The Health 202: Trump White House finds new reason to target Medicaid

As our colleagues Jeff Stein and Tracy Jan wrote over the weekend, it's the same old Republican position with a new twist. Whereas for years the GOP's reason for overhauling the safety net programs was because they didn't work to bring people out of poverty, the Trump White House is now essentially saying the decades-old efforts were a success, so are no longer needed. 

The White House Council of Economic Advisers argues that "a dramatic reduction in material poverty" has "coincided with a substantial reduction in self-sufficiency of the non-disabled working-age population." 

"Non-disabled working-age adults have become increasingly reliant on welfare and experienced stalled employment growth, in part because of the disincentives welfare programs impose on increasing one’s own income," they write. "Program work requirements, which require recipients to work or engage in work-related activities in order to maintain benefits, can help overcome this problem."

But critics have long countered that "work requirements impose additional barriers to receiving health care and food for those who need such assistance," our colleagues write. "And [critics] accuse the administration of underestimating the difficulty of climbing out of poverty, even in a robust economy."

Let's focus here on what this debate means for Medicaid. 

Earlier this year, President Trump signed an executive order giving states more autonomy over their Medicaid programs by allowing them to request waivers from the federal government to add parameters like work requirements. So far, four states' applications have been approved by the Centers of Medicare and Medicaid Services: Arkansas, Indiana, Kentucky and New Hampshire, while seven other states have applications pending: Arizona, Kansas, Maine, Mississippi, Utah, Ohio and Wisconsin. 

Kentucky was primed to be the first to implement the requirements before a federal judge ruled just a few weeks ago that the government hadn't fully considered the implications and sent the plan back for further consideration. CMS Administrator Seema Verma, in a meeting with reporters last week, said she couldn't talk about the specific case, but that the administration was committed to lifting people on Medicaid out of poverty. 

"This administration is committed to giving states flexibility . . . states are trying to do inventive things and we’re trying to be supportive of that," she said. "[Medicaid] has evolved and changed. It was intended to be for a very vulnerable population and with the ACA it's serving able-bodied individuals. We should give them a pathway out of poverty."

Groups that advocate for the poor that brought the suit against Kentucky contend, among other reasons, that such substantial changes to Medicaid should go through Congress. 

If it were up to the House GOP, that wouldn't be a problem. Adding work requirements to safety-net programs has been a long-time goal. In fact, the majority party recently released a proposal it says will balance the budget in nine years with large cuts to entitlement programs, including a work requirement for Medicaid. 

This new report from the White House doubles down on that effort by trying to paint a rosier picture of poverty in America. It points out that Medicaid, which costs $566 billion to cover 71 million people, grew from 6 percent in 1969 to 22 percent in 2017, but that poverty had fallen 90 percent since the program began. 

Suzanne Mettler, a political scientist at Cornell University, told our colleagues that the Trump officials' take on the government's anti-poverty efforts is "an opportunistic frame to try to advance the same end."

"It is ironic," she added. "For ages [Republicans have] been saying it’s a failure, and suddenly they are trying to declare victory and call it all off.”

To underscore it's position that Medicaid disincentivizes healthy, low-income Americans from working, the administration says that 61 percent of recipients on Medicaid are non-disabled, working-age adults, yet 60 percent of that group work less than 20 hours per week. 

But the Kaiser Family Foundation has a completely different set of statistics for the Medicaid population that shows 43 percent of recipients work full-time and 19 percent work part-time. And in the states that did expand Medicaid under the Affordable Care Act, low-wage, part-time work would not be sufficient to even afford ACA marketplace health coverage, Kaiser researchers write.

In an article titled, "Implications of Medicaid Work Requirements, they wrap up what's at stake this way:

These data points show that even among those working full-time, work can be fragile, unpredictable, and may not help people rise out of poverty. Even a temporary illness or emergency situation for those working in hourly jobs could result in failure to meet new hourly work requirements. The subsequent loss of health coverage could exacerbate financial insecurity. Finally, workers will need to verify work status regularly, and many Medicaid adults may face barriers in complying with reporting requirements due to limited experience with or access to computers. Three in ten Medicaid adults say they never use a computer, but Arkansas is requiring use of on-line accounts to verify work status, and other states may rely on online reporting.

And Eliot Fishman, senior director of Health Policy at FamiliesUSA and former head of the government’s work with states on Medicaid waivers at CMS, tweeted last night a thread about the White House's new report, writing there's no evidence from job numbers that Medicaid, or the expansion of it, led to less people entering the workforce. In fact, he counters, "you could make the case that extending health coverage to low income people helped them to re-enter the workforce, for example by accessing mental illness or substance use treatment."

So, where does this all leave Medicaid? For now, exactly as its long been: A partisan football to be lobbed back and forth when politically expedient.

But President Trump's Supreme Court nomination gives conservatives an advantage in its quest to make Medicaid access contingent on factors like employment. If a case questioning states' right to make changes to its Medicaid program comes before the highest court, a rightward turn of the bench could result in a fragmented program wherein eligibility limits are based on where a person lives. 

AHH: The Food and Drug Administration late last week approved the first drug to treat smallpox, an anti-viral pill that could potentially stop the spread of a deadly pandemic, the New York Times’s Donald G. McNeil Jr. reports.

Most people under the age of 40 have not been vaccinated for smallpox because routine administration of the vaccine stopped after it was eradicated in 1980. The approved pill, known as Tpoxx, has not yet been tested on humans with the eradicated disease. “But it was very effective at protecting animals deliberately infected with monkeypox and rabbitpox, two related diseases that can be lethal,” Donald writes. “It also caused no severe side effects when safety-tested in 359 healthy human volunteers, the F.D.A. said.”

FDA commissioner Scott Gottlieb said the advancement “affords us an additional option should smallpox ever be used as a bioweapon.” Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases told the TImes the FDA's approval  of the drug is “definitely a good thing."

“Research on tecovirimat — originally designated ST-246 — began at the institute after the 9/11 terrorist attack on the World Trade Center,” Donald reports. “The research accompanied efforts to stretch the national stockpile of smallpox vaccine by safely diluting it.”

OOF: The Department of Health and Human Services’s internal iatchdog concluded in a 58-page report that former secretary Tom Price wasted at least $341,000 in government funds over the course of his tenure amid a failure to follow federal travel requirements, our Post colleagues Mark Berman and Amy Goldstein report.

Price resigned in September following criticism over his extensive use of charter flights.

“Our rigorous review of [Price]'s use of chartered, military, and commercial aircraft found that 20 out of 21 trips did not comply with applicable federal regulations and HHS policies and procedures, resulting in waste of at least $341,000 in federal funds,” a spokesman from the inspector general’s office said in a statement. “We recommend the Office of the Secretary review the lack of compliance with federal requirements and determine appropriate actions to recoup the travel costs.”

The report found Price’s office did not compare charter flight costs with commercial travel costs, or for certain chartered flights, did not choose cheaper alternatives.

In a statement, a spokesman for Price criticized media coverage of the report, stating it “inaccurately states the report takes issue with Dr. Price’s actions… In fact, the report addresses overall functions of Department staff charged with administering travel.”

OUCH: McDonald’s has stopped selling salads at 3,000 of its restaurants nationwide over a parasite outbreak that sickened dozens of customers in multiple states, mainly in the Midwest, according to The Post’s Lindsey Bever.  The salads were removed from the restaurants until McDonald’s can get a new supplier, the chain said in a statement.

“The announcement comes after public health authorities in Illinois and Iowa warned that a number of recent cyclospora infections in those states appear to be linked to the salads,” Lindsey writes. She wrote the cyclospora cayetanensis parasite can contaminate food and water and can lead to a non-life-threatening intestinal illness called cyclosporiasis, per the CDC.

“McDonald's is committed to the highest standards of food safety and quality control,” the company said in a statement, adding it was cooperating with the outbreak investigation.

— The federal judge involved in the ongoing reunification of migrant families called out the Trump administration late last week for suggesting that expediting the process would be risky for children.

“U.S. District Judge Dana M. Sabraw in San Diego called an unscheduled, after-hours hearing via conference call Friday after a key federal official filed a sworn statement with the court saying that Sabraw’s deadlines for reuniting children were forcing the government to shorten the vetting process,” The Post’s Maria Sacchetti reports. “The statement implied that the deadlines could result in the government placing as many as 175 children with people who were not their biological parent, among other risks.”

During the call, Sabraw chided the administration for the “parade of horribles” it listed to portray the order as potentially hazardous. “That is on the government,” Sabraw said, per Sacchetti. “And that’s a failure of the process and it is inconsistent with the court’s order.”

Sabraw had also on Friday praised the administration for its “substantial” effort to reunite by last week’s deadline more than half of the 103 children in U.S. custody that had been separated.

Now, the government faces a July 26 deadline to reunify children between the ages of 5 and 17. HHS said it has identified 2,551 migrant children in that age group who are “potentially” eligible to be reunified with their parents, but officials will now have to determine whether the parents are able and fit to take the children.

Officials said they are set to return up to 200 kids a day to their parents, per our colleague. “Officials also signaled late Friday that not every family will be reunited; the same occurred with the smaller group of some 100 children age 5 or younger,” she added.

In a Friday night court filing, the Trump administration said it plans to expedite the reunification process for those 2,551 children, specifically noting it would adjust some of the methods used when reunifying children under age 5, including no longer using fingerprint and DNA testing to confirm parent identities, Politico’s Dan Diamond reports.

According to Politico’s Ian Kullgren, Sabraw also called for a 9:30 am status hearing today with attorneys for the federal government and the ACLU.

— Families who fled to the United States seeking asylum and were separated by U.S. officials may face another difficult choice once they are reunited. After migrant children are returned to their parents, parents will have to decide whether to work toward staying in the country legally, navigating a complex immigration system, or turn the children over to U.S. authorities so the kids will be allowed to stay even if parents are deported, Bloomberg’s ­­Kartikay Mehrotra explains.

“On Friday, the American Civil Liberties Union and U.S. government attorneys disclosed an agreement that leaves it up to immigrant parents to decide whether their children will stay with them in detention or be placed with social service workers,” Kartikay reports. “For the government, the agreement ensures its authority to detain adults in federal custody remains intact while families are reunified. The ACLU, meanwhile, got an assurance that if families consent to being held in custody, they aren’t waiving other legal rights going forward.”

Our Post colleague Michael Miller spoke with some of the migrant kids who have been kept in shelters after they were separated from their families.

“Experts warn that many of these children may be deeply traumatized by their experiences,” Michael writes. “Their voices have seldom been heard during the frenzied debate over family separation.”

“They always kept the boys and the girls separate,” said an 8-year-old girl from Guatemala. “And they punished us if we went near each other.”

One 11-year-old boy from Guatemala said he had to ask permission to hug his sister.

A 9-year-old boy from Brazil said: “I felt like a prisoner … I felt like a dog.”

 — In an interview with the Daily Mail's Piers Morgan, Trump said he understood the concern that abortion-rights supporters have with his Supreme Court nominee. But he suggested it would be a “long time” before the Supreme Court may hear a case that could lead to a reversal of Roe v. Wade.

“I do understand, but I also understand that you know, that’s a 50/50 question in this country,” Trump said about the debate over Roe.

“I think he is going to be confirmed and someday in the distant future there could be a vote,” Trump added, referring to nominee Brett M. Kavanaugh. “There’s also a very good chance there won’t be a vote. We’ll have to see what happens. A case has to get up there. It could be a long time before a case ever gets up there.”

Meanwhile, our Post colleagues Robert Barnes and Ann E. Marimow detail Kavanaugh's "first judicial hero" — the late Chief Justice William H. Rehnquist, who had a conservative record on issues including abortion.

Last year, Kavanaugh told the American Enterprise Institute in a Constitution Day speech that Rehnquist was his hero for his rejection of a “wall of separation between church and state” in his Roe v. Wade dissent. “Liberal groups, abortion rights activists and antiabortion organizations all have seized on the speech, as well as Kavanaugh’s rulings involving a undocumented teenage immigrant seeking an abortion while in federal custody,” our colleagues write.

— HHS is set to delete two decades of medical resources currently maintained by its Agency for Healthcare Research and Quality, also known as the National Guideline Clearinghouse.

It’s a key collection of medical guidelines and evidence-based research used by doctors and researchers, the Sunlight Foundation's Jon Campbell wrote in piece for The Daily Beast, and the “guideline.gov” site is set to go offline after today. 

“Guideline.gov was our go-to source, and there is nothing else like it in the world,” Oregon Health & Science University professor Valerie King told Jon. “It is a singular resource.”

“When doctors want to know when they should start insulin treatments, or how best to manage an HIV patient in unstable housing — even something as mundane as when to start an older patient on a vitamin D supplement — they look for the relevant guidelines,” Jon writes. “The documents are published by a myriad of professional and other organizations, and NGC has long been considered among the most comprehensive and reliable repositories in the world.”

“AHRQ agrees that guidelines play an important role in clinical decision making, but hard decisions had to be made about how to use the resources at our disposal,” AHRQ spokesperson Alison Hunt told Jon in an email. "The operating budget for the NGC last year was $1.2 million, Hunt said, and reductions in funding forced the agency’s hand."

— The Obamacare tables have turned for Democrats who are centering their campaigns around defending the same health-care law once used to target and defeat them, our Post colleague Sean Sullivan reports.

Now, Democratic candidates are pointing their fingers at Republicans' failure to rescind the health-care law last year, and looking to rally voters around the ACA and convince them supporting Trump’s Supreme Court nominee would increase the likelihood that the high court would dismantle Obamacare.

“The strategy marks a dramatic turnabout from the previous two midterms when many Democrats avoided defending Obamacare, and illustrates the extent to which the law has taken root as millions of Americans have come to depend on it,” Sean writes “Republicans, who relentlessly attacked Democrats for supporting the ACA in 2010 and 2014, are now largely steering their campaigns toward different topics.”

“We’ve learned a lesson,” Sen. Richard J. Durbin (D-Ill.), the second-ranking Democratic senator said. “The American people are tuned in to the failure of the Republicans to come up with an alternative to Obamacare.”

Chris Wilson, a Republican pollster, told Sean Obamacare was “something to fire up our base. Now ‘protect Obamacare’ is a rallying cry for Democratic enthusiasm.”

—Alexandria Ocasio-Cortez and Sen. Bernie Sanders (I-Vt.) are heading to Kansas on July 20 to rally for Democratic congressional candidates running in red states.

“I’ve believed for years that the Democratic Party has committed political malpractice by writing off half the states in this country,” Sanders told our Post colleague Dave Weigel. “They’ve got to fight for every state in this country.”

Sanders and New York City congressional nominee Ocasio-Cortez will rally for James Thompson in the state’s 4th Congressional District and for Brent Welder in the state’s 3rd Congressional District.

Our colleague previously reported that Kansas’s 3rd district is the only one in the Great Plains that voted for Hillary Clinton in the 2016 presidential election. Welder has been endorsed by Sanders and Ocasio-Cortez and is running on a platform that includes a $15 minimum wage and a push for “Medicare for all,” Dave wrote.

“All over this country, you have people who understand that we need to [change] the minimum wage to a living wage; that health care is a right; that we need to rebuild our infrastructure,” Sanders said. “Those are popular issues in the Bronx. These are popular issues in Vermont. In Kansas, they’ve gone through the [former governor Sam] Brownback agenda, and they do not believe you should give tax breaks to the rich and cut Social Security.”

— A new report from Senate Democrats reveals the link between Swiss pharmaceutical giant Novartis and Trump’s personal lawyer Michael Cohen may have been broader than what the company disclosed in previous and perhaps misleading statements, Stat’s Ed Silverman and Ike Swetlitz report.

“Novartis explicitly sought to hire Cohen to gain access to ‘key policymakers’ and provided him with ideas for lowering drug costs, which later appeared in the Trump administration blueprint that was developed to address the issue,” they write. “With the findings, the report highlights a sensational series of events that have underscored concerns about the extent to which the pharmaceutical industry has attempted to influence the Trump administration. And the conclusions place Novartis in a very unflattering light, as the documents indicate the company saw the arrangement as a golden opportunity to buy access to the White House.”

Novartis said in a statement that it “disagree[s] with the report’s conclusion that we issued a misleading public statement regarding the extent of our engagement with Mr. Cohen,” according to Stat.

— In a report requested by Gov. Andrew M. Cuomo, the New York State Department of Health recommended legalizing marijuana, noting that “the positive effects of a regulated marijuana market in NYS outweigh the potential negative impacts.”

Cuomo had asked for a report assessing the health, criminal justice, public safety, economic and educational impacts of a marijuana program by the state, our Post colleague Christopher Ingraham reports.

“It found that the legal regime of marijuana prohibition has ‘not curbed marijuana use and has, in fact, led to unintended consequences,’ like the disproportionate criminalization and incarceration of minorities,” Christopher writes. He adds such a program could be worth between $1.7 billion and $3.5 billion and bring in from $248 million to $677 million in tax revenue a year for New York. The report also acknowledges that pot is not as harmful as alcohol and tobacco and that legalization would lessen any limited harm.

“The report is notable for its full-throated adoption of arguments that have been put forth by legalization supporters for years,” Christopher writes.

— And here are a few more good reads from The Post and beyond: 

State abortion ballots prepare for post-Roe world (Politico)

Testosterone boost feeds US men’s hunger for luxury products, study indicates (Melissa Healy)

Food recalls explained: Why it seems like food contamination is on the rise (Corilyn Shropshire)

Australian experiment kills over 80% of disease-spreading mosquitoes (Axios)

Amid the opioid crisis, some seriously ill people risk losing drugs they depend on (Sarah Vander Schaaff)

Toronto medical official calls for decriminalizing drugs as opioid overdoses skyrocket in Canada (Amanda Coletta)

Coming Up

• The House Veterans Affairs Subcommittee on Oversight and Investigations holds a joint hearing with the House Small Business Subcommittee on Investigations, Oversight and Regulations on “Achieving Government-wide Verification of Service Disabled Veteran Owned Small Businesses” on Tuesday.
• The House Veterans Affairs Committee holds a hearing on “The VA Accountability and Whistleblower Protection Act: One Year Later” on Tuesday.  
• The Senate Health, Education, Labor and Pensions Committee holds a hearing on health care costs on Tuesday.
• The House Ways and Means Subcommittee on Oversight holds a hearing on combating Medicare fraud on Tuesday.
• The House Ways and Means Subcomittee on Health holds a hearing on “Modernizing Stark Law to Ensure the Successful Transition from Volume to Value in the Medicare Program” on Tuesday.
• PhRMA holds an event on “The State of Care: Innovation & Access” on Tuesday.
• Politico holds its second Pro Summit on Tuesday.
• The Senate Special Committee on Aging holds a hearing on “Supporting Economic Stability and Self-Sufficiency as Americans with Disabilities and their Families Age” on Wednesday.
• Brookings Institution holds a event with FDA Commissioner Scott Gottlieb on Wednesday.
• The FDA’s Blood Products Advisory Committee holds an open session on Wednesday.
• The National Academies of Sciences, Engineering, and Medicine holds a workshop on the integration of health care and social services on Thursday.
• The House Energy and Commerce Subcommittee on Health holds a hearing on “21st Century Cures Implementation: Examining Mental Health Initiatives” on Thursday.
• The Alliance for Health Policy holds an event on “State Responses to the Evolving Individual Health Insurance Market” on Friday.

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