THE PROGNOSIS

House Democrats came into power by proclaiming they will prevent the GOP from gutting the Affordable Care Act -- and its popular protections for people with preexisting conditions. Many winning Democratic candidates campaigned on the idea of a more sweeping approach to health care coverage by touting a Medicare-for-all system.

But now that they're in the House majority, Democrats have a choice to make: Will they make good on their idealistic campaign trail promises or scale back their goals, given the unlikelihood they will be fully achieved with a GOP-controlled Senate and President Trump in the White House?

So far, they appear to be taking the idealist route when it comes to health care on everything from more coverage to tackling exorbitant prescription drug prices. They're introducing bills with no realistic chance of support from most Republicans. And yesterday they opted for politics over practicality, trying to zing Republicans over an anti-Obamacare lawsuit instead of passing measures that could actually halt it.

Consider this. House Budget Committee Chairman John Yarmuth (D-Ky.), who is preparing to hold hearings on Democratic-led health proposals popularly referred to as Medicare-for-all, asked the Congressional Budget Office this week to examine single-payer systems in which the federal government is the primary payer of health insurance.

But that kind of effort wouldn’t get far in the Senate. Republican lawmakers aren’t even on board with more moderate proposals to provide Americans with a single government plan known as a "public option" alongside private insurance offerings (although such an idea is relatively popular with voters).

Yarmuth is planning to examine a large-scale Medicare-for-all bill from Rep. Pramila Jayapal (D-Wash.), one that is similar to the sweeping measure long touted by Sen. Bernie Sanders (I-Vt.).

But it’s unclear whether Yarmuth will also draw from a range of Medicare-for-all plans proposed by more centrist Democrats, including ideas to include a Medicare option in the individual insurance marketplaces or allow people to join the program as early as age 55. Health policy experts say those types of bills stand a far greater chance of gaining traction.

Today, Sanders and Rep. Elijah Cummings (D-Md.) will propose a bucket of policies they say would reduce prescription drug prices in the United States by 50 percent. Two bills would peg the price of U.S. drugs to the median price in five major countries and allow the federal government to directly negotiate lower prices for Medicare Part D drugs — also nonstarters with Republicans. A third bill allowing drug importation from Canada and other major countries may face brighter prospects.

House Democrats know these next two years represent a chance to explore legislation they would enact should they find themselves in control of the White House in 2020. But they're also using their new governing power to define where the party should be on health care in a political sense, as many 2020 candidates will have to decide whether to adopt these ideas.

Democrats need to avoid the trap Republicans fell into when they controlled the House, appeasing their base with repeated votes to repeal Obamacare. But the GOP never did the hard work of crafting politically feasible legislation to replace it -- and their efforts to repeal and replace the ACA when they had the chance failed spectacularly.

“It’s time to incubate new ideas, have those internal debates about the right course of action and do so in a way that allows Democrats to move with relative dispatch if they were to win the White House in the next election,” University of Michigan law professor Nick Bagley told me.

But yesterday, political messaging was clearly Democrats' top priority. House Democrats could have advanced a bill yesterday to end a hot-button lawsuit attacking the ACA. Instead, they went with a political-messaging effort intended to make GOP lawmakers squirm.

The bill, passed 235 to 192 with nearly all Republicans opposing it, authorized the House general counsel to intervene in a controversial lawsuit against the ACA brought by Texas and other GOP-led states, which could result in the entire ACA being eliminated if a Texas judge's decision is ultimately upheld in higher courts. Democrats leveraged the bill to cast themselves as the protectors of Americans with serious health concerns while pushing Republicans into a tight political corner (only three of them backed the measure).

“In forcing the vote, House Speaker Nancy Pelosi (D-Calif.), who was crucial in ensuring passage of the 2010 law, now has Republicans on record on the lawsuit, and those votes could be used in campaign ads next year,” my Washington Post colleague Mike DeBonis writes.

Rep. Pramila Jayapal (D-Wash.): 

Rep. Raúl M. Grijalva (D-Ariz.):

Practically speaking, the measure is unnecessary. Democratic attorneys general around the country, led by California Attorney General Xavier Becerra, are already vigorously defending the ACA against the Republican attacks. And some legal experts have contended the House lacks standing to intervene in the lawsuit at all.

There are three ways Congress could act to end the ACA lawsuit, as Bagley and his colleague Richard Primus explain in this Atlantic article. Essentially, Pelosi could have instead chosen to advance bills that would effectively topple the argument being used against Obamacare.

This is the Republican-led states' argument: The Supreme Court only ruled the ACA constitutional in 2012 by calling its penalty for lacking insurance a “tax.” But because Congress has since repealed the penalty, the basis for the law’s constitutionality is gone, Republicans argue, and therefore the entire law should now be struck down.

But if the House wanted to, it could pass legislation effectively reinstating the tax by raising the penalty from zero dollars to one dollar. Or it could pass bills making clear Congress intended for the rest of the ACA to stand with or without the mandate to buy coverage (this was another big question in the 2012 case). Those actions would take the legs out of the lawsuit, which contends Obamacare can't exist without the individual mandate.

“If congressional intent is the key to [the Texas lawsuit's] decision, Congress can intervene,” Bagley and Primus write. “And the best way for it to do so is not to enter the litigation, as [Pelosi] has said she’ll do. It’s to legislate. Congress could fix the problem by saving, severing, or sinking the mandate.”

AHH, OOF and OUCH

AHH: Our Post colleagues Tracy Jan and William Wan have more detail on the impact to the social safety net of the partial government shutdown. Cabinet heads say they're working to ensure benefits continue through February.

Along with the food stamp program, which the Agriculture Department announced would continue to be funded through February, Secretary Sonny Perdue said that other programs -- including school meals and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) -- would also be funded through next month. WIC provides food, baby formula and breast-feeding support to more than 7 million mothers and children under 5 years old, our colleagues write.

But like the food stamp program, those benefits may not continue if the shutdown drags into March or beyond. “Beginning in March, families could see an average cut of at least $90, or close to 40 percent, assuming the agency spreads the $1.8 billion shortfall evenly across the 19 million households receiving SNAP benefits, according to an analysis by the Center on Budget and Policy Priorities,” our colleagues write. “When the SNAP contingency money runs out in April, the food assistance program will probably be closed altogether, anti-poverty advocates said.”

OOF: The shutdown is also putting the nation’s food safety at risk, as the furloughing of hundreds of employees at the Food and Drug Administration means food inspections have been sharply reduced.

The FDA has suspended all routine inspections of domestic food-processing facilities, our Post colleagues Laurie McGinley and Joel Achenbach report, noting the agency oversees 80 percent of the food supply. The FDA is continuing to conduct inspections of foreign manufacturers, imports and domestic producers involved in recalls or outbreaks.

“We are doing what we can to mitigate any risk to consumers through the shutdown,” FDA Commissioner Scott Gottlieb told our colleagues, adding he is working to get inspectors back as soon as next week to work on inspections for high-risk facilities.

“The FDA, for example, typically conducts about 160 routine food inspections a week in the United States, with about a third involving high-risk processing facilities,” Laurie and Joel report, adding Gottlieb said “legal guidance from the 2013 shutdown said the agency couldn’t do regular food inspections during a funding shortfall. But after canceling more than 50 high-risk inspections, he said he has obtained new guidance that he believes will allow him to call back about 150 furloughed inspectors to focus on high-risk facilities."

OUCH: There are thousands of researchers among the 800,000 furloughed federal employees whose work has been brought to a halt by the shutdown.

Scientists at various federal departments are prohibited from doing any work — “they cannot so much as open an email,” our Post colleagues Ben Guarino, Carolyn Y. Johnson, Sarah Kaplan and Lenny Bernstein report.

Sen. Richard J. Durbin (D-Ill.) decried how the shutdown “impacts the lab’s employees who are not able to work and are not getting paid.” He said research “including preliminary testing building on a recent discovery at the lab that amplifies the effectiveness of antibiotics has been put on hold.”

“At the White House Office of National Drug Control Policy, which coordinates drug policy across the government, only three people are still working out of a staff of about 80,” our colleagues write. “The office is largely responsible for developing drug policy and strategy, and it administers two grant programs. One sends money to state and local law enforcement agencies in ‘high-intensity drug-trafficking areas.’ The other helps support community groups working to curb youth substance abuse." One of the three people still working at the office is the agency’s director, James Caroll, who was confirmed by the Senate last week.

HEALTH ON THE HILL

— Dozens of Democratic lawmakers sent a letter to party leaders calling on them to make the opioid crisis a key agenda item in the new Congress.

“As our Congress enters a transitional period and Democrats re-gain the Majority, we must make our top priorities known to our body of government and to the American people,” the group of Democrats, led by Rep. Marcy Kaptur (D-Ohio), wrote in the letter. “At a time when our state and local partners are begging for federal assistance to combat the opioid crisis in their communities, Congress must answer the call through increased resources, creative solutions, and with more legislative staff.”

The letter was sent to Pelosi and House Majority Leader Steny Hoyer (D-Md.).

It called for dedicated committee staff members who could examine broad federal needs to address the crisis as well as state and district-specific needs.

AGENCY ALERT

— Following a reported meeting at the White House of top officials, which the president convened to discuss rising drug costs, Health and Human Services Secretary Alex Azar wrote on Twitter that “prices must start coming down.”

The former Eli Lilly executive called out drugmakers who began the year announcing drug price hikes, and also blasted pharmacy benefit managers — a frequent target of the administration’s ire — who could benefit from rising costs. In a Fox Business Network interview on Wednesday, Azar also said he and the president “were meeting about our plans to bring down drug prices, and I want to be really clear to PhRMA companies out there and to the pharmacy benefit managers, the president and I will not stop until list prices of drugs come down.”

“This behavior has to stop,” he added, signaling there will be “more regulatory and legislative proposals” and bipartisan efforts to bring down prices.

He also praised by name drugmakers who had lowered prices: 

— Doctors, drug companies and the nation’s top drug regulator are expressing concern that drugmakers who make the most advanced, costly, name-brand biologic drug therapies are spreading doubt about switching to generic versions of their medicines as a way to protect their profits. Those scare tactics come as even the FDA has said those unbranded versions are safe and effective, our Post colleague Christopher Rowland reports.

“The campaign against those cheaper versions, known as biosimilars, could delay affordable access to a host of novel therapies, hurting patients and driving up health-care costs,” Christopher writes.

In an interview, FDA Commissioner Gottlieb said he was “worried that there are either deliberate or unintentional efforts by branded companies to create confusion” about the safety and effectiveness of unbranded versions of drugs, adding that kind of message “can potentially undermine consumer confidence in biosimilars in ways that are untrue.’’

Christopher describes some of the warnings from some makers of costly and advanced drugs, that unbranded versions could “put you in the emergency room” or could carry “additional risks.” “The FDA approves the unbranded biologic copies by analyzing their structure and reviewing data from limited human tests. Drugs that make it through this process, according to the FDA, contain ‘no clinically meaningful differences in safety, purity, and potency,’” he writes.

He adds: “Gottlieb indicated the FDA may take action if it determines a company is deliberately misleading the public about the safety of biologic copies, by issuing warning letters to the drugmakers involved.”

— The Center on Budget and Policy Priorities released a report this morning warning that Medicaid work requirements will have an inadvertent consequence of people being dropped from coverage who are in fact working or who should otherwise be exempt from the requirement.

The report, written by senior fellow Judith Solomon, warns there’s no way to “fix” work requirements in a way that would ensure this doesn't happen. 

Among the reasons for this, Solomon says are problems with paperwork and red tape that lead to eligible people losing coverage. She also writes the requirements are “ineffective in promoting employment because they don’t accurately identify those who can work but aren’t working … nor do they assess their needs or provide them with supports."

She argues the requirements ignore that Medicaid coverage itself makes it possible for low-income people to maintain employment. 

— And here are a few more good reads: 

House Ways and Means Committee Chairman Richard Neal (D-Mass.) announced late Wednesday the names of 10 Democratic lawmakers who have been appointed to the powerful panel, which has jurisdiction over tax, trade and health care issues.
The Hill
The move comes amid a campaign to place progressive freshmen on key panels.
Politico
Maryland Politics
Two people familiar with the veteran politician’s health said he is being treated for prostrate cancer.
Ovetta Wiggins and Rachel Chason
INDUSTRY RX
The Justice Department has said in a court filing that a partial government shut...
Reuters
The offer was, ultimately, rebuffed.
The Daily Beast
MEDICAL MISSIVES
"This outbreak appears to be over," the US Centers for Disease Control and Prevention said Wednesday of the E. coli outbreak linked to romaine lettuce from some regions of Northern and Central California.
CNN
The Chinese scientist who announced in November that twin girls had been born from gene-edited embryos says he is "actually doing quite well."
Stat
Sports
Adrianne Haslet underwent eight hours of surgery to repair her "shattered" left side and is now beginning to start rehab all over again.
Cindy Boren
The U.S. birth rate has been declining for years, but some places are more fertile than others, according to federal data. In 2017, only South Dakota and Utah reached the level needed to sustain the current population.
Wall Street Journal
TRUMP TEMPERATURE
National
Many farmers, among Trump’s loyal base in rural America, can’t make ends meet and are considering abandoning their crops.
Annie Gowen, Jeff Stein and Sean Sullivan
DAYBOOK

Today

  • The 37th annual J.P. Morgan Healthcare Conference continues in San Francisco.

Coming Up

  • A joint meeting of the FDA’s Arthritis Advisory Committee and the Drug Safety and Risk Management Advisory Committee is scheduled for Friday.
  • Brookings India and Tufts University hold a roundtable on ‘Opportunities for India Beyond 2019: The Future of Health and Geopolitics’ on Jan. 15.
  • Politico hosts an event on health care innovators on Jan. 16.
SUGAR RUSH

Pelosi calls Trump 'insensitive' to shutdown's impact

For federal employee Nicole Bryner, the partial government shutdown has left her without a paycheck, and paying for child care she can’t use: