THE PROGNOSIS

Sen. Elizabeth Warren (D-Mass.) is working to finalize a proposal to finance Medicare-for-all before the next Democratic presidential debate on Nov. 20, where she may face more land-mine questions over how she’d pay for the whole thing.

But her task would be easier if she backed a less sweeping approach than the Medicare-for-all legislation written by her opponent, Sen. Bernie Sanders (I-Vt.). Warren herself has yet to release a plan, and has dodged questions about whether she would raise taxes to pay for it.

“Warren, who opposed single-payer in her 2012 Senate run, said her Medicare-for-all financing plan has been ‘months and months’ in the making,” my Washington Post colleague Jeff Stein reports. “A campaign spokeswoman would not share any details of what is under consideration but said a plan would be released in the next several weeks. The spokeswoman added the campaign has made no final decisions.”

Analysts on both the political right and left have estimated the Sanders legislation, which Warren has said she wholly backs, could cost more than $30 trillion over a decade. By comparison, the overall federal government spent about $4 trillion last year. Passing the Sanders legislation — which would provide every American with a comprehensive set of benefits, largely without any co-pays — could expand the government’s financial obligations more than 50 percent over the next 10 years.

So finding ways to finance the Sanders plan is a daunting task for Warren, for multiple reasons.

For one thing, she’s already taken heat for refusing to answer direct questions in the debates about whether implementing such a plan would require increasing taxes on middle-class families. Sanders has admitted more freely that taxes would go up — but he has argued that overall health-care costs would decrease for most people because they would no longer have to pay for private coverage.

And Warren has already committed all the money she would raise from a new wealth tax to other proposals, including expanding child care and canceling student debt. So she’d need to find other sources of revenue — preferably ones that don’t enact any sizable taxes on the middle class if she isn't to get major political blowback for them.

From Post political reporter Dave Weigel:

Internal and external economists and advisers are trying to help Warren figure out how to pay for the dramatic overhaul, Jeff reports. Longtime Warren aide Bharat Ramamurti is spearheading the effort, and Robert Pollin, a left-leaning economist at the University of Massachusetts at Amherst, is also contributing.

“They want to figure out — with one go — how to stop the ‘How are you going to pay for it?’ question,” one outside economic adviser told Jeff. “She wants something airtight but easy to understand.”

Pollin said he thinks two-thirds of the needed funds could come from redirecting existing spending from Medicare, Medicaid and the Department of Veterans Affairs. The remaining third would come from raising business, sales and wealth taxes. Here’s how he would do it:

— A $600 billion annual “gross receipts” tax on businesses, which Pollin says would be less than the $650 billion firms currently spend on health care.

— A 3.75 percent sales tax on “non-necessities” that exempts low-income households, raising $200 billion.

— A 0.38 percent wealth tax on wealth above $1 million, raising the remaining $200 billion needed.

Another adviser to Warren, Cornell University professor Robert Hockett, told Jeff he has urged the senator’s campaign to propose funding Medicare-for-all in part with a “public premium” that would go to the government as a tax, rather than a private insurance company.

Warren is the only remaining presidential candidate who says she fully backs the Sanders legislation even as other contenders have softened their positions and proposed alternatives that would keep private insurance intact. The senator, a leading candidate for the 2020 nod, is endearing herself to liberals by backing the Sanders bill, but there’s a wide range of ways to get the country to universal health coverage — nearly all of them less expensive than Medicare-for-all.

Analysts at the left-leaning Urban Institute and the Commonwealth Fund recently released a paper analyzing eight incremental approaches to get more — and potentially all — Americans insured. Let’s take a quick spin through the approaches, each one building on the previous one:

1. Make the Affordable Care Act’s subsidies more generous and set up reinsurance programs.

Right now, the private plans in the individual insurance marketplaces are still unaffordable for many Americans with incomes above 300 or 400 percent of the federal poverty level, who qualify for little or no premium subsidies from the goverment.

Reinsurance programs, which about a dozen states have set up with permission from the Trump administration, cover the costs of the sickest, most expensive patients, helping insurers keep premiums lower for everyone else.

2. Reinstate the ACA’s penalty for lacking health coverage and reverse the administration’s expansion of short-term health plans.

President Trump got rid of the penalty for failing to buy health coverage and made it easier for people to buy short-term health plans that are much cheaper than marketplace plans but also cover fewer benefits. Both steps were viewed as detrimental to the marketplaces because they draw out healthier people and leaving sicker ones behind.

3. Extend marketplace subsidies to people living in the 17 states that haven’t yet expanded Medicaid. These people fall into a “coverage gap” in which they’re not eligible for Medicaid or marketplace assistance, after the Supreme Court ruled in 2012 that states could refuse to expand Medicaid as envisioned under the ACA.

4. Add a “public option” plan to the marketplace to compete with the private plans sold there. This idea — backed by several of the presidential candidates, including former vice president Joe Biden and Sen. Amy Klobuchar (D-Minn.) — is something Congress tried to add to the ACA but was forced to ultimately remove.

5. Automatically enroll people in the public option and charge them income-based premiums if they don’t actively select a plan on their own. Allow anyone to buy marketplace plans even if they have a coverage offer from their employer.

“This is the first reform package in the series that effectively achieves universal coverage for all legally present U.S. residents,” the study’s authors write.

6. Further increase government subsidies to help people afford monthly premiums and cost-sharing.

7. Eliminate private coverage and move everyone to a “single-payer” government health plan. People wouldn’t pay premiums but would have cost-sharing for medical services based on their income. Benefits would be similar to current marketplace plans.

8. Further expand the single-payer system by adding coverage for dental and vision services as well as for long-term care. Eliminate cost-sharing requirements. This approach is closest to what Sanders has proposed in Medicare-for-all.

AHH, OOF and OUCH

AHH: President Trump is expected to nominate Stephen Hahn to be the next Food and Drug Administration commissioner, replacing former commissioner Scott Gottlieb.

"Last month, [acting FDA chief Norman “Ned” Sharpless] won the endorsement of dozens of cancer and other groups and several previous FDA commissioners,” our Post colleague Laurie McGinley reports. “Ultimately, Trump turned to Hahn after meeting with him in the Oval Office in early September.”

If Hahn, a top official at MD Anderson Cancer Center in Houston, is nominated, Sharpless could remain in his role until Hahn is confirmed by the Senate, even though his acting term expires Nov. 1.

OOF: The Veterans Affairs internal watchdog found in a scathing report that the agency’s new Office of Accountability and Whistleblower Protection — part of Trump’s key initiatives to turn around a troubled agency — failed from the beginning.

Trump created the office soon after entering the White House, meant as a solution to a culture of retaliation at VA, but the report found it has “held almost no wrongdoers accountable,” our Post colleague Lisa Rein reports. “We are sending a strong message: Those who fail our veterans will be held, for the first time, accountable,” Trump said in 2017 when establishing the office. “We will make sure that they’re protected,” he said of employees who report wrongdoing.

“The office has shown ‘significant deficiencies,’ including poor leadership, skimpy training of its investigators, a misunderstanding of its mission and a failure to discipline senior leaders for misconduct, according to Inspector General Michael Missal’s 100-page report,” Lisa writes.

The report says the office “acted in ways that were inconsistent with its statutory authority while it simultaneously floundered in its mission to protect whistleblowers.” A spokesman for the agency insisted the report highlighted efforts under individuals no longer at the agency.

OUCH: A widely used health algorithm employed by hospitals meant to flag which patients need medical care dramatically favors white patients over the sickest black patients, our Post colleague Carolyn Y. Johnson reports.

According to the report published in the journal Science, researchers found correcting for the bias would more than double the number of black patients who would be pinpointed as being at risk of complicated medical needs. “When the company replicated the analysis on a national data set of 3.7 million patients, they found that black patients who were ranked by the algorithm as equally as in need of extra care as white patients were much sicker: They collectively suffered from 48,772 additional chronic diseases,” Carolyn writes.

The algorithm, sold by leading health services company Optum, appeared to have a race-blind metric of how much individual patients may cost the health-care system going forward. “But cost isn’t a race-neutral measure of health-care need,” Carolyn writes. “Black patients incurred about $1,800 less in medical costs per year than white patients with the same number of chronic conditions; thus the algorithm scored white patients as equally at risk of future health problems as black patients who had many more diseases.”

HEALTH ON THE HILL

— Sen. Bernie Sanders (I-Vt.) released a plan to legalize marijuana nationwide and expunge criminal convictions related to marijuana.

Under the plan, Sanders would wield executive power to reclassify marijuana as a dangerous controlled substance and would call on Congress to pass legislation to permanently legalize the drug. The plan also calls on federal and state authorities to review and expunge criminal marijuana convictions.

Our Post colleague Sean Sullivan writes that the proposals from Sanders and other 2020 presidential contenders are a “shift from past presidential elections when Democrats, like Republicans, often promoted more toughness. Changing attitudes toward drug crimes, and a growing number of states legalizing cannabis, have ushered in a primary where ideas once seen as provocative have become mainstream.”

— Warren, Ron Wyden (D-Ore.) and Patty Murray (D-Wash.) have sent a letter to the Health and Human Services Department calling for more information about why former Health and Human Services secretary Tom Price has not repaid hundreds of thousands of dollars to the government related to his use of chartered flights.

Price resigned in 2017 amid criticism for extensive use of taxpayer-funded chartered flights. The letter from the Senate Democrats notes that the agency’s internal watchdog later found that the office ““improperly used Federal Funds” that “resulted in waste ... totaling at least $341,000.” The watchdog also recommended that the agency recover the money.

“American taxpayers deserve full transparency and' accountability for former Secretary Price's exorbitant travel habits, and they deserve to be repaid in full,” the senators write. The letter calls for additional information include details on how much money the department has recouped, whether Price has paid for any travel taken by his wife and when the agency plans to address the “OIG’s non-monetary recommendations.”

MEDICAL MISSIVES

— There are now 1,604 reported cases of vaping-related illnesses in every state except Alaska, as well as the District of Columbia and the U.S. Virgin Islands.

There’s also been 34 reported deaths in 24 states, according to the new data from the Centers for Disease Control and Prevention, ranging in age from 17 to 75.

“The CDC has reported that all patients in the outbreak had a history of using e-cigarette products, and most have reported a history of using products containing tetrahydrocannabinol or THC, the primary psychoactive component of cannabis,” CNN’s Jamie Gumbrecht reports.

STATE SCAN

— Two former top health officials in the Obama administration are now making an impressive mark on health insurance in North Carolina.

Mandy Cohen, now the state's secretary of health and human services, and Patrick Conway, who until recently led the CEO of Blue Cross Blue Shield of North Carolina together “made North Carolina arguably the most innovative state in the country when it comes to improving how health care is delivered and addressing the underlying social and economic drivers, like homelessness, of poor health and high costs,” Politico’s Joanne Kenen reports.

North Carolina is one of the few states that has not yet expanded Medicaid under the Affordable Care Act. And Cohen has had to work towards a mandate set by the state's former Republican governor to shift the state’s Medicaid system to managed care. “But she also undertook broad efforts to tackle homelessness, hunger, lack of transportation, domestic violence and other socioeconomic drivers of poor health —sometimes by smartly leveraging a Medicaid dollar, sometimes by partnering with another state agency or community-based organization,” Joanne writes.

— Both Conway and Cohen sought to address social issues like homelessness that fueled poor health, Joanne writes, describing how they carried that out through an urban safety net hospital, a small town family physician and a community clinic.

— And here are a few more good reads: 

Health
The United States does well in five of six preparedness categories but ranks 19th — after Australia, Canada, Singapore and more than a half-dozen European countries — in measures that assess the overall risk environment and vulnerability to biological threats. The factors driving down the U.S. score include the risks of social unrest and terrorism, and low public confidence in government.
Lena Sun

TRUMP TEMPERATURE

Immigration
The children had been released from federal custody before a judge ordered the Trump administration to stop the practice and reunite detained children with their parents.
Maria Sacchetti

AGENCY ALERT

The government just sweetened the pot for doctors and other health professionals who provide care in underserved communities with an infusion of $319 million for loan repayment and scholarship programs.
FierceHealthcare

INDUSTRY RX

Three major U.S. retailers, including Walmart, are removing all 22-ounce bottles...
Reuters
Amazon.com Inc said on Wednesday it bought healthcare start-up Health Navigator,...
Reuters
Health
Researchers think “auto-brewery syndrome” is probably underdiagnosed.
Marisa Iati

REPRODUCTIVE WARS

Asia & Pacific
The Kazakh women’s stories reveal a wider pattern of abuse aimed at China’s Muslim minority, including Uighurs and others, advocates say.
Amie Ferris-Rotman

OPIOID OPTICS

A few hundred hospitals have banded together to sue drugmakers in state courts, but far more are staying on the sidelines to avoid 'unflattering attention' about their role in the opioid crisis.
NPR

DAYBOOK

Coming Up

  • The House Veterans' Affairs Subcommittee on Oversight and Investigations holds a hearing on protecting whistleblowers and promoting accountability on Oct. 29. 
  • The House Judiciary Subcommittee on Immigration and Citizenship holds a hearing on the Impact of Current Immigration Policies on Service Members and Veterans, and their Families on Oct. 29. 
  • The House Veterans' Affairs Subcommittee on Health holds a hearing on native veterans' access to healthcare on Oct. 30. 
  • The Senate Health, Education, Labor and Pensions Committee holds a business meeting on Oct. 31. 

SUGAR RUSH

Several lawmakers paid tribute to Rep. Elijah E. Cummings at the U.S. Capitol: