THE PROGNOSIS

It’s Thanksgiving Eve. Which for Health 202 begs this question: What is everyone thankful for this year when it comes to health policy?

We suspect that maybe – just maybe –you’d get vastly different answers from doctors versus insurers versus drugmakers versus consumers versus any other stakeholder in the $3.6 trillion U.S. health-care industry complex. Everyone has competing interests, which is a prime reason why the country’s besetting problems of ever-rising costs and subpar medical outcomes never quite seem to get solved.

So before you tune out the news cycle for Turkey Day, here’s our best guess at what’s giving each health-care stakeholder an attitude of gratitude.

—The White House and Republicans: Democrats are fixated on Medicare-for-all.

The GOP could hardly be more eager to focus on Medicare-for-all proposals from the Democratic presidential candidates. They view it as a way to veer the political conversation away from their own, unpopular actions on health-care policy and to depict Democrats as out-of-touch with voters.

President Trump and his top health officials have repeatedly decried Medicare-for-all, including during an October speech where the president announced an executive order boosting the role of private plans in the Medicare program.

“Every major Democrat in Washington has backed a massive government health care takeover that would totally obliterate Medicare,” the president said during that address. “These Democratic policy proposals ... may go by different names, whether it's single payer or the so-called public option, but they're all based on the totally same terrible idea: They want to raid Medicare to fund a thing called socialism.”

—Democrats: The Trump administration is refusing to defend the Affordable Care Act.

Democrats are well aware that the refusal by Trump’s Justice Department to defend the Affordable Care Act from a challenge by GOP-led states is a political gift. They spent the 2018 election castigating the administration for not standing by the health-care law’s protections for patients with preexisting conditions – and it helped them win the House majority. 

They plan to hammer that message again in 2020, as they seek the White House.

—The Department of Health and Human Services: Obamacare hasn’t been struck down (yet).

A federal appeals court is expected to rule any time now on the challenge to the ACA, which was upheld by a lower court last year. As The Health 202 has written, the decision against defending the law was a deeply controversial one inside the administration.

HHS Secretary Alex Azar and Seema Verma, administrator of the Centers for Medicare and Medicaid Services, tried to persuade the White House to defend the law. If the courts ultimately strike down the ACA, the administration will be on the hook to propose a replacement that would preserve health coverage for millions of Americans who gained it under the health-care law.

—Health-care advocates: Marketplace premiums are somewhat more affordable.

After several rough years for the ACA’s individual marketplaces, they got some good news this year. Average premiums for mid-level “silver” plans fell four percent for 2020 – a marked shift from the double-digit increases shoppers have typically seen.

That doesn’t mean plans are suddenly affordable for consumers ineligible for government subsidies. But it does mean insurers have found a sustainable way to keep participating in the marketplaces – and the marketplaces are here to stay for people without access to employer-sponsored coverage.

—Drugmakers: Chances for a major, bipartisan drug pricing deal this year are fading.

One of the pharmaceutical industry’s biggest fears is that Congress passes legislation allowing the federal government to directly negotiate lower prices in the Medicare program – a move the industry describes as government “price-fixing.”

Trump used to support allowing direct negotiations, and his staff was even in discussions with House Speaker Nancy Pelosi’s (D-Calif.) office earlier this fall over the potential for a bipartisan effort along these lines.

But the president and his aides have increasingly distanced themselves from Pelosi’s bill to allow direct negotiations. Now it looks like House Democrats will pass that measure as a messaging tactic, only to see it blocked in the GOP-led Senate. A bipartisan Senate bill capping how much drugmakers can annually raise prices has somewhat better prospects, but even that measure has made many Republicans suspicious.

In the end, only minor and less-controversial drug pricing measures may end up being attached to a longer-term spending bill.

—Doctors and hospitals: Any legislation protecting patients from “surprise” medical bills will almost certainly include arbitration – an approach that means higher payments for them.

Virtually every member of Congress agrees American patients should be protected from the surprise bills that can result when they visit an emergency department outside their health plan’s provider network or get care from an out-of-network provider at an in-network hospital.

But how to solve that has turned into an insurers-versus-doctors food fight.

Insurers and the Trump administration want to use a benchmarking approach to resolve out-of-network bills, in which the payments are tied to average prices in the same geographic area. That approach would save the government money, the Congressional Budget Office has said.

But doctors – and some dark-money groups that represent their interests – have been spending millions of dollars to push Congress toward adopting an approach called arbitration. In arbitration, which CBO has said would cost the government more money, the medical provider and the insurer each submit a bid to a third party arbiter, who then make a final decision.

Doctors believe arbitration would translate to beefier payments for them – and outcomes from New York’s arbitration system supports that notion. So if Congress passes surprise billing legislation, it will likely include some element of arbitration given the heavy influence by the doctor lobby.

—Regular Americans: Not much.

We hate to say it, readers, but there’s little for you to be thankful for this year when it comes to health-care policy. Costs for employer-sponsored coverage are going up and coverage plans are getting less generous. Congress appears unable to pass major reforms on the biggest consumer concerns. And the next election is likely to result in a government severely split over how to improve health-care – making it likely the status quo will prevail for some time.

But Happy Thanksgiving, anyway!

PROGRAMMING NOTE: Happy (almost) Thanksgiving from The Health 202 team. We won’t be publishing on Thursday and Friday. Enjoy your holidays and we’ll be back in your inbox on Monday.

AHH, OOF and OUCH

AHH: A federal judge in Oregon blocked the Trump administration from denying immigrants visas unless they prove they can afford medical insurance or acquire health insurance within 30 days of entering the country.

US. District Court Judge Michael Simon ruled the “requirement that immigrants buy unsubsidized insurance — meaning they couldn't get financial assistance through Obamacare — barred poor people from entering the country, which he said clearly infringed on the law,” Politico’s Susannah Luthi reports.

"The proclamation is anticipated to affect approximately 60 percent of all immigrant visa applicants," Simon wrote. "The president offers no national security or foreign relations justification for this sweeping change in immigration law."

The White House issued a proclamation last month to deny visas to immigrants that “will financially burden” the nation’s health-care system. “Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs,” Trump said in the proclamation.

OOF: Young and middle-aged Americans are dying at alarming rates. New research published in the Journal of the American Medical Association shows these deaths are a result of suicide, drug overdoses, liver disease and numerous other causes driving down life expectancy for people ages 25 to 64, our Post colleague Joel Achenbach reports.

“Despite spending more on health care than any other country, the United States has seen increasing mortality and falling life expectancy for people ages 25 to 64, who should be in the prime of their lives,” he writes. “...Although earlier research emphasized rising mortality among non-Hispanic whites in the U.S., the broad trend detailed in this study cuts across gender, racial and ethnic lines." 

The location of the spike in death rates is notable, too. About a third of the estimated 33,000 “excess deaths” that occurred since 2010 were in Ohio, Pennsylvania, Kentucky and Indiana. New Hampshire saw the biggest percentage increase in death rates among working people.

—Virginia Commonwealth University's Steven Woolf told Joel the extent and pervasiveness of the trend revealed in the research “suggests that the cause has to be systemic, that there’s some root cause that’s causing adverse health across many different dimensions for working-age adults.”

—Howard Koh, a professor of public health at Harvard University said: “There’s something more fundamental about how people are feeling at some level — whether it’s economic, whether it’s stress, whether it’s deterioration of family. People are feeling worse about themselves and their futures, and that’s leading them to do things that are self-destructive and not promoting health.”

OUCH: Internal feuds and a personal rivalry between Health and Human Services Secretary Alex Azar and Seema Verma, the administrator for the Center for Medicare and Medicaid Services, have hindered health-care efforts Trump has been banking on amid a reelection bid, including a proposal for replacing the ACA, Politico’s Rachana Pradhan, Adam Cancryn and Dan Diamond report.

For one, Azar rejected a proposal Verma worked on for six months for an alternative plan to the ACA. Before it was presented to Trump, the administration had to start from scratch, they write, because Azar said the plan would bolster the ACA instead.

“Behind the policy differences over Obamacare, drug pricing and other initiatives, however, is a personal rivalry that has become increasingly bitter,” they write.

In the fall, Azar reportedly blocked Verma from traveling with the president on Air Force One until Verma complained to White House staff. Over the summer, Verma “criticized a major drug pricing proposal Azar had been pushing for months” at a White House meeting with Azar, Trump and other top administration officials. Later, Azar killed Verma’s Obamacare replacement plan before the president had been briefed.

"The amount of time spent dealing with things like this, and having to have these fights and have these issues, are time that could've been spent thinking of better drug pricing proposals or other ways to advance parts of the agenda,” one health-care official told Politico.

“Verma was often mentioned as a potential successor as HHS secretary following Price's fall 2017 resignation,” Rachana, Adam and Dan write. But since Trump tapped Azar for the post, “the two have competed over which would get credit from Trump for advancing his health policies.”

Meanwhile, an Azar spokesman dismissed such tensions as “absurd.” A CMS spokesman did not directly respond to questions about Azar and Verma’s working relationship.

OPIOID OPTICS

The First Lady was booed loudly by a crowd of mostly high school and middle school students at an opioid awareness event in Baltimore.

"Thank you to all of the students who are here. I am so proud of you for the bravery it takes to share that you have been strongly affected by the opioid epidemic in some way," Melania Trump said over the crowd at University of Maryland, Baltimore County.

"The boos were sustained for two minutes of her five-minute speech, and the audience spoke throughout," our Post colleague Jada Yuan reports. "The first lady did not acknowledge the reaction and carried on with her remarks, as the logo for her 'Be Best' initiative was shown on the screen behind her. One of the initiative’s focuses is combating youth opioid abuse."

In a statement to CNN, the first lady said in response to the reception: “We live in a democracy and everyone is entitled to their opinion, but the fact is we have a serious crisis in our country and I remain committed to educating children on the dangers and deadly consequences of drug abuse."

It’s the first time the first lady has been publicly booed at a solo event, via CNN's Kate Bennett: 

AGENCY ALERT

A new report from the Centers for Disease Control and Prevention may help explain why the vaping-related disease appeared and spread so quickly across the country, and lends support to the evidence that a chemical compound, vitamin E acetate, is a likely culprit, Stat’s Megan Thielking reports.

The report found vitamin E acetate, used as an additive in some vaping products was discovered in vaping products used by 11 out of 12 patients who fell ill in Minnesota. The products also contained THC — the ingredient in marijuana that produces a high.

“The new report also points to a potential answer to a question that has stumped the public health community: Why do the illnesses appear to have only started in 2019, when vaping has been popular for years?,” Megan writes. “Minnesota health officials tested 10 THC-containing vaping products seized by law enforcement in 2018, before the EVALI outbreak began. They also tested 20 products seized from a raid in 2019, which happened amid the outbreak. None of the products seized in 2018 tested positive for vitamin E acetate — but all of the products in 2019 did. The authors say that suggests ‘that vitamin E acetate might have been introduced recently as a diluent or filler.’”

Our Post colleague Lena H. Sun wrote a behind the scenes look this week at the scramble inside the CDC to solve the mystery of the vaping illness.

HEALTH ON THE HILL

— Numerous leaders, including former president Barack Obama and House Speaker Nancy Pelosi (D-Calif.), across the Democratic Party are warning about the risks of pushing for Medicare-for-all.

Democratic elected officials, strategists and pollsters have increasingly been voicing concerns that pushing for a single-payer system, rather than saying committed to the Affordable Care Act as they did in 2018 and 2019, will harm any political advantage on health care, the New York Times’s Lisa Lerer and Katie Glueck report.

“Warnings are being issued at all levels of the Democratic Party, from union members who fear losing hard-won benefits, to candidates running in swing districts, all the way up to former President Barack Obama, who offered a pointed warning about the risks of overreach at a gathering of donors in Washington, D.C., this month,” they write. “People close to the former president said his remarks were rooted in his experience passing the health care law, which prompted his concerns about how willing voters would be to embrace an even more sweeping change.”

On the 2020 campaign trail, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) have ramped up the efforts to overhaul the nation’s health-care system, but many in the party want to shift the conversation.

“Privately and publicly, party strategists focused on the nation’s most competitive House and Senate seats next cycle are frustrated that conversation in the Democratic presidential race often devolves into arcane debates about Medicare for all, rather than last year’s easier-to-grasp message about protecting people with pre-existing conditions,” Lisa and Katie report. “Many are gravely concerned about the impact that having a presidential nominee who backs Medicare for all at the top of the ticket would have on the most vulnerable Democratic candidates.”

STATE SCAN

— The Supreme Court announced it will hear oral arguments on March 4, 2020 in Louisiana’s abortion case. The court is set to assess the 2014 law that would require doctors at abortion clinics to have admitting privileges at nearby hospitals.

The Louisiana law, which is not currently in effect, is similar to a Texas law the high court struck down in 2016.

CBS News’s Kate Smith has reported the state could be the first to be without legal abortion access depending on the outcome of the Supreme Court case.

"All eyes must be on the Supreme Court come March. This case will have lasting consequences for abortion access across the country," Nancy Northup, president and chief executive officer of the Center for Reproductive Rights told CBS News about the upcoming case. "Many states have been openly defying Supreme Court decisions in an effort to criminalize abortion. At this critical juncture, the Court needs to set those states straight."

— And here are a few more good reads: 

TRUMP TEMPERATURE

State officials are moving forward with prescription drug importation programs on President Donald Trump's repeated assurances that he wants to allow states to import drugs from Canada, though HHS has not approved any such program. Vermont on Tuesday will become the second state to submit an importation plan to HHS behind Florida.
Modern Healthcare

MEDICAL MISSIVES

Health
The government has declared a state of emergency and mandated children and teenagers get immunized, as CDC sent officials to help.
Ben Guarino, Neena Satija and Lena Sun
Nearly a quarter of a million people in the Democratic Republic of Congo are thought to have been infected by measles in 2019 alone, the World Health Organization said.
New York Times
D.C. Politics
Encounters with guns are most common in the District’s poorest neighborhoods, a Washington Post poll finds.
Paul Schwartzman and Emily Guskin
WASHINGTON (AP) — The District of Columbia is joining several states in suing the nation’s largest e-cigarette maker Juul Labs, saying the company’s online ads and promotions illegally targeted...
Associated Press
Federal prosecutors have opened a criminal investigation into whether pharmaceutical companies intentionally allowed opioid painkillers to flood communities, employing laws normally used to go after drug dealers.
Wall Street Journal

DAYBOOK

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee will hold a business meeting to consider various nominations, including Stephen Hahn to lead the Food and Drug Administration on Dec. 3.  
  • The House Energy and Commerce Subcommittee on Oversight and Investigations holds a hearing on the flu season preparedness and response on Dec. 4.

SUGAR RUSH