The Trump administration has dropped one of the meatiest portions of its plan to reduce drug prices.

The Department of Health and Human Services said it will no longer pursue a rule that would have prohibited the payment of certain rebates on drugs in Medicare Part D and Medicaid plans.

The idea was to target the middlemen, pharmacy benefit managers, whose negotiations with drugmakers and insurers influence the costs consumers pay for drugs.

The hope was the rule would have effectively pressured drugmakers to give discounts to consumers instead of middlemen, HHS secretary Alex Azar said in remarks to the media in February. “Passing discounts directly on to the patient will move us toward a real market for drugs,” said Azar. “We’re going to fundamentally rewire how we pay for drugs in this system.”

Right now, if you’re a Medicare Part D beneficiary, and you need to pick up a drug that has a $120 list price, you might have to pay that full price, even if the middleman that negotiates on behalf of your insurer only pays a net price of $100 for it, after rebates. The idea of this proposal was that the consumer would only have to pay the discounted price.

When the rule was first announced, drugmakers supported the idea, and some drug pricing experts said it could be an effective move. “This is a huge potential change, transformative,” Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh told NPR.

But some critics were concerned that the move wouldn’t address drugs’ list prices that are the starting point for negotiations.

Also, there was a worry that the elimination of rebates could ultimately cost seniors more, in higher premiums on their Medicare plans. The nonpartisan Congressional Budget Office in May determined the plan would cost the federal government $177 billion over nine years, largely from increases in the government’s share in the cost of premiums.

In a briefing with reporters Thursday, Azar said the administration scrapped the plan after getting feedback from the public and stakeholders. “At the end of the day, while we support the concept of getting rid of rebates, while we appreciate and are passionate about the problems and the distortions in the system caused by this opaque rebate system, we’re not going to put seniors at risk of their premiums going up.”

“Congress perhaps might even take this up — they have more tools than we do,” Azar said. “They can actually look more holistically at changes to the system that could also mitigate or protect seniors from bearing any impact of change. I don’t have those tools; they might have those tools.”

A senior Trump administration official, who spoke on background during a separate briefing Thursday, echoed those sentiments, saying their primary focus is to support a legislative deal to lower drug prices and that there was concern this change would disrupt those efforts.

Drugmakers were in favor of trying to bring consumer prices down by targeting middlemen. The drug industry trade group PhRMA called the rollback of the plan “a blow to seniors who could have paid less for their medicines at the pharmacy counter.”

“Of all the policies proposed in Washington right now, this was the only proposal that would provide immediate savings at the pharmacy counter, instead of only saving the government or insurance companies money,” said Holly Campbell, PhRMA’s deputy vice president of public affairs in a statement.

Other stakeholders cheered the administration’s reversal of the proposed rule, including groups representing private insurers, public sector health plans and pharmacy benefit managers. They pointed to the prices set by drugmakers as a better focus for efforts to reduce drug costs.

“Any solution should start with addressing drug prices,” T.J. Crawford, a spokesman for CVS Health, which operates a large pharmacy benefit manager, wrote to NPR.

Matt Eyles, president and CEO of America’s Health Insurance Plans, said in a statement: “As we all know, drug prices and price increases are set and controlled solely by drugmakers. They alone could decide to reduce prices – and can do so today.”

The rebate reversal is the second defeat for the administration on drug pricing in a week, coming just days after a court struck down another pillar of its drug pricing plans, a proposed regulation to require that drug companies disclose prices in ads.

Azar says the administration hasn’t given up on lowering drug prices. But Congress will have to play a bigger role. “We have many other things that we’re doing in drug pricing,” he says. “We are working on a bipartisan basis with Congress on drug pricing legislation.”

The White House official who briefed reporters Thursday said people in the administration don’t plan to “twiddle our thumbs” while the legislative process plays out, and are working on a number of plans.

President Trump hinted at one idea last week — a “most favored nation” clause that would tie American drug prices to what other countries pay. The administration has not released any details about how that would work or when it would roll out.

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Updated 6:30 p.m.

The Trump administration has announced an ambitious plan to change treatment for kidney disease in the United States.

President Trump signed an executive order Wednesday directing the Department of Health and Human Services to develop policies addressing three goals: reducing the number of patients developing kidney failure, reducing how many Americans get dialysis treatment at dialysis centers and making more kidneys available for transplant.

“With today’s action, we’re making crucial progress on another core national priority: the fight against kidney disease,” Trump said at a speech prior to signing the order.

Kidney disease is the ninth-leading cause of death in the U.S. and a major expense for the federal government. Medicare pays for end-stage renal disease treatment, including dialysis and kidney transplant.

“Taxpayers spend more on kidney disease — over $110 billion — than we do on the National Institutes of Health, the Department of Homeland Security and NASA combined,” Joe Grogan, head of the White House’s Domestic Policy Council told reporters.

The executive order pushes for changes in three areas: prevention, dialysis care and kidney donation. To implement parts of the order, the Centers for Medicare and Medicaid Services announced Wednesday five proposed payment models intended to increase innovation in the delivery of kidney care.

Better prevention of kidney failure is desperately needed, according to Dr. Holly Mattix-Kramer, a kidney specialist at Loyola University Chicago and the president of the National Kidney Foundation. Mattix-Kramer was among dozens of kidney specialists and patient advocates who attended the announcement Wednesday.

“We’re extremely excited,” she says. “For so long we felt like no one was paying attention to this epidemic of kidney disease.”

One problem, she explains, is that there hasn’t been financial incentive to get doctors to screen for kidney disease or to diagnose and educate patients about it. “Once you get kidney failure then there’s a payment structure for that,” she says. “But there lacked a good payment structure incentive for preventing kidney failure, which seems not intuitive and seems obviously something that we should fix.”

The executive order proposes to change the way Medicare providers are paid to motivate them to focus on patient education and preventing the progression of kidney disease. It also calls for an awareness campaign. “Forty percent of Americans with some stage of kidney disease do not know they have it,” Health and Human Services secretary Alex Azar told reporters on a call Wednesday morning.

A key focus of the executive order is effort to encourage in-home dialysis. One of the new, proposed CMS models incentivizes clinicians to offer this option to patients.

Currently, most dialysis is delivered at dialysis centers, a multibillion-dollar industry dominated by two for-profit companies. In-center dialysis can be time-consuming and burdensome for patients.

“Currently only 12% of American dialysis patients receive it at home. That would compare to 56% in Guatemala and 85% in Hong Kong,” said Azar. “We want to get to 80% of those who are under treatment either in-home dialysis or transplanted eventually — so a radical change from where we stand now.”

CMS Administrator Seema Verma explained that the current system prioritizes payment to in-center dialysis, but her agency wants to start to incentivize in-home dialysis and transplants.

“The way we currently pay for chronic kidney disease and kidney failure isn’t working well for patients,” said Verma in a statement.

Mattix-Kramer says the administration’s targets for increasing the proportion of patients getting dialysis at home may be overly ambitious. “It’s great to have big goals like that, but I do think 80% is going to be incredibly difficult,” she says.

For a lot of her patients, it wouldn’t be easy to switch to in-home treatment. “You need social support and you need a clean house and you need someplace to have equipment. Many of our patients live in areas where they don’t even have a grocery store in their neighborhood,” she says. “A lot of those socioeconomic issues would need to be addressed.”

Another focus of the executive order is the organ transplant system. Currently, close to 100,000 people are on a waiting list for kidneys.

“Many, many people are dying while they wait,” Trump said, addressing a room full of kidney doctors, advocates and patients in Washington, D.C., just before signing the executive order. “We’ll do everything we can to increase the supply … of the available kidneys and getting Americans off these waitlists.”

Azar said he believes it’s possible to double the number of kidneys available for transplant by 2030. “There is currently a lack of accountability and wide variability among these organ procurement organizations,” he said. “The executive order will demand a much higher level of accountability.” He also said living donors could receive compensation from the government for lost wages and child care.

Finally, the executive order encourages research and development of an artificial kidney, an innovation that could someday replace the need for transplants.

Administration officials touted Wednesday’s news as the first major action related to kidney disease in decades. Previous administrations, including Barack Obama’s, have suggested similar initiatives, but not much has changed.

Andy Slavitt, who ran the Centers for Medicare and Medicaid Services under President Obama, praised Wednesday’s announcement on Twitter. “Care of kidney patients has been broken in the US for a long time, plagued with a corporate duopoly [and] a lower income minority population losing out,” he wrote.

But he also pointed out that as the Trump administration makes this announcement, it is arguing in court that the Affordable Care Act should be struck down as unconstitutional. “There is one law that makes this new change possible. The same law that requires people with [preexisting] conditions get coverage. The ACA,” he tweeted. “Without it, there is no authority to do this.”

It was unclear how quickly these changes could roll out. Frequently, Trump’s executive orders instruct agencies to develop federal rules, a lengthy bureaucratic process. One more immediate change is in how Medicare providers are reimbursed; CMS announced that its proposed payment models would roll out starting in January 2020.

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California has become the first state in the country to offer government-subsidized health benefits to young adults living in the U.S. illegally.

The measure signed by Gov. Gavin Newsom on Tuesday extends coverage to low-income, undocumented adults age 25 and younger for the state’s Medicaid program.

Since 2016, California has allowed children under 18 to receive taxpayer-backed healthcare despite immigration status. And, state officials expect that the plan will cover roughly 90,000 people.

“The law will not give health insurance benefits to everyone 25 and younger, but only those whose income is low enough to qualify,” reported the Associated Press.

The idea of giving health benefits to undocumented immigrants is supported by most of the Democratic candidates running for president, and California’s move comes as the Trump administration continues to ramp up its hardline crackdown on unauthorized immigrants. On Tuesday, Newsom said the state law draws a sharp contrast with Trump’s immigration policies.

“If you believe in universal health care, you believe in universal health care,” Newsom said. “We are the most un-Trump state in America when it comes to health policy.”

In California, extending health benefits to undocumented immigrants is widely popular. A March survey conducted by the nonpartisan Public Policy Institute of California found that almost two-thirds of state residents support providing coverage to young adults who are not legally authorized to live in the country.

California, the institute notes, has more immigrants than any other state. And an estimated 14% of them are living in the state without legal status.

A national poll suggests that many Americans across the country are far less accepting of the notion of giving health coverage to those who came into the U.S. illegally. A CNN poll conducted after the Democratic debates last month found that 59% of those surveyed do not think government-backed health coverage should be provided to undocumented immigrants.

In most states, people living in the country illegally are not eligible for federal health insurance programs like Medicaid and Medicare, except is some cases, like medical emergencies and pregnancies, according to the National Conference of State Legislatures.

Republican lawmakers in California criticized the law, arguing that the state should be spending health care dollars on those living in the state legally.

“We are going to be a magnet that is going to further attract people to a state of California that’s willing to write a blank check to anyone that wants to come here,” said Republican Senator Jeff Stone at a May legislative hearing. “We are doing a disservice to citizens who legally call California their home.”

The plan does not cover all unauthorized immigrants under 25, only those whose incomes are low income to qualify. State officials estimate in the first year the program will cover around 138,000 residents and cost California taxpayers $98 million.

Trump has publicly attacked Newsom’s plans.

“It’s crazy what they’re doing. It’s crazy,” Trump told reporters last week. “And it’s mean, and it’s very unfair to our citizens. And we’re going to stop it, but we may need an election to stop it.”

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We all hope for some peace and comfort at the end of life. Hospices are designed to make that possible, relieving pain and providing emotional and spiritual support. But two new government studies released Tuesday morning find that the vast majority of hospices have sometimes failed to do that.

And there’s no easy way for consumers to distinguish the good hospices from the bad.

The reports are the government’s first to look at hospice deficiencies nationwide. The Office of the Inspector General in the Department of Health and Human Services found that from 2012 through 2016, health inspectors cited 87% of hospices for deficiencies. And 20% percent of hospices had lapses serious enough to endanger patients.

Deputy Regional Inspector General Katherine Harris cites the case of a patient who had untreated bed sores, or pressure ulcers, on both heels.

“These ulcers rapidly worsened,” says Harris. “The patient developed gangrene and needed a leg amputation.”

In the dry terminology of government reports, this is called “poor care planning.” And having plans of care developed in conjunction with the patient and the patient’s family, Harris says, is a fundamental requirement of hospice,.

“So when we discover that hospices are not doing them, there is reason for concern,” she says.

For example, there’s the case of Karen Bishop Collings and her 85-year-old dad, Dean Bishop. Though Bishop had chronic lung disease, he’d been doing OK and living independently. Then, last winter, he was hospitalized with pneumonia. When he was transferred to a residential care facility to recuperate, he began receiving hospice services. That was a surprise to his daughter.

“We only agreed to pre pre-assessment of his conditions, to even see if he qualified for hospice or palliative care,” she says.

Collings has shared some of her father’s medical records with NPR, and they verify her recollection. The hospice never held a meeting with Bishop or the family to establish a care plan. So Collings was shocked when hospice workers gave her father two new medications: morphine and the anti-anxiety drug Ativan.

“We knew something distressing had happened,” she says. “His whole physicality and mental capacity was completely altered.”

Dean Bishop died a couple of days later.

If this hospice had previously been cited for deficiencies, Collings would have had a hard time finding out. The Centers for Medicare and Medicaid Services, or CMS, doesn’t make that information available on Hospice Compare, its website for consumers, even though the agency has the authority to post at least some of that data.

“We live in a time when we don’t even think about booking a hotel without checking its ratings and reviews,” says Harris. “Why do we demand less for hospices?”

The reports also highlight the the options CMS has for disciplining hospices are few. The agency can drop substandard hospices from the Medicare program altogether. But it lacks the legal authority to assess fines. It would take an act of Congress to give CMS that power.

In response to the Inspector General’s reports, CMS issued a written statement that the agency “has zero tolerance for abuse and mistreatment of any patient.” The statement also says that the agency has added consumer feedback to the Hospice Compare website. Katherine Harris thinks that’s not enough.

“There are a lot of great hospices out there,” Harris says. “There are a lot of highly skilled, committed professionals who are dedicated to helping others leave this life in comfort and with dignity — and the public should know about them.”

The amount of money that Medicare spends on hospice services has roughly doubled since 2006. But Harris says this isn’t just a matter of taxpayer dollars.

You’re only going to die once, she says. It’s important that things go right.

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