THE PROGNOSIS

As usual, there is plenty Democrats hate in President Trump’s budget request, but this year the proposal contains something that might bring them to the table: a large infusion of funding to end HIV transmissions in the United States.

Trump — who last month pledged to end the HIV epidemic in this country by 2030 — asked Congress for $291 million in mostly new funding for the ambitious project in the budget request the White House released yesterday. The funding, about half of it flowing through the Centers for Disease Control and Prevention, would be targeted toward 48 counties and the rural areas of seven (mostly southern) states where more than 50 percent of new HIV cases are diagnosed.

“In many of these places, it is hard for people at risk of contracting HIV to find the medication critical to protecting them from the virus and ending the 38-year-old epidemic,” my Washington Post colleague Lena H. Sun writes. “The CDC estimates that the decline in HIV infections has stalled because effective prevention and treatment are not reaching those who could most benefit.”

Health and Human Services Secretary Alex Azar heads to Capitol Hill over the next three days for a trio of hearings on the budget request. There, he’ll probably ask lawmakers to grant the additional dollars even as he faces probing questions from Democrats on a host of other issues, including HHS’s efforts to lower prescription drug costs and its role in migrant family separations.

Today, Azar will appear before the House Energy and Commerce Committee, and on Thursday he’ll visit the Senate Finance Committee. Tomorrow, he’ll sit before the House Appropriations Health subcommittee, where Rep. Rosa DeLauro (D-Conn.) holds the key to the HIV funding Trump wants.

While the Democratic-led House won’t pass the vast majority of the items requested by the president, the HIV project is an area of bipartisan concern and one that DeLauro may act upon when it comes time to appropriate money to keep the government running. DeLauro said that while she’s “encouraged” by the HIV initiative, she’s also concerned the administration’s proposed cuts to other health programs, including Medicaid, would counteract the effort.

“I am concerned that the president’s proposed cuts to the National Institutes of Health’s HIV research portfolio, along with deep cuts to Medicaid and the proposed repeal of the Affordable Care Act, would be counterproductive to the goal of reducing HIV infections,” DeLauro said in a statement to The Health 202. “We cannot allow mixed signals on this important issue.”

Many Democrats and health-care advocates echoed similar feelings that Trump was sending mixed signals with his budget request.

Even as the president proposed more money aimed at domestic HIV transmissions, his 2020 budget retains prior proposals to slash global HIV/AIDS dollars, stem Medicaid spending by transforming it into a block grant program and cut the National Institutes of Health budget. The budget also envisions a leaner HHS, proposing to slash its discretionary funding by 12 percent, down to $87.1 billion annually.

“Congress will forget this budget by Friday, but the signal it sends to the world’s poorest will be remembered," said Tom Hart, North America executive director for the ONE Campaign. "It’s pretty simple — we can’t end the AIDS crisis by cutting programs proven to fight this disease.”

Carl Schmid, deputy executive director of the AIDS Institute, told me he’s frustrated by those proposed cuts. But he’s focusing on what would be a historical investment in ending HIV transmissions if Congress funded the project.

Of the $291 million requested in Trump's budget, the CDC would get $140 million in entirely new funding — an 18 percent increase over the agency’s current budget. Another $70 million would go to the Ryan White program, which provides care to low-income patients who are HIV-positive, and the Indian Health Service would get $25 million to screen for HIV and prevent and treat Hepatitis C.

Community health centers would use $50 million to provide PrEP, a drug that greatly reduces the chances of acquiring HIV, and NIH would use $6 million for AIDS research – although it’s not clear from the budget documents released yesterday whether those would be new or just reallocated funds. The White House is expected to release additional budget details early next week.

Jen Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation:

Schmid said he hopes only new dollars would be used for the HIV project so that other priorities don’t lose funding. But overall, he’s thrilled the administration is putting a sharp focus on HIV/AIDS — a public health issue that has historically brought lawmakers together.

“I don’t know why Democrats wouldn’t be supportive of it,” Schmid said. “They’ve always wanted more funding for HIV, and this gives them an opportunity.”

The administration’s goal is to reduce HIV transmission by 75 percent within five years and by at least 90 percent by 2030. That would prevent 250,000 new infections, my colleague Lena noted.

“A recent report from the CDC shows the significant decline in annual HIV infections has stalled,” she explains. “The report provides the most recent data on HIV trends in the United States, from 2010 to 2016. It shows that after about five years of substantial declines, the number of HIV infections began to level off in 2013 at about 39,000 per year.”

In most of the Deep South, it's difficult for people at risk of contracting HIV to find the medication critical to protecting themselves from the virus, my colleague Lenny Bernstein reports.

Use of PrEP is rising nationwide but lagging in the South, Lenny reports. In 2017, there were about 20,000 new HIV diagnoses in the South, more than in the rest of the country combined. Researchers at Emory University’s Rollins School of Public Health found the 2017 ratio of PrEP use to need  was more than three times higher in the Northeast than in the South.

Azar called the project “one of the most important public health initiatives undertaken this century.”

TRUMP TEMPERATURE

Here are more highlights of some of the health-care related issues addressed in the budget request: 

— Major cuts to health programs for the poor, elderly and disabled: Trump’s budget includes a marked slowdown in Medicaid spending, with a $1.5 trillion cut to Medicaid over a decade, and $1.2 trillion added for a block grant system, our Post colleagues Jeff Stein and Amy Goldstein report. The proposal shifts Medicaid into a system of block grants to states to give them flexibility in setting their own rules about how to cover people. “The budget also would eliminate funding for Medicaid expansion under the Affordable Care Act, which has gone to about three dozen states over the past five years,” they write.

Despite the president’s vows to protect Medicare funding, Trump's budget also calls for a marked cut for the federal health program for seniors — $845 billion over the next 10 years. Most of the cuts are related to “changing payments to doctors and hospitals, and renewed efforts to ferret out fraudulent and wasteful billing — oft-cited targets by presidents of both parties.”

— Cuts and adds to cancer funding: The budget proposes a $50 million boost for pediatric cancer research while at the same time cutting the total funding for the National Cancer Institute by almost $900 million. “The budget said the childhood cancer request was the first step in investing $500 million over the next 10 years, something President Trump called for last month in his State of the Union address,” our Post colleague Laurie McGinley writes. “Cancer researchers and advocates said that the net effect of cutting about 14.5 percent from the cancer institute budget, even while adding the money for pediatric research, would hurt children and adults. They called on Congress to rebuff the cuts — as lawmakers have in the past few years.”

— Reduced NIH funding overall: The proposal includes a roughly $4.5 billion cut to NIH’s budget. The biggest cuts there would include dropping the NCI from $6.1 billion to $5.2 billion; and the National Institute of Allergy and Infectious Diseases budget from $5.5 billion to $4.75 billion, our Post colleagues Joel Achenbach, Ben Guarino, Sarah Kaplan and Brady Dennis write.

—Funding for a small children's health program requested by golfing champion Jack Nicklaus, one of Trump's golfing buddies. As Politico's Dan Diamond notes, the HHS budget would provide $20 million for a mobile children's hospital project at Miami's Nicklaus Children's Hospital.

"Nicklaus had lobbied Trump on the golf course in Florida, and he met with HHS Secretary Alex Azar and then-OMB Director Mick Mulvaney in Washington, D.C., to request funds, say two individuals with knowledge," Dan writes. "Trump personally directed HHS to earmark the funds to help Nicklaus develop mobile children's hospitals, one individual said."

— More Food and Drug Administration funding: The administration is asking for $6.1 billion in funding for the agency, which is a $418.5 million increase over the current budget.

— A crackdown on e-cigarettes: The request includes a user-fee proposal requiring the e-cigarette industry to pay $100 million a year as part of the effort to combat youth vaping. Currently, other tobacco products like cigarettes and cigars are subject to such fees. The funds would go to boosting the FDA’s regulatory oversight, Laurie reports.

The proposal says the user fee “would ensure that FDA has the resources to address today’s alarming rise in youth e-cigarette use as well as new public health threats of tomorrow. New tobacco or nicotine products that are regulated by FDA should also pay a user fee, just as other tobacco related products that are subject to FDA’s user fee.”

— Slashing drug costs: There's also a proposal to cap out-of-pocket prescription costs for seniors under Medicare, an idea the administration has proposed before. The budget calls for limiting the amount Medicare beneficiaries pay for medicine, “providing financial certainty to both patients and drug manufacturers while leaving the government to pick up the tab for anything seniors spend on drugs past a certain threshold,” Stat’s Lev Facher writes.

But the budget would also get rid of some  help Medicare beneficiaries receive to pay for their drugs, CNBC’s Sarah O’Brien reports. The proposal would slash cost-sharing that helps low-income patients pay for generic drugs and also stops allowing drug manufacturer discounts to count toward out-of-pocket costs in Medicare Part D’s coverage gap.

— More for opioid crisis: “The budget plan does propose some new funding to fight the opioid crisis, including $245 million over 10 years to let states ‘extend Medicaid coverage for pregnant women with substance use disorder to one year postpartum,’” Vox’s German Lopez reports. “But it also proposes cuts to some opioid-related programs, particularly at the Department of Justice … It’s also far short of the tens of billions of additional dollars that experts say is needed to address the opioid crisis.”

— Boost for spending on veterans: Trump's request would increase the budget at the Department of Veterans Affairs by about 7.5 percent. The Wall Street Journal’s Ben Kesling reports the increase includes 10 percent more for medical care, providing "$8.9 billion to implement a sweeping law passed in 2018 to change the way veterans’ health care is provided and streamlining access to private-sector care.”  The department would also get $1.6 billion to establish a new electronic health-records system.

See more here from our colleagues on what's in the president's 2020 budget request: 

See how each agency’s discretionary funding would be affected by Trump’s proposal.
Kate Rabinowitz and Kevin Uhrmacher
Economy
President Trump's budget would keep $1 trillion deficits coming for years, even after making significant cuts to non-military programs, including Medicare.
Heather Long
AHH, OOF and OUCH

AHH: Today, major health insurer UnitedHealthcare and its pharmacy benefit manager, OptumRx, will announce the expansion of a program in which customers directly receive the discounts provided by drugmakers. Starting in January, all of UnitedHealthcare's employer-sponsored health-care plans must pass along point-of-sale rebates directly to consumers. UnitedHealthcare says its initial direct-rebate program, started last year, has lowered drug costs by an average of $130 per prescription.

The rebates drug companies give to insurers have increasingly come under fire from the Trump administration and lawmakers, who blame them for incentivizing the pharmaceutical industry to push list prices higher. In turn, drugmakers blame insurers for not passings on to consumers the savings from the rebates.

OOF: The cuts to Medicare spending in Trump's proposed budget set up a potential messaging battle ahead of the 2020 election between Democrats pitching an expansion of the popular federal health program and Republicans who are taking a Medicare-for-less approach that focuses on cutting back spending, our Post colleagues Toluse Olorunnipa and Sean Sullivan report.

Democrats, including some who are seeking the Democratic nomination for president in 2020, quickly pounced on the proposed Medicare cuts.

Sen. Bernie Sanders (I-Vt.): 

Sen. Kamala Harris (D-Calif.): 

“On one hand, you don’t like handing the other side a potential campaign message at any point, and Democrats will inevitably try to make this into a ‘Trump wants to cut your Medicare’ argument,” Republican pollster Chris Wilson told our colleagues, adding that the messaging wouldn’t stick in the same way efforts to repeal and replace Obamacare did. “A proposed cut to entitlements in a budget proposal that has no chance of passing the House just isn’t going to enter the public consciousness in the same way.”

OUCH: Hackers may have gained access to the personal information and medical data of more than 600,000 people in Michigan in a cyberattack potentially impacting customers of several health-care companies, our Post colleague Hamza Shaban reports.

The breach may have included data from Blue Cross Blue Shield of Michigan, Health Alliance Plan and McLaren Health Care, said Dana Nessel, the state’s attorney general.

The cyberattack targeted Wolverine Solutions Group, a health-care firm that partners with health plans and hospital systems. A public notice from the company doesn’t say how hackers got access to its systems, how long the attack went undetected and how the company learned of the breach.

“WSG said it discovered the breach in September, when malicious actors accessed and infected its network with malware,” Hamza writes. “Rather than merely stealing customer data, WSG said, the hackers seized control of the company’s records, encrypting them and making them inaccessible in an effort to extort the company. Hospitals and government offices are among the frequent targets of ransomware.”

— And here are a few more good reads: 

AGENCY ALERT
The Fix
Experts say the vast majority of drugs come into the United States through legal ports of entry — not illegal border crossings.
Eli Rosenberg
National Security
The proposed White House budget would slash 24 percent of spending by the State Department and USAID.
Carol Morello
Some have called FDA Commissioner Scott Gottlieb's resignation a boon for the e-cigarette industry. It may prove more complicated.
CNBC
HEALTH ON THE HILL
Fact Checker
Rep. Ocasio-Cortez (D-N.Y.) misleadingly compares Trump's action on border-wall funding with the response to the opioid health-care emergency.
Glenn Kessler
MEDICAL MISSIVES
Sports
A silver medalist in team pursuit in the 2016 Rio Olympics, the cyclist took her life last week.
Cindy Boren
INDUSTRY RX
The Trump administration wants to use Facebook and other social media to help identify people who are receiving Social Security disability benefits without being truly disabled.
New York Times
Care.com, the country’s largest marketplace for babysitters and other caregivers, unveiled a set of policies aimed at overseeing its members and said it had taken steps to remove fake day-care center listings.
Wall Street Journal
STATE SCAN
Local
There were 1,848 overdose deaths in the state in the first nine months last year.
Meredith Cohn
OPIOID OPTICS
The opioid crisis is bigger than Purdue Pharma.
Axios
REPRODUCTIVE WARS
MALPRACTICE
BRAIN WAVES
SECOND OPINION
DAYBOOK

Today

  • The House Energy and Commerce subcommittee on Health holds a hearing on the HHS budget request for 2020.
  • The House Education and Labor Subcommittee on Civil Rights and Human Services holds a hearing on examining federal child nutrition programs.

Coming Up

  • The House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies holds a hearing on the HHS budget request for 2020 on Wednesday.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on lowering prescription drug costs on Wednesday.
  • The Senate Finance Committee holds a hearing on the president’s 2020 budget request on Thursday.
SUGAR RUSH

The lingering questions about Medicare-for-all:

From the Fact Checker: Rep. Alexandria Ocasio-Cortez (D-N.Y) misleading complaint: Trump did not transfer funds for the opioid emergency: