THE PROGNOSIS

Sen. Elizabeth Warren (D-Mass.) was the final presidential candidate fully on board with a swift and complete Medicare-for-all overhaul of the U.S. health-care system.

No longer.

Like the other Democratic contenders, Warren has somewhat softened her position on the sweeping — and what some term radical — Medicare-for-all system envisioned by Sen. Bernie Sanders (I-Vt.). On Friday she released a proposal to first adopt a public option approach similar to what the race’s moderates are calling for — a marked shift from her previous calls for quickly moving all Americans to government-backed health insurance.

Warren introduced her proposal this way:

This latest Warren health-care proposal comes ahead of the fifth Democratic presidential debate on Wednesday, which could bring more politically tricky discussions of how to expand health insurance to around 30 million people who still lack it. Democrats spent considerable time in past debates wrangling over the pros and cons of a single-payer approach of uprooting existing coverage and raising taxes in the interest of ensuring everyone has a comprehensive and affordable set of benefits.

Many of the candidates started their campaigns enthusiastically backing the Sanders bill, which would replace all private health coverage with a generous public plan over a four-year transition period. But one by one they’ve qualified their support, releasing proposals to preserve a role for private coverage or private insurers to ensure people don’t get involuntarily dropped from plans they might want to keep.

Warren was the lone candidate to still support the Sanders plan without any qualifications. But now she’s tacitly acknowledging Medicare-for-all’s political difficulty by proposing that people should be allowed — but not forced — to enroll in government health insurance as a first step toward universal health coverage.

Under her proposal published Friday in a Medium post, Warren says in her presidency’s first 100 days she would push Congress to expand Medicare to people age 50 and older and create a Medicare-type plan anyone else could buy, subsidized more heavily than the private plans available in the Obamacare marketplaces. Democrats would have to win a majority in the Senate so they could use the budget reconciliation process, which would allow them to bypass Republican support.

“By the end of my first 100 days, we will have opened the door for tens of millions of Americans to get high-quality Medicare for All coverage at little or no cost,” Warren wrote.

Rep. Pramila Jayapal (D-Wash.), sponsor of the House Medicare-for-all bill:

Activist Ady Barkan, who has testifed before Congress in favor of Medicare-for-all, praised Warren:

A self-described Sanders supporter wasn't so enthused:

New Republic's Libby Watson: 

Warren insists she’d pass Medicare-for-all in the third year of her presidency. But there’s reason to believe this could be even more unlikely than if she pushed for it right out of the gate (and passing it immediately would already be a tall order, if Republicans retain control of the Senate in 2020).

For one thing, getting more Americans covered via incremental methods – like a public option – would reduce the population of uninsured people and therefore the urgency for passing something as drastic as Medicare-for-all. That's a point made by hard-left provider groups that have enthusiastically backed Medicare-for-all. Adam Gaffney, president of Physicians for a National Health Program, told my colleague Annie Linskey that a two-step approach could halt momentum for Medicare-for-all and even torpedo it.

“Doing this in stages creates a political danger and an opening for opponents to prevent further progress,” Gaffney said. “The longer the rollout, the more political risk.”

And consider this. The president’s political party typically loses seats during midterm elections – meaning Warren would likely have even fewer Democrats in Congress to help her pass Medicare-for-all during her third year in office.

“It’s a clear shift for the senator from Massachusetts as she attempts to ward off criticism that her single-payer health plan is unrealistic substantively and toxic politically,” Annie writes. “Warren for months had signaled a full-throated embrace of Medicare-for-all, and this new approach significantly tempers that urgency.”

Other candidates have also taken detours from the Medicare-for-all highway. Sen. Kamala Harris (D-Calif.) wants to preserve a role for private insurance companies to sell Medicare plans to everyone. South Bend, Ind., Mayor Pete Buttigieg wants to let anyone buy into Medicare without unraveling the system of employer-sponsored coverage – an approach that looks remarkably similar to what former vice president Joe Biden has proposed.

In short, each of the top Democratic candidates now has his or her own, nuanced proposal for reaching universal health coverage. And as the primaries approach, they’re increasing beating each other up over those differences. Warren was on the receiving end over the weekend.

“Having discovered how problematic her embrace of Medicare-for-all has become….Senator Warren is now trying to muddy the waters even further,” said Kate Bedingfield, communications director for former vice president Joe Biden.

Sen. Michael F. Bennet (D-Colo.) said she was “backtracking.” Buttigieg spokeswoman Lis Smith accused her of trying to “paper over a very serious policy problem.”

Sanders didn't directly criticize Warren's proposal, but his campaign did tweet a statement from National Nurses United, which is pushing for Medicare-for-all and has endorsed him:

Comments from former President Barack Obama, via the New York Times's Lisa Lerer: 

Sanders also appeared to indirectly contrast his approach with Warren's by adding a line to his stump speech yesterday, Annie reports.

“Today I tell you that on our first week in office, we are going to introduce Medicare-for-all ­single-payer legislation,” he said Saturday in East Los Angeles.

Warren is likely to face many questions during Wednesday’s debate about her tempered new approach. In response to reporter questions over the weekend, she rejected the idea that her proposal acknowledges single-payer health care isn’t feasible in the United State.

“I don’t see it that way at all,” Warren said. “The way I see this, is that there is an intense need right now for relief.”

But here's an intense need for Warren: To seize back support from Iowa caucusgoers. While Warren led the Iowa polls in September, a new poll by the Des Moines Register and CNN released Saturday night showed her in a three-way tie for second place with Biden and Sanders, while Buttigieg surged ahead of the pack. The poll shows Buttigieg with 25 percent support and Warren, Biden and Sanders all with about 15 percent support.

AHH, OOF and OUCH

AHH: President Trump has backed off of a ban on most flavored e-cigarettes, worried about the consequences such as lost jobs and angry shop owners and customers that could hurt his 2020 reelection bid.

The ban had already been cleared by federal regulators, and a Nov. 5 morning news conference was planned. But the night before, Trump refused to sign a “decision memo,” our Post colleagues Josh Dawsey and Laurie McGinley report.

A senior administration official told them the president “didn’t know much about the issue” and that he’d been pushing for it because of Melania and Ivanka Trump, who were urging him to take action on the issue.

“As he had done so many times before, Trump reversed course — this time on a plan to address a major public health problem because of worries that apoplectic vape shop owners and their customers might hurt his reelection prospects, said White House and campaign officials,” they write. “He also believed job losses tied to the ban would cost him as he sought to trumpet economic growth. It was the latest example of the chaotic way policy is made — and sometimes unmade — in a White House where the ultimate decider often switches gears after making a controversial vow, whether on combating gun violence, pulling troops from Syria or promising to deliver an Obamacare replacement plan.”

Trump had been rattled by the blowback to the possible ban, and the president was now upset with Health and Human Services Secretary Alex Azar, who had taken a lead on the plan.

Now, it’s unclear whether a policy will be unveiled at all. 

OOF: The Trump administration announced a rule mandating that hospitals publicly disclose the discounted rates they negotiated privately with insurers. It’s a rule that was “resisted for months by a broad swath of the health-care industry, hospitals,” our Post colleague Amy Goldstein reports.

The requirement, which will go into effect in January 2021, means that hospitals will have to reveal rates for hundreds of services that can be scheduled in advance, including X-rays and Caesarean sections.

“For decades, hospitals, insurance companies, lobbyists, and special interests have hidden prices from consumers so they could drive up costs for you. And you had no idea what was happening. You’d get bills that were unbelievable and you have no idea why,” Trump said in Friday remarks at the White House.

The administration has been expecting a legal challenge to the rule from the hospital industry — and the two biggest hospital trade groups, the American Hospital Association and the Federation of American Hospitals, said they will challenge it.

“In a new twist, the administration is also proposing to require most health plans that Americans get through their jobs to disclose the rates they negotiate with hospitals and doctors in their insurance networks, as well as the amounts they pay to doctors out-of-network,” Amy writes. “…Taken together, the pair of actions — one a final rule, the other in draft form — is part of President Trump’s 2020 electoral strategy to capi­tal­ize on polls that show health care ranks among Americans’ top domestic concerns. Public opinion surveys consistently show that consumers are looking to government especially to ease the burden of escalating out-of-pocket costs.”

OUCH: Researchers have found that invasive heart procedures such as stent insertions and bypass surgery are no more effective for individuals with stable heart disease than drugs.

But the study did find that such procedures were “measurably” better than pills at reducing chest pain during exercise, our Post colleague Carolyn Y. Johnson reports.

The closely anticipated federally funded study results “suggest that invasive procedures, stents and bypass surgery, should be used more sparingly in patients with stable heart disease and the decision to use them should be less rushed, experts said.”

“The ISCHEMIA trial shows that an early invasive approach does not protect patients against death or the overall chance of a heart attack, but does effectively relieve chest pain — the more chest pain a patient has, the more likely they are to benefit,” said Elliott Antman, a cardiologist at Brigham and Women’s Hospital, who was not involved in the research.

“The new study was designed to finally settle the question of whether stents are better for patients with stable heart disease — and some physicians said it could change how tens of thousands of people are treated in hospitals, transform how cardiologists talk with patients about their options and save hundreds of millions of dollars in health-care spending each year,” Carolyn writes.

MEDICAL MISSIVES

—Telemedicine centers are filling a gap left by the shrinking availability of hospitals and doctors in rural areas across the country, where choices are sometimes between having a doctor help you from a screen or not at all.

One center, Avera eCare, provides remote care for 179 hospitals in 30 states. But they’re operating out of cubicles. “They wear scrubs to look the part of traditional doctors on camera, even though they never directly see or touch their patients,” our Post colleague Eli Saslow writes in this deeply reported piece. “They respond to more than 15,000 emergencies each year by using remote-controlled cameras and computer screens at what has become rural America’s busiest emergency room, which is in fact a virtual ER located in a suburban industrial park.”

Emergency telemedicine is increasing in the poorest, sickest and most remote regions in the United States, as ER patients have spiked by 60 percent in the past decade in rural areas, and the number of physicians and hospitals in those areas has decreased by up to 15 percent.

“In less than a decade, the virtual hospital has grown from a few part-time employees working out of a converted storage room into one of the country’s most dynamic 24-hour ERs, where a rural health-care crisis plays out on screen,” Eli writes. “Each month the monitors show an average of 300 cardiac episodes, 200 traumatic injuries, 80 overdoses and 25 burns. There are patients suffering from heat stroke in South Texas and frostbite in Minnesota — sometimes on the same day. There are drowning deaths in summer, gunshot wounds during hunting season, car accidents on icy roads, and snakebites in spring.”

— Two out of three Americans say marijuana use should be legal, the Pew Research Center has found.

The survey data shows just 8 percent say it should not be legal at all, down from the 15 percent who said it should be completely illegal in 2016, our Post colleague Christopher Ingraham reports.

The Pew survey found 78 percent of Democrats and 55 percent of Republicans support legalization. It also found 59 percent of Americans say it should be legal for both medical and recreational use, and 32 percent said it should be legal just for medical use.

“As with many political issues, the public’s preferences on marijuana are well to the left of where the policy currently stands,” Christopher writes. “The plant remains illegal for all purposes under federal law. Recreational marijuana is legal in 11 states plus D.C., in most cases because of voter-approved ballot initiatives. Most other states have some form of medical marijuana law, although in many cases there are severe restrictions on the conditions for which medical marijuana can be used, or on the types of marijuana that can be used.”

INDUSTRY RX

— Most of the advertisements spreading false information about vaccines on Facebook were funded by two groups, including the World Mercury Project, a group led by Robert F. Kennedy Jr., our Post colleague Lena H. Sun reports.

“Researchers said the results surprised them. Much of the anti-vaccine content posted on social media platforms such as Facebook and Twitter may appear to be organic, grass-roots discussions led by neighborhood groups and concerned parents, said David A. Broniatowski, an associate professor at George Washington University and one of the authors of the study,” Lena writes. “…The study was conducted before Facebook changed its policies around anti-vaccine advertising, but researchers said it provides a look at how the platform has been used to spread misinformation.”

False claims have spread online and social platforms in recent years as more parents delay or otherwise choose not to get their children vaccinated. Kennedy’s World Mercury Project has pushed the false message that “vaccines are contributing to a vast array of childhood illnesses.”

Of the ads assessed for the research, there were 145 that were anti-vaccine and 83 groups that promoted them. The study found “five groups accounted for 75 percent of anti-vaccine messages. The top two were the World Mercury Project and Stop Mandatory Vaccination.” Stop Mandatory Vaccination is led by Larry Cook, who calls himself an “advocate for natural living.”

— And here are a few more good reads: 

Technology
Apple removed all vaping-related apps from its App Store on Friday, siding with experts who call vaping “a public health crisis” and “a youth epidemic.”
Marie C. Baca
Johnson & Johnson rushed to announce its famous baby powder contained no asbestos after the Food and Drug Administration triggered a recall last month—but results of J&J’s tests weren’t cut and dried.
Wall Street Journal

OPIOID OPTICS

Health
Correcting a math error he made, Judge Thad Balkman said the giant health-care company must pay the state $465 million, not $572 million.
Lenny Bernstein

REPRODUCTIVE WARS

An anti-abortion activist recorded the videos to try to show that the group was illegally selling fetal tissue.
New York Times

STATE SCAN

Edwards won re-election by casting himself as a conservative Democrat who supports Medicaid expansion and increases in teacher salaries while backing stringent restrictions to abortion rights. He’s sought to downplay disagreements with Trump and was the only Democrat invited to the president’s first-ever state dinner last year.
Vox

AGENCY ALERT

The White House is ramping up its push to get a bill through Congress that curbs prescription drug costs, feeling a new urgency as the impeachment investigation advances amid the 2020 election campaign.
Associated Press
Immigration
There have been more than 50,000 people in Immigration and Customs Enforcement detention on any given day in the past year, an all-time high, as deportations have slowed.
Abigail Hauslohner
Politics
White House press secretary Stephanie Grisham said it is “absolutely not” true that the president’s visit to a doctor Saturday was anything other than a routine physical exam.
Felicia Sonmez

DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee will hold a hearing on the nomination of Stephen M. Hahn to lead the Food and Drug Administration on Wednesday.
  • Senate Finance Committee Chairman Chuck Grassley (R-Iowa) will participate in a Committee for a Responsible Federal Budget event on health care on Thursday.

SUGAR RUSH