It’s crunchtime. Congressional negotiators are grappling with thorny questions as they rush to craft a plan extending health coverage to 2.2 million poor adults.

Democrats have pledged to use Biden’s massive social spending bill to expand Medicaid in the dozen states where GOP officials have refused to do so for nearly a decade. 

The move would fill one of Obamacare’s last remaining holes and is a huge priority for those who drafted the health law, such as House Speaker Nancy Pelosi. But the party is still wrestling over whether to spend the cash to make the program permanent and how to prevent states from dropping coverage so the federal government picks up the tab, according to five sources with knowledge of the situation. 

The cost conundrum is tricky politics.

Democrats are increasingly cognizant of just how expensive it is to make their health priorities a reality before the midterms, likely forcing them to dial down the length of some of the new policies in the $3.5 trillion bill. Behind the scenes, key lawmakers have not yet decided how long the new Medicaid expansion program would last, despite a Sept. 15 deadline for committees to write their pieces of the legislation, according to six sources.

Within the last few days, advocates for a permanent fix have ratcheted up the pressure. 

  • Leaders of the Congressional Hispanic Caucus and Congressional Black Caucus urged leadership to pursue a lasting fix to the Medicaid coverage gap.
  • State groups argued that their residents should know their health coverage won’t get taken away.
  • Wade Henderson, the head of the Leadership Conference on Civil and Human Rights, called the policy a “test of [Congress’] commitment to racial equity.”

Judy Solomon, senior fellow at the Center on Budget and Policy Priorities:

But Democrats also have their sights on other huge (and pricey) new programs, such as an expansion of Medicare — championed by Sen. Bernie Sanders (I-Vt.) — to cover dental, vision and hearing. Nonpartisan scorekeepers projected in an analysis of a House bill in 2019 that the new benefits could cost roughly $358 billion over a decade — and that doesn’t include the price tag of financial assistance Democrats want to provide starting next year, while the formal benefits are set up.

Crafting a Medicaid fix is no simple task. 

Lawmakers are rallying around a leading option for closing the coverage gap. People who fall into this gap would get free plans on Obamacare’s insurance marketplaces for several years, while federal health officials create a new Medicaid-like program. These Americans are below the poverty level – making them ineligible to get marketplace subsidies – but earn too much to qualify for Medicaid in non-expansion states.

But Democrats are still fleshing out another key piece of the puzzle: how to ensure states that took up Obamacare’s expansion long ago don’t drop their coverage to get a better deal under a new federal solution.  

“There’s no magic here,” said Matthew Fiedler, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy. “Your options are to offer a bonus to states that adopt expansion, penalize states that drop expansion or do some combination of the two.”

Congress is eyeing possible incentives, such as bumping up federal funding to expansion states, according to one source with knowledge, though that would cost even more money. Meanwhile, there are potential legal questions around limiting the policy only to Medicaid expansion holdout states. 

A Democrat familiar with the negotiations said the length of the Medicaid policy is still being discussed, so that decision precludes finalizing other details. 

It’s unclear which states, if any, may seek to get rid of their expansion programs. Some point to Republican states, though Fiedler said he’d expect both red and blue governors to take a look at doing so if the legislation doesn’t include any financial penalties or rewards. (Several states contacted by The Health 202 said it was too soon to speculate.) 

Keep in mind: The party has no margin for error. 

It needs the support of all Democratic senators to pass, as a crucial swing vote — Sen. Joe Manchin (D-W.Va.) — thrust the effort into jeopardy last week when he called for a “strategic pause” due to the high price tag.  

Ron Klain, White House chief of staff, on CNN:

Ahh, oof and ouch

AHH: The Justice Department is exploring ways to challenge Texas’s restrictive abortion law.

Attorney General Merrick Garland said the department would explore “all options” to challenge the Texas law and vowed to provide support to abortion clinics that are “under attack” in the state, The Post’s Hamza Shaban reports. 

The statement comes just days after the Supreme Court refused to block the law, which bans abortions as early as six weeks of pregnancy and permits private citizens to bring lawsuits against abortion providers. 

President Biden, who called the Texas restriction almost un-American on Friday, has asked the Justice Department to explore ways to combat the new law.

The Texas law has also reinvigorated calls from some Democratic lawmakers to pass a law protecting the right to abortion nationwide. To do that, however, lawmakers would need to abolish the filibuster in the Senate, which requires 60 senators to pass most bills. Sens. Manchin and Kyrsten Sinema (D-Ariz.) have both said they oppose doing away with the filibuster.

Even before last week’s Supreme Court decision, abortion opponents had already had a very successful year, with Republican states passing 90 new abortion restrictions in first six months of 2021, according to the Guttmacher Institute. While many of those restrictions have been halted by the courts, the success of Texas’s law could provide a blueprint for GOP-led states. Republican officials in at least seven states have suggested they may change their laws to mirror Texas’s legislation.

OOF: Seven people died in chaotic Louisiana nursing home evacuations during Hurricane Ida. 

Family members told reporters they were left in the dark, unable to locate loved ones.

“I feel like they herded my mom and these poor people like cattle,” Melissa Barbier, 36, told The Post, after days spent seeking word from her mother, only to find she had been evacuated from Maison DeVille Nursing Home in Harvey, La., to a warehouse, where conditions were reportedly poor.

In the face of the impending hurricane, seven nursing homes evacuated nearly 850 residents to a warehouse in a plan approved by the state, the New Orleans Times-Picayune reported. Local officials said they were told the facility could hold less than half as many people. 

Frail, elderly evacuees reportedly languished on mattresses packed together on the floor, some lying in their own urine and feces. EMTs called to the scene were turned away, officials told the Leesville Daily Leader, a local newspaper. 

Seven residents who were sent to the warehouse died, with five of the fatalities deemed “storm-related,” according to the state department of health, which over the weekend ordered the seven nursing homes closed.

OUCH: At least 1,000 schools have closed because of covid-19 since the start of the school year.

The finding, from the New York-based data service Burbio, underscores the extent to which the most recent surge in coronavirus cases has already disrupted the first weeks of school, the Wall Street Journal’s Yoree Koh reports.

Variations in data reporting make it hard to determine how hard schools have been hit by the virus, but a Wall Street Journal analysis of available data from state health departments found the number of coronavirus infections in school-aged children has climbed more rapidly in states where schools opened earlier. 

A recent study from the Centers for Disease Control and Prevention found that pediatric hospitalizations for covid-19 have increased nearly fivefold from late June to mid-August. The hospitalization rate is 10 times higher in adolescents who are unvaccinated compared with those who are vaccinated.

Coronavirus boosters

Fauci says Moderna boosters may take a little longer.

Anthony Fauci told CBS’s “Face the Nation” on Sunday that the Pfizer booster shot should be ready by Sept. 20, but that additional shots of the Moderna vaccine could take a little longer to get the greenlight from the Food and Drug Administration.

“I think it’s going to be at the most a couple of weeks, a few weeks delay, if any,” said Fauci, who serves as Biden's chief medical adviser. 

An FDA advisory panel is set to review Pfizer’s application for booster shots on Sept. 17, just three days before they are supposed to start.

Top health officials warned the White House on Thursday that they do not yet have sufficient data to roll out boosters for people who received the Moderna or Johnson & Johnson vaccines.

More in coronavirus news

The week ahead

We've got a busy week coming up. Here's the rundown:

The FDA will decide the fate of Juul. The FDA is supposed to decide by Sept. 9 whether the e-cigarette company Juul will be able to keep selling its products in the United States. The agency is also reviewing millions of other products made by hundreds of other cigar, pipe and cigarette companies but has said the massive number of marketing applications will make it hard to complete its reviews by the deadline.

Many health groups are hoping the agency will ban all flavored cigarettes, which they say hook kids on nicotine. Health groups are generally less worried about tobacco-flavored e-cigarettes, but when it comes to Juul, they say the company can’t be trusted and they want all products off the market, The Post’s Laurie McGinley reports.

Opening statements in the trial of Elizabeth Holmes kick off tomorrow in federal court in the Northern District of California in San Jose. Holmes, the founder of the health-care start-up Theranos, is facing charges that she knowingly misled patients and investors about the capability of her company’s blood testing technology. Holmes is expected to claim she was a victim of abuse by her former boyfriend and the company’s president. Stat’s Casey Ross says evidence in the trial could shed light on the broader collision between the “move fast and break things” culture of Silicon Valley and the more cautious culture of health care.

On the Hill, all eyes are on the $3.5 trillion reconciliation package. Lawmakers gave themselves a deadline of Sept. 15 to hash out a budget deal, but the details of many health-care provisions remain up in the air. We’ll be keeping an eye on what’s in, what’s out and whether the deal will get the votes to pass.

Sugar rush