WHITE HOUSE:

As we hit the one-month mark of the Presidency, there’s no end in sight to the Administration’s efforts to place their stamp on the federal bureaucracy and American policy. This week, they highlighted just some of the many actions governed by the 73 (!) executive orders already signed (with an accompanying press conference describing the first 30 days in more detail), continued their efforts to secure the border, and expanding access to In Vitro Fertilization (IVF). Two items of interest for us:

• • While it comprises several executive orders, I’m roping this all into one note. Continuing the crackdown on the bureaucracy, they issued an order to “reduce” the federal bureaucracy, “deconstruct” the Administrative state, and consolidate control of independent agencies under the Administration. Ultimately, the theme remains the same: the White House is looking to minimize the federal government as much as possible and limit the ability of agencies to issue regulations. This is something that is of significant interest to those who interact with the federal government on a daily basis.

• • Continuing DOGE’s efforts to root out wasteful spending, the President sent out a Memorandum to all federal agencies requiring more transparency on agency spending. While not specifically targeted at any group, considering the efforts by Congress to identify significant pockets of saving, this is yet another sign of the effort that is being put into seriously tackling the federal debt and what it may mean for future funding.

CONGRESS:

Despite a looming March 14^th deadline to fund the government, the GOP majority remains committed to figuring out a Reconciliation bill that would implement the President’s priorities along party lines. Although the President first called for one “big, beautiful bill”, the political math needed to get there is so difficult that the President later acknowledged it might take time to get there. The Senate only complicated matters for GOP House Speaker Mike Johnson by passing a “skinny” bill that only funds border & defense issues, leaving the thornier tax cuts till later this year.

The big issue for the House bill, of course, is that to get to the full $4.7 trillion dollar target they will need to tackle Medicaid, something that the Senate has no interest in doingand that a significant number of House Republicans are pushing back on, as highlighted by this letter to the Speaker from the Congressional Hispanic Caucus. Additionally, there are quite a few Republican districts, including the Speaker’s (!), where more than 20% of constituents in the district get health insurance via Medicaid, highlighting yet again the political peril of trying to tackle entitlement programs. With the House back in town this week to begin the voting process, it’s sure to be a hectic time in DC. Elsewhere in the political world:

• • We’ll get into more detail on DOGE’s efforts below, but the federal efforts to freeze funds is starting to get another pushback: Republican lawmakers, whose constituents are getting significantly impacted as the federal funds dry up and more workers are fired.

• • It’s important to realize that every “unprecedented” move made the President become the new standard for future Presidents. This new norm can upset the delicate political system of checks & balances that have existed between the different branches of government to date. Axios has an excellent summary of the dynamic shifting that we’ve seen in the last 30 days.

• • One area that is likely to end up in any final bill is work requirements for eligible Medicaid recipients. As can be seen from Georgia, the only state that successfully implemented work requirements, it’s not clear that work requirements accomplish the anticipated cost-savings. In fact, most eligible beneficiaries are already working.

• • Two useful CRS reports from the week (links are to the PDF):

• • • LSB11270: This is more for those who treat the drug rehab population, but the CRS tracked the state of the federal settlement between the companies responsible for the opioid overdose epidemic and the flow of settlement dollars to the states. It can be useful to track which states may have grant programs available for those who deal with this population.

• • • LSB11271: This is a little wonky, but with so many of the executive actions by the President tied up in court, the CRS looked at what enforcement mechanisms exist to ensure the court orders are complied with.

AGENCIES:

The chaos caused by DOGE continues. The week started with more layoffs at federal agencies, with HHS and the IRS impacted, and ended with a request that every federal needs to explain what they work upon or risk being fired. As with all things DOGE, the legal authority is murky and led to conflicting guidance from each agency. DOGE also started a website to track savings from their work, but the math is somewhat suspect. Despite their efforts at secrecy, reports are starting to crack through the DOGE bureaucracy. For now, DOGE’s work continues unabated and has left the federal bureaucracy completely unsettled.

The OIG at HHS found that Colorado made payments to MCO’s after enrollee’s deaths, showcasing yet again the inefficiencies of Managed Care Organizations. The summary is here (PDF) while the full report is here (PDF).

RFK Jr’s first week as head of HHS was somewhat… rocky.

The Wall Street Journal reported that the Justice Department has opened a civil investigation into United Healthcare for their billing practices. On the heels of the lawsuit against United Healthcare regarding their use of AI in prior authorization denials being allowed to continue, it was a bad week for Medicare Advantage.

The FDA has determined that the shortage of weight loss drugs such as semaglutides is over, meaning that compounding pharmacies will no longer be allowed to produce a compounded version as of April 22^nd.

FROM THE NOTEBOOK:

• • Virginia’s legislature passed a budget, although as with many state budget efforts right now, the decisions in DC can significantly impact the availability of federal dollars and may force the Legislature to make changes.

• • With Medicaid cuts in the news, the Kaiser Family Foundation gave a great breakdown of just how integrated Medicaid is to the provision of healthcare in America. They also explored the interplay between immigrants and Medicaid.

• • While specifically geared at home care, the latest KFF survey on how states are approaching healthcare workforce shortages in home care is instrumental for the entire workforce shortage.

• • Indiana is taking a look at their Medicaid expansion program.

• • A good read on the political realities on the frontlines for Republican lawmakers that are faced with cutting Medicaid.

• • We talk at length about Medicare Advantage vs Medicaid in this space. If you want to understand the real-world implications of how MA impacts SNF's, Z-Intel founder Marc Zimmet wrote about in a piece titled "Crimson Tsunami".