The number of refugees the United States admits fluctuates somewhat from year to year but for decades has hovered around 95,000 annually. But under President Trump, the State Department has lowered the cap each year. In 2017, it was 50,000. This past year it was 45,000, although only about 22,500 refugees were actually admitted into the country.

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Secretary of State Mike Pompeo announced in September the cap would be set at 30,000 refugees in the next fiscal year. He had privately advocated a higher cap to the White House but was mostly shut out of the decision. Top Trump adviser Stephen Miller is widely viewed as the driving force behind much stricter immigration limits. And Andrew Veprek, another refugee skeptic who is close to Miller and joined State in March as a deputy assistant secretary, also wields influence.

This has created an untenable situation for several hundred centers around the country that help refugees fleeing persecution, war or famine, assisting them in finding employment, housing and medical care. Plummer’s group, for example, had to cut 10 full-time staffers over the past two years — a significant reduction to its workforce, which now numbers 52.

At the end of last year, 324 centers offering refugee resettlement were in operation. Thirty-five of the centers have either closed or had to cut off those services, according to a count by Church World Service, a group that supports affiliate centers around the country.

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You could argue the cutbacks are appropriate and needed, given the reduced number of refugees entering the United States. But hardly anyone thinks the lower number of refugees being admitted to the country will stay so low for the long term.

The Trump administration will end either in two or another six years, depending on how the 2020 election turns out. And immigrant advocates have high hopes the next president will be friendlier to refugees and asylum-seekers. After all, other past presidents including Barack Obama, Bill Clinton and both Bushes all supported much higher refugee caps.

“We have confidence future administrations will seek to rebuild the refugee resettlement program,” said Jen Smyers, associate director of immigration and refugee policy for Church World Service.

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But that also means the centers on which the program relies will have to claw their way back to full capacity — not an easy task after such drastic cuts. “We will be rebuilding it with all these offices across the country who have been there for decades, and suddenly they’re not there,” Smyers said.

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Plummer told me one of her biggest challenges is whether to keep on staff translators, who play a critical role in facilitating communication with refugees who may speak little to no English. Because so few refugees are now being admitted from any given country, it’s hard to justify paying people in-house just because they can communicate with someone from, say, Somalia or Nepal.

“Last year was extremely difficult operating,” Plummer said. “This era of uncertainty is challenging for everyone.”

There are few signs of the administration softening its stance. On Monday, the United States was one of just two nations at the U.N. General Assembly who voted against adopting a Global Compact on Refugees, which calls for better supports for the world’s 25.4 million refugees and lays out a plan for measuring improvements in their well-being.

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“Although there are more refugees and asylum seekers than at any time since World War II, contrary to conventional wisdom, poor and lower middle-income nations like Bangladesh, Uganda and Jordan host 85 percent of the world’s refugees,” David Miliband, president of the International Rescue Committee, wrote in a Washington Post op-ed about the compact.

“In fact, if the United States hosted refugees in the same proportion as Uganda, it would house 8.5 million refugees instead of the 3 million resettled since 1980,” Miliband wrote.

Trump tweeted this in the first few months of his presidency, shortly after the stricter limits were announced:

Trump’s antagonism toward refugees is doubly confounding to advocates, who note the number of people trying to escape often life-threatening circumstances worldwide has exploded over the past few years.

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“Some 68m people are now displaced by violence and persecution—equal to a fifth of the population of America, nearly half that of Russia and more than the entire population of Britain,” actress Angelina Jolie wrote in a piece published yesterday by the Economist.

Here’s another inconsistency in Trump’s crackdown: His State Department is allowing in far fewer Christian refugees — who are facing increasing persecution in countries including Somalia, Afghanistan and Pakistan — despite the clout the president appears to have with American evangelicals and despite Pompeo’s promises to be more welcoming to persecuted Christians.

In July, Pompeo hosted a major gathering of 80 minister-level officials from around the world focused on international religious freedom. He promised conservatives at the Values Voters Summit in September he would stand up for persecuted minorities around the world.

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But in 2017 just 22,637 Christians were resettled in the United States, compared with 36,822 the year prior. And there’s no evidence the numbers will increase for 2019.

World Relief, one of nine groups responsible for refugee resettlement around the country, is an evangelical Christian organization that said it was forced to close five offices that had resettled more than 25,000 refugees over the past four decades.

The International Rescue Committee and Church World Service are also among the nine organizations who operate affiliate centers helping refugees access help and supports. The affiliates are paid $1,000 through the State Department for each refugee they help resettle.

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But the Department of Health and Human Services also plays a major role here, providing additional funds through its Office of Refugee Resettlement, an agency that came under fire this past year for its role in sheltering unaccompanied migrant children under Trump’s family separation policy.

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Former ORR director Scott Lloyd, who had scant experience with resettlement issues, was moved to a lower-profile role in November. Yesterday, the administration announced it would ease fingerprinting requirements for sponsors of migrant children, as way of more quickly releasing and reuniting the kids with family members.

The ORR provides reimbursement to organizations that provide refugees with cash and medical assistance and help unaccompanied refugee children. Of the office’s $1.9 billion for 2019, $561 million is for the refugee program, according to figures provided by ORR.

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Programming Note: The Health 202 is taking a break for the holidays starting on Friday, Dec. 21. We will see you back in your inboxes ready to go for 2019 on Jan. 7. Thanks for reading this past year and we hope you, your family and friends have a relaxing and happy holiday season and New Year.

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AHH, OOF and OUCH

AHH: The Trump administration vowed to do more to prevent veteran suicides, but no such effective measures were taken. That's partially because of the dearth of leadership at the Department of Veterans Affairs, our Post colleague Lisa Rein reports.

About 20 veterans die by suicide each day, she writes. But even as the numbers have climbed and is now nearly twice the rate of suicide among nonmilitary Americans, “VA’s media outreach plunged in fiscal years 2017 and 2018 — with fewer social media posts, public service announcements and paid advertisements compared with the agency’s efforts during the Obama administration, auditors said.”

Of the $6.2 million set aside to pay for ads for VA’s crisis hotline, as of September only 1 percent of the budget had been spent, according to auditors.

In response to the auditors’ report, VA Secretary Robert Wilkie told them “every death by suicide is a tragedy. We will not relent in our efforts to connect veterans in need with lifesaving support.”

Auditors also wrote in a report that issues “became particularly evident during a recent period of turnover and reorganization in the office responsible for the suicide prevention outreach campaign,” adding the agency “did not assign key leadership responsibilities or establish clear lines of reporting, and as a result, its ability to oversee the outreach campaign was hindered.”

OOF: The nation’s capital is ground zero for a wave of the opioid epidemic that’s largely impacting black heroin users, our Post colleague Peter Jamison reports in this illuminating story.

While the drug epidemic in the country is frequently associated with white communities and rural and suburban parts of the United States, Peter writes that in the District of Columbia, 279 people died of opioid overdoses last year, “a figure that surpassed the city’s homicides and was greater than three times the number of opioid deaths in 2014. More than 70 percent of cases involved fentanyl or its analogues, according to the District’s chief medical examiner, and more than 80 percent of victims were black.”

“Since 2014, the national rate of fatal drug overdoses has increased more than twice as fast among African Americans as among whites, according to the Centers for Disease Control and Prevention,” he adds.

The epidemic taking the lives of African Americans at unprecedented levels is not impacting young people, nor those who first became dependent on prescription pills.

“Instead, they are the long-term drug users who have endured the older, slow-burning opioid epidemic that began with heroin’s spread through American cities in the Vietnam War era,” he writes, noting that many “had developed a semblance of functional addiction, getting by with menial jobs on factory floors and construction sites. Until they began dying.”

OUCH: U.S. Surgeon General Jerome Adams issued a rare public health advisory declaring the use of e-cigarettes among young people an “epidemic.”

"I am officially declaring e-cigarette use among youth an epidemic in the United States," Adams said at a Tuesday news conference, NPR’s Rob Stein writes. "Now is the time to take action. We need to protect our young people from all tobacco products, including e-cigarettes."

“The surgeon general's advisory called on parents and teachers to educate themselves about the variety of e-cigarettes and to talk with children about their dangers,” Rob writes. “Health professionals should ask about e-cigarettes when screening patients for tobacco use, the advisory said. And local authorities should use strategies, such as bans on indoor vaping and retail restrictions, to discourage vaping by young people.”

"We need to protect our kids from all tobacco products, including all shapes and sizes of e-cigarettes,” Adams said in the advisory. “Everyone can play an important role in protecting our nation’s young people from the risks of e-cigarettes.”

OPIOID OPTICS

— Drug companies and regulators did not stop the movement of millions of opioid pills into rural West Virginia, a congressional report has found, even with widespread warning signs that the flow of pills was contributing to the national opioid epidemic.

The congressional report is 324 pages and follows an 18-month probe of alleged pill dumping in West Virginia, our Post colleague Katie Zezima reports. The report from the majority staff of the House Energy and Commerce Committee investigated Cardinal Health, AmerisourceBergen and McKesson Corp, the nation's three largest drug distributors.

The report "found that distributors, which fulfill orders for prescription drugs to pharmacies, failed to conduct proper oversight of their customers by not questioning suspicious activity and not properly monitoring the quantity of painkillers that were being shipped to individual pharmacies," Katie reports. The report also found the Drug Enforcement Administration failed to use a database meant to track the movement of opioids that could have pointed to the high volume of pills being set to pharmacies in the state.

"The report also said that distributors continued to pump pills into pharmacies even after it became clear that doctors and physicians who practiced hundreds of miles from the pharmacies were writing suspicious prescriptions to be filled there," she adds.

— In Lewiston, Maine, a self-styled "church" acts as a place of salvation where harm-reduction advocates distribute clean syringes, rubber tourniquets and the overdose antidote naloxone.

Jesse Harvey, 26, founded the Church of Safe Injection and branded it as a church intentionally because it “could also provide a strange element of legal protection,” Stat’s Lev Facher reports. “If Harvey is arrested for his work — and he hopes he will be — he will argue that he was merely carrying out his own First Commandment: harm reduction.”

And the church is expanding, with six chapters in Maine and in six other states.

“At a time when more than 70,000 Americans die each year from overdose and when infectious disease rates have spiked across the country, he will argue it is more criminal to follow a state law prohibiting the possession of more than 10 syringes than to disobey it,” Lev writes. “The church’s legally hazy efforts, Harvey said, are an attempt at the salvation public health officials across the country have failed to provide.”

The organization’s spread also coincides with the growth of a movement to push for harm-reduction practices across the United States and Canada. The Health 202 has written about the push for safe injection sites in various cities, some styled after an existing site in Canada. In California, outgoing Gov. Jerry Brown (D) vetoed a bill that would allowed for the first sanctioned safe-injection site in the United States, but Lev reports state lawmakers are optimistic Gov.-elect Gavin Newsom (D) will sign such a bill.

AGENCY ALERT

— At a private meeting on Tuesday, scientists at the National Institutes of Health said they would continue supporting some use of fetal tissue in research despite the current efforts against it, our Post colleague Amy Goldstein reports.

“The commitment by a senior official of NIH’s National Institute for Allergy and Infectious Diseases to continue funding for researchers who work for nongovernment labs came at the end of a seven-hour meeting with about 40 researchers from around the country,” she reports, citing two participants in the meeting. “The pair of scientists were part of an invitation-only workshop to evaluate the politically loaded question of whether adequate alternatives exist to fetal tissue in studies pursuing treatment and possible cures for diseases from HIV to cancers to Zika.”

That workshop came as HHS is conducting a broad audit of federal funding of such research, as social conservatives press the administration to end federal funding for fetal tissue research.

“The future of NIH’s spending on fetal tissue research in its own labs sounded iffier, according to the two participants,” Amy writes. “At one point, Brett Giroir, HHS’s assistant secretary for health who has played a lead role in much of the fetal tissue reconsideration, told the scientists that any fears that the administration had decided to halt such funding were misplaced and that the question was being reviewed, one participant said.”

— When states impose work requirements on Medicaid beneficiaries or those who receive food stamps, the result can mean big profits for private companies that manage those work requirements, Tracie McMillan reports in this lengthy piece for the independent nonprofit Investigative Fund and Mother Jones.

“Business processing behemoths like Hewlett-Packard and IBM often run the minutiae of public-benefit paperwork and accounting,” Tracie writes. “Local nonprofits sometimes contract for services like job training and case management.” She writes of one such company, Maximus, which helps run programs in 41 states and assists with “holding contracts for everything from job training to child support enforcement to health care enrollment.”

“Though Maximus is barely known to the taxpayers who underwrite the programs it helps run in 41 states and for multiple cities and counties and the Social Security Administration, as of September 2017 it had nearly $2.5 billion in annual revenue and 20,400 employees on four continents.”

STATE SCAN

— In Delaware, a new approach to contraception aims to reduce unintended pregnancies, state Medicaid spending and poverty levels among women, all at once. Over the past three years, nearly every doctor in the state has started asking women of childbearing age during visits whether they want to get pregnant in the next year.

“If her answer is no, clinics are being trained to ensure she gets whatever form of birth control she wants that very day, whether a prescription or an implant in her arm,” the New York Times’s Margot Sanger-Katz reports. The program is “having big effects on the number of women requesting and receiving contraception in a state that recently had the nation’s highest rate of unplanned pregnancies," she writes.

The new program may be bringing down the state’s abortion rate, too. Margot notes the majority of abortions are due to unplanned pregnancies. Children “whose births are unplanned are likelier to have health complications, to be born into poverty, to stop their education sooner and to earn less," she writes. "Mothers of unplanned children tend to give birth when they are younger, leave school earlier and earn less when older.”

TRUMP TEMPERATURE

— A new poll out this morning from Patients for Affordable Drugs has found there’s wide support for the Trump administration’s proposal to peg some drug prices in the United States to lower international levels, through a Medicare Part B international pricing index.

Eighty percent of respondents supported the proposed change, while 9 percent opposed it. Eighty-three percent of Republicans said the Senate's GOP majority should support the proposal and 69 percent of Democratic respondents said the House's new Democratic majority should support it.

Furthermore, 85 percent of voters said Congress should tackle drug prices as a “top” or “important” priority, and only 9 percent said they believe prescription drug prices are so high because it costs “billions of dollars to develop new prescription drugs.”

— And here are a few more good reads from The Post and beyond:

HEALTH ON THE HILL

INDUSTRY RX

MEDICAL MISSIVES

DAYBOOK

Today

The Senate and House Veterans Affairs committees hold a joint hearing on "Tracking Transformation: VA MISSION Act Implementation."

Coming Up

The House Veterans Affairs Subcommittee on Oversight and Investigations holds a hearing on "The Veterans First Program after Kingdomware" on Thursday.

SUGAR RUSH

— Senate backs sweeping bipartisan overhaul of criminal justice system in victory for Trump: