THE PROGNOSIS

Former special counsel Robert S. Mueller III will face tough questions when he appears before members of Congress tomorrow. But here’s what a group of psychiatrists wants asked: Did Mueller ever consider requesting an evaluation of President Trump’s mental capacity?

Mueller's long-awaited report was released publicly in April, and much of the discussion centered around its examination of Russian interference in the 2016 election and whether Trump onbstructed the special counsel's probe. But to Yale University professor Bandy Lee and four other mental health experts, the report provided proof the president lacks basic capacity to make sound, rational decisions. Using the Mueller report to evaluate the president's mental fitness is a controversial tactic, and Lee has her share of critics, including other medical professionals.

The president’s mental state is so fundamental to his behavior — specifically, how he might exercise his commander-and-chief role — that it overrides any other concerns about his actions, Lee and her colleagues contend.

“What was really alarming to us is the president did not meet any of the criteria for mental capacity and the level of incapacity was beyond our expectation,” Lee told me in a phone conversation, referring to her reading of Mueller's report.

Lee and her colleagues — who have gone out on the controversial limb of evaluating the president’s mental abilities without personally examining him — are inviting members of Congress to join a conference call this afternoon, followed by an online presentation for the public. They’ll use both forums to lay out questions they think Mueller should be asked in his dual appearances before the House’s Judiciary and Intelligence committees on Wednesday.

Lee will be joined by Edwin Fisher, a clinical psychologist from the University of North Carolina at Chapel Hill, and psychiatrists Leonard Glass of Harvard Medical School, James Merikangas of George Washington University, and James Gilligan of New York University.

The five professors teamed up this spring on a 19-page analysis based on Mueller’s report, in which they used the special counsel's interviews with Trump aides and staffers to perform what they call a “capacity evaluation” of the president’s mental abilities.

They analyzed Trump’s behavior based on four criteria: His ability to take in information accurately, process that information, make sound decisions based on it and refrain from placing himself or others in danger. They concluded that Trump was unable to make responsible, informed decisions and he would have placed the country at huge risk if not for advisers around him who refused to carry out his various demands. Lee and her colleagues have not evaluated Trump personally and the American Psychiatric Association says it's unethical to diagnose public officials without evaluating them personally.

The group's analysis recommended that Trump be formally evaluated by a panel of independent experts.

“We didn’t expect this, but the Mueller report turned out to be a wealth of high-quality data on what the president’s close associates thought of him at his job,” Lee told me in a phone conversation. “This is now hard, intimate data, exactly the kind we need, and we don’t need any more.”

But Lee’s assertions are deeply controversial among mental health professionals. The APA has doubled down on its so-called “Goldwater Rule,” which prohibits armchair diagnoses.

The rule arose back in the 1970s, as a reaction to a survey published by Fact magazine during the 1964 presidential election. Fact published the results of a survey in which more than 12,000 psychiatrists were asked whether the GOP nominee, Sen. Barry Goldwater, was psychologically fit for the presidency. Goldwater subsequently sued and won a defamation lawsuit against Fact.

After some psychiatrists challenged the rule when Trump was elected — signing a letter to the New York Times expressing concerns about his mental state — the APA clarified the Goldwater Rule bans not just armchair diagnosing but also offering any professional opinions about anyone other than a patient.

“In its opinion, APA’s Ethics Committee asserts that while it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination,” says a blog post published on the APA’s website.

Lee, who has also written a book entitled “The Dangerous Case of Donald Trump,” contends she’s not breaking the Goldwater Rule as it was originally applied. She argues it’s the APA that has violated medical ethics by banning the most qualified people — psychiatrists — from saying anything at all about Trump’s fitness to handle the most sensitive, classified information that could affect the safety of millions of Americans.

And she insists that analyzing Trump’s behavior as detailed in the Mueller report is no different from mental capacity evaluations that police or military officers are often required to undergo. She says she's not giving the president a diagnosis — she’s just evaluating from afar whether there’s evidence he can make sound decisions.

“We found overwhelming evidence supporting that he does not meet capacity and very little information to show he does meet criteria,” she said.

AHH, OOF and OUCH

AHH: Some clinics now getting federal funds through the Title X program are focusing their services on abstinence and natural family planning as birth control methods, our Washington Post colleague Ariana Eunjung Cha reports.

For example, in California, Obria Group’s health centers are modeled after faith-based crisis pregnancy centers. Chief executive Kathleen Bravo told Ariana the clinics are a “pro-life” alternative to Planned Parenthood. And these clinics also try to cater to younger clients with online apps that encourage the patients “away from sexual risks as their only option in life, to an option of self-control.” They also offer an “abortion pill reversal,” a procedure that Ariana notes the American Congress of Obstetricians and Gynecologists warns is not supported by scientific research.

“Political analysts have called the Obria grant a game-changer for the antiabortion movement that may lead to similar clinics being eligible for more types of federal grants, reimbursement from Medicaid and participation in private insurance plans,” Ariana reports. “The Department of Health and Human Services granted $1.7 million to Obria in fiscal year 2019, with the possibility to be renewed for two more years for a total of $5.1 million — part of a larger effort by religious conservatives in the Trump administration to transform women’s health-care services to promote alternatives to abortion and hormonal birth control, such as birth control pills, and to promote marriage between a man and woman.”

OOF: There’s one critical element that contribute to surprising and eye-popping medical bills that’s been left out of the effort by lawmakers to address surprise bills.

 Ambulance companies are the biggest source of unexpected medical bills, with 51 percent of ground ambulance rides resulting in out-of-network bills, according to research from health economist Christopher Garmon at the University of Missouri-Kansas City, the New York Times’s Sarah Kliff and Margot Sanger-Katz report. Comparatively, 19 percent of emergency room bills are out of network, as are 9 percent of elective inpatient procedures.

“Five states have passed laws this year to restrict surprise billing in hospitals and doctor’s offices. Congress is working on a similar package of measures, after President Trump held a news conference in May urging action on the issue,” they write. But none of those efforts tackle bills coming out of ordinary ambulance transport. “Congress has shown little appetite to include ambulances in a federal law restricting surprise billing. One proposal would bar surprise bills from air ambulances, helicopters that transport patients who are at remote sites or who have life-threatening injuries. (These types of ambulances tend to be run by private companies.) But that interest has not extended to more traditional ambulance services — in part because many are run by local and municipal governments.”

OUCH: A proposed change from the Agriculture Department could mean cutting food stamp benefits to about 3 million people.

Agriculture Secretary Sonny Perdue and Acting Deputy Under Secretary Brandon Lipps told reporters on a call the proposed new rules for the food stamp program, known as Supplemental Nutritional Assistance Program (SNAP), was meant to limit food stamps for those with savings or other assets, ending automatic eligibility for people who are already getting federal and state assistance, our Post colleague Laura Reiley reports, a move officials said would save $2.5 billion a year.

“Forty-three states now grant automatic eligibility to low-income people already receiving other government benefits -- without undergoing income or asset tests,” Laura writes. “…Current rules give states latitude to raise SNAP income eligibility limits so that low-income families with housing and child care costs that consume a sizable share of their income, can continue to receive help affording adequate food. This option also allows states to adopt less restrictive asset tests so that families, seniors and people with a disability can have modest savings or own their own home without losing SNAP benefits.”

Stacy Dean, vice president of food assistance policy at the Center on Budget and Policy Priorities, said the chance could have a negative impact on seniors, working families and people with disabilities.

HEALTH ON THE HILL

—  Some Democrats, especially those in centrist districts, are worried what all the talk about Medicare-for-all will mean about their chances to keep the House in 2020, our Post colleagues Sean Sullivan and Emily Davies report.

“I think it’s a losing message for 2020, and I think the Democratic presidential candidates have to realize that this is not a far-left country nor is it a far-right country,” said Rep. Anthony Brindisi (D-N.Y.) after Sanders delivered a speech touting his plan on a recent afternoon. “I think we’re all very vulnerable the further to the left some of the presidential candidates go.”

Brindisi unseated a Republican in a battleground New York District in November. Rep. Kim Schrier (D-Wash.), a pediatrician and a Democrat who won a Republican-held seat last year, said she supports letting people opt into a government system rather than mandating it. “I think it is a mistake to want to blow up the system that is working pretty darn well the way it is,” she said.

“The tension is evident across the country, from suburbs where voters fear higher taxes, more government and the demise of private insurance, to campaign rallies in Iowa and New Hampshire, where some candidates are cheering Medicare-for-all as a moral imperative,” Sean and Emily write. “The health-care dispute is part of a larger question Democrats face in the lead-up to the 2020 election: Do they want to run on a platform that takes an ax to laws governing health care, immigration, the environment and financial regulation, or is it better to use a chisel?”

While many centrist freshman Democrats took their seats from Republicans in November, they want to repeat that success in 2020 and they’re in a tough spot as the some in the party shift to the left.

INDUSTRY RX

— According to a new white paper out today from independent nonprofit FAIR Health, there was a marked in increase individual private insurance treatment claims for telehealth services between 2014 to 2018. Overall, claims for telehealth services grew 624 percent in that time, according to the data, a point that underscores what’s been an increasing trend of virtual care, or telehealth, that medical providers, including hospitals and clinics, have adopted to fill some gaps in patient care.

The biggest increase in telehealth use was for non-hospital-based telehealth services: There was a 1,393 percent increase in private insurance claims from 2014 to 2018 for such services, described as virtual communication between the patient and provider without any link to a hospital or hospitalization. In 2018, these types of services made up 84 percent of all telehealth treatment claims, based on data from FAIR Health’s source of more than 29 billion private health-care claim records.  

Among these non-hospital-based services, patients most often sought treatment for acute upper respiratory infections, mood disorders, and anxiety and other nonpsychotic mental disorders, according to the white paper. The research also found non-hospital telehealth claims increased more for urban areas: a 1,227 percent growth in urban regions compared to an 897 percent growth in rural areas. 

Your Health 202 author wrote in March a two-part series about a Missouri-based virtual care center that’s part of the new trend, and about why lawmakers haven’t warmed to the expansion of virtual care.

AGENCY ALERT

 — Centers for Medicare & Medicaid Services Administrator Seema Verma criticized public option health-care plans that some Democrats have proposed as a compromise or steppingstone to an all-out Medicare-for-all system. Verma said public option plans are “equally dangerous” to Medicare-for-all.

“As head of the nation's largest insurer — Medicare, Medicaid, and the Obamacare exchanges — I see the day-to-day challenges of government-run programs, and am deeply concerned about the proposals we have seen to upend healthcare in America, particularly Medicare for All and the public option,” Verma said in prepared remarks for a summit yesterday in Washington for Medicare Advantage.

“Make no mistake — the public option is a Trojan horse with a single payer hiding inside,” she added.

Instead, Verma said the Trump administration wants to “protect Medicare and Medicaid programs” and touted Medicare Advantage programs as a part of the system that works.

Her remarks come as candidates in the Democratic presidential field have been butting heads over the health-care debate — former vice president Joe Biden, for one, has been arguing for providing a public option for people in addition to expanding the Affordable Care Act as a more moderate alternative to Sen. Bernie Sanders's (I-Vt.) Medicare-for-all proposal.

REPRODUCTIVE WARS

— Leana Wen, who was ousted from Planned Parenthood last week, explained in a candid op-ed in the New York Times her view about her departure from the organization, detailing what she describes as a difference of opinion over making the abortion debate about health care rather than politics.

“While the traditional approach has been through prioritizing advocating for abortion rights, I have long believed that the most effective way to advance reproductive health is to be clear that it is not a political issue but a health care one,” she wrote. “I believed we could expand support for Planned Parenthood — and ultimately for abortion access — by finding common ground with the large majority of Americans who can unite behind the goal of improving the health and well-being of women and children.”

She said she looked to “depoliticize” the organization, saying that the recent challenges Planned Parenthood faced, from numerous states approving abortion restrictions to the administration’s Title X enforcement, gave the group a reason to “emphasize its role in providing essential health care to millions of underserved women and families.” “But in the end, I was asked to leave for the same reason I was hired: I was changing the direction of Planned Parenthood,” she wrote.

Our Post colleagues Lenny Bernstein, Ariana Eunjung Cha and Amy Goldstein reported last week about Wen, who was forced out of her job after just eight months in the role.

— And here are a few more good reads: 

Memo appears to contradict Leana Wen’s claim that she tried to depoliticize abortion, leading to her firing.
Politico
TRUMP TEMPERATURE
Politics
The president announced his intention two days after the Senate minority leader visited migrant detention centers that he called “inhumane.”
John Wagner
MEDICAL MISSIVES
Health
Medicaid rules in several states exclude sexual reassignment treatment, others allow it. Advocates argue restrictions stem from prejudice, not medical science.
Michael Ollove
A long troubled U.S. Indian Health Service hospital continued to be plagued by poor medical care, untrained staff and leadership turnover, despite improvements made there by top agency officials, a government watchdog said.
Wall Street Journal
“It is women, in particular, who are bearing the burden of this increased gun ownership,” the lead author of the study said.
New York Times
Congo's health minister resigned on Monday after being stripped of responsi...
Reuters
STATE SCAN
Public Safety
Decades of service at the Man Alive treatment center in Baltimore was abruptly halted when a man demanding methadone walked into the center and opened fire.
Lynh Bui and Laurel Demkovich
DAYBOOK

Coming Up

  • The House Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies holds a hearing on oversight of the unaccompanied children program on Wednesday.
  • The House Oversight and Reform Subcommittee on Economic and Consumer Policy holds a hearing on Juul’s role in the youth nicotine epidemic on Wednesday and Thursday.
  • The House Homeland Security Subcommittee on Intelligence and Counterterrorism holds a hearing on the security implications of the opioid crisis on Thursday.
SUGAR RUSH

Here are seven questions Mueller did not answer in his report: