1 big thing: Medicare Advantage debate rekindled by watchdog report

2. Praise for FDA's proposed menthol ban

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3. Watch out for a blockbuster obesity drug

4. Tackling the multiple sclerosis mystery

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5. Dog of the week

Good morning. Happy Friday. It's Caitlin Owens filling in for today.

Today's word count is 794, or a 3-minute read.

Plus, support for a menthol cigarette ban

Axios Vitals: Medicare Advantage under fire

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Axios Vitals

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1 big thing: Partisanship undermines pandemic playbook

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2. Children's health issues getting worse

3. "Family glitch" fix on the horizon

4. As masks lift, spirits rise

5. Catch up quick

Today's word count is 987, or a 4-minute read.

Plus, we may not be learning our pandemic lessons.

1 big thing: Americans' COVID culture war

2. America's giant medical debt

3. Out-of-pocket limits aren't silver bullets

4. Having a baby isn't cheap

5. How COVID can damage the brain

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6. Dog (news) of the week

🎧 Listen: The second episode of "How It Happened: Putin's Invasion" came out this morning and features Axios world editor David Lawler, politics managing editor Margaret Talev and climate and energy reporter Andrew Freedman breaking down the consequences of the war in Ukraine.

Today's word count is 1,039, or a 4-minute read.

1 big thing: America's other public health threat

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2. Another European warning

3. A potential case of telehealth gone wrong

4. Opioid overdose rate's racial reversal 

5. While you were weekending

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Today's word count is 790, or a 3-minute read.

1 big thing: The next abortion litmus test 

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2. Waiting on boosters as cases climb

3. Seniors can soon spread out drug costs

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4. Record gun deaths among kids 

Good morning, Vitals readers. Today's newsletter is 936 words or a 3½-minute read.

Situational awareness: The FDA approved the first vaccine that can be given to pregnant patients to protect infants against RSV.

Thanks for reading Axios Vitals, and to health care editor Jason Millman and senior copy editor Bryan McBournie. Please ask your friends and colleagues to sign up.

National

Data: U.S. Census; Chart: Tory Lysik/Axios Visuals

The expected spike in poverty — particularly child poverty — between 2021 and 2022 shows the impact of letting major pandemic-era safety net program expansions expire, a policy experiment with no precedent in the U.S.

Why it matters: The pandemic programs were enacted as temporary measures. But their expiration still stings for the Americans who experienced an economic boost only to lose it — and there's more to come.

Driving the news: Real median household incomes fell by 2.3% in 2022 and the poverty rate increased by 4.6 percentage points to 12.4%, according to data released yesterday by the U.S. Census Bureau. 

Child poverty more than doubled fr0m 5.2% in 2021 to 12.4% in 2022.

A separate poverty measure that doesn't include government programs found no significant change in poverty from 2021 to 2022 — highlighting the impact of pandemic-era aid.

The increase in poverty reflects the expiration of the expanded child tax credit and the end of stimulus payments — which occurred as inflation caused the cost of living to rise.

Although more people had health insurance in 2022 than in 2021, this was almost certainly a fleeting phenomenon that has been undone by the unwinding of pandemic-era Medicaid policies.

Between the lines: The conventional wisdom used to be that Washington didn't let benefit programs expire, not least because taking benefits away from people is politically unpopular. 

But that's exactly what happened last year, despite some calls to extend the enhanced child tax credit. 

The economy has subsequently risen to being a dominant issue heading into the 2024 election — and one that President Biden is on the losing side on, according to public opinion polling. 

But Republicans' economic priorities have largely been centered on reducing government spending. "There's a real opening on the right for some bold family policy," said Joe Grogan, director of the Domestic Policy Council under the Trump administration. 

What they're saying: "The rise reported today in child poverty is no accident—it is the result of a deliberate policy choice congressional Republicans made to block help for families with children while advancing massive tax cuts for the wealthiest and largest corporations," Biden said in a statement. 

What we're watching: Government relief programs have continued to expire this year, and more still are coming.

Student loan payments are coming due again next month for the first time in three years, although the Biden administration has announced a new plan that will slash many borrowers' monthly payments.

At least 6.4 million people have been disenrolled from Medicaid already, per KFF, the majority of which had their coverage terminated for procedural reasons. 

And families with children may feel even deeper economic pain this fall after pandemic-era funding for child care providers expires, which is expected to cause thousands of child care centers to close and millions of children to potentially lose care.

End of pandemic-era safety net programs increased poverty

America has never attempted to take away benefits at this scale before.

Poverty

Politics & Policy

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Data: Morning Consult; Chart: Axios Visuals

Americans most often blame Mexican drug cartels for the country's opioid crisis — followed by drug users themselves, according to Morning Consult polling data provided exclusively to Axios. 

Why it matters: Voters see the crisis as more of a security issue than a health issue, an accompanying analysis argues, giving Republicans an edge on the issue heading into the 2024 elections. 

"[G]iven the salience of the issue and the relative credibility of the GOP on immigration and security among U.S. voters, we expect Republican candidates to continue to focus on drug trafficking in general and the foreign policy of fentanyl in particular," wrote Morning Consult managing director Sonnet Frisbie.

The big picture: Republican politicians repeatedly invoke the fentanyl crisis alongside migration issues, sometimes misleadingly, although much of the U.S. supply does come from Mexico across the southern border.

Survey respondents said they trust congressional Republicans more than Democrats on national security and immigration issues. 

Democrats, meanwhile, are more trusted on health care.

The intrigue: Voters in border states blame the U.S. government for the opioid crisis more than other voters do by an 11 percentage point margin.

They're also more likely than the general population — and nearly as likely as Republicans — to say that punishing drug users would be a "very effective" way to limit the supply of illegal drugs in the country.

"This tendency toward enforcement, coupled with their frustration with the federal government over the drug epidemic, is a risk factor for Arizona's Democratic candidates in the upcoming presidential and Senate races, and in several competitive House districts along the border that are in play in 2024," the analysis concludes.

Go deeper: Opioids surged past guns as Americans' top public health concern, last month's Axios-Ipsos American Health Index found.

Methodology: This survey was conducted Aug. 29-Sept. 1 among a representative sample of 1,995 registered voters. 

Results from the full survey have an unweighted margin of error of ±2 percentage points.

Security concerns give GOP edge on the opioid crisis: Poll

Voters are more likely to see opioids as a national security issue, an analysis argues.

Opioid epidemic

Bar chart showing who U.S. adults believe is most responsible for the opioid crisis. Mexican drug cartels, U.S. drug users and Chinese suppliers of fentanyl were the top three responses.

Americans most often blame Mexican drug cartels for the country&#x27;s opioid crisis — followed by drug users themselves, according to Morning Consult polling data provided exclusively to Axios. Why it matters: Voters see the crisis as more of a security issue than a health issue, <a class="gtmContentClick" data-vars-link-text="an accompanying analysis argues" data-vars-click-url="https://pro.morningconsult.com/analysis/foreign-policy-fentanyl-gop-2024" data-vars-content-id="2942c166-5100-4728-8433-a2ef54a5b24a" data-vars-headline="Security concerns give GOP edge on the opioid crisis: Poll" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://pro.morningconsult.com/analysis/foreign-policy-fentanyl-gop-2024" target="_blank">an accompanying analysis argues</a>, giving Republicans an edge on the issue heading into the 2024 elections.

Two of the country's biggest unions have joined a coalition calling on federal regulators to protect workers' mental health the way they enforce standards for physical health and safety. 

Why it matters: The press comes amid widespread post-pandemic burnout, growing awareness of the country's worsening mental health and some of the strongest pro-union sentiment in decades. 

Driving the news: A letter sent Wednesday to the Occupational Safety and Health Administration from David Michaels, who led the agency under President Obama, argues that "the agency's grant of authority from Congress includes the power to protect workers' mental health from workplace hazards."

Co-signers of the letter, which was provided exclusively to Axios, include the National Education Association and the Service Employees International Union. The left-leaning Governing for Impact and the Economic Policy Institute are also among the signers.

The groups call for the agency to initially issue guidance and take enforcement actions, but to also "take steps towards using its regulatory authority ... to set an enforceable workplace safety and health standard."

What they're saying: "OSHA's lack of focus on psychosocial risks is really an obvious hole in the worker safety protection system," Michaels told Axios.

"The law says that employers must provide a work environment free of serious hazards," he added. "Every worker has the right to go home at the end of the day in the same condition that they arrived. That's the fundamental reason why OSHA should get involved."

OSHA has taken steps like providing a checklist for managers in response to the rise in the number of people experiencing anxiety and depression. It's also joined in suicide prevention efforts. 

The groups acknowledge efforts like these but want the agency to go further.  

Between the lines: It's not surprising that the unions calling for more workplace protections represent teachers and health care workers —professions that have struggled immensely with burnout and workforce shortages post-COVID, although the health care labor shortage is easing.

Although students' needs have become more complex after the pandemic, "I don't think that before the pandemic or after the pandemic that there's been enough mental health support for educators," said Shannon McCann, an NEA executive committee member. "This is all also coinciding with an increased societal recognition that mental health is health."

McCann said that the educator shortage is "very closely connected" to mental health concerns.

"Workers of all stripes — but especially essential, frontline workers in nursing homes, hospitals and home care — often face emotionally and psychologically challenging situations at work that can carry into their lives," said Janelle Jones, SEIU's national policy director and chief economist.

What we're watching: The letter comes following the summer of strikes and as the United Auto Workers union holds a historic strike against General Motors, Ford and Stellantis.

"Labor unions are enjoying a moment of high public approval and strong belief in the benefits they offer to workers, businesses and the economy," a recent Gallup analysis concludes.

Translation: It's a good time for unions to make demands.

letter to the Occupational Safety and Health Administration

Unions press feds for more workplace mental health protections

A coalition led by a former OSHA director argues the agency can and should do more to safeguard workers' mental health.

Illustration of many yellow sticky notes with a pink one in the center with a brain on it

Mental health

Two of the country&#x27;s biggest unions have joined a coalition calling on federal regulators to protect workers&#x27; mental health the way they enforce standards for physical health and safety. Why it matters: The press comes amid widespread post-pandemic burnout, growing awareness of the country&#x27;s worsening mental health and some of the strongest pro-union sentiment in decades.

The legal challenges to President Biden's drug price negotiation law could be on a collision course with the 2024 election.

Why it matters: Should the Medicare negotiation program survive its first courtroom showdown tomorrow, analysts say drug companies challenging the law could still have several chances to stop the program before next year's election — which could undercut Biden's ability to campaign on his victory over Big Pharma. 

Driving the news: A federal judge in Ohio on Friday will hear oral arguments on the U.S. Chamber of Commerce's request to halt the program before Oct. 1, the deadline for companies to agree to Medicare negotiations on the first 10 selected drugs. 

The Biden administration and the Chamber are expected to clash over when exactly drug companies will face "harm" from the Inflation Reduction Act program. 

That will be a key question for judges across the country who are handling seven other lawsuits from drugmakers and a leading industry group.

Only the Chamber so far has asked for a preliminary injunction, while other plaintiffs have asked for a summary judgment against the program without a trial.  

It only takes one nationwide injunction to pause the Biden administration's implementation of the program, although the administration would certainly appeal such a ruling. 

Analysts closely watching these cases said plaintiffs could have a stronger case for halting the program next summer, just before Medicare will announce negotiated prices — and in the height of the presidential campaign.

Details: The judge presiding over the Chamber's lawsuit is Michael Newman, a Trump appointee who was assigned to the case after a different judge recused himself earlier this month.

The Chamber, in its request for an injunction, said the IRA already has and will continue to cause its members "unrecoverable economic losses."

The Department of Justice, which contends the Chamber doesn't have legal standing to challenge the program, said the court should throw out the case because any financial injury to drug companies wouldn't happen until 2026, when the negotiated prices will take effect. 

Between the lines: It's hard to predict how these overlapping challenges might play out.

Notably, some lawsuits were filed in parts of the country where there's a better chance drug companies draw a sympathetic panel of appellate court judges. And the Supreme Court could also ultimately become involved.

"There could be a little bit of a bump in the road and noise and conflicting injunctions, but ultimately the Supreme Court will determine whether an injunction takes effect," said Nick Bagley, a law professor at the University of Michigan who is supportive of the law.

"At the end of the day, [drug companies are] just not harmed until they're paid less for their drug, which isn't going to happen for a few years," he added.

Yes, but: The Sept. 1 deadline for Medicare to announce the negotiated prices could serve as an important legal flashpoint. That could bolster drug companies' argument that they're being harmed before prices take effect, said Raymond James analyst Chris Meekins.

Meekins in an investor note yesterday said he's expecting at least some delay in implementation and the possibility that the Supreme Court strikes down negotiations entirely. 

Bagley, on the other hand, said that the question of the program's constitutionality, rather than implementation deadlines, may end up being more relevant to a judge sympathetic to the drug companies' arguments.

The Biden administration, which previewed its legal defense of drug negotiations earlier this week, has expressed confidence that courts will uphold the program. 

Zachary Baron, a Georgetown University health law expert, said political optics will hang over any court considering whether to halt the program. 

"Part of the question in this upcoming year is, if you're a district court judge or you're in the 5th Circuit or the 6th Circuit, in the run-up to a presidential election, do you want to be seen as blocking this drug negotiation program that has widespread public support, per polling, or do you want to let this litigation process proceed," Baron said.

The bottom line: How the legal process plays out ahead of the 2024 election could either bolster or undermine Biden's talking points on an issue popular with voters.

Bagley argued that an even injunction could give Biden a political boost.

"An injunction like that is a big fat sloppy wet kiss for Joe Biden. That's not how it'll be viewed at first, but it's an opportunity for him to rail against the courts," Bagley said. 

"Even if there's a bad outcome at an intermediate stage, it puts the focus on something Joe Biden wants to talk about."

Legal battle over drug negotiations could collide with 2024 race

Drug companies challenging the law in court could still have several chances to stop the program before next year's election.

Illustration of text boxes in the shape of a hundred dollar bill and a pill clashing

Medicare

The legal challenges to President Biden&#x27;s drug price negotiation law could be on a collision course with the 2024 election.Why it matters: Should the Medicare negotiation program survive its first courtroom showdown tomorrow, analysts say drug companies challenging the law could still have several chances to stop the program before next year&#x27;s election — which could undercut Biden&#x27;s ability to campaign on his victory over Big Pharma.

Health Care Policy

It's budget week in the House Budget Committee — which means another round of creative maneuvering around the political grenade that is Medicare.

Why it matters: There are many ways to reduce Medicare spending without reducing seniors' benefits, but they all tend to get clumped together when it's politically advantageous.

The catch now is that one of these cost-saving policies — site-neutral payments — is a source of bipartisan interest in multiple committees.

Driving the news: The Budget Committee will mark up its 2024 budget on Wednesday, a spokesperson confirmed to Axios. 

Chairman Jodey Arrington told Semafor last week that a markup on a balanced budget was "imminent," and that Medicare and Social Security would be untouched. 

Balancing a budget without touching Medicare and Social Security would require enormous cuts to every other kind of government spending. But a big question is whether the budget will literally not address either program, or whether it just won't touch seniors' benefits. 

Between the lines: The House is due to take up a bipartisan price transparency package today that, among other things, would require equal Medicare reimbursement rates for drugs administered at hospital-owned outpatient facilities and doctors' offices.

That's a small-scale form of site-neutral payments, which will save a few billion dollars over the next decade. But the larger-scale versions would save hundreds of billions of dollars, and are frequently included on lists of how to achieve substantial budget savings. 

So it wouldn't be surprising if they show up in the committee's budget, along with other policies like reducing payments to Medicare Advantage plans. 

Sometimes details don't really matter when it comes to scoring political points. The Inflation Reduction Act, for example, reduces Medicare spending by lowering payments to drug companies.

But regardless, Democrats' reaction to bipartisan ideas when they're included in a partisan budget would be interesting, to say the least. 

The intrigue: Another way to deal with Medicare in a 10-year budget is to assume the program costs the federal government less money over the next decade because of slower cost growth. 

A recent attention-grabbing New York Times story explored how Medicare spending growth has been much slower over the last decade than expected, and the per-beneficiary spending has largely leveled off. No one really knows why. 

The Congressional Budget Office — and plenty of others — drastically overestimated how quickly costs would grow. 

The story raises the question: What if CBO is still overestimating Medicare cost growth, thus meaning Congress wouldn't have to slash spending by as much to balance a budget?

One GOP lobbyist said the committee has looked at using different Medicare cost growth estimates than CBO.

Yes, but: Josh Gordon, director of health policy at the Committee for a Responsible Federal Budget, said CBO has adjusted its assumptions about cost growth over time and warned against "making some kind of independent opinion that they're still too high."

Budgets that assume lower Medicare growth without including policy changes to achieve that lower growth would "be a budget gimmick," he added.

recent attention-grabbing New York Times story

House Republicans go on budget offense

The House Budget committee will mark up its budget this week.

Illustration of suit hand holding a dollar sword

House Republicans

It&#x27;s budget week in the House Budget Committee — which means another round of creative maneuvering around the political grenade that is Medicare.Why it matters: There are many ways to reduce Medicare spending without reducing seniors&#x27; benefits, but they all tend to get clumped together when it&#x27;s politically advantageous.

Caitlin Owens

Stories

Unions press feds for more workplace mental health protections

House Republicans go on budget offense

Security concerns give GOP edge on the opioid crisis: Poll

Legal battle over drug negotiations could collide with 2024 race

End of pandemic-era safety net programs increased poverty

Newsletter editions

Abortion litmus test

Axios Vitals: Medicare Advantage under fire

Axios Vitals: Children's health crises

Axios Vitals: Another looming threat

Axios Vitals: Massive medical debt