THE PROGNOSIS

The Trump administration wants to slash Medicaid spending through block grants — a strategy conservatives in Congress have repeatedly tried to implement without success. Here’s the tricky part: It would have to persuade states to accept fewer federal dollars than they’re getting now.

A small group of people within the Centers for Medicare and Medicaid Services is working on a plan to allow states to ask permission for their federal Medicaid dollars to be provided in a single lump sum instead of the way they are currently awarded as a percentage of states’ total costs. If they succeed, it could check off a top Republican priority of lowering spending on the health insurance program for low-income Americans, a dream goal they have frequently sought.

The agency hasn’t confirmed the effort, which was first reported by Politico, but some Medicaid policy experts told me officials have coalesced around the concept and are trying to finalize plans on how to present it. A likely vehicle could be through guidance similar to the expansive new ways CMS has invited states to experiment with their Obamacare marketplaces (we wrote about that here).

It also could be one in a string of regulatory actions on health care undertaken by the Trump administration after its top priority to repeal and replace the Affordable Care Act failed in Congress.

CMS leaders aren't seeking help from many departments within the agency that would normally weigh in on such an extensive change, Andrey Ostrovsky, CMS's former chief medical officer over Medicaid, told me, saying two employees have described the effort to him as “incredibly close to the chest.”

It’s not hard to figure out why CMS Administrator Seema Verma isn’t touting this effort at the moment. Republicans learned the hard way through their 2017 efforts to repeal and replace the ACA that suggesting big reductions to Medicaid spending isn’t a winning political strategy.

One version of a repeal bill offered by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) would have converted Medicaid to a block grant program. The health-care bills advanced in the House and the Senate would have also reduced future Medicaid spending by capping funding for states per enrollee. All of the measures polled badly at the time, and the Medicaid cuts gave Democrats a potent narrative that Republicans were trying to scale back benefits for the most vulnerable Americans.

Democrats similarly jumped on initial reports that CMS was looking into Medicaid block grants. Sen. Bob Casey (D-Pa.):

Rep. Don Beyer (D-Va.):

Rep. G.K. Butterfield (D-N.C.):

Health-care providers, particularly those who serve the low-income, aren’t excited about the idea of block grants, either. Medicaid already reimburses them at significantly lower rates than Medicare or private insurers, and block-granting the program could prompt states to cut Medicaid enrollment or lower payments even further.

“Congress could not pass Medicaid block grant legislation because it would have put too many of the most vulnerable at risk, so it seems misplaced to consider establishing waivers to block grant Medicaid by fiat," said Chip Kahn, president of the Federation of American Hospitals.

Rick Pollack, president of the American Hospital Association, said his group questions whether CMS has the legal authority to allocate Medicaid dollars through block grants. “We have long voiced concerns about how block granting Medicaid could ultimately result in losses of coverage and negatively impact access to quality care,” Pollack said in a statement.

Yet the agency does have broad latitude to permit states to experiment with their Medicaid programs and the marketplaces by applying for waivers. Verma is vigorously deploying that latitude by approving work requirements in multiple states and inviting states to seek ways of sidestepping certain ACA coverage mandates.

Some of those waivers are being challenged in court, but it’s not clear the agency would be stepping beyond its legal boundaries by allowing states to request their Medicaid dollars in block grant form. But here’s a key question: Would they sign up for a system that could result in fewer federal dollars in their pockets?

“What are they offering that would entice a state to enter into this bargain — that’s question number one,” said Matt Salo, executive director of the National Association of Medicaid Directors.

Verma often speaks of “flexibility” for states to run their own Medicaid programs and marketplaces as they wish. Salo pointed to several waiver requests made by states that Verma could grant if she wanted to show she’s serious about giving them flexibility.

Several states, including Arkansas and Massachusetts, have asked for permission to expand Medicaid to people earning just 100 percent of the federal poverty level, rather than 138 percent of it as provided in the ACA. Massachusetts has asked — and been denied — permission to choose which drugs Medicaid covers.

Ostrovsky noted something else: Getting the maximum amount of federal funds isn’t the foremost priority for some states, such as the conservative ones that rejected the ACA’s offer of Medicaid expansion. For some GOP governors and state lawmakers, it might be more politically advantageous to be able to tout to voters that they pulled back on the program.

“Money is not the primary motivator for several states,” he said. “Some political leaders don’t think certain populations — like the adult, generally healthy poor population — deserves Medicaid.”

AHH, OOF and OUCH

AHH: The 800,000 federal employees who remain furloughed amid the partial government shutdown were warned they will have to pay their own dental and vision premiums starting this week to prevent coverage loss.

“The workers are not at risk of losing their health insurance benefits, which will stay in effect through the duration of the shutdown — and for as long as a year — even if they are not receiving a paycheck, with their accumulated premiums deducted from their pay once their agency reopens,” our Post colleagues Lisa Rein and Eric Yoder report. “However, that protection does not extend to vision and dental insurance.”

Starting with workers’ second missed paycheck, which will occur on Friday, federal employees will be directly billed for premiums for dental and vision insurance. If the shutdown drags into a third missed paycheck, those who signed up for long-term care insurance will also be billed directly for the premiums. 

In a letter to the Office of Personnel Management, Sens. Mark Warner (D-Va.), Tim Kaine (D-Va.), Ben Cardin (D-Md.) and Chris Van Hollen (D-Md.) called on the agency to work to prevent federal employees' dental and vision coverage from being halted if they don't pay their premiums.

“Your guidance to employees has been insufficient and fails to account for the significant financial strain already placed on these employees and their families,” the letter reads. “If the status quo persists, you are undoubtedly risking the health and wellness of federal workers, their spouses, and children enrolled in federal vision and dental plans. We have already heard from individuals who are worried about what this will mean for them and their health care needs.” 

OOF: At least a dozen U.S. residents who traveled to Mexico for surgery returned with a rare and potentially deadly strain of bacteria that’s resistant to nearly all antibiotics.

One woman, 40-year-old Tamika Capone from Arkansas, went to Mexico for bariatric surgery. Her physician recommended the surgery to help her control her weight and blood pressure, but because her husband’s health insurance wouldn’t cover the $17,500 cost, Capone opted for a $4,000 procedure her friend got in Tijuana, our Post colleague Lena H. Sun reports.

Months later, Capone is still “seriously ill despite being treated with a barrage of drugs,” Lena writes. An infectious disease doctor at the University of Arkansas for Medical Sciences in Little Rock said he’s “not yet had a patient with zero options, but this is as close as I’ve had.”

The outbreak drove the Centers for Disease Control and Prevention to issue a rare warning earlier this month, “urging travelers to avoid surgery at Grand View Hospital, linked to eight of the infections, until Mexican authorities confirm its safety,” Lena writes. “Mexican authorities said they temporarily closed the hospital’s operating unit in December, but the facility has since reopened and resumed surgeries, according to patients posting on its website.” The cases also represent a growing number of Americans who seek medical care abroad, only to acquire antibiotic-resistant infections.

Tell us: If you or someone you know has recently had a similar experience with an antibiotic-resistant infection and you want to share your story, scroll to the submission form at the bottom of Lena’s story to share details with The Post.

OUCH: A 36-year-old male nurse has been charged with sexual assault and abuse of a vulnerable woman in a vegetative state who gave birth at a Hacienda HealthCare facility in Phoenix. The nurse, Nathan Sutherland, had been at least partly responsible for the woman’s care, our Post colleagues Cleve R. Wootson Jr. and Michael Brice-Saddler report.

“The birth — and the sexual assault that must have preceded it — cast a harsh glare on conditions at a nonprofit organization that bills itself as a leading provider of health care for Phoenix’s medically fragile,” Cleve and Michael report. “The 29-year-old woman, who gave birth a few days after Christmas, was a special — and especially dangerous — case: She had been in a persistent vegetative state since 1992, when she was just 3.”

Police are also investigating whether Sutherland may have assaulted other people at the facility, where he has worked since 2011, and Phoenix Police Sgt. Tommy Thompson said it would be up to families whether to have incapacitated individuals tested for signs of sexual assault. Cleve and Michael write that “investigators don’t know whether he was an employee or a contractor — or whether he simultaneously worked at other facilities, too.”

Cleve and Michael report that the mother was healthy following the birth and that the baby appears to be in good health as well, according to Thompson.

TRUMP TEMPERATURE

— President Trump called on his administration officials to examine how to prevent surprise medical bills at a Wednesday roundtable at the White House.

“The health care system too often harms people with some unfair surprises” the president told reporters after he held a roundtable with invited patients and guests sharing experiences with medical bills, Kaiser Health News’s Emmarie Huetteman reports. “The pricing is hurting patients… we’re going to stop all of it, it’s very important to me.

David Silverstein, founder of Colorado-based nonprofit Broken Healthcare, attended the roundtable and told KHN the president called for a solution with “the biggest teeth you can find.”

Retired doctor Paul Davis, who also attended the meeting, said administration officials signaled price transparency is a “high priority” for the president. “These people seemed earnest in wanting to do something constructive to fix this,” Davis told KHN.

INDUSTRY RX

— The uninsured rate in the United States is the highest it’s been since 2014, according to a new report.

The Gallup National Health and Well-Being Index found during the last quarter of 2018, nearly 14 percent of adults in the country were uninsured, an uptick from the almost 11 percent who were uninsured in the final quarter of 2016. That increase represents about 7 million adults without insurance, according to the report.

Gallup notes the latest figure is still below the 18 percent rate of U.S. adults who were uninsured before the Affordable Care Act implemented an individual mandate in 2014.

The report found uninsured rates rose the most for women, adults under 35 years old and people in households with annual incomes under $48,000. Young adults reported an uninsured rate of more than 21 percent, a 4.8-point rise from two years prior, and the rate of uninsured women rose from 8.9 percent to 12.8 percent during that time.

STATE SCAN

— In Ohio, Republican Gov. Mike DeWine said he plans to sign the “Heartbeat Bill” that was previously vetoed by former governor John Kasich (R). In an interview with conservative radio host Hugh Hewitt, DeWine said he would “absolutely” sign the bill, which would ban abortions after a fetal heartbeat can be detected or as early as six weeks, before some women realize they are pregnant.

“We will do this. I just saw the headline, a court struck down another heartbeat bill for another state,” DeWine said in the interview, perhaps referring to a state judge in Iowa who ruled this week that the state “fetal heartbeat” restriction was unconstitutional.

The governor said he anticipates the legal challenges likely to follow his signature. “But ultimately, Hugh, you and I both know that this thing, once it’s passed in Ohio, once we sign it, once it becomes law, Planned Parenthood is going to be in the next day, or that day, filing a lawsuit,” he said. “But ultimately, this will work its way up to the United States Supreme Court. And they’ll make that decision."

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

The Trump administration approved the requirements just days before Paul LePage left office, but Gov. Janet Mills says that change would leave more Mainers uninsured.
Portland Press Herald
Concerned about the mental well-being of federal workers affected by the longest government shutdown in history, at least one local health system is offering free counseling.
Chicago Tribune
Food
The relief efforts cover everything from emergency kitchens to a website where you can buy a furloughed employee a beer.
Tim Carman
Business
The effort is a sign the Trump administration is bracing for a long funding lapse.
Damian Paletta and Juliet Eilperin
HEALTH ON THE HILL
Politics
“We are trying to figure out how we get beyond tomorrow,” said Sen. Lisa Murkowski as both sides wonder whether the votes’ outcome will lead to a resolution.
Sean Sullivan
The maker of controversial e-cigarettes spent $750,000 on lobbying during the last three months of 2018, a dramatic increase over $210,000 it spent in the second quarter of the year.
NPR
“I think more and more people are viewing the NRA with more cynicism and suspension," Rep. Anthony Brown says.
Politico
AGENCY ALERT
Politics
In a battle against Trump, it may not matter.
Philip Bump
Some consumers could risk losing tax credits to help pay for their ACA coverage, an Indian agency can’t continue paying clinics and insurers are scrambling to design plans for next year due to a shortage of government staff and funding.
Wall Street Journal
Medicaid enrollment is falling. Obamacare enrollment is falling. And a new survey shows that more Americans are living without insurance.
New York Times
MEDICAL MISSIVES
A growing body of evidence suggests that sometimes our immune systems simply don’t follow the instructions a vaccine tries to give them.
Stat
Business
Now in its second month, the shutdown is hobbling key parts of the financial system as companies across the country ditch plans and scramble to operate without the help of regulators. One biotech company with roots in 1980s fashion is among those putting hopes on hold.
Renae Merle
Public Safety
The deaths have prompted warnings from authorities in Fairfax County.
Justin Jouvenal
DAYBOOK

Coming Up

  • The Pew Charitable Trusts holds a live webcast on the opioid crisis and access to medication-assisted treatment in cities on Friday.
  • The National Institute for Health Care Management Foundation hosts a webinar on addressing inappropriate care on Friday.
SUGAR RUSH

Duke of Cambridge Prince William opened up about suffering from mental health issues during the annual World Economic Forum in Davos, Switzerland: 

White House press secretary Sarah Sanders said the president is the "only one" trying to help people during the shtudown: