The Health 202: Most states Trump administration pinpointing for HIV prevention didn't expand Medicaid

THE PROGNOSIS

Most of the states the Trump administration is focusing on in its ambitious effort to stem HIV transmissions have refused to expand Medicaid under Obamacare — creating an even bigger challenge for the federal government as it seeks ways to help get virus-suppressing medications to low-income patients.

Missouri, Oklahoma, Arkansas, Alabama, Mississippi, South Carolina and Kentucky have some of the highest rates of HIV transmissions in the nation. All except for Kentucky and Arkansas are GOP-led states that have opted out of expanding the low-income health insurance program to people earning 138 percent of the federal poverty level — meaning they have uninsured rates well above the national average.

As a result, the Department of Health and Human Services will have to rely even more heavily on federally funded community health centers to distribute PrEP — the once-a-day pill that protects users against HIV infection — as the agency tries to progress toward its goal of halting 90 percent of transmissions in a decade.

“[Community] Health Centers are a key point of entry of people undiagnosed with HIV,” said George Sigounas, administrator of the agency’s Health Resources and Services Administration, adding that nearly 2 million Americans get an HIV test and more than 160,000 patients receive HIV-related care at these centers every year.

Brett Giroir, the HHS assistant secretary for health, said the agency didn’t assume those states would expand Medicaid — or that there would be any other major changes to the country’s insurance structure — as they wrote the details of the plan. “I will say up front we did not assume any dramatic changes in the landscape of insurance, Medicaid [or] other coverage,” Giroir said. 

Sigounas and other top HHS officials were addressing new appointees to the Presidential Advisory Council on HIV/AIDS (PACHA) — a group that sat dormant for more than a year after President Trump fired its remaining members at the end of 2017. The administration appointed a slew of new experts to the panel this week, on the heels of a budget proposal that requests $291 million for the new HIV initiative.

The officials laid out more details in a meeting yesterday afternoon for how they propose to put in motion the ambitious initiative, which Trump first announced in his State of the Union address. In additional to the seven states, they’re also homing in on 48 counties where more than 50 percent of new HIV cases are diagnosed.

“We’ve had [National Institutes of Health] do things, we’ve had [Centers for Disease Control] do things, but this is the first time we’ve come together with a team … with a secretary of HHS who has completely bought into this,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. 

“This is unique,” Fauci added. 

CDC Director Robert Redfield, a key instigator of the project, said it’s the geographic concentration of HIV transmissions that makes him confident the administration’s goals are realistic.

“I will tell you, when Dr. Fauci and I saw this map, we looked at it and said, ‘Wow, this is a really focused challenge,’ ” Redfield said, referring to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.  “When this map came up we said, ‘This is doable.’ ”

HHS Secretary Alex Azar:

But plenty of obstacles stand in the way. There’s the issue of a persistent, substantial uninsured rate among lower-income Americans, particularly in the areas of the South the administration is trying to target.

And, as I detailed in this Health 202, Democrats in Congress would have to be willing to appropriate the new funds the administration is requesting to follow through on all its goals. The HHS officials expressed optimism in that regard, saying they had met earlier this week with House Democratic members of the HIV/AIDS Caucus and the Congressional Black Caucus, including Reps. Sheila Jackson Lee (D-Tex.) and Frederica Wilson (D-Fla.).

Jackson Lee’s district includes Houston, one of the areas the Trump administration is targeting in its efforts. She spoke positively about the initiative’s focus on African-American and Latino men — a population disporportionately affected by the spread of HIV — telling me she doesn’t want to “look opportunity in the face and ignore it.”

“Those of us who have been engaged in this for years are looking for any bright light that would address the HIV population in the 21st century,” she said.

And while Democrats appear open to working with the administration on the issue, there are stark differences between the two parties on what health insurance — whether public or private — should look like in the United States. Despite requesting extra funds for HIV mitigation, the president’s budget also called for sharp spending reductions to Medicaid even though more than 2 in 5 Americans with the virus depend on the program, my Washington Post colleagues Amy Goldstein, Laurie McGinley and Lena H. Sun report.

“Such a contradiction — giving while also taking away — runs through the budget arithmetic for many of the Trump administration’s health-care priorities,” Amy, Laurie and Lena write.

“In addition to combating HIV, the president has taken aim at childhood cancer and the opioid crisis, but his budget would undermine all those efforts by shrinking the health infrastructure that people struggling with those issues rely on while throttling back national cancer research spending — even as it offers discrete pots of money for those causes, policymakers say.”

“If you’re cutting Medicaid, you’re taking the legs out from underneath the system” of help for people with the AIDS virus, Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation, told them.

AHH, OOF and OUCH

AHH: The Centers for Disease Control and Prevention wants to send more experts to Congo soon to train international and local personnel amid the ongoing Ebola outbreak.

The outbreak, which has so far killed nearly 600 people, is far from under control, CDC Director Robert Redfield said in an interview with our Post colleague Lena Sun. “Three CDC personnel are on temporary assignment about 200 miles south of the epicenter,” Lena reports. “If U.S. security personnel give their approval, ‘We’re hoping to augment that team significantly to increase that training,’ Redfield said in an interview. Government sources said the CDC hopes to send as many as 10 people for the temporary training assignments.”

One obstacle: Those CDC experts wouldn’t be able to be in the epicenter of the outbreak, which is in a conflict-ridden area in eastern Congo. There was an armed attack against in the area just hours before Redfield and World Health Organization Director General Tedros Adhanom Ghebreyesus arrived there last week. It was just one of a number of attacks on Ebola treatment centers in North Kivu province that have increased in recent weeks.

“This is a complicated response,” Redfield told Lena. He added the outbreak, now in its eighth month, is “not under control” and may last into 2020.

OOF: The Trump administration is looking to establish an international coalition against access to abortion and contraceptives, an effort to promote traditional family values across the globe, our Post colleagues Lena and Ariana Eunjung Cha report.

Part of that effort was having Valerie Huber, a top HHS official, appear as the special guest at an event in New York this week with representatives of dozens of nations there for a women’s rights conference at the United Nations. The appearance was sponsored by C-Fam, a think tank with Catholic ties that aims to “defend life and family at international institutes.”

“Over the past few months, Huber and other U.S. officials have traveled the world inviting other nations to join the cause,” they write. “In meetings, according to people privy to the discussions who asked not to be identified due to the sensitivity of the negotiations, Huber, who previously founded an abstinence-only sex education group, has explained that ‘health and rights mean different things to different people.’”

At the U.N’s. Commission on the Status of Women meeting this week, U.S. negotiators are looking to remove references from an annual document about empowering women to “universal access to sexual and reproductive health and rights,” which they say promotes abortion. The U.S. negotiators also want to add a section acknowledging “women’s contribution to the home, including through unpaid care and domestic work, which is not adequately recognized, generates human and social capital.”

OUCH: U.S. Immigration and Customs Enforcement officials are considering phasing out family detention at a Texas facility, which could mean a marked reduction in the ability to hold families crossing the border.

Instead, the government would use the Karnes County Residential Center in Texas to detain “easier-to-deport” single adults, our Post colleagues Nick Miroff and Maria Sacchetti report. There are currently 528 adults and children detained at the Karnes facility in South Texas. It’s one of two large family “residential centers” that ICE operates there.

“Families held there would be issued notices to appear in immigration court and would then be released into the U.S. interior, according to two officials with knowledge of the discussions,” Nick and Maria write. “Because U.S. federal courts have limited the amount of time children can be held in immigration jails to 20 days, the families often are released into the U.S. interior anyway, sometimes with GPS ankle monitoring bracelets that allow ICE to track their whereabouts.”

HEALTH ON THE HILL

— Where do 2020 Democratic contenders stand on Medicare-for-all and other health-care issues? This interactive graphic from our Post colleagues Kevin Uhrmacher, Kevin Schaul, Jeff Stein and your Health 202 researcher Paulina Firozi looks at some health policy areas dividing the Democratic presidential primary field so far. 

They reached out to Democratic campaigns and analyzed tweets, interviews and other public statements to get answers to some key questions. You should bookmark this page: It will continue to update as new candidates announce their run and policy positions develop throughout the campaign. 

— HHS Secretary Alex Azar told lawmakers on the Senate Finance Committee his agency has, without congressional approval, had discussions with states about implementing Medicaid block grants.

“We have discussions with states where they will come in and suggest ideas,” Azar said. “There may be states that have asked about block granting, per capita, restructurings around especially expansion populations.” He added: “It’s at their instigation.”

Such a move to authorize states to impose changes to Medicaid without congressional approval could spark legal challenges, The Hill’s Peter Sullivan reports. “To say that I and many others will fight these cuts with an unyielding passion is an understatement,” Sen. Bob Casey (D-Pa.) said during the hearing. He told Azar regarding discussions with states: “We need to know what’s happening in those conversations.”

The Health 202 wrote in January about the Trump’s push to slash Medicaid spending by issuing block grants, “a strategy conservatives in Congress have repeatedly tried to implement without success.” And this week, Trump’s budget request made it clear lowering Medicaid spending is a priority.

AGENCY ALERT

— The Centers for Medicare and Medicaid Services has updated its drug spending dashboard with information on pricing and spending from 2017 as a way to boost drug cost transparency. The updates include data about thousands of drugs purchased by Medicare parts B and D as well as Medicaid.

The Health 202 wrote last May about the administration’s plans to launch the improved version of the database meant to show how much the government spends on prescription medicines for seniors and low-income people.

In a statement, CMS Administrator Seema Verma said prescription drug spending increased at an average yearly rate of 10.6 percent in Medicare Part D, 10 percent in Part B, and 14.8 percent in Medicaid from 2013 to 2017. “Today’s update to the drug dashboards continues the Trump Administration’s commitment to price transparency. The dashboards pinpoint the sources of rising prescription drug prices to help guide our continued work to address this problem,” Verma said in the news release.

— And here are a few more good reads:

MEDICAL MISSIVES

STATE SCAN

INDUSTRY RX

DAYBOOK

Today

  • AHIP’s national conference on individual and small group markets continues. 

SUGAR RUSH

From the Fact Checker: Democrats engage in ‘Mediscare’ spin on the Trump budget: