THE PROGNOSIS

China’s recent crackdown on fentanyl shows how easily President Trump wanders into controversy and misleading statements even when touting a success.

In a series of tweets yesterday, Trump hailed China’s announcement that it would regulate fentanyl as a “controlled substance” and start working with the United States to control the highly potent synthetic opioid, after he’d talked with Chinese President Xi Jinping over the weekend.

Trump, in his usual style, made some big, bold claims about how China’s policy shift would affect drug overdoses in the United States:

Let’s start with the basics. Trump didn’t quite get his figures right. There’s no denying fentanyl has been a prominent factor in the spike in opioid-relatded deaths; indeed, the substance and its synthetic cousins caused more than 28,000 overdose deaths last year, about 60 percent of all opioid overdose deaths.

But that’s still far fewer than the 77,000 figure Trump tweeted. It’s unclear exactly where the president got that number, considering that deaths from all drug overdoses — not just from opioids — totaled about 70,000.

Trump’s right about this one thing: China’s new intentions bode well for combating an increasingly urgent and troubling contributor to the American opioid epidemic. But the way he talked about the development prompted some pushback — and warnings by experts not to expect major improvements anytime soon.

The flow of fentanyl into the United States through the mail is driving the spike in opioid overdose deaths, as the drug is much more potent than heroin. Government officials believe China is the primary supplier of fentanyl found within the United States, according to a November report by the U.S.-China Economic and Security Review Commission, which partly blames China’s “weak regulations” governing pharmaceuticals.

Policymakers and lawmakers have taken notice. The Justice Department has gone after online dealers trying to peddle fentanyl to Americans, and in its opioids package this fall, Congress included a provision requiring the Postal Service to collect electronic information on merchandise arriving in the country so that customs inspectors can screen packages for the drug.

China also needs to do its part, so Beijing’s newly stated intention to punish its illegal fentanyl dealers to the maximum penalty under the law was well-received by many who follow the issue, my colleagues Katie Zezima and Lenny Bernstein reported.

Daniel Ciccarone, a professor at the University of California at San Francisco, told Katie and Lenny he is encouraged the United States and China managed to reach any agreement on the issue even as the two countries spar over other issues such as tariffs and trade.

“This is a very welcome announcement during this so-called trade war, that we can still focus on things that are meaningful in other ways,” Ciccarone said. “We don’t have to hold this hostage.”

Yet Trump — in his very Trumpian way — still managed to prompt some criticism in the way he talked about the negotiation with China. As he's done before, the president emphasized a need for harsh penalties on drug dealers, noting that China does allow capital punishment for drug trafficking and smuggling of controlled substances.

Trump’s “tough guy” stance stands in stark contrast to how many others in the health-care world — including his own Health and Human services secretary, Alex Azar — talk about the problem of drug overdose. Many experts say the key is better treatment for drug users versus stricter penalties on dealers.

“President Trump’s push for China to execute more of its citizens for drug offense is morally repugnant and ignores the decades-long failure of extremely harsh drug policies here in the U.S.,” Grant Smith, deputy director of national affairs for the Drug Policy Alliance, said in a statement yesterday.

“Fentanyl has indeed become the leading cause of overdose deaths in the U.S., but health-based measures are far more effective than criminalization,” Smith added.

And while experts say China’s announcement is a good sign, they warn it probably won’t have an immediate effect on overdose deaths. Academic and law enforcement authorities told Katie and Lenny that it’s unclear exactly how China plans to curb fentanyl.

“The primary complication for any effort in China, several experts said, is that chemicals for legal fentanyl are produced in hundreds, perhaps thousands, of legitimate pharmaceutical plants and imported to the United States by drug companies,” my colleagues explained. “Rooting out illegal clandestine labs is much easier than finding diversion by rogue operators in approved facilities.”

And then there are questions of how heavily China plans to crack down on its pharmaceutical sector which, as is true in the United States, provides significant jobs and revenue that help boost the country’s economy.

“I think it’s a very good thing,” said Vanda Felbab-Brown, an expert on illicit economies at the Brookings Institution. “However, I wouldn’t hold my breath on how big that impact will be.”

‘Addiction in America’ event U.S. Surgeon General Jerome Adams will be at The Washington Post to discuss the opioid crisis in America. He joins leading experts to discuss funding challenges, treatment programs and the latest strategies for combating the worst addiction epidemic the country has ever seen.The Washington Post: Dec. 7 from 9 – 10:30 a.m. Please email washpostlive@washpost.comto inquire about registration.

AHH, OOF and OUCH

AHH: Wisconsin's Republican-controlled legislature worked through Tuesday night into Wednesday morning to pass a bill to weaken the power of the incoming Democratic governor and attorney general that has implications for health care in the state.

It included "a plan to lock in place a work requirement for Medicaid and food stamps, which would force tens of thousands of indigent yet able-bodied and childless adults under the age of 50 to work to qualify for these public benefits,” our Post colleagues Isaac Stanley-Becker, Mark Berman and Katie report. Democratic Gov.-elect Tony Evers previously signaled he may  try to halt a federal waiver Wisconsin obtained from the federal government to implement work requirements, a policy health-care providers, insurers and hospitals opposed.

The legislature also passed a plan to strip the attorney general of authority to remove the state from a lawsuit seeking to overturn the Affordable Care Act. The Republican-passed bill would require a legislative committee to approve such a move. Outgoing Republican Gov. Scott Walker (R), who has telegraphed support for the legislation, has 10 days to sign the measure.

Democrats panned the move as a power grab. “Wisconsin has never seen anything like this,” Evers said in a statement. “Power-hungry politicians rushed through sweeping changes to our laws to expand their own power and override the will of the people of Wisconsin who asked for change on November 6th."

OOF: Minnesota could lose a whopping $100 million in federal dollars from its reinsurance program, meant to help stabilize the state’s insurance marketplace.  

The news came from state Sen. Tony Lourey, who said state officials received a letter from the federal government that the state’s reinsurance program would receive $99.1 million less in 2019 than it had initially expected, Minnesota Public Radio’s Briana Bierschbach reports.

“We, literally, lost about $100 million of federal support for the reinsurance program, and that needs to be understood as we work through this, and that it is not incorporated,” Lourey said during a state Senate hearing on Wednesday, Briana reports.

“This isn’t the first time the state has run into trouble with federal funding for reinsurance,” Briana writes. “In 2017, the federal government did not approve funding for another piece passed as part of the reinsurance deal, and the state is losing roughly $90 million each year as a result, Lourey said.”

OUCH: Critics of a new allocation policy for transplant livers say the rules will benefit transplant centers in big cities to the detriment of rural and low-income regions, our Post colleague Lenny Bernstein reports.

The organization that controls liver transplant distributions changed its controversial policy once again this year. Now it says liver transplants will follow a “sickest-first” model, sending organs recipients who could be hundreds of miles away if they have the greatest need, shifting from the a system with geographical boundaries that “largely given transplant centers first shot at livers collected from brain-dead donors in hospitals nearby,” Lenny writes.

“The United States faces a severe shortage of livers, kidneys, hearts, lungs and other organs for transplant,” he writes. “Nearly 115,000 people are on waiting lists for those organs, and at least 20 die waiting each day. In 2017, 13,583 people were on the list for livers but just 7,715 transplants were performed. Four or five people waiting for livers die each day.”

The transplant network board voted 30-to-7 on Monday to give priority to people within 500 nautical miles of a donor hospital who are in critical and emergent need of a liver, Lenny reports. “After that, it offers livers to the sickest patients within 150, 250 and 500 nautical miles, in that order. Severity of illness is based on a score calculated via blood tests that show how far the disease has progressed.”

Raymond J. Lynch, a liver transplant surgeon and assistant professor of surgery at Emory University School of Medicine in Atlanta explained to Lenny that “poor and rural residents have less access to care than people in large cities and therefore less chance of being diagnosed with liver disease and gaining a spot on the waiting list.”

INDUSTRY RX

— CVS Health announced it will offer a new prescription benefit to pass through all rebates and discounts from drugmakers to its health plan clients, the latest move from a pharmacy benefit manager (PBM) to increase transparency and deflect growing criticism of opaque practices.

The new plan could take the heat off of CVS amid criticism that PBMs profit off the difference between a drug’s list price, which is set by the manufacturer, and the net cost of the medication after rebates from drugmakers, which are doled out to gain preferential placement on the list of drugs covered by insurance companies.

“PBMs like CVS’ Caremark unit make a profit by using their scale to negotiate drug prices and by providing cost-management strategies to health plans,” Reuters’s Deena Beasley reports. “Under its new option, CVS takes on the risk of drug price inflation and shifts in drug use — at least for the term of each contract.”

The new plan from CVS also creates a model system for the PBM for a rebate-free world. “If rebates go away, this model accommodates that,” CVS Caremark president Derica Rice told Deena. “But as long as we get to the lowest net cost we are indifferent.”

The move follows one from rival PBM Express Scripts last month, as The Health 202 wrote about, which introduced a new drug formulary option that aimed to move away from the existing rebate structure.

STATE SCAN

— The Idaho Supreme Court has agreed to consider a suit that looks to reverse the expansion of the state’s Medicaid program approved by voters in a ballot initiative during last month’s midterm election.

The court is slated to hear arguments on Jan. 29 in the case brought by the Idaho Freedom Foundation, the Associated Press’s Robyn Nance reports.

“The lawsuit says the wording of the proposition cedes too much control to the federal government and the Idaho Department of Health and Welfare,” Robyn writes. “The expansion will cover those who earned too much to qualify for Medicaid, but didn't earn enough to be able to get subsidized health insurance coverage under the state health insurance exchange."

Voters in the state approved by a 61-to-39 margin expansion of such coverage to more than  an estimated 60,000 low-income residents. The state was one of the three red states that passed a Medicaid measure through voters during the election.

AGENCY ALERT

— There have been 81 migrant children separated from their families at the U.S. border with Mexico since June, when the Trump administration halted separations following scrutiny over its “zero tolerance” immigration crackdown.

“Despite the order and a federal judge’s later ruling, immigration officials are allowed to separate a child from a parent in certain cases — serious criminal charges against a parent, concerns over the health and welfare of a child or medical concerns,” the Associated Press’s Coleen Long reports. “Those caveats were in place before the zero-tolerance policy that prompted the earlier separations at the border.”

A spokeswoman for the Department of Homeland Security told the AP the latest data shows separations are “rare.” “While there was a brief increase during zero tolerance as more adults were prosecuted, the numbers have returned to their prior levels.”

“From June 21, the day after President Donald Trump’s order, through Tuesday, 76 adults were separated from the children, according to the data,” Coleen writes. “Of those, 51 were criminally prosecuted — 31 with criminal histories and 20 for other, unspecified reasons, according to the data. Nine were hospitalized, 10 had gang affiliations and four had extraditable warrants, according to the immigration data. Two were separated because of prior immigration violations and orders of removal, according to the data.”

By comparison, more than 2,400 children were separated from their families at peak levels over the summer.

— And here are a few more good reads:

MEDICAL MISSIVES
Local
The warden of the women’s prison in Maryland has been overhauling the menu in an effort to improve the health of inmates.
Meredith Cohn
Scientists who examined He Jiankui's slides from last week's Hong Kong summit say his embryo editing was plagued with massive technical shortcomings.
Stat
A cutting-edge program to help severely mentally ill people live on their own has endangered people who were not ready, a new investigation shows.
The New York Times
OPIOID OPTICS
Wonkblog
A new study will disappoint extremists on both sides of the debate.
Keith Humphreys
HEALTH ON THE HILL
Since releasing the results in October, the ancestry issue clouding her possible presidential campaign has only intensified.
The New York Times
TRUMP TEMPERATURE
Politics
After President Trump’s controversial reaction to the deadly violence, VA leaders had a tense exchange over how the agency should respond.
Lisa Rein
DAYBOOK

Coming Up

  • Brookings Institution holds a roundtable discussion on health care and data on Dec. 10. 
  • The House Energy and Commerce Subcommittee on Health is scheduled to hold a hearing on the 21st Century Cures Act on Dec. 11. 
  • The House Energy and Commerce Committee Subcommittee on Oversight and Investigations is scheduled to hold a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States" on Dec. 12.
  • The Heritage Foundation holds an event on "Defending the Rights and Wellbeing of Children Today" on Dec. 12.
SUGAR RUSH

— Memorable moments from George H.W. Bush's D.C. funeral