THE PROGNOSIS

Obamacare is precarious yet entrenched as 2019 approaches. Even many of the GOP-led states seeking to knock it down in court would be in a real bind should they succeed.

Of the 20 states involved in a high-profile Texas-led lawsuit arguing the Affordable Care Act is unconstitutional, nearly half have already accepted its extra dollars to expand their Medicaid programs or are moving that direction. States don’t have to expand Medicaid under a 2012 Supreme Court decision, but most have found it advantageous because the federal government foots most of the bill.

These states — nine in total — would suddenly be facing a much larger expense for hundreds of thousands of low-income earners newly enrolled in Medicaid under the ACA, should last week's decision by U.S. District Judge Reed O’Connor rolling back the entire health-care law ultimately stand.

They include Louisiana, North Dakota and West Virginia, along with Arizona, Arkansas and Indiana, three states that expanded Medicaid but with some modifications. In three other states — Maine, Nebraska and Utah — voters approved ballot initiatives adopting expansion.

Yet these states are asking the courts to overthrow not just Obamacare’s protections for people with preexisting conditions – the part of the lawsuit that has gotten the most attention — but also the entire sweeping law, which is now firmly a part of the country’s health-care ecosystem eight years since its passage. More than 12 million people have become eligible for Medicaid since ACA passage, while another 11 million have enrolled in the ACA’s federally subsidized private marketplaces.

“God help us all, because the dark age is not that far from us again,” said Sen. Joe Manchin (D-W.Va.). “It will be worse than before because there won’t be the money to help rural clinics and hospitals.”

Developments in the past week — including the court ruling and slightly lagging marketplace enrollment figures released yesterday by the Trump administration — underscore the political divides dogging Obamacare even though Republicans in Congress and at the state level have embraced some of its major components.

Nearly 8.5 million people signed up for 2019 plans in the 39 states using the HealthCare.gov website (the other states run their own marketplaces), per figures from the Centers for Medicare and Medicaid Services. Enrollment was just 4 percent less than a year ago, due to a last-minute rush that suggests consumers were undeterred by the court ruling, our Washington Post colleague Amy Goldstein reports.

“After lagging by about 11 percent most of the six weeks of open enrollment — a shortened period adopted by the Trump administration a year ago — the more than 400,000 who selected coverage during the final week actually exceeded the year before,” Amy writes.

CMS Administrator Seema Verma seemed unperturbed by the reduced enrollment numbers, saying they merely show new GOP and administration policies to roll back some ACA requirements on insurers and consumers are working.

But if the entire law gets scrapped by the Supreme Court ( we should note, the case still has a long way to go in the legal system), it will quickly become clear the ACA — for whatever its faults — has extended benefits to Americans they’ve now come to expect. Despite their persistent rhetoric against the law, Republicans have found it politically necessary to embrace big parts of it, including its protections for people with preexisting conditions — and, in some states, its Medicaid expansion.

Case in point: West Virginia. Its Republican attorney general, Patrick Morrisey, has joined the lawsuit against Obamacare even though the state embraced its Medicaid expansion, growing its enrollment in the program by nearly one-third. The federal government covers more than 90 percent of the cost of the newly eligible enrollees.

When I asked Morrisey’s office about what striking the ACA would mean for Medicaid recipients, his office provided a statement praising O’Connor’s ruling and discussing premium hikes in the marketplaces — but didn’t mention Medicaid.

“Our nation must move beyond Obamacare, innovate, provide more choices to consumers, and attack the skyrocketing premiums that have caused such pain and hardship on West Virginian and American families,” the statement said.

In some cases, the decisions by state attorneys general to join the anti-ACA lawsuit has put them at odds with their governor. Louisiana’s Democratic governor, John Bel Edwards, moved quickly to expand Medicaid when he took office in 2016. Nearly half a million people have enrolled in Medicaid since then, growing the state’s program by 27 percent.

Edwards hasn’t hidden his disdain for Louisiana Attorney General Jeff Landry (R), who has called the law an “unconstitutional overreach.” Edwards issued a critical statement after last Friday’s decision.

“This was a short-sighted lawsuit, to say the least,” Edwards said in a statement. “I intend to vigorously pursue legislation to protect individuals with pre-existing conditions from losing their health insurance and ensuring the working people of our state aren't penalized because of this decision.”

PROGRAMMING NOTE: Starting tomorrow, The Health 202 is taking a break for the holidays. We hope you have a wonderful and relaxing holiday season, and we'll see you back here on Jan. 7.

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AHH, OOF and OUCH

AHH: Republicans blocked a resolution offered yesterday by Senate Democrats to authorize the Senate legal counsel to defend the ACA in the Texas-led lawsuit. Democrats, noting the Trump administration is refusing to defend the health-care law, insisted that if their GOP counterparts really wanted to protect people with preexisting conditions (as they promised during the midterm elections) they'd agree to intervene.

"Let’s put in place the promises you all made," said Sen. Patty Murray (D-Wash.).

Sen. John Barrasso (R-Wyo.) blocked a vote on the measure by objecting to Democrats' unanimous consent motion. “Regardless of what happens in this legal process, we look to protect people with pre-existing conditions," Barrasso said.

Senate Democrats also wrote to President Trump, asking him to condemn O'Connor's ruling and order the Justice Department to start defending the ACA, which remains the law of the land. "We urge you and the DOJ to immediately request a stay of this order and to uphold the rule of law by defending the constitutionality of current law," they wrote. "Millions of Americans are relying on you."

OOF: The Trump administration has released a plan aimed at accomplishing what Congress couldn’t in the recently passed farm bill: Requiring hundreds of thousands more Americans to work if they want to keep receiving food stamps.

While the U.S. Department of Agriculture currently requires most adults without dependents to work to receive food stamps for more than three months in a three-year period, states can waive that requirement in areas with at least 20 percent greater unemployment rates than the national level. But now, the USDA is “proposing that states could waive the requirement only in areas where unemployment is above 7 percent,” our Post colleagues Danielle Paquette and Jeff Stein report. “The current national unemployment rate stands at 3.7 percent.”

That means roughly 755,000 live in areas that could lose the waivers.

“The announcement comes hours before President Trump is expected to sign an approximately $870 billion farm bill with funding for the nation’s agricultural programs and for food stamps,” Danielle and Jeff write. “That legislation does not impose any tougher work requirements, even though the House version of the bill had restricted the waiver program and also imposed new requirements on parents with children ages 6 to 12, among other changes. The Senate version did not include those provisions.”

Agriculture Secretary Sonny Perdue told reporters on a call the proposed changes “restores the dignity of work to a sizable segment of our population.” The public will have 60 days to comment on the changes once they are published in the Federal Register.

OUCH: The surge of opioid overdoses among African Americans in the District of Columbia was largely ignored by city officials who misspent federal grant dollars and failed to implement lifesaving strategies in place elsewhere, our Post colleague Peter Jamison reports in the second part of his investigation. (Read the first part of his in-depth report on the opioid crisis in the District here.)

“In a city where growing prosperity conceals profound divides of race and class, the damage done by heroin and fentanyl has fallen squarely on African Americans,” Peter describes. “Of the 860 people known to have died of opioid overdoses since 2014, 4 in 5 were black, according to the chief medical examiner."

But these deaths have largely gone unnoticed by the district’s residents and have seen a subpar response from city officials that medical professionals say "would never have been tolerated in whiter and more affluent neighborhoods,” Peter writes.

Even as more people died from opioid overdoses than homicides in Washington last year, officials distributed the overdose antidote naloxone at a lower rate than cities facing similar problems. “As fatal overdoses peaked last year, Baltimore handed out more than four times as many naloxone kits per capita as the District; and Philadelphia, more than three times as many, according to city data,” Peter writes.  "Officials at the nonprofit groups that collaborated with the District on its naloxone campaign called it 'woefully inadequate' and 'disastrous.' "

Last year, the District began receiving what will eventually total $4 million in grants from the U.S. Substance Abuse and Mental Health Services Administration. But many promised programs never launched. “Officials at the clinic contracted by the District with most of its federal funds said not a single patient has been referred to them for addiction treatment,” Peter writes.

HEALTH ON THE HILL

— The bipartisan criminal justice bill that easily passed the Senate and is expected to pass the House and head to the president’s desk is representative of a major GOP shift has made from its
"war-on-drugs" stance to supporting policies aimed at reducing some prison sentences.

That pivot “comes as crime rates have dropped, the opioid crisis has ravaged the country and prison populations, after reaching record highs, are now on the decline,” our Post colleagues Katie Zezima and Sean Sullivan report. “Many Republicans are also embracing the legalization or decriminalization of marijuana, which is legal in 10 states and the District.”

Republicans' embrace of new policies is in part a way to redeem an era of anti-drug policies by restoring fairness to the criminal justice system, Katie and Sean write. Some Republicans have also embraced treating drug addiction as part of a public health effort, rather than a law-and-order one. But the policy shift has a financial motive, too: Supporters hope to save money by moving low-level offenders out of the prison system.

Sen. Rob Portman (R-Ohio) insisted the pivot doesn’t mean the party’s values have changed. “I think Republicans are still law and order — but the question is, you know, with crack cocaine and powder cocaine in particular, how do you level the degree of consequence? And I think that’s the common-sense thing. And on other drugs, the idea is to get people into treatment and not lock them up,” he said.

— Sen. Ron Wyden (D-Ore.), the top Democrat on the Senate Finance Committee, is calling on Pfizer to explain the steep increase of the price of its nerve pain drug, Lyrica. Stat’s Nicholas Florko reports it could be a signal of Wyden will up his actions to hold drug companies to account.

“The cost of Pfizer’s drug, Lyrica, has grown tremendously over the past several years,” Wyden wrote in a letter sent to Pfizer. “In 2016 alone, over 850,000 Medicare beneficiaries were prescribed Lyrica resulting in $2.1 billion Medicare spending. The main cause of this increase has been Pfizer’s consistent and egregious price increases.”

A bottle of 90 of the pills now sets one back more than $650 before rebates and discounts, compared with $150 in 2005, Nicholas reports, citing Elsevier’s Gold Standard Drug Database.

Wyden’s letter also asks Pfizer about the decision to announce several price increases and about whether it plans to hike the price of Lyrica further. He also asks for marketing and revenue information for Lyrica.

STATE SCAN

— In California, where recreational marijuana has been legal since January, the problem that seemingly went unanticipated is the stench that radiates from all the new cannabis plants.

Here’s how one resident described it to the New York Times’s Thomas Fuller: “If someone is saying, ‘Is it really that bad?’ I’ll go find a bunch of skunks and every evening I’ll put them outside your window.”

The booming business and billowing smell has now led to residents in Sonoma County filing suit to ban cannabis operations in their neighborhoods, Thomas writes. And in Mendocino County, there are now zones banning cultivation. Growers in Santa Barbara Country are spending top dollar installing odor-control systems.

“The ballot measure legalizing recreational marijuana passed in 2016 with a comfortable majority of 57 percent. Many of those complaining about cannabis odors say they were among those who supported it. They just don’t want it stinking up their property,” Thomas writes. “Cannabis executives recognize that pot grows can be odorous, but say their industry is no different from others that produce smells.”

INDUSTRY RX

— Nearly 30 pharmaceutical companies are set to raise the U.S. prices of their drugs in January, after a pause in price hikes were announced under pressure from the Trump administration, Reuters’s Michael Erman and Robin Respaut report.

Novartis, Bayer, Allergan, GlaxoSmithKline, Amgen, AstraZeneca, and Biogen are among the drugmakers set to hike their prices at the start of the new year.

“Twenty-eight drugmakers filed notifications with California agencies in early November disclosing that they planned to raise prices in 60 days or longer,” Michael and Robin write. “Under a state law passed last year, companies are required to notify payers in California if they intend to raise the U.S. list price on any drug by more than 16 percent over a two-year period.”

The increases are a wrinkle for an administration that has vowed to tackle high prescription drug costs. “Lowering prescription drug prices was a top priority in Republican Trump’s 2016 presidential campaign,” they add. “Rival Democrats are expected to step up congressional scrutiny of drug price hikes next year after gaining control of the U.S. House of Representatives in elections in November.”

— Altria Group, the make of Marlboro cigarettes, is nearing a deal to buy 35 percent of e-cigarette start-up Juul Labs, at about $38 billion, the Wall Street Journal’s Dana Mattioli, Jennifer Maloney and Dana Cimilluca report. Such a deal would make the start-up one of the most valuable private companies.

“At $38 billion, three-year-old Juul would be worth more than several well-known Silicon Valley startups, including Airbnb, the home-sharing service; Elon Musk’s space venture SpaceX; and three times as much as Pinterest,” they write.

The news also comes at a time when e-cigarettes have come under fire due to the surge in youth vaping. “Juul says its products are designed to help adult cigarette smokers switch to a less-harmful way to inhale nicotine, but the company’s own research shows its sleek device has hooked many people who had never smoked or had quit smoking,” Dana, Dana and Jennifer write.

Earlier this year, an annual survey from the Food and Drug Administration and the Centers for Disease Control and Prevention found vaping among high school students had increased 78 percent compared with last year, and 48 percent among middle schoolers.

That rise has alarmed federal regulators, who have put more pressure on Juul. In turn, the company has taken its own steps to reduce sales to minors. The company pulled all its flavored products, except for menthol, mint and tobacco, from retail stores.

TRUMP TEMPERATURE

— A coalition of 10 antiabortion groups has sent a letter to Trump calling for his administration to end federally funded fetal tissue research. The letter comes as the administration conducts a wide-ranging review of the use of tissue and cells from aborted fetuses in medical research.

Susan B. Anthony List, March for Life, Americans United for Life, the Family Research Council and other groups applauded Health and Human Services Secretary Alex Azar for “initiating the audit and for announcing new grants to pursue ethical alternatives to aborted fetal tissue research.”

“During your first two years in office your administration has been dedicated to, and widely successful in, making policy to protect vulnerable unborn children and women,” the letter says. “No doubt these policies have already saved babies and their mothers in the U.S. and abroad from the pain of abortion … Pro-life voters across America reject the use of their tax dollars to purchase the body parts of children and expect a comprehensive pro-life policy change at the end of this process.”

The Health 202 wrote last week about a contentious hearing before two subpanels of the House Oversight and Government Reform Committee, as Republican lawmakers questioned experts -- including two associated with the Charlotte Lozier Institute, the research arm of Susan B. Anthony List -- on potential alternatives to fetal tissue in research.

— And here are a few more good reads from The Post and beyond: 

AGENCY ALERT
Local
A challenge to the validity of Whitaker’s appointment as acting attorney general was made by Maryland officials.
Ann E. Marimow
National Security
But lawmakers offered few solutions for the surge of families overwhelming U.S. agents.
Nick Miroff
National Security
Amid fallout from the girl’s death, U.S. Customs and Border Protection issues a new prompt-notification policy to inform Congress and the public of similar incidents. 
Robert Moore and Nick Miroff
MEDICAL MISSIVES
Business
Drug companies are trying to limit public disclosures after Post story on alleged `cartel’
Christopher Rowland
National Security
Two members of the Air Force filed suit, saying the Pentagon violated the Constitution by ending their military careers owing to their HIV-positive status.
Paul Sonne
A judge in Missouri upheld the verdict, one of the largest personal injury awards on record, in which women said their ovarian cancer was linked to the company’s baby powder.
The New York Times
As the number of people who inject drugs has soared, the rate of hepatitis C infection has climbed steeply, too, because the disease can be tied to sharing needles. Yet many drug patients are not c…
Kaiser Health News
Health insurer Cigna and pharmacy benefit manager Express Scripts cleared federal and state regulatory hurdles less than a year after they first announced their plan to merge in March.
Modern Healthcare
Outbreak logisticians supply response teams, find them beds to fall into at the end of exhausting days, and food to sustain them.
Stat
The average weight for men and women, of all ages and races, is going up.
Axios
DAYBOOK

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