THE PROGNOSIS

In an address scheduled shortly before noon today, President Trump will call on Congress to pass legislation protecting Americans from the all-too-common problem of surprise medical bills, incurred after a patient receives care from a doctor who is outside his or her health plan’s network.

The president — who in January directed Health and Human Services Secretary Alex Azar and Labor Secretary Alex Acosta to pursue a fix — is expected to lay out principles he wants upheld in any legislation on surprise billing Congress might consider, lobbyists and advocates confirmed to The Health 202.

Trump’s remarks come as a bipartisan group of six senators work to finalize a bill outlining how insurers and doctors should go about settling billing disputes resulting from out-of-network care. That effort is being led by Sen. Bill Cassidy (R-La.) and by Sen. Maggie Hassan (D-N.H.), whose offices confirmed they will attend today’s address at the White House. The group is expected to roll out legislation by the end of May.

Lawmakers aren't targeting just any medical bills that catch people unaware. They are seeking to curtail medical bills widely regarded as truly unfair because patients couldn’t avoid them despite their best efforts.

Even when patients carefully select a hospital in their network, they may still end up receiving care during a hospital stay from a radiologist, anesthesiologist or pathologist who isn't part of their insurance's coverage network. As a result, they’ll receive higher bills reflecting out-of-network rates — charges that can amount to thousands or even tens of thousands of dollars.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a January roundtable on the subject.

Joe Grogan, director of the White House Domestic Policy Council, told hospitals in March they had better address the problem or else expect action from policymakers and lawmakers.

“If hospitals, providers and issuers don’t protect these patients from financial harm, Congress and the administration will need to act,” Grogan said at the Federation of American Hospitals’ annual conference.

Insurers, doctors and hospitals all publicly say they agree that patients should be protected from these kinds of charges. But the effort sets up a potential fight among different stakeholders, as they each try to duck the extra costs that would be shifted away from patients.

Both providers and insurers agree there should be a process to determine payment rates. The goal here is to bridge the gap between the charge from a hospital or doctor and what insurers say they’re willing to pay for out-of-network care. But there are a few different ways to get there.

— Several previous bills have proposed an arbitration process, where an impartial arbiter examines the figures presented by each side and selects one as the final payment. Proponents of this approach point to New York’s baseball-style arbitration process in place since 2015, which has prompted a major decline in out-of-network medical bills in the state.

— Another approach is to set a fixed standard in which out-of-network care would be reimbursed at a rate such as 125 percent of Medicare rates, or the 80th percentile of rates paid by commercial plans.

— Some economists have also suggested that bundling payments for hospitals and their on-site doctors could help solve the problem.

The trick with all these possible approaches is to make sure the payments aren’t set too high, which could incentivize doctors to leave a hospital’s network, nor too low, to ensure providers still get adequately compensated and that insurers don’t gain too much leverage.

America’s Health Insurance Plans, the major health insurers association, favors a set payment method, warning that an arbitration process could lead to higher premiums. Doctors appear favorably inclined to both methods, but they’ve stress that insurers should be required to contract with a sufficient number of doctors and specialists — a further way to shield patients from encountering an out-of-network physician during a hospital stay.

“Overly narrow provider networks — particularly those that lack sufficient numbers of specialists — are a major factor in unanticipated billing,” Barbara McAneny, president of the American Medical Association, wrote in an op-ed published Tuesday by the Hill.

AHH, OOF and OUCH

AHH: Drugmakers will be required to display the list price of medications in television advertisements, according to a rule finalized yesterday by HHS. The advertisements must also display the sentence “If you have health insurance that covers drugs, your cost may be different,” as an acknowledgment that list prices are usually much higher than what insured consumers must pay out-of-pocket for their medications. It will apply to medicines that cost more than $35 for a month supply.

The regulation, which the pharmaceutical industry decried yesterday, is among a basket of steps the Trump administration is taking to improve transparency in the drug pricing system and put pressure on drugmakers to ease their prices.

“Requiring drug companies to level with American patients about their prices is about working toward a system where the patient — not the insurer, not the drug company, not the government but the patient — is the one in control of her health care,” Azar told reporters.

OOF: Sen. Elizabeth Warren (D-Mass.) said she would donate the $4,500 in campaign contributions she has previously accepted from the prominent Sackler family, which owns one of the country’s top opioid manufacturers, Purdue Pharma.

In a Medium post announcing a plan to use $100 billion in federal funding to address the opioid epidemic, Warren criticized the family and its role in the crisis.

“The opioid epidemic teaches us that too often in America today, if you have money and power, you can take advantage of everyone else without consequence. I think it’s time to change that,” she wrote. “That’s the America we deserve … An America where, when people like the Sacklers destroy millions of lives to make money, they don’t get museum wings named after them, they go to jail.”

It’s not clear to what groups Warren will donate the funds, the Wall Street Journal’s Joshua Jamerson reports, adding the Massachusetts Democrat has received money from numerous members of the family going back to 2012.

— Warren's $100 billion plan to tackle the opioid epidemic is also an “eye-catching amount that reflects a broader strategy by Democrats to focus on issues important to President Trump’s base where they say he has fallen short,” our Post colleagues Annie Linskey and Katie Zezima report.

Yesterday the Trump administration released a report listing action it has taken to address the opioid crisis, including securing $6 billion in funding from Congress, upping the number of prosecutions of fentanyl traffickers and increasing the availability of medication-assisted treatments and overdose-reversing medication. James Carroll, director of the White House Office of National Drug Control Policy, claimed “significant progress" in combating the epidemic.

“The spotlight thrown on the topic by leaders of both parties shows the potency of addiction as a political issue and the continued impact of an overdose crisis that resulted in roughly 70,000 deaths in 2017, most of them from opioids,” Annie and Katie write.

But in an interview, Warren insisted Trump “has been all talk and no action” and dismissed a question about whether the Trump administration has increased attention on opioids. “It doesn’t matter if you don’t back it up with real resources and help for the people who need it,” Warren said. “He hasn’t made it a priority.”

OUCH: People living in rural areas are increasingly responsible for the rise in global obesity rates. Our Post colleague William Wan reports a consortium of researchers found in the past three decades, the global rise in obesity has mostly been propelled by unhealthy weight gain in rural pockets, rather than in urban areas.

“The study — a massive collaboration by more than 1,000 researchers, drawing on more than 2,000 studies of 200 countries — found that more than 55 percent of the global increase in body mass index in the past 30 years has come from rural populations,” he reports. “The trend was even sharper in low- and middle-income countries, with more than 80 percent of the worsening BMI driven by rural populations.”

Barry M. Popkin, a University of North Carolina food science researcher who was not involved in the new study, told William: “It means we need to think of policies that address rural areas or have an effect in rural and urban areas equally. We can’t just ignore it anymore.”

AGENCY ALERT

— Robert Pear, a 40-year veteran of the New York Times and relentless health-care reporter, died this week at age 69. He was, as our Post colleague Emily Langer writes, “one of the most relentlessly probing journalists on the health-care beat, enlightening readers and rankling partisans with the clarity of his reportage and his savantlike understanding of the federal government and its arcana. With a seemingly ever-present byline on Page One of the Times, Mr. Pear was a constant and authoritative presence in Washington for four decades.”

As the New York Times’s Sam Roberts writes, Pear tenaciously pursued scoop after scoop, and in the course of more than 6,700 Times articles “went about his reporting meticulously and, to the wider public, inconspicuously.” In his memory, the New York Times is retiring the slug “HEALTH,” because as editors said: “it can only be by Pear.”

Many in the health-care industry, fellow reporters and lawmakers reacted to Pear’s death, including Senate Minority Leader Chuck Schumer (D-N.Y.):

From the Times's Maggie Astor: 

Soon-to-be-Times reporter Sarah Kliff:

Andy Slavitt, who headed CMS under President Barack Obama:

HEALTH ON THE HILL

— Democrats on the House Appropriations Committee batted down a Republican effort to block funding to entities that provide abortions unless certain requirements were met related to babies born alive after attempted abortions, as our Post colleague Erica Werner reports.

The 23-29 defeat of the amendment by Rep. Tom Cole (R-Okla.) followed impassioned remarks from Rep. Jaime Herrera Beutler (R-Wash.) in support of the measure. She detailed how multiple health-care providers told her to end her pregnancy with her first child, now 6 years-old, who was born without her kidneys. Her first daughter, Abigail, is now doing well and Herrera Beutler is expecting her third child this month.

“I just think how many other instances are there?” the Washington Republican told the committee. “Most of these are moms who want these babies. They’re not wanting to terminate late because they didn’t want the pregnancies, it’s because there’s a problem and they were told there’s no chance.”

Rep. Rosa DeLauro (D-Conn.) dismissed the Republican effort as a “ruse to ban safe and legal abortion in the United States.”

— Later in the day, the House Appropriations Committee also voted to block a new Trump administration rule aimed at protecting health-care providers, insurers and employers who object to providing or paying for services like abortion that violate religious beliefs. 

"The measure by Rep. Barbara Lee (D-Calif.) would prevent spending to implement the new rule, which Trump announced last week during a speech before faith leaders," Erica writes. Lee's amendment passed on a 30-23 vote along party lines. 

"This dangerous and discriminatory rule attempts to enshrine discrimination in virtually all facets of health care by granting new rights to those who believe their personal beliefs should determine the care a patient receives,” Lee said. Meanwhile, Republicans called Lee's measure a "poison pill" that would hinder passage of the broader spending bill being debated. 

— And the full Democrat-led House plans to vote today on a bill blocking HHS from granting states Affordable Care Act waivers that could make way for some health plans with fewer protections for individuals with preexisting conditions. The White House threatened to veto it.

In a policy statement threatening a veto, the White House suggested the bill’s title — the Protecting Americans with Preexisting Conditions Act of 2019 — was “misleading.” “This bill would not extend any additional protections for people with pre-existing conditions. Rather, it would harm the ability of States to improve coverage for people both with and without pre-existing conditions,” the statement read.

In response, Protect Our Care chair Leslie Dach also pointed to Republican efforts to undermine the health-care law and its protections for people with preexisting conditions, including a GOP-backed lawsuit aiming to invalidate the ACA: “[T]he record shows they’ll do everything they can to let insurance companies gut coverage for patients with pre-existing conditions.”

From House Speaker Nancy Pelosi (D-Calif.):

Sen. Tammy Baldwin (D-Wis.):

Rep. Don Beyer (D-Va.):

MEDICAL MISSIVES

— Robert F. Kennedy Jr.’s own family is calling out his anti-vaccine views, as the United States grapples with its worst measles outbreak in years that’s been in part blamed on the spread of misinformation.

In a piece published in Politico Magazine, Kennedy’s brother former congressman Joseph P. Kennedy II (D-Mass.), sister Kathleen Kennedy Townsend and niece Maeve Kennedy McKean lament the growing number of measles cases that are “amplified by internet doomsayers.”

“Robert F. Kennedy Jr. … is part of this campaign to attack the institutions committed to reducing the tragedy of preventable infectious diseases,” they write. “He has helped to spread dangerous misinformation over social media and is complicit in sowing distrust of the science behind vaccines.”

The trio express their love for Kennedy and praise his work in other areas. “He is one of the great champions of the environment… However, on vaccines he is wrong”

TRUMP TEMPERATURE

— Shelters at the U.S. border are bursting at the seams after thousands of migrant families have come seeking asylum. For example, one 66,000-square-foot space to house migrants in Tucson is full, the Wall Street Journal’s Alicia A. Caldwell reports.

“The border has seen illegal-immigrant waves before. This one is different,” Alicia writes. “Instead of the single job seekers of a decade ago who aimed to sneak in undetected, these are families openly seeking asylum—more like the groups of refugees familiar on borders elsewhere in the world, where wars, famine and genocide have created massive camps of displaced families with nowhere to go.”

This fiscal year, about 248,000 parents and children crossed illegally into the country by April -- more than had done so in any prior full year, according to federal data. 

A tent city has opened in Donna, Tex., in the latest effort to house migrant families, but Alicia writes such facilities are only meant to temporarily house 500 family members and unaccompanied minors and “won’t make a dent in the crisis.”

“A Homeland Security Advisory Council in a report last month recommended construction of more permanent regional processing centers,” she adds. “Without legal changes, they are ‘nothing but a welcoming center and will have no impact on stemming the flow of these family units coming across the border in these remote locations,’ said Karen Tandy, chairwoman of the Homeland Security Advisory Council panel that produced the report, who headed the Drug Enforcement Administration under President George W. Bush.”

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

Climate and Environment
A federal court also has ordered the EPA to ban chlorpyrifos, but the Trump administration has appealed the ruling.
Brady Dennis and Juliet Eilperin
Federal health officials rolled out two new draft guidances about how to study drug safety and efficacy in pregnant and lactating women.
Stat
OPIOID OPTICS
Politics
Shirts sporting the moniker are selling fast, but some drug policy experts have said the apparel is in bad taste.
Reis Thebault
REPRODUCTIVE WARS
Polling done a decade ago by the senior White House adviser finds its way into a new federal rule cheered by religious activists.
Politico
Health
It started with a report noting that Texas saw a 14 percent rise in parents opting out of their children’s vaccinations.
Deanna Paul
Politics
Pennsylvania state Rep. Brian Sims called antiabortion activists "Bible bullies," bigots and misogynists.
Marisa Iati
SECOND OPINION
Opinions
This House majority was won not on the platform of national single-payer health care, but on a commitment to improve the ACA.
Heidi Heitkamp
STATE SCAN
True Crime
The referendum was the first in the country to consider changing the status of psilocybin mushrooms, which some say could have positive effects on depression, pain and addiction.
Tom Jackman
Virginia Politics
In the landmark ruling, the judge said a state law requiring a physician is unconstitutional.
Rachel Weiner and Laura Vozzella
Local
The wedding was held on a recent Saturday on the lower level of Meridian Hill Park in D.C.
Theresa Vargas
INDUSTRY RX
Business
The retailer is also phasing out fruit- and dessert-flavored e-cigarettes from its Walmart and Sam's Club stores amid pressure from the FDA.
Abha Bhattarai
Following a campaign by activists, Gilead announced a generic version of Truvada, or PrEP, will be available next September, a year earlier than expected.
NBC News
DAYBOOK

Today

  • The House Energy and Commerce Subcommittee on Health holds a hearing on lowering prescription drug prices.
  • The House Oversight and Reform Committee hold a hearing on the Trump administration’s response to the drug crisis.
SUGAR RUSH

President Trump made a joke when a supporter at his Florida rally reportedly suggested migrants crossing the Southern border should be shot:

Prince Harry and Meghan made their first public appearance with their newborn son Archie Harrison Mountbatten-Windsor