with Paulina Firozi


A whole host of factors — such as friends, housing and transportation — affect a person’s health and how much they need the social safety net. It’s time the government’s big health insurance programs took this reality into account, some lawmakers and policymakers are starting to argue.

Republicans on the Joint Economic Committee will release a report today finding that Americans have fewer people around to help provide care as they age compared with two decades ago. It says Medicare and Medicaid spending projections may be too low because they fail to take into account the declining social networks of aging baby boomers.

The study found adults from ages 61 to 63 are now less likely to be in close geographical proximity to their loved ones. Seventy-five percent were married or cohabitating in 1994, compared with 69 percent in 2014. The share of adults attending church at least three times a month fell from 56 percent to 41 percent, and the share of those with a child living within 10 miles fell from 68 percent to 55 percent during the same time frame.

The report also found declines in the share of adults with a good friend or a relative living in their neighborhood. This weakened network could translate to a heavier burden on Medicaid and Medicare if more adults seek formal paid rehabilitation, long-term care and hospice services as a result, the report says.

“That generation is going to have many fewer friends and children and spouses and people from church to care for them as they get old,” said Robert Putnam, a professor of public policy at Harvard University who testified at a 2017 hearing on social capital convened by the committee’s top Republican, Sen. Mike Lee (Utah).

“We’re not going to just leave them on the street, so more of them will have to be cared for through paid care,” Putnam added.

There are efforts afoot right now in the Medicaid program to take into better account the nonmedical needs of patients. They include accounting for those lacking adequate housing or access to transportation, or poeple experiencing food insecurity.

The Trump administration gave the go-ahead in the fall to North Carolina to start a pilot program in which health plans will identify high-need Medicaid patients and guide them toward a specific package of services tailored to them. Through these “Healthy Opportunities” pilots, private health plans that administer Medicaid benefits can also fund and sponsor programs to help people who lack housing, food, personal safety and employment.

It’s not the same as Medicaid directly paying for these additional services — that’s outside the program's scope. But the North Carolina experiment does represent a way for the state and federal health insurance program to encourage a more comprehensive approach to health care.

“We cannot pay for housing, but we do understand there are social determinants of health,” Centers for Medicare and Medicaid Services Administrator Seema Verma said in December.

North Carolina’s experiment could feed into CMS's larger goal of ultimately reducing Medicaid spending and enrollment, something the federal agency has sought to do through allowing work requirements for the program for low-income Americans. Verma often speaks in terms of personal responsibility when she discusses Medicaid — a value perhaps reflected in the agency’s use of the phrase “healthy opportunities” to describe the pilot program instead of “social determinants of health.”

“The phrase ‘social determinant of health’ connotes bad things in the conservative blogosphere,” Matt Salo, executive director of the National Association of Medicaid Directors, told me. “'Determinants' implies people are just at the whim of external circumstances and have no agency.’”

However the effort is described, it’s a significant step for Medicaid. Salo said social factors that impact people's health “is something people have been talking about forever.” Studies have suggested a wide range of social factors — including not just housing and food but also things such as education and debt — influence about 20 percent of a person’s health and well-being.

It’s not just North Carolina taking steps to address social factors in health. In 2017, 19 states required Medicaid managed-care organizations to screen patients for social needs and/or refer them to social services, according to the Kaiser Family Foundation.

As we've noted, states can’t use Medicaid dollars to pay for housing. But they can use the money to help patients find and retain affordable housing. In Louisiana, the state health department partners with the housing authority with the goal of reducing homelessness among people with disabilities.

“While states have different ideas and approaches to serving the needs of their beneficiaries, we can all agree that one of our prominent goals should be to help individuals live healthier more complete lives by addressing the whole human need,” Verma wrote in the journal Health Affairs. “We should keep exploring ways to achieve this goal so that we can identify best practices and replicate them.”

President Trump on Jan. 24 reiterated that “many” of furloughed government employees were “totally in favor of what we’re doing.” (The Washington Post)

AHH: After warning federal employees that they’ll soon have to pay directly for vision and dental coverage premiums, the Trump administration said it would give those affected by the shutdown an additional two weeks before they’re billed.

Now, the 800,000 employees who have been furloughed or are working without pay have until the third missed paycheck before they will be billed for their vision and dental coverage instead of the second paycheck, our Post colleague Lisa Rein reports. Federal workers will miss their second paycheck on Friday.

“Since the lapse in funding began, OPM has worked diligently with payroll and healthcare providers in order to find flexibility that may help mitigate the effects of the shutdown for furloughed and excepted employees,” a spokeswoman for the Office of Personnel Management said in a statement. “We will continue to focus our efforts to make the partial lapse as painless as possible, consistent with law.”

Sen. Mark Warner (D-Va.), who along with three other Democratic senators on Wednesday sent a letter to OPM expressing concern about employees’ dental and vision coverage, said he is “pleased to see that OPM took some action to respond to our concerns.”

Trump officials have suggested furloughed federal workers are getting free vacation and questioned why they are going to homeless shelters for food. (JM Rieger/The Washington Post)

OOF: Commerce Secretary Wilbur Ross said he doesn’t understand why furloughed federal employees are going to food bank, suggesting instead that employees look into low-interest loans to help them.

When asked about federal workers going to food banks during an interview on CNBC, Ross said: “I know they are, and I don’t really quite understand why.”

Ross suggested federal workers should take out loans to cover their expenses during the shutdown. “These are basically government-guaranteed loans because the government has committed, these folks will get back pay once this whole thing gets settled down,” Ross said. “So there is really not a good excuse why there really should be a liquidity crisis now.”

He acknowledged “people might have to pay a little bit of interest, but the idea that it's paycheck or zero is not a really valid idea.”

“Ross leads one of the agencies that is directly affected by the shutdown that began Dec. 22, and more than 40,000 of his employees haven’t been paid for weeks,” our Post colleague Damian Paletta reports. “Food banks nationwide have reported a spike in visits, and some have begun setting up services in discreet locations to help federal workers who are worried about the stigma of accepting free food.”

House Speaker Nancy Pelosi (D-Calif.) quickly criticized the remarks. “Is this the ‘Let them eat cake’ kind of attitude?” she asked. “Or, ‘Call your father for money’? Or, ‘This is character-building for you. It’s all going to end up very well just so long as you don’t get your paychecks’?”

Asked about Ross's comments, Trump responded this way: "Perhaps he should have said it differently. Local people know who they are when they go for groceries and everything else, and I think what Wilbur was probably trying to say is that they will work along." Ross has "done a great job," the president added.

Our Post colleague Jackie Alemany wrote in Power Up this morning about dozens of federal workers visiting food banks less than a mile from the White House. 

OUCH: There’s a looming public health crisis everyone may be familiar with: not enough sleep. Brain researchers are warning that a casual disregard for sleep may be dangerous. This comes as research on sleep and brain function is expanding, with further examinations into how sleep impacts disease and normal cognitive function such as memory, our Post colleague Carolyn Y. Johnson reports. And such research is starting to change policy, she adds, as scientists are increasingly pushing a message that a lack of sleep is a public health crisis that deserves more attention.

“Preschoolers who skip naps are worse at a memory game than those who snooze, even after the children ‘catch up’ on sleep the next night,” Carolyn writes. “An alarming new line of research suggests poor sleep may increase the risk of Alzheimer’s, as even a single night of sleep deprivation boosts brain levels of the proteins that form toxic clumps in Alzheimer’s patients. All-nighters push anxiety to clinical levels, and even modest sleep reductions are linked to increased feelings of social isolation and loneliness.”

“It used to be popular for people to say, ‘I’ll sleep when I’m dead,’ ” Daniel Buysse, a professor of sleep medicine at the University of Pittsburgh told Carolyn. “The ironic thing is, not sleeping enough may get you there sooner.”


— Senate Finance Chairman Chuck Grassley (R-Iowa) and the committee’s ranking Democrat, Sen. Ron Wyden (Ore.), introduced a bipartisan bill meant to stop pharmaceutical companies from overcharging Medicaid by misclassifying medications. It’s the latest indication that Grassley and Wyden are serious about trying to tackle high drug spending.  

In a statement, Grassley criticized drugmakers “that make millions from government programs like Medicaid," saying they "owe it to taxpayers to treat their hard-earned dollars with respect.” He added: “Gaming the system by intentionally misclassifying drugs to reduce rebate obligations is nothing short of stealing taxpayer dollars and it’s inexcusable. This bipartisan bill fixes that problem and sends a clear signal to drugmakers that cheating taxpayers doesn’t pay and won’t be tolerated.”

Wyden said the bill, called the “Right Rebate Act,” “marks an important first step in the work that lies ahead to lower prescription drug prices for families and hold drug makers accountable.”

The measure will allow the Health and Human Services Department to reclassify a drug and reclaim rebates and enable it to take action against companies suspected of misclassifying drugs on purpose, according to the committee.

— Grassley released a list of witnesses yesterday who will appear before the committee for its Tuesday hearing on drug pricing. The list includes Doug Holtz-Eakin, the president of the American Action Forum; Mark Miller, vice president of health care at the Laura and John Arnold Foundation; Peter Bach, director of Memorial Sloan Kettering Center for Health Policy and Outcomes and Kathy Sego, a mother of a child with insulin-dependent diabetes. 

 — While detailing Democratic lawmakers' priorities for the new Congress, Pelosi specifically mentioned lowering drug costs, expanding Medicaid and discussing options that move toward universal health coverage.

During remarks at the Families USA conference, she said Democrats are working to "lower the cost of health care, to start by lowering the cost of prescription drugs and preserving the benefits contained in the Affordable Care Act, to expand Medicaid, to consider all options to have us reach health care for all Americans.”

During her remarks, the speaker also criticized Republicans for “assaults they are making on health care,” including the effort to impose work requirements for Medicaid beneficiaries.


—  A team of scientists has discovered evidence of the deadly Ebola virus in a bat in Liberia, the first time this has happened in West Africa.

Bats have been long thought to be natural hosts for the deadly virus, meaning the bats can carry Ebola but not be harmed by it. But our Post colleague Lena H. Sun writes that “more than 40 years and over two dozen outbreaks after Ebola emerged in Central Africa, researchers still don’t know what animal or animals carry it, much less how it spreads to people.” Scientists also explained in the recent finding that there was antibodies in the bat’s blood, suggesting an immune response to the infection.

The scientists’ finding is a critical step toward understanding more about the source of Ebola outbreaks and further understanding where human Ebola cases originate, although no human cases of Ebola are linked to this finding.

Epstein and others warned more research is needed. “Scientists are writing a research paper about their discovery,” Lena writes. “But Liberian officials did not want to wait for publication, which can take a year, before releasing the information, Epstein said. Officials want to use the information to reinforce a public health message to Liberians to avoid bats to prevent potential infection.”

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



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

Late-night hosts react to Wilbur Ross’s tone-deaf comments about furloughed workers

Late-night hosts had a lot to say on Jan. 24 about Commerce Secretary Wilbur Ross downplaying the hardships caused by a partial government shutdown. (Drea Cornejo/The Washington Post)