The Health 202: PhRMA's top priority pushed to sidelines by border wall fight

The industry is pushing to ditch the steeper discounts — projected to cost it around $4 billion annually — in a year-end spending bill over which Democrats and Republicans are butting heads. But larger fights over border wall funding are consuming the attention of top lawmakers, and the White House isn’t making the so-called “doughnut hole” fix a top issue, either, according to lobbyists and former Hill aides.

The budget battle hit a fever pitch at the White House and on Capitol Hill yesterday. Top Senate Republican Mitch McConnell (Ky.) warned his chamber it may work through the Christmas break if members don’t start cooperating with each other. And President Trump threatened top House Democrat Nancy Pelosi (Calif.) and top Senate Democrat Chuck Schumer (N.Y.) with a partial government shutdown if they don't agree to $5 billion in border wall funding.

“The stunning public spat, during which Schumer accused the president of throwing a ‘temper tantrum,’ ended with no resolution and appeared to increase the chances of a partial government shutdown at the end of next week, just before Christmas,” my colleagues Erica Werner and John Wagner write.

“The three leaders pointed fingers, raised their voices and interrupted each other repeatedly as they fought over policy and politics, laying bare their differences for all to see,” Erica and John write. “Pelosi and Schumer both implored Trump not to shut down the government. Trump initially said he did not want a shutdown either but in the end announced he did.”

“I am proud to shut down the government for border security, Chuck,” Trump declared. “Because the people of this country don’t want criminals and people that have lots of problems and drugs pouring into this country. So I will take the mantel, I will be the one to shut it down. I won’t blame you for it.”

In the middle of this fluid and volatile situation, drugmakers are working to reverse a policy that will hit them where it hurts. A provision in the spending bill Congress passed in February says that starting in 2019, drugmakers will have to discount drugs for seniors by 70 percent once they hit a Medicare coverage gap known as the “doughnut hole.” The current discount they must provide is 50 percent.

Pretty much everyone agrees the “doughnut hole” has long been a problem for seniors, most of whom are on a fixed income. Once they hit a certain level of spending on prescription drugs, Medicare no longer covers their medications until they’ve spent enough to qualify for catastrophic coverage. But drugmakers argue that insurers administering Medicare’s prescription drug benefits should cover more of the costs once seniors reach that spending limit.

“The changes made … reduced insurers’ payment responsibility in the doughnut hole to just 5 percent — a shift in payment burden that should be concerning for anyone advocating for seniors and access to the medicines they depend on,” said Juliet Johnson, deputy vice president for public affairs at the Pharmaceutical Researchers and Manufacturers of America.

Lobbyists for drug companies have been striving for months to reverse the steeper discounts. They worked aggressively to get a measure to do so included in the opioids package Congress passed in the fall and via a separate Health and Human Services spending bill. But in the end, the provision was left out of both measures. 

“If history has taught us anything, it’s that Big Pharma will try to exploit every legislative angle they can to advance their agenda and protect their bottom line,” said Lauren Blair, spokeswoman for the Campaign for Sustainable Rx Pricing. “That much was made clear when drugmakers tried to hitch a ride on legislation intended to address the opioid epidemic — a crisis they helped create.”

Opponents of the “fix” sought by the pharmaceutical industry say they’re now feeling optimistic it won’t happen at all.

Democrats, particularly Schumer, are refusing to allow the reversal onto the negotiating table. Sen. Ron Wyden (D-Ore.), ranking member of the Senate Finance Committee, said at the very least it would have to be paired with other measures to tamp down drug costs.

“Voters went to the polls to protect their loved ones’ health care,” Wyden said. “Passing a multibillion dollar bailout for Big Pharma without meaningful steps to hold down drug costs flies in the face of the message sent by voters.”

And while 155 House Republicans and 50 House Democrats have signed letters backing the fix, some lobbyists say the White House would rather keep it in play as leverage with drugmakers to pass parts of its drug pricing blueprint next year.

Lawmakers are also feeling pressure from AARP, which has emerged as a top opponent to reducing costs for drugmakers, deploying two national television ads as well as radio, digital and print ads that cast the proposed fix as a “bailout” for the pharmaceutical industry:

One of AARP's television ads:

AHH: The Trump administration has pushed out Peter O’Rourke, a political appointee at the Veterans Affairs Department, for spending months “doing little to no work,” our Post colleagues Lisa Rein and Josh Dawsey report.

O’Rourke, who had served as VA’s acting secretary for months earlier this year, had since August held the title of senior adviser, earning a salary as high as $161,000. In an interview with The Post he explained he was “available for anything the secretary asked me to do,” acknowledging “there were times I didn’t have a lot to do.”

VA Secretary Robert Wilkie asked for his resignation on Friday.

“O’Rourke’s departure marks an unceremonious fall for a Trump loyalist once seen as a rising star at VA, where he nonetheless had a rocky tenure, first leading a high-profile office handling whistleblower complaints, next as chief of staff and then, for two months, as the agency’s acting secretary,” Lisa and Josh write. “O’Rourke was a central figure during a tumultuous period from which VA has not yet fully recovered, when infighting at its senior levels threatened the president’s agenda for veterans.

"When Wilkie arrived in late July, he tried to sideline O’Rourke, according to people familiar with the matter. When Trump would not fire him, O’Rourke became a senior adviser to the secretary after turning down at least one low-profile job Wilkie offered.”

O’Rourke told our colleagues he is still “very supportive of the president and the agenda of the Trump administration” and would like to rejoin the administration.

OOF: A new study from the Kaiser Family Foundation found 4.2 million individuals who are uninsured are eligible to get an ACA plan with no premium. 

The report, which examines 15.9 million uninsured people “who could be shopping on the Marketplace, regardless of whether or not they are eligible for a subsidy.” It found that 27 percent of those people “are eligible to purchase a bronze plan with $0 premiums after subsidies in 2019.”

“Rather than continuing to go without insurance, the 4.2 million uninsured people eligible for $0 bronze plans would benefit from the financial protection health insurance offers,” the KFF report continues. “However, bronze plans have an average deductible of $6,258, and many people eligible for a $0 bronze premium would also be eligible for significant cost-sharing assistance by instead purchasing a silver plan.”

From Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation:

And Larry Levitt, senior vice president for health reform at KFF:

Whether or not eligible enrollees sign up for a low-or-no cost plan still comes down to whether they are aware of the ACA enrollment period at all. The deadline for open enrollment in 2019 Obamacare plans is Dec. 15. Experts have pointed to a lack of awareness of the enrollment period, either as a result of reduced marketing and outreach or because of less media coverage, as contributing to slower enrollment rates so far. 

OUCH: Cocaine deaths rose markedly from 2011 to 2016, according to new data from the National Center for Health Statistics, as the drug made a comeback in popularity amid a nationwide crisis of fatal overdoses mostly driven by opioid abuse, our Post colleague Katie Zezima reports.

During that five-year window, cocaine-related overdose deaths spiked 18 percent each year. The data from the National Center for Health Statistics also found a sharp rise in fentanyl-related deaths – 113 percent each year from 2013 to 2016.

Cocaine deaths also doubled from 2014 to 2016, and the drug was the second or third-most common cause of overdose each of the five years, a rise after the stimulant “had been waning in popularity.”

“The report, released Wednesday, provides a deeper look at drug overdoses than annual overdose data, attempting to identify the drugs that most commonly lead to overdose,” Katie writes. “For opioids, oxycodone, a prescription painkiller, contributed to the most opioid overdoses in 2011. Heroin took over as the top overdose drug from 2012 to 2015, and fentanyl caused the most overdose deaths in 2016.”

— With just days left until the Dec 15. deadline to enroll for ACA health plans through Healthcare.gov, the Centers for Medicare and Medicaid Services said it was experiencing an increase in call volumes to call centers and individuals using HealthCare.gov.

As has been the practice in previous years, the agency said some consumers would be asked to “leave their contact information and will be allowed to enroll in a plan after the December 15 deadline. This will allow these consumers to come back and complete their enrollment for January 1 coverage,” a CMS spokesman said in a statement.

Those who are asked to leave their information will be contacted after the deadline to complete the enrollment process. CMS also said it experienced “the highest traffic of this Open Enrollment” on Monday, when some consumers were placed into a temporary "waiting room" during higher-traffic periods. 

— The $867 farm bill passed by the Senate also includes the legalization of hemp and does not include strict limits on the federal food stamp program, which House Republicans had previously pushed.

“House Republicans’ farm bill would have forced states to impose work requirements on those ages 49 to 59 who get food stamps,” our Post colleague Jeff Stein reports. “It would have also forced states to impose work requirements on parents with children ages 6 to 12, among other changes. One estimate found those proposals could mean that 1.1 million households would face cuts to benefits, although conservatives and Republicans contested those numbers.”

“The bill includes SNAP revisions, although they won’t shrink individual benefits. The final bill does include several new changes to the SNAP program, though none will restrict families’ food stamp benefits, according to congressional aides.”

The bill was applauded by liberal groups, including the Center on Budget and Policy Priorities, whose president praised the “bipartisan compromise that maintains and modestly strengthens SNAP, ensuring that millions of struggling Americans will continue to be able to count on SNAP to help them put food on the table.”

Jeff also reports the farm bill includes legalizing the production of hemp, a form of cannabis with lower levels of THC than marijuana.

— — What are the possible negative consequences of lower drug prices? Austin Frakt breaks down for the New York Times some answers to this question, with insight from health-policy experts on the impact of four potential policies: getting private insurance plans to lower prices, having Medicare negotiate directly with drugmakers, following the lead of foreign countries that align medication price to value and using a “value-based insurance design,” which determines coverage based on “the price-benefit trade-off.”

For private insurers, which provide drug coverage for most people, including those on Medicare, one problem is there’s no mechanism to keep prices low, according to experts. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School, told the Times “drug manufacturers with monopoly products can raise prices to whatever extent the market will bear.” He added Medicare “can’t walk away from the table” and refuse to cover medication. “Medicare rules that require insurance plans to cover all drugs in certain classes, including for cancer, help undermine plans’ ability to negotiate prices downward,” Austin writes.

Having Medicare negotiate with drugmakers directly poses a similar problem. Doing so “would only be effective if it could say, ‘No, we won’t cover your product’ to a drug manufacturer,” Fiona Scott Morton, an economist at the Yale School of Management told the Times. “Is that really plausible? I’m not sure that’s what Medicare beneficiaries would want.” Excluding pricey drugs “would benefit taxpayers, but it would mean reduced access to drugs for the program’s current beneficiaries and slower innovation of drugs in the future,” Austin writes.

Another potential move is to follow other countries’ system of only paying for expensive drugs if they deliver a parallel benefit, Austin writes. Scott Morton said the reason a similar system isn’t in place “in the U.S. is that drug manufacturers lose when insurers know which drug is most cost-effective. It is in pharma’s interest to protect their profits and lobby vigorously against any government body that would reveal which drugs have the highest value.” Nicholas Bagley, a professor of law at the University of Michigan, suggested under such a system, “drug manufacturers would steer their research investments toward more effective drugs."

In a value-based design, an “insurer or public program could use information about the price-benefit trade-off to establish not whether to cover a drug, but how generously,” Austin writes. He adds that “ultimately, all these approaches have limitations.”

—  New research pinpoints some of the challenges for grandparents who step in and care for children, noting there are “unprecedented numbers” of grandparents taking on parental responsibility in part as a ripple effect of the ongoing opioid crisis.

The survey of 1,000 grandparents from health-care think tank Altarum out today found 20 percent of grandparents cited parental drug abuse as the reason they are taking care of their grandchildren. Other factors included incarceration, death, homelessness and mental health issues, per the report.

A spokesperson for Altarum told The Health 202 that 18 percent of those surveyed said they were raising their grandchildren because the children’s parents were struggling with opioid abuse.

Beyond drug abuse specifically, the report also found 16 percent of grandparents said the grandchildren they are taking care of are dealing with “persistent mental and behavioral health conditions,” and that a fourth of the surveyed grandparents said their grandchildren experienced “some form of abuse or neglect."

“At this point, the fallout from our nation’s opioid epidemic is impacting multiple generations; children of individuals struggling with substance use disorder are at risk of being unable to make up the ground lost as a consequence of the trauma of their fundamental years,” the report notes. “A way to mitigate this damage is through supporting the grandparents who are in extremely difficult situations, attempting to provide safety and stability for their young grandchildren who, in their short lives, have already accumulated a lifetime’s worth of hardship.”

—  And here are a few more good reads: 

Kaleo, maker of $4,100 overdose antidote, to offer generic for $178 - STAT (Stat News)

How Do You Recover After Millions Have Watched You Overdose? (The New York Times)

Fears of metal-tainted meat prompt recall of 28,000 pounds of Jimmy Dean sausage nationwide (Alex Horton)

McDonald’s to Trim Antibiotics From Its Beef (Wall Street Journal )

The Loneliest Generation: Americans, More Than Ever, Are Aging Alone (Wall Street Journal )

FDA chief blasts insulin prices, touts far-off new rules for the market (Stat)

Half of academic scientists leave the field within 5 years, according to a new study (Christopher Ingraham)

Incoming Dem chairman open to hearing on 'Medicare for all' (The Hill )

House passes bill to keep drug companies from overcharging Medicaid (The Hill )

Pennsylvania auditor urges laws to crack down on PBM contracts for Medicaid (Stat)

Trump administration’s approach to funding family planning is back in court (Ann E. Marimow)

Today

• The House Energy and Commerce Committee Subcommittee on Oversight and Investigations is scheduled to hold a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States."
• The Heritage Foundation holds an event on "Defending the Rights and Wellbeing of Children Today."
• Sens. Lamar Alexander (R-Tenn.) and Tim Kane (D-Va.) and Rep. Seth Moulton (D-Mass.) join Axios for a health care event.

Coming Up

• The House Oversight and Government Reform Subcommittee on Healthcare, Benefits and Administrative Rules holds a hearing on “Exploring Alternatives to Fetal Tissue Research” on Thursday.
• Medicaid and CHIP Payment and Access Commission holds a public meeting on Thursday and Friday.

— The full, on-camera shouting match between President Trump, House Minority Leader Nancy Pelosi (D-Calif.) and Senate Minority Leader Chuck Schumer:

— Fact-checking Trump, Pelosi and Schumer's oval office showdown: