THE PROGNOSIS

One of President Trump's most vocal Republican critics released a report Tuesday extolling the benefits of expanding Medicaid. Meanwhile, on Capitol Hill, the federal official in charge of Medicaid testified in Congress about why the expanded program is unsustainable.

Four years ago, Ohio Gov. John Kasich (R) bucked his party to accept the Affordable Care Act's offer to add more low-income residents to the government-run health care program. On Tuesday, the state highlighted the success its had through Medicaid expansion.

Medicaid is currently at a crossroads. The Trump administration is pressing forward with efforts to allow states to add work requirements to be eligible for the coverage at the same time as three red states, Nebraska, Utah and Idaho, are giving voters the chance to decide on whether to implement expansion through November ballot initiatives. What happens in this debate could determine the future of the safety net program for the poorest Americans.

During a Senate hearing on Medicaid fraud also Tuesday, CMS Administrator Seema Verma in her prepared remarks said, "Medicaid expenditures have grown rapidly and are consuming ever-increasing shares of State budgets."

She blamed expansion for exploding the federal budgets because the federal government has paid 100 percent of costs to cover the expansion population and by 2020 will pay 90 percent into perpetuity. So far 33 states and the District of Columbia expanded Medicaid to cover people earning up to 138 percent of the poverty line or about $16,000 a year. 

"The structure of how we've set this up, it really does create an incentive for the states to spend more and more," she said. She said Medicaid should be shifted from an "open-ended entitlement to a fixed amount of money," which is a common talking point of Republicans who believe Medicaid funding to states should be capped. 

Kasich, for his part, has been a proponent of block grants or per capita caps for Medicaid, but during a press conference Tuesday to tout his state's expansion program, he sounded a dire warning about the program's future. 

"It is affordable now, (but) if the federal government plays games and tries to put us in a perilous fiscal position, we will have to change this position on Medicaid expansion. There is no way that we can put our state deep in the hole and wreck economic development and more prosperity,” Kasich said. The Ohio report showed that an additional 700,000 individuals a year were covered by the expansion, and 89 percent of them were previously uninsured. 

For Kasich, who is one of 17 GOP governors to expand the program, perhaps the strongest argument he has to skeptical members of his own party is that 290,000 people who received the benefits have since left the rolls because they were started working or began earning more. Most of the recipients told the state that having insurance helped them find or keep their job. 

Notably, Ohio is among the states that filed a waiver this year to add work requirements to its Medicaid program, pushed to do so by a GOP-led legislature still irked that Kasich expanded the program. The decision to answer the Trump administration's call to apply for such waivers infuriated state Democrats who have called on Kasich to rescind the application. Ohio officials says most of the able-bodied adults on Medicaid are already working and that it would affect around 36,000 enrollees. 

Critics of adding eligibility parameters to Medicaid say it sets up low-income people to fail because typically reporting work or asking for an exemption requires doing so online, if they know to do it at all. 

In Arkansas, the first state to implement work requirements, 83 percent of beneficiaries who were supposed to go online to report activity didn't, according to Joan Alker, a law professor at Georgetown University, who tracks these programs. "With two strikes against them, it’s clear that many beneficiaries appear to be unaware that they were even sent up to bat," she wrote in a blog post. 

Verma has defended the work requirements, saying it provides an incentive to lift people out of poverty.  "This is the idea of helping people to obtain independency and the skills they need," she told senators.

At the hearing, Sen. Tom Carper (D-Dela.)  talked about the moral imperative of the Medicaid program and used one politician to make his point.  "One of my best friends is this guy named Kasich. We were freshman in Congress together 400 years ago," Carper said. "He was asked why he decided  to expand Medicaid. And he said, 'When I stand at the pearly gates someday and I'm trying to get into heaven and they ask me what did you do to deserve getting into heaven, I want to be able to say that when people needed health care, I helped them get it."

Also, at the hearing, Verma assured Democrats that if a pending lawsuit against the Affordable Care Act was successful, she would help Congress write legislation to ensure people with pre-existing conditions stay protected. 

“I am deeply concerned about individuals with pre-existing conditions. My job is to implement the law, but if the law changes in some way, I would work with Congress to make sure we had protections in place for people with pre-existing conditions,” she said. 

Sen. Claire McCaskill (D-Mo.) pressed Verma on this point, telling her that it's "outrageous" there's no plan in place to address this if the ACA is overturned by the courts, and said "there doesn't seem to be any sense of urgency" in Congress to act. Sen. Heidi Heitkamp (D-N.D.) later said it was "disingenuous" for the administration to say they believe in pre-existing conditions if they won't defend them in court. Both senators are in difficult re-election fights and this is a top issue they're campaigning on. 

"Let's not pretend there is any commitment here from the Department of Justice to preserve pre-existing conditions for the American people," she told Verma. "It's not your decision, but I want that on the record. "

AHH, OOF and OUCH

AHH: Supreme Court nominee Brett Kavanaugh told Republican Sen. Susan Collins (R-Maine) yesterday that he agreed with Chief Justice John G. Roberts Jr. that  Roe v. Wade was “settled law.” Collins told reporters that she had discussed the topic with Kavanaugh during a more than two-hour Tuesday meeting with the nominee.

“We talked about whether he considered Roe to be settled law,” said Collins, who supports abortion rights, our Post colleagues Elise Viebeck and Gabriel Pogrund report. “He said that he agreed with what Justice Roberts said at his nomination hearing, in which he said it was settled law. We had a very good, thorough discussion.”

Collins has not said whether she will support Kavanaugh but has said she would vote against any nominee who “demonstrates hostility” to the landmark 1973 Supreme Court decision.

Meanwhile, Senate Minority Leader Chuck Schumer (D-N.Y.) left his own meeting with the nominee less confident in the fate of Roe v. Wade.

“I understand that the judge told other members today that he considered Roe v. Wade settled law. He did not say that to me,” Schumer said following his 90-minute meeting with Kavanuagh, Politico’s Nolan D. McCaskill reports. “But that is not the important or decisive question… “Everything the Supreme Court decides is settled law until a majority of the Supreme Court decides to unsettle it. Conservative justices have a habit of saying something is settled law during their confirmation and then overturning the minute they get on the bench.”

Schumer told reporters that he explicitly asked Kavanaugh about whether he believes Roe v. Wade and Casey V. Planned Parenthood were “correctly decided.” ““He would not say yes. That should send shivers down the spine of any American who believes in reproductive freedom for women,” he warned.

OOF: Hospitals often don’t know the actual cost of doing common surgical procedures. And that can cost patients.

“Competitive forces are out of whack in health care,” the Wall Street Journal’s Melanie Evans reports. “Instead, they often increase prices to meet profit targets. Patients, especially those with insurance, often don’t know the price of a procedure and rarely shop around.”

“This dynamic is a driving force in the explosion in health-care spending in the U.S., which will soon reach close to 20% of GDP,” Melanie adds. “Americans spend more per capita on health care than any other developed nation, even though they aren’t buying more health care overall. The rise in hospital prices has outpaced economywide inflation for decades.”

She featured one hospital’s quest to figure out the true cost of a knee-replacement surgery. Gundersen Health System did an 18-month review, complete with the help of an efficiency expert and found that the cost was $10,550 at most, but that hospitals were listing the price as five times that number.

“Armed with the new information, Gundersen was able to pinpoint waste, and it set out to cut inefficiencies and lower costs,” Melanie writes. “Changes to the process mean the knee surgery now costs the hospital an average $8,700 at most to perform, an 18% savings.”

OUCH: The Trump administration’s proposed Affordable Clean Energy rule, a measure that will replace the Obama administration’s rule that set strict carbon dioxide limits for states and sped up coal plant closures, will have a huge impact on public health.

The rule will allow coal-fired power plants to run longer if they become more efficient, our Post colleague Juliet Eilperin reports, meaning there will be more soot and smog-forming pollutants emitted into the atmosphere. “The EPA projects that the rule could lead to 470 to 1,400 premature deaths each year compared with the Obama-era rule,” she writes.

“A key component of the rule would allow plants to run longer if they can convert coal to electricity more efficiently, without having to install new controls to curb fine particulate matter, or soot, as well as sulfur dioxide and nitrogen oxides,” Juliet explains. “Fine particulates are linked to heart and lung disease, while the other two pollutants can cause respiratory illnesses.”

AGENCY ALERT

— The Food and Drug Administration announced yesterday it will extend the expiration date of EpiPens amid a national shortage of the life-saving allergy medication.

For 0.3mg doses of EpiPen auto-inejctors with expiration dates that currently read between April and December 2018, extending the expiration date to between August 2018 and April 2019, according to a statement  from drugmaker Pfizer, which manufactures EpiPens for Mylan. The Pfizer statement also indicates in detail the current and updated expiration dates for the product.

“EpiPens typically have a shelf life of 20 months, according to the FDA, which said it's allowing the additional four months after reviewing stability data provided by Mylan,” CNBC’s Meg Tirrell reports. “The move comes as parents of children with allergies are finding EpiPens hard to come by in pharmacies as they stock up for back-to-school season.”

HHS Secretary Alex Azar addressed the announcement during an interview with FOX Business Network’s Varney & Co. When asked whether it is safe to use expired auto-injector pens, Azar referred to the FDA and said “I would like FDA to comment on that directly because I do not want to provide any type of direction to parents that the FDA has not done. And in fact one item that parents should look to FDA for is in terms of the regulatory action that we’re pursuing- the FDA has just announced as we’ve been on the air the extension of expiration dates for certain lots of EpiPen that will allow parents to continue to use EpiPens that might be shown on the label as being expired but for a longer period of time.”

— A new report released by the Veterans Affairs department watchdog found the agency did not follow proper procedures in handling hundreds of claims from veterans who sought support for sexual trauma suffered while on duty, the Wall Street Journal’s Ben Kesling reports. Of the 12,000 claims from veterans that were denied last year, the department made errors in processing 1,300, “fumbling a variety of procedures put in place to ensure victims of sexual trauma receive the benefit of the doubt by officials processing their claims,” Ben adds.

Within the IG report, top VA official Paul Lawrence said the department would look to make changes in training for claims processors, and would review trauma claims going back to late 2016. The department doesn't expect fixes to the claims process to be done until fall 2019. 

REPRODUCTIVE WARS
— Sen, Rand Paul (R-Ky.) has filed an amendment to the Department of Health and Human Services appropriations bill to defund Planned Parenthood or any group that offers abortions.
 
“One of the top priorities for a Republican Congress that professes pro-life values on the campaign trail should be to stop taxpayer funding for abortion providers. This is our chance to turn our words into action, stand up for the sanctity of life, and speak out for the most innocent among us that have no voice,” Paul said in a statement.
 
Senate leadership has agreed not to take up any “poison pills” that could derail the appropriations process, but Paul is pressing forward. He has a petition on his PAC’s website for people to sign to tell senators not to give tax dollars to abortion providers. The amendment is similar to one included in the House version of the bill.
 
Dawn Laguens, executive vice president of Planned Parenthood, in an emailed statement to The Health 202 said, “Once again, some Senators are putting politics and their anti-women’s-health agenda above the health of millions of women, men, and young people. Whether it’s attacking  access to preventive care at Planned Parenthood health centers or pushing a Supreme Court nominee who would decimate women’s constitutional rights, this proposal is a continuation of the stunning disregard for women’s health and rights that we’ve seen from congressional Republican leaders and the Trump-Pence administration. Americans will not stand for their elected representatives continuing to attack and devalue women.”
STATE SCAN

— The Trump administration has approved a federal waiver for Maryland to create its own reinsurance program. Under such a program, the state would cover the costs of high cost medical claims in order to stabilize the Affordable Care Act’s individual markets and keep premiums from rising.

“The plan imposes a one-year state tax on insurance companies and uses that revenue to subsidize the most expensive health insurance claims from policies sold through Maryland’s health exchange,” the Baltimore Sun’s Michael Dresser reports. “If lawmakers had done nothing, officials said, the individual market had the potential to collapse weeks before the Nov. 6 election.” Maryland is the sixth state to gain federal approval for such a program.

The Health 202 wrote last month about how reinsurance programs are the “unicorn of health care.”

MEDICAL MISSIVES

— An government medical panel now says women over 30 can now choose to opt out of a Pap smear, instead opting to get a test for human papillomavirus, or HPV.

The U.S. Preventive Services Task Force published new recommendations in the latest issue of the Journal of the American Medical Association, which now says that that while women under 30 should still get a Pap smear every three years, women older than 30 now have three options: Get an HPV test every five years, get a Pap smear test every three years, or do a combination of the two every five years.

NBC News’s Maggie Fox reports cervical cancer I still diagnosed in 13,000 women in the United States every year, killing more than 4,000 women a year, according to the American Cancer Society.

The task force’s recommendations note: “Most cases of cervical cancer occur among women who have not been adequately screened.”

“While the new guidelines may seem confusing, they are simpler than the last batch, said Dr. Kathleen Schmeler, a cervical cancer specialist at the University of Texas MD Anderson Cancer Center,” Maggie writes.

Correction: An earlier version inaccurately stated the report suggests the HPV test is the most effective way to assess the risk of cervical cancer. The U.S. Preventive Services Task Force suggests “regular screening for prevention of cervical cancer is highly effective, whether it is with cervical cytology alone, hrHPV testing alone, or both in combination.”

— And here are a few more good reads: 

Republicans are heading into a national election deeply divided and defensive over healthcare, the very issue that propelled them to majorities in the House and Senate.
Los Angeles Times
Many of the most popular news stories about health research include overstated findings or substantial inaccuracies, suggests a new study.
Journalists Resource
Medicare could have saved nearly $1 billion in 2016 if it used generic versions of pricey combination drug-device products instead of the brand name versions, according to a new study.
Washington Examiner
INDUSTRY RX
Dr. Maulik Majmudar has spent years toiling on getting physicians to incorporate novel technologies into their practices.
Stat
The Switch
Google’s trying to get you off the couch by simplifying the look of its “Fit” app to measure just two things: how much you move and how good that is for your heart.
Hayley Tsukayama
DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on “Science and Stewardship at the National Institutes of Health” on Thursday.
SUGAR RUSH
President Trump held a rally in West Virginia hours after his longtime lawyer Michael Cohen pleaded guilty and former campaign manager Paul Manafort was convicted

Trump denounces ‘social media censorship':