delaware, the District of Columbia, Hawaii, Iowa, Illinois, Maine, Maryland, Minnesota, New Jersey, New Mexico and North Carolina.

OOF: A federal judge ruled that U.S. officials who gave psychotropic medication without parental consent to migrant children in custody were in violation of state child welfare laws, our Post colleague Samantha Schmidt reports. Some children said they were given pills “every morning and every night.”

The judge ordered the Trump administration to get consent for administering any such medications unless “in care of dire emergencies,” Samantha writes. The judge also ordered the government to move all children out of the Shiloh Residential Treatment Center in Manvel, Tex. unless they were determined to be a "risk of harm" to themselves or others, Samantha adds. She reports staff members at the treatment center "admitted to signing off on medications in lieu of a parent, relative or legal guardian, according to [U.S. District Judge Dolly Gee]’s ruling. Government officials defended this practice, saying they provided these drugs only on ‘an emergency basis’ when a child’s ‘extreme psychiatric symptoms’ became dangerous.” 

But the judge didn’t accept this explanation, Samantha writes, noting the frequency that some children said they were administered medication. “I witnessed staff members forcefully give medication four times,” one child held at Shiloh testified in a court filing, adding “two staff members pinned down the girl . . . and a doctor gave her one or two injections.”

OUCH: A new report from HHS’s Office of Inspector General is calling on federal regulators to increase oversight of hospice care, citing 10 years of research into “inadequate care, inappropriate billing and outright fraud by hospices, which took in $16.7 billion in Medicare payments in 2016,” Kaiser Health News’s Melissa Bailey reports.

“A Kaiser Health News investigation last year revealed that while many of the nation’s 4,000-plus hospices earn high satisfaction rates on family surveys, hundreds fell short of their obligations, abandoning families at the brink of death or skipping other services they had pledged to provide,” Melissa writes. “The OIG report points to similar gaps in care and raises concerns that some hospices are milking the system by skimping on services while taking in daily Medicare payments.”

Here are some of the reports key findings:

  • In 2016, 664 hospices provided patients with just the basic level of care, which is routine home care, rather than other types of care including, “general inpatient care for acute conditions such as uncontrolled pain, continuous care in a crisis and respite care to offer a caregiver temporary relief.”
  • Hospices did not provide adequate services, including nursing, physician or medical social services in 9 percent of general inpatient care stays in 2012.
  • In 2012, hospices provided an average of 4.8 hours of visits a week, which cost $1,100 in weekly Medicare payments.
  • In the same year, 210 patients did not receive any hospice visits, despite Medicare paying out $2.3 million for their care.

— As expected, the Trump administration issued its final rule allowing Americans to purchase skimpier, short-term health insurance plans for up to 12 months. Previously these plans were considered stopgap coverage and were only allowed for three months. The White House says broadening access to these cheaper plans will make health care more affordable, but critics say it will peel off healthier, younger Americans from the ACA exchanges and drive up premiums.

This is the Trump administration's second recent effort to allow cheaper plans for more Americans that don't cover all the "essential" benefits like maternity and mental health care required in Obamacare. "Making it easier to buy health plans that avoid the law’s protections is part of a strategy being employed by Trump and his aides of relying on executive powers to undercut aspects of the law, whose demolition has been one of Trump’s central goals since his 2016 campaign," our Post colleague Amy Goldstein writes.


— Our Post colleague Jeff Stein has more on the study published Monday by libertarian-leaning think tank  Mercatus Center. He writes that both parties are correct in their opposing views that the study shows “Medicare for All” would cost the federal government $33 trillion by 2031, as well as that it would save Americans $2 trillion.

“It’s a surprisingly positive view of Medicare for All from a very conservative research institute,” the Kaiser Family Foundation’s Larry Levitt told The Post of the report.  “According to the analysis, you could provide universal coverage with no patient cost-sharing and actually spend less on health care than we would under the status quo.”

Another expert, the University of Chicago’s Harold Pollack explained how both sides have an argument to make, based on the study. “I don’t look at this report and say it is a partisan hack job: The basic idea the Sanders plan would require a substantial increase in federal budget outlays is correct,” he said. “But over the long run, the Sanders people are very correct that you could implement a system like this that would be more disciplined, more economical and more fair than the current U.S. health system.”

— A new poll from Axios and Survey Monkey found 57 percent Americans disapprove of the Trump administration’s efforts to chip away at the Affordable Care Act, and 59 percent also believe lawmakers should allow the health-care law to stand. Looking deeper at specific demographics, the most popular response among African-American women, people ages 18 to 34, white suburban women and “Never Hillary” independents, was to change the ACA to make it “do more,” according to Axios’s Sam Baker.

“This is why Democrats want to be talking about health care this fall,” Sam writes, “and it's also why the progressive wing of the party feels so comfortable staking out a more liberal position on health care, whether that's the revival of a public insurance option or some form of ‘Medicare for All.’”

— Sen. Marco Rubio (R-Fla.) is set to today introduce a paid family leave bill that would allow parents to draw early from their Social Security benefits.

“Our proposal would be a consistent application of Social Security's original principle — to provide assistance to dependents in our care — to the challenges of today,” Rubio writes in a USA Today op-ed this morning detailing the bill, along with Rep. Ann Wagner (R-Mo.).

“Like Social Security, the benefits under our plans would be most generous to working class families,” they continue. “Parents taking the option would receive monthly payments that will help cover costs like rent, groceries and new baby supplies during a time of significant income constraints.”

The proposal would also allow the benefits to be transferrable between parents and would be available for both “stay-at-home moms and dads.”

The Tampa Bay Times’s Alex Leary reports the plan is similar to the one backed by the Independent Women’s Forum, which “called for 12 weeks of paid leave per parent. To get that, an adult would defer Social Security retirement benefits by six weeks.”

— Sen. Claire McCaskill (D-Mo.) who is in a difficult reelection battle, now asks constituents at every event she attends in her state to stand if they have a preexisting condition. The response has been overwhelming, she tells the New York Time's Margot Sanger-Katz.

The anecdote is illustrative of Democrats' newfound eagerness to discuss Obamacare, and more specifically the threat to the popular provision protecting people with preexisting conditions. It's new territory for Democrats, who have spent the last decade fending off attacks from the right on health care issues.


— An effort to combat the ongoing opioid crisis may cause pain patients to instead turn to riskier treatments,  a consequence illustrated by the growth in popularity of anti-inflammatory injection-based drug Depo-Medrol, the New York Times’s Sheila Kaplan reports.

The drug, made by Pfizer, was previously approved for a treatment for muscle and joint pain, Sheila reports. But Pfizer had previously called on the Food and Drug Administration to ban the drug after complaints about injuries and complications related to the injections. The FDA declined to ban the drug, but strengthened a warning on the drug label.

“After concerns were raised about the off-label treatments, use of the injections declined,” Sheila write. “But the opioid epidemic appears to be spurring their popularity despite risks known to public health officials and doctors… The number of Medicare providers giving steroid injections along the spine, including Depo-Medrol and other drugs, had increased 13 percent in 2016 from 2012. The number of Medicare beneficiaries receiving these injections is up 7.5 percent. The Department of Veterans Affairs reported a 17 percent increase in the injections from 2015 to 2017.”


— Genetic testing companies Ancestry and 23andMe joined others yesterday in setting new guidelines for how they will proceed with the sharing of customers’ DNA, including for when the data is given to researchers, businesses or the police, our Post colleagues Tony Romm and Drew Harwell report.

The companies say they will now request “separate express consent” from users before they turn any genetic information over to another party. The guidelines also indicate that the companies will disclose the number of requests from law enforcement they receive every year.

“The new commitments come roughly three months after local investigators used a DNA-comparison service to track down a man police believed to be the Golden State Killer, who allegedly raped and killed dozens of women in California in the 1970s and 1980s,” Tony and Drew write. “Investigators identified the suspect using a decades-old DNA sample obtained from the crime scene, which they uploaded to GEDmatch, a crowdsourced database of roughly a million distinct DNA sets shared by volunteers.”

Companies including Helix, MyHeritage, Habit, African Ancestry and FamilyTreeDNA also signed onto the new guidelines, according to the Future of Privacy Forum.

“Yet users still may not know everything,” Tony and Drew write. “Under the industry-made rules, DNA testing services don’t have to tell their consumers every time their data has been stripped of their identity, combined with others' genetic information, combed for insights, then turned into statistics, and perhaps shared with a third party for further analysis.”

— And here are a few more good reads: 

Pfizer to Raise R&D Spending as Pipeline Focus Sharpens (Wall Street Journal)


The shocking reason that this man’s legs and hands were amputated: A dog’s saliva (Kristine Phillips)

Why Americans Spend So Much on Health Care—In 12 Charts (Wall Street Journal)

World’s doctor gets second chance on Ebola (Politico)

Chinese parents are leaving the country to get vaccines for their babies (Danielle Paquette and Luna Lin)

Alan Alda Reveals He Has Parkinson’s Disease (The New York Times)



Coming Up

  • 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.  

From The Fact Checker: Unraveling President Trump's top 5 claims: 

The Fact Checker is keeping a running list of the false or misleading claims Trump says most regularly. Here’s what you need to know. (Video: The Washington Post)

Trump says only Abraham Lincoln was 'more presidential' than him:

President Trump on July 31 compared his presidency to that of Abraham Lincoln, noting that the leader was "tough." (Video: The Washington Post)