THE PROGNOSIS

The Trump administration is contemplating some time-sensitive questions about how far states can go in shrinking Medicaid spending, as its top health officials seek to remold the low-income insurance program into a more conservative shape.

It all revolves around how the Department of Health and Human Services responds to a request from Utah, which is seeking to expand its Medicaid program less than three weeks from now. But despite pressing questions from Democrats, HHS Secretary Alex Azar provided few hints yesterday to the House Energy and Commerce Health subcommittee in a hearing on President Trump’s budget request.

“I see the direction you’re going with this, and I don’t like this,” Rep. G. K. Butterfield (D-N.C.) told Azar. “But you answer to the president, and the president has the notion of taking Medicaid in the wrong direction.”

By April 1, Utah needs federal approval for its new plan to only partially expand Medicaid. Under the plan, which the state legislature passed to override a November ballot resolution, Utah would expand Medicaid only to people earning up to 100 percent of the federal poverty level — not the 138 percent threshold envisioned under the Affordable Care Act.

To improve the plan’s chances for approval from the GOP-led administration, the state is also asking for its federal Medicaid contributions for the newly eligible patients to be limited to a fixed amount per enrollee — a so-called “per capita” structure congressional Republicans suggested in their 2017 health-care bills as a way to cut Medicaid spending overall. A spokeman for the state's health department told me the state "anticipates" opening enrollment on April 1 and is preparing for that date.

The administration has already gone out on a legal limb by approving Medicaid work requirements in several states, which are being challenged in court. If it goes along with Utah’s request, it would set new precedents for how state and federal governments can seek to limit spending on Medicaid — which covers nearly 1 in 5 low-income Americans — and whether states may only partially expand the program under the ACA.

It’s clear that lowering Medicaid spending is a fervent wish of the administration. Like its budget request last year, the White House’s latest proposal suggests a cut of nearly $1.5 trillion in Medicaid over a decade and for $1.2 trillion to be added for the block grants or per-person caps that would start in 2021 (a block grant would also limit Medicaid spending by providing the federal portion in a single lump sum instead of as a percentage of states’ total costs).

And earlier this year, a small group of people within the Centers for Medicare and Medicaid Services were working on a plan to allow states to ask for their Medicaid dollars to be provided via block grants. Butterfield sharply criticized that effort at the time, and yesterday drilled Azar on how it was going.

“Does the administration believe you have the authority to block grant Medicaid on your own without the participation of Congress?” Butterfield asked Azar.

Azar noted that states may request waivers for making changes to their Medicaid programs -- including for block grants (or, presumably, a per capita cap a la Utah). He said if HHS were to receive that kind of a proposal, “we would have to assess that with our legal counsel" and with the White House Office of Management and Budget.

Butterfield said such a move would create a “firestorm” because of the benefit cuts Medicaid programs may be forced to make under a block grant system. “It’s deeply troubling to see this administration double down,” he said. “It appears you’re going to be aggressive with this.”

Alex Ruoff, health-care reporter for Bloomberg Government:

The administration is juggling a lot of balls on Medicaid right now, as it seeks to open pathways for states to implement stricter rules. On Thursday, a federal judge in the District of Columbia is scheduled to hear oral arguments in a lawsuit challenging Kentucky and the administration for seeking to implement work requirements.

The work requirements have created their own firestorm of sorts, becoming a focal point for Democrats and progressives who accuse the administration of trying to undermine Medicaid’s core goals of providing health insurance to low-income Americans.

Bloomberg's Anna Edney:

Politico's Dan Diamond:

In turn, Azar and CMS Administrator Seema Verma have stressed their goal is to enable people to ultimately leave the Medicaid program by obtaining coverage through a job. Azar repeated that argument yesterday.

“We believe it’s a fundamental aspect for able-bodied adults, if you are receiving free health care from the taxpayer, that it’s not too much to ask you would engage in some form of community activity,” Azar told the subcommittee.

OPIOID OPTICS

— THE FENTANYL FAILURE: Former President Obama's administration failed to act in the face of a mounting crisis around the deadly synthetic opioid fentanyl, even after a group of 11 national health experts implored top officials to do so. Thousands of people were dying from overdoses linked to the potent painkiller that’s 50 times more powerful than heroin. Immediate action was critical for responding to the epidemic that intensified over three years, the experts warned in May 2016. 

major investigative report from our colleagues Scott Higham, Sari Horwitz and Katie Zezima out this morning explores what they write was “one in a series of missed opportunities, oversights and half-measures by federal officials who failed to grasp how quickly fentanyl was creating another — and far more fatal — wave of the opioid epidemic.” “This is a massive institutional failure, and I don’t think people have come to grips with it,” John P. Walters, chief of the White House Office of National Drug Control Policy between 2001 and 2009, told our colleagues. “This is like an absurd bad dream and we don’t know how to intervene or how to save lives.”

Their lengthy report includes telling graphics and striking details of a crisis leading to the deaths of more than 67,000 people between 2013 and 2017. It also includes the names of some of the people who died during that time from fentanyl and other synthetic opioids. The Post has also published a FAQ page on fentanyl here.

Here are a few of the other standout details from the story:

  • The first signs of the crisis were noticed in the spring of 2013 in Rhode Island, where there was a spike in overdose deaths at a state morgue in Providence. That August, the CDC highlighted the spike in a weekly report, but it didn’t attract much national attention.
  • In June 2014, former attorney general Eric Holder received a personal briefing on fentanyl from the Drug Enforcement Administration. But he didn't take any action. "His former spokesman said it was up to the DEA to ask the attorney general for specific action...Ten months after the briefing, Holder left the administration. By then, fentanyl was spreading across the country."
  • In March 2016, Sen. Edward Markey (D-Mass.) used a rare one-on-one moment on Air Force One with Obama to tell him the opioid epidemic was “morphing into increasingly a fentanyl epidemic.” Markey said Obama was “very concerned about it.” But the president didn’t focus on the rise of fentanyl until the final months of his administration.
  • About a month later, the 11 public health experts wrote to administration officials calling for an emergency public health declaration. Michael Botticelli, then the White House drug czar “and another recipient of the request, said the Obama administration’s priority was getting more money from Congress for treatment… But many leading voices in the field feel an emergency declaration could have saved lives by shining a bright spotlight that would have galvanized the administration, awakened the public and warned users of the danger they faced."
AHH, OOF and OUCH

AHH: Senate Finance Chairman Chuck Grassley (R-Iowa) and the committee’s top Democrat, Ron Wyden (Ore.), have invited five pharmacy benefit managers — the middlemen often vilified for their confusing role in the drug-pricing chain — to testify before lawmakers next month.

The bipartisan leaders sent letters to Cigna, Prime Therapeutics, OptumRx, Humana, and CVS Health and CVS Caremark, inviting them to testify in an April 3 committee hearing. It will be the third such hearing from the powerful committee in an effort to address skyrocketing prescription drug costs and will follow a February hearing with top pharmaceutical executives.

The hearing should give PBMs a chance to speak to their role in the drug pipeline, after drug execs spent part of the last hearing pointing fingers at insurers and PBMs.

“Middlemen in the health care industry owe patients and taxpayers an explanation of their role. There’s far too much bureaucracy and too little transparency getting in the way of affordable, quality health care,” Grassley and Wyden said in a statement. “We’ve heard from pharmaceutical companies and it’s only fair that the committee has the opportunity to ask questions of other players in the health care supply chain.”

OOF: Trump said he’s “very seriously” considering designating Mexican drug cartels as foreign terrorist organizations.

In an interview with Breitbart News, Trump said: “We’re thinking about doing it very seriously. In fact, we’ve been thinking about it for a long time. . . . As terrorists — as terrorist organizations, the answer is yes. They are.”

Our Post colleague John Wagner writes: “According to the State Department, a foreign terrorist organization (FTO) must be a foreign organization that either practices or has the means to practice terrorism and ‘threatens the security of United States nationals or the national security of the United States.’ ”

In the interview, Trump said that “Mexico, unfortunately, has lost control of the cartels. They’ve totally lost control of the cartels.”

Republican lawmakers have previously called for this kind of designation. Reps. Mark Green (R-Tenn.) and Chip Roy (R-Tex.) last month proposed something similar to the State Department.

OUCH: Georgia Democratic Rep. Dar’shun Kendrick has unveiled what she has dubbed the “testicular bill of rights.”

It’s a response to the antiabortion “heartbeat bill” her Republican colleagues passed in the Georgia House last week to ban the procedure when a heartbeat is detected in the fetus, at about six weeks of pregnancy.

Kendrick tweeted out an outline of what her legislation looks to accomplish, including forcing men to get permission from their sexual partner before getting erectile dysfunction medication, banning vasectomy procedures in the state, creating a 24-hour waiting period for men who want to purchase porn or sex toys, requiring men to take a DNA test and to pay child support when a woman is six weeks and one day pregnant, and making sex without a condom an “aggravated assault.”

“Kendrick, who has been a state legislator since 2011, hopes to have her counter-bill drafted by the end of the week.,” our Post colleague Katie Mettler writes. “She told Rolling Stone she knows the bill will not pass — definitely not this year, because the filing deadline has already passed, and maybe not ever. But that was never the point, she said. She proposed her testicular bill of rights to ‘bring awareness to the fact that if you’re going to legislate our bodies, then we have every right to propose legislation to regulate yours,’ Kendrick told Rolling Stone.”

AGENCY ALERT

— Veterans Affairs Secretary Robert Wilkie has pushed to be the next secretary of defense, our Post colleagues Lisa Rein, Seung Min Kim and Josh Dawsey report. 

His career has " long gravitated to military matters," and his internal push comes as the president has not yet formally nominated a replacement for Jim Mattis, the retired Marine general who quit as Pentagon chief last December because of differences with the president. 

Wilkie has been leading VA for about eight months, and came to the role after serving as under secretary of defense for personnel and readiness at the Pentagon. "He has pitched himself to top White House officials as an experienced hand in defense policy and running large bureaucracies, according to an administration official and another person close to the administration who requested anonymity to discuss personnel matters," our colleagues report. 

"Mattis’s deputy, former Boeing executive Patrick Shanahan, has been auditioning for the role as acting secretary since early January," they write. "Shanahan is widely expected at the Pentagon to be nominated as permanent secretary, but officials have said there’s no certainty about his elevation until a White House announcement. The president has been known to change his mind on personnel decisions."

In an email, VA spokesman Curt Cashour said Wilkie “remains 100 percent focused on his job as VA secretary.”

— National Cancer Institute Director Norman “Ned” Sharpless will take over for Scott Gottlieb as acting director of the Food and Drug Administration when Gottlieb leaves next month, our Post colleagues Laurie McGinley and Amy Goldstein report.

Azar announced the appointment of Sharpless, who has been the nation’s cancer chief for about a year and a half, at a hearing before the House Energy and Commerce Health subcommittee. "We are going to be carrying forward Dr. Gottlieb’s vision,” Azar said. “His agenda is my agenda. My agenda is his agenda.”

Sharpless, 52, has earned praised from cancer advocates, patient groups and researchers during his time as head of the cancer institute.

“In his relatively short tenure at the cancer institute, Sharpless pushed for increased data sharing, analysis and aggregation to develop new understanding and treatments for cancer,” Laurie and Amy write. “He also pressed to modernize clinical trials and worked to increase funding for academic investigators around the country, even when that required cutting internal programs.”

In a statement, Azar said Sharpless’s “deep scientific background and expertise will make him a strong leader for FDA … There will be no let-up in the agency’s focus, from ongoing efforts on drug approvals and combating the opioid crisis, to modernizing food safety and addressing the rapid rise in youth use of e-cigarettes.”

From CMS administrator Seema Verma: 

HEALTH ON THE HILL

— The House Energy and Commerce Health subcommittee will consider seven bills this morning aimed at lifting barriers to generic medications as a way of lowering drug prices overall.

But minority Republicans on the committee charge they were mostly left out of the process, saying they were given only 24 hours to identify Republican cosponsors for the Democrat-led bills (just three of the bills are bipartisan) and complaining that one of the bills on the docket -- the CREATES Act -- is bereft of some details added to other bipartisan versions of the legislation to address concerns about unintended consequences. 

"Regrettably, while Republicans share the goal of the today’s hearing – lowering the cost of prescription drugs – the process has been anything but inclusive," Rep. Greg Walden, ranking member of the full Energy and Commerce Commitee, will say at the hearing, per advance remarks shared with The Health 202.

— Post Fact Checker Glenn Kessler gave Rep. Alexandria Ocasio-Cortez three Pinocchios for a misleading comparison of the administration’s response to the opioid crisis and funds the president transferred for action on the border wall. 

During a hearing last week, the New York Democrat questioned James W. Carroll, the White House’s director of drug policy, about money the president transferred from the Public Health Emergency Fund. Ocasio-Cortez asked about “whether the declaration of a public health crisis regarding opioids should have triggered a transfer of money from other agencies, a la Trump’s maneuvers to build a wall,” Glenn writes. “Did the declaration of a public health emergency for opioids make any additional funding available to expand treatment for individuals for overdose to provide services for people in recovery?” Ocasio-Cortez asked during the hearing. 

But the comparison of the two moves is misleading. While the president demanded nearly $6 billion from lawmakers for his proposed border wall, Congress refused to provide that funding – the impasse led to a lengthy government shutdown, which prompted Trump to declare a national emergency. He also said he would transfer funds from other agency accounts to pay for his wall.

For the opioid emergency, meanwhile, Congress appropriated more than $6 billion to address the public health crisis, which means there was “little need for him to transfer funds without congressional authorization.”

“Ocasio-Cortez is making a misleading comparison,” Glenn concludes. “Trump has no need to transfer billions of dollars for the opioid emergency because Congress already has appropriated billions of dollars. Trump’s backing of a national public-health emergency did more than raise awareness; it triggered a congressional response. So it’s the exact opposite of the standoff over the wall.”

— Republican Sens. Joni Ernst (Iowa) and Mike Lee (Utah) unveiled a paid parental leave proposal that would allow both adoptive and natural parents to get up to three months of paid leave in exchange for delaying retirement.

The Cradle Act would let new parents take one, two or three months of paid leave. They would then postpone collecting Social Security benefits at retirement for two, four or six months.

“One of the most significant stumbling blocks for many new families is the lack of paid family leave for new parents...Giving every new mom and dad the flexibility to stay home for some of that time is something all Americans would like to see,” the senators wrote in a Tuesday op-ed in The Post. “The question has always been: How do you pay for it?”

During a news conference to introduce the plan, Lee said the hope is for the proposal to be budget neutral in the long term, but said there will be around $7 billion to $9 billion in annual costs short-term, and he added they are looking into ways to offset those initial costs.

— And here are a few more good reads: 

TRUMP TEMPERATURE
Conquering the epidemic was a vow made on the campaign trail.
Jacqueline Alemany
MEDICAL MISSIVES
Women say a culture of harassment, discrimination and exclusion lives inside the Veterans Affairs medical system as they try to use the government benefits they earned with military service.
New York Times
The Olympic medalist died of suicide last week at the age of 23.
Cindy Boren
WORCESTER, Mass. (AP) — This industrial city in central Massachusetts has had many nicknames through the years, including “the Heart of the Commonwealth” and “Wormtown.” Among them was this less-known medical moniker: “Hepatitisville.”
Associated Press
A bill in Washington state would give parents more rights — while trying to still give teens authority over their own mental health care.
Stat
INDUSTRY RX
National
Craig Landau told The Washington Post that Purdue is developing a powerful anti-overdose drug in a pro-bono effort to combat the effects of the opioid crisis.
Katie Zezima
UnitedHealth Group and OptumRx, are expanding a new program that passes along pharmacy discounts they get from drug manufacturer rebates to new employer customers.
Forbes
Hospitals and insurers are gearing up to battle a Trump administration plan that could require the public disclosure of negotiated prices for medical services, part of an effort to lower U.S. health-care costs.
Wall Street Journal
Two Blue Cross Blue Shield insurers based in Oregon and North Carolina plan a tie-up that will bring together powerful regional players generating some $16 billion in revenue and cover more than six million people.
Wall Street Journal
REPRODUCTIVE WARS
National Security
The law cut off funding for services such as cancer screening because the organization also provides access to abortion.
Fred Barbash
Abortion rights leaders in Congress will ask House Speaker Nancy Pelosi (D-Calif.) to hold a vote on a bill that would allow abortion coverage to receive federal funding. 
The Hill
BRAIN WAVES
Business
The less profit-driven legalization options available haven’t gotten much attention.
Keith Humphreys
DAYBOOK

Today

  • The House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies holds a hearing on the HHS budget request for 2020.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on lowering prescription drug costs.

Coming Up

  • The Senate Finance Committee holds a hearing on the president’s 2020 budget request on Thursday.
SUGAR RUSH

Here's how Trump's 2020 budget proposal would impact federal agencies: