California's pending crackdown on homeless crisis Presented by

With Alice Miranda Ollstein and Rachel Roubein

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Quick Fix

— California is weighing a tougher approach to its growing mentally ill homeless population, with state officials pursuing involuntary tactics.

— FDA's crackdown on CBD safety is a warning shot to the industry and could provoke a fight with Senate Majority Leader Mitch McConnell.

— Advocates filed their opening brief in a Supreme Court case that could significantly shape abortion rights.

THIS IS TUESDAY PULSE — Where your author was struck by this story: An NFL player sat out on Sunday with anxiety — with full support of his team. "I’m NOT ashamed or embarrassed by this," he wrote in a post on Twitter.

The world gets a little more tolerant every day. Tips to [email protected].

Driving the Day

LIBERAL CALIFORNIA's PENDING HOMELESS CRACKDOWN — State officials are considering aggressive tactics to deal with the escalating crisis of people with mental and physical illnesses living on the streets, POLITICO's Victoria Colliver reports.

The growing homeless encampments — which have led to a rise in human waste, trash and open-air drug dealing — have united unlikely allies: Progressive lawmakers and President Donald Trump, who's assailed California's politicians over the crisis, calling it "a disgrace to our country" and threatening federal intervention.

“The crisis is so bad people’s minds are really opening up and the policies are shifting,” said Democratic state Sen. Scott Wiener of San Francisco. “Legislation that would have had no chance five or 10 years ago can pass.”

— One possible approach: Pursuing involuntary commitment. A new state law authored by Weiner makes it easier for three counties to “conserve” — or take guardianship over — homeless people with several mental illness or substance use disorders who bounce in and out of short-term psychiatric commitments. And California voters could weigh in next year on a proposed ballot measure that would sentence homeless offenders to treatment instead of jail time.

— But advocates are worried about ramping up involuntary approaches. “If we’re talking about involuntary care, you’re basically waiting until someone is in really bad shape before they get help,” said Jennifer Friedenbach, executive director of the Coalition on Homelessness, a San Francisco advocacy organization.

FDA WARNS ON CBD SAFETY — The agency sent warning letters to 15 companies on Monday for selling CBD products that it believes are illegal under federal law. It's among the most aggressive actions that FDA has taken yet to police the rapidly growing market for CBD products, POLITICO's Paul Demko writes.

"The FDA has seen only limited data about CBD safety and these data point to real risks that need to be considered before taking CBD for any reason," the agency wrote in an accompanying consumer update.

— The agency has been grappling with how to regulate CBD ever since the 2018 farm bill legalized hemp, with patients taking hemp-derived CBD products to address every ailment from insomnia to cancer. FDA warnings that it’s illegal to use CBD in food or dietary supplements have been widely ignored, Paul writes.

— Is a clash coming between FDA and Senate Majority Leader Mitch McConnell? The Kentucky senator, who drove the farm bill language on hemp, has spent months urging the agency to appropriately speed CBD products to market. McConnell asked FDA nominee Stephen Hahn about his plans to regulate the products when the two men met last week.

"Like many Kentuckians who are taking advantage of hemp’s legalization, I am eager for FDA’s plans to create certainty for CBD products," McConnell said in a statement after his meeting with Hahn.

In the Courts

SCOTUS: PLAINTIFFS FILE BRIEFS IN ABORTION CASE — The Center for Reproductive Rights filed its opening brief in a momentous case at the Supreme Court that could reshape abortion rights.

The reproductive-rights group argues that the high court should strike down Louisiana regulations requiring abortion clinics to have admitting privileges at local hospitals because they're identical to Texas state rules that the court struck in a 5-3 decision in June 2016, POLITICO's Alice Miranda Ollstein reports. Two conservative justices, Neil Gorsuch and Brett Kavanaugh, have since joined the court, while former justice Anthony Kennedy — who sided with the court's liberals to strike the Texas regulations — has departed.

"If the fundamental rules of the road are not honored in our most contentious cases, then the public and political branches may cease respecting the courts as true guardians of the rule of law," argue Center for Reproductive Rights attorneys, adding that the law would leave Louisiana with just a single practicing abortion provider.

The state of Louisiana has to file its reply brief by late December. The high court will hear the case early next year.

Inside the Humphrey Building

INFO ON DIRECT CONTRACTING IS OUT — CMS released Monday key details of two new payment models, both of which were signature initiatives of recently departed CMMI head Adam Boehler.

The two voluntary direct contracting models are (1) aimed at having larger providers and entities shoulder financial risk, and (2) testing whether that saves Medicare money and increases the quality of care. The performance period begins in 2021, with a Dec. 10 deadline to submit a letter of intent to participate, POLITICO's Rachel Roubein reports.

There will be two application periods, which the National Association of ACOs applauded as giving the provider community more time to “understand important details” and “weigh their participation options.”

Eye on FDA

FIRST IN PULSE: WARREN JOINS DEMOCRATS WARNING ON ACTING FDA HEAD — Sen. Elizabeth Warren charges that the interim FDA chief has put politics over public health during his time in the Trump administration and demands assurances that he will "commit to evidence-based policy" in his time overseeing the agency, according to a letter shared with Alice.

"[Y]ou have undermined evidence-based programs and promulgated policies based on political ideology — behavior that is antithetical to the very mission of HHS and the agency you are now charged with leading," Warren wrote on Friday to acting FDA chief Brett Giroir, singling out his record on sexual health and fetal tissue funding. As HHS assistant secretary for health since February 2018, Giroir has overseen HHS efforts to steer federal funds toward abstinence-only sexual education and limit federal funds for fetal tissue research, among other priorities.

— Giroir is a trusted ally of HHS Secretary Alex Azar, who tapped Giroir to oversee FDA early this month while Stephen Hahn, an MD Anderson executive and oncologist nominated to lead the agency, is awaiting Senate confirmation. Democrats, including Senate HELP Committee ranking member Patty Murray, have also blasted Giroir's record on rolling back the Title X federal family planning program and are eager to install his replacement.

Giroir also has played a key role in the administration's efforts to end HIV transmission and overhaul kidney care, which have received bipartisan support.

Around the Nation

MERCATUS: IMPROPER MEDICAID PAYMENTS WENT UP WITH ACA EXPANSION — The conservative think tank is out with a new review of Medicaid payment errors, concluding that Obamacare's expansion "exacerbated the incentives for careless spending" as enrollment surged and payments went up. "There are some areas, such as New York City and Los Angeles, where the problem is so egregious that it may be a sign of purposeful abuse of the program rules and potentially of fraud," write Brian Blase and Aaron Yelowitz.

The argument has gained traction inside the Trump administration. CMS Administrator Seema Verma recently warned that a spike in the annual Payment Error Rate Measurement report was the "canary in the coal mine" and justified tighter restrictions on eligibility.

— Medicaid advocates have countered that critics like Blase — who left the White House National Economic Council this summer — and Verma are overstating the importance of the improper payment rate, adding that it's driven by technical factors like state noncompliance with provider screening. "Instead of twisting the PERM results to fit an erroneous narrative of rampant beneficiary fraud, we should acknowledge that mistakes will be made and act to reduce identified errors collaboratively," writes Kelly Whitener of Georgetown's Center for Children and Families.

Public Health

ONLINE SALES BAN HITS CHINA's VAPING INDUSTRY — The nation banned all sales of e-cigarettes online as of Nov. 1, perhaps the heaviest blow yet to the global industry, Zhuang Pinghui writes for the South China Morning Post alongside POLITICO's Sarah Owermohle.

China’s national health commission estimated that there are now 10 million e-cigarette users over the age of 15. Vaping had been largely unregulated before the online sales ban, and even now loopholes remain in the regulations, such as online promotion efforts.

Tobacco has long been identified as a major public health challenge in China: The country is the world’s largest tobacco producer and has more than 300 million smokers, according to the World Health Organization.

What We're Reading

With Rachel Roubein

BYU-Idaho reversed course on its Medicaid ban and apologized for the turmoil its policy caused, James Dawson reports for Boise Public Radio. The ban sparked local outrage after Dawson broke the news two weeks ago and ultimately attracted national attention in the NYT this week.

The CDC recommended detained migrants get the flu vaccine, but CBP decided against it, arguing a vaccination system would be “logistically very challenging for a number of reasons,” Robert Moore reports for The Washington Post.

CMS spent $11 million revamping its Medicare Plan Finder, but consumer advocates worry the service is malfunctioning and offering wrong information, ProPublica’s Akilah Johnson reports.

More college students are seeking mental health help, but the services on campus haven’t kept pace – they’re often waiting weeks or seeking help elsewhere, the Associated Press’ Collin Binkley and Larry Fenn found, after analyzing data from over three dozen public universities.

A top activist-investment firm, Starboard Value LP, has taken a stake in CVS Health, Corrie Driebusch writes in The Wall Street Journal.

WaPo's Lena H. Sun takes a deep dive into the CDC lab team trying to solve the mystery behind the vaping-related illness.

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