THE PROGNOSIS

Bitter infighting among President Trump’s top health officials — which reached a fever pitch this week — is undermining the administration’s efforts to take major regulatory action on lowering drug prices and other health-care issues.

White House officials are frantically trying to resolve the fractured relationship between Health and Human Services Secretary Alex Azar and Seema Verma, head of the agency’s Centers for Medicare and Medicaid Services. But it’s not clear they’ll succeed.

Vice President Pence convened a five-way meeting yesterday afternoon aimed at reconciling the two’s bitter differences. Acting White House chief of staff Mick Mulvaney and Pence's chief of staff Marc Short were also present at the meeting, where the officials told Verma and Azar that Trump likes both of them but that they need to start getting along.

Axios's Caitlin Owens:

Verma and Azar’s feuding has recently become public, alongside multiple damaging leaks about Verma’s use of contractors to boost her profile at a cost of nearly $3 million to taxpayers and an attempt to recoup $47,000 from the government for jewelry and clothing stolen on a work trip, stories that were first reported by Politico.

Verma once enjoyed a positive relationship with the White House for publicly attacking Medicare-for-all and championing Medicaid work requirements. But the reports of misusing taxpayer money have damaged Verma’s reputation, two senior officials told me and my Washington Post colleagues Yasmeen Abutaleb, Josh Dawsey and Amy Goldstein in this deeply reported piece laying out how and why Trump’s health-care agenda has stalled on so many fronts.

Some congressional Democrats are starting to call on Verma to resign. Per Politico's Dan Diamond:

Aides said yesterday’s meeting was a last-ditch effort to keep Verma and Azar both in the administration and persuade them to work together. But their interpersonal drama — along with tricky legal and policy questions — has already complicated Trump’s quest to lower steep drug prices in the United States. 

The president has delivered little on that goal, despite rolling out a policy blueprint 19 months ago. Two drug pricing proposals he has championed — allowing the importation of certain cheaper drugs from Canada and basing the price of some Medicare drugs on the lower prices paid by several other countries — have been stalled by internal disputes, as well as technical and regulatory issues.

“The chaos and conflict continue to thwart Trump’s agenda by consuming significant time and dividing White House and senior administration officials into camps,” Yasmeen writes.

The two camps look something like this, according to our story. Verma’s supporters include Ivanka Trump, Domestic Policy Council head Joe Grogan and Marc Short, the vice president’s chief of staff, while White House Counsel Pat Cipollone and first lady Melania Trump tend to take Azar’s side.

For a prime example of how the alliances have hindered policymaking, consider the administration’s now-abandoned effort to end the rebates drugmakers give pharmacy middlemen. As Azar worked earlier this year on the proposal, Grogan and Verma collaborated to undercut his efforts. Verma and Grogan argued in an Oval Office meeting with Trump that its nearly $200 billion price tag over 10 years was exorbitant and would raise Medicare premiums just before the election. 

The administration ultimately backed down from the effort, even though it was Azar’s pet project. Verma and Azar’s relationship deteriorated after the meeting, people close to them said.

The two haven’t gotten along for years, including when they both worked in Indiana. But officials say the tension among them and other players at the White House and HHS has grown untenable in recent months.

“This isn’t a band of brothers. It’s each man on his own. It’s a group of mercenaries,” a senior administration official told my colleagues, adding that senior officials pursue differing and even conflicting policies to fulfill the president’s requests.

Indiana writer Adam Wren, poking some fun:

One individual familiar with events told us that Verma is the victim of a “smear campaign” of “strategic leaks coming from inside HHS.” Verma has also relayed to the HHS general counsel several instances of perceived sex discrimination relayed to her by female employees of HHS and CMS, with the suggestion that HHS conduct sensitively training, that individual said.

Yet others who have worked with Verma say she's not a team player and that she worked in the past to undermine Trump's first HHS secretary, Tom Price.

“This is warfare between Alex and Seema,” said a source familiar with the drama. “What Pence should say to Seema is ‘cease and desist.’ ”

 And then there’s a slew of other obstacles to Trump’s drug pricing agenda, including the president's own changing moods and interests and the administration’s difficulty in identifying clear goals for Congress and helping get them passed. It remains unclear whether lawmakers will manage to pass bipartisan legislation tackling drug prices or surprise medical bills, not to mention Republicans’ well-documented failure to repeal and replace Obamacare back in 2017 despite Trump’s insistence that the law would be ditched.

Yet the president still has his defenders. Some current and former administration officials say Trump has changed the conversation around drug pricing by forcing Republicans to talk about an issue they traditionally ceded to Democrats, and by pressuring pharmaceutical companies to lower some prices, if only temporarily, after shaming some of them on Twitter.

“I’m very proud of the Trump administration’s record on health policy,” said Brian Blase, former special assistant to the president for health-care policy, told me. “It’s hard to change things administratively and we were able to accomplish a great deal, I think, as well as lay out a vision of where the Republican Party should be on health care.” 

AHH, OOF and OUCH

AHH: The House passed on a 377-to-48 vote a $738 billion defense bill extending 12 weeks of paid parental leave to more than 2 million federal workers in exchange for the creation of a Space Force.

The National Defense Authorization Act passed “even as liberals signaled dissatisfaction with compromises Democratic lawmakers reached by voting against the legislation,” our Post colleagues Paul Sonne and Karoun Demirjian report

Trump signaled he would sign the bill, which includes one of his top priorities for the Pentagon: the establishment of the Space Force. 

The provision for parental leave that was tacked onto the House version of the defense bill stemmed from legislation led by Rep. Carolyn B. Maloney (D-N.Y.), chairwoman of the House Oversight Committee. Yet the president seemed to take credit for the parental leave provision, “even though Democratic lawmakers pushed for that measure as a trade for the Space Force, facing down Republican opposition to the expansion of federal worker benefits," our colleagues write.

OOF: The House Ways and Means Committee has released a proposal to end surprise medical bills, one that differs from the bicameral, bipartisan proposal announced by House Energy and Commerce and the Senate Health, Education and Labor committee over the weekend.

The latest alternate plan from Reps. Richard Neal (D-Mass.) and Kevin Brady (R-Tex.) “could throw an obstacle into speedy passage of legislation,” the Hill’s Peter Sullivan and Jessie Hellmann report. “Neal said Wednesday that he thinks his proposal will be better than the Energy and Commerce bill" -- although the White House has already said that's the legislation it supports.

A release from Ways and Means says the plan would first enable insurance groups and doctors to try to determine a payment “without interference.” If they cannot agree, then there would be an arbitration process.

OUCH: The Centers for Disease Control and Prevention are sending teams of experts to Pacific island nations amid fears that the major measles outbreak on Samoa could intensify the spread of measles elsewhere.

In numerous Pacific island countries, measles vaccine coverage rates are below what the World Health Organization recommends, our Post colleague Lena H. Sun reports.

CDC teams are headed to Tonga, Fiji and American Samoa, which are experiencing smaller outbreaks. Experts from the agency are already in Samoa amid the outbreak that’s sickened nearly 4,900 people, killing 71, in the country of about 200,000. There are also medical teams there from around the world, “including a group of 70 doctors and nurses from Hawaii led by Lt. Gov. Josh Green, to help with last week’s vaccination campaign.” 

Robert Linkins, a global immunization official at CDC’s headquarters in Atlanta, told The Post that officials want to communicate that “the disease is dangerous and that the vaccine is good.” “These other countries are also seeing cases of measles, and they are at risk for importation” from the Samoa outbreak, he added. “The need is very big. There are a lot of Pacific islands. All are at risk of seeing cases. You need a lot of people to get on planes to go to these islands to get them the information they need.”

AGENCY ALERT

— The Food and Drug Administration has sent a warning to a drug company that its printed advertisement for Vivitrol, its long-acting addiction medication, leaves off information about the potential for overdose, our Post colleague Lenny Bernstein reports.

“The print ad is false or misleading because it omits important risk information associated with the use of Vivitrol,” the FDA wrote in a Dec. 2 letter to the manufacturer, Alkermes. “… [T]hose utilizing Vivitrol for the treatment of opioid dependence should be made aware of the vulnerability to potentially fatal overdose at the end of a dosing interval, after missing a dose, or after discontinuing Vivitrol treatment.” 

The agency called on the company to develop a plan to “disseminate truthful, non-misleading, and complete corrective messages” to people who saw the misleading ad.

Medically assisted treatment, such as medications including Vivitrol, buprenorphine and methadone, is increasingly used in efforts to address the nation’s opioid crisis.

REPRODUCTIVE WARS

— Planned Parenthood will open 50 clinics in Los Angeles County high schools, our Post colleague Ariana Eunjung Cha reports. The centers will provide birth control options, testing and treatment for sexually transmitted infections and pregnancy counseling for an estimated 75,000 teens. The clinics will not provide abortions. 

The funding will come from an initial $10 million investment from Los Angeles County and $6 million from Planned Parenthood. The program is launching in a state that has been leading the charge to oppose efforts by the Trump administration to cut funding for the women’s health organization and increase restrictions on abortions.

“Students will be able to walk into the clinics or make appointments and will be allowed to leave class for them,” Ariana writes. “Information about the appointments will be in protected medical files not accessible to school officials. Under California law, minors can consent to certain medical services, such as receiving birth control or mental health counseling, and health-care providers are not allowed to inform a parent without the minor’s permission.”

— A new report from Abortion Care Network found about a third of independent abortion providers have shut their doors or stopped providing the procedure in the past five years as a result of abortion restrictions.

The report from the abortion rights group found that since 2012, the number of independent clinics have reduced by 32 percent. It also states that such independent clinics serve nearly 60 percent of individuals who have an abortion.

“Independent clinics serve some of the most politically hostile areas of the country, provide a breadth of reproductive health services, and work with their communities and local abortion funds to ensure that services are available to those patients with the fewest resources for accessing care,” the report reads. “… Yet independent abortion care providers lack the institutional support, visibility, name recognition, or fundraising capacity of national health centers and hospitals, making it especially difficult for these community-based providers to garner the resources they need to provide care in their communities.”

SECOND OPINION

— Andy Slavitt, the former acting administrator of the Centers for Medicare and Medicaid Services in the Obama administration, joined the president of conservative advocacy group FreedomWorks, Adam Brandon, to call for an overhaul to the way organs are procured in the United States. 

In an op-ed in USA Today, the pair cite troubling statistics, including that 1,000 patients die each month waiting for an organ and approximately 113,000 Americans are on waitlists for organ transplants as reasons to look at inadequacies in what they call a “broken system of government-granted monopoly contractors called organ procurement organizations (OPOs) that have lacked accountability for decades.” 

“While 95% of Americans support organ donation, the number of people on organ waiting lists continues to outpace the number of organs available for transplant,” they write. “… When someone dies in a way that makes them medically eligible for donation (such as strokes or opioid overdoses) OPOs are charged with showing up at the hospital and working with the surviving family to coordinate a potential donation. But research shows that OPOs are grossly inefficient, and that up to 28,000 organs go unrecovered from potential donors each year.”

Slavitt and Brandon praised a bipartisan bill from Sens. Todd Young (R-Ind.) and Michael Bennet (D-Colo.) to address accountability in the OPOs and also pointed to a Trump administration executive order calling on HHS to issue a rule on OPO transparency. “That rule could come anytime now, and patients need it to be as strong as possible,” they write. 

— In a column in the Washington Examiner, executive editor Philip Klein argues that Democrats are harming their own strategy to win the support of suburban voters with proposals to do away with private health coverage.

“Put simply, Democratic healthcare proposals that would disrupt or eliminate private insurance are like heat-seeking missiles targeting voters in these relatively well-off suburban communities, where residents overwhelmingly have solid (and private) healthcare coverage,” he writes. 

Phil looked at counties in Pennsylvania that border Philadelphia; several Wisconsin counties surrounding Milwaukee and Oakland and Macomb counties in Michigan, which include suburban Detroit. Four of the congressional seats that Democrats flipped in 2018 came from one of these counties, and they'll all play a key role in next year’s election. In all of these counties, larger majorities of residents have private health plans.

“Typically, political campaigns want to run on policies that will benefit a wide number of people, while leaving most others no worse off,” Phil writes. “But in these crucial suburbs, Democrats will be advocating drastic solutions to help a small percentage of residents while severely disrupting the lives of the vast majority of the population.” 

— And here are a few more good reads:

Advisers weigh the merits of a one-term pledge by the 77-year-old former vice president.
Politico

MEDICAL MISSIVES

In a historic reversal, fewer patients are dying in hospitals. But experts warn that many families are unprepared to care for seriously ill relatives at home.
New York Times
Health
Heart disease is a leading cause of death, but non-Hispanic black people are more than twice as likely to die of it.
Lateshia Beachum
A handful of popular apps whose users are primarily gay, bisexual and transgender have begun encouraging users to disclose their status and get tested.
Politico

HEALTH ON THE HILL

White House hopeful Andrew Yang on Wednesday unveiled two plans to invest in mental health coverage and expand telehealth services.
The Hill

DAYBOOK

Today

The Senate Health, Education, Labor and Pensions Committee holds a business meeting on various legislation. 

SUGAR RUSH