Seema Verma declared to a roomful of state Medicaid officials yesterday that they can -- for the first time -- impose work requirements on recipients of the health program for low-income Americans. But guess who the director of the Centers for Medicare and Medicaid Services will really have to convince of this shift? The courts.

Over the next few months, watch for CMS to approve requests from a half-dozen GOP-run states that want to mandate work or community volunteering for those enrolled in Medicaid. Verma essentially promised to give the go-ahead in a sweeping speech yesterday at the National Association of Medicaid Directors in which she laid out several ways the Trump administration wants to put its mark on the program – most dramatically through requiring Medicaid beneficiaries to get a job. It’s a 180-degree swing from the approach taken by the Obama administration, which had slammed the brakes on states attempting to go that direction.

If CMS gives the go-ahead — probably most immediately to Kentucky and then perhaps Indiana — there will almost certainly be lawsuits challenging the federal government’s ability to allow states to create these kinds of mandates for a program that is supposed to make medical care accessible to people who can’t afford it.

The central question will be: Do work requirements go against the original purpose of the Medicaid program when Congress created it in 1965?

At the time, President Lyndon B. Johnson said the aim of approving an insurance program for the poor “is not only to relieve the symptoms of poverty, but to cure it and, above all, to prevent it.” Verma recited that very quote during her speech Tuesday — indicating that she and other CMS officials probably have thought about how they’d argue for work requirements before a judge.

“If we are going to live up to the promise of Medicaid, we need to do more than simply pay for health-care services,” Verma said. “It’s why we believe community engagement requirements are actually in the spirit of Johnson’s idea.”

Verma and other advocates for employment requirements say that enrollees should be incentivized to find employment, as jobs obviously improve peoples’ lives. They point to studies showing that adding work requirements to Temporary Assistance for Needy Families (TANF), the federal welfare program, increased labor force participation for single mothers and lowered their poverty rates.

Verma even used the term “soft bigotry” to describe those who oppose more requirements for enrollees.

“Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said. “Those days are over.”

Kentucky Medicaid Commissioner Stephen Miller, who is expecting CMS to approve his state’s waiver request soon, told me that requiring people to be more involved in their communities (Kentucky is requesting permission to require certain “employment activities” for Medicaid enrollees) has a direct connection to better health outcomes.

“If you look at different pyramids about what impacts health status, you’re looking at access to care, you’re looking at genetics, you’re looking at social determinates,” he said. “Social determinates are the biggest one by far — the personal choices people make. We’re trying to put them in a position where they can make better choices.”

It’s hard to argue that employment doesn’t have a big effect on well-being. Studies show that being unemployed is closely linked to higher rates of depression. Work provides not only financial stability, but emotional stability, too, as people feel they have a purpose in life.

But whether low-income Americans should be required to find a job to get Medicaid coverage is another question, and one that the Trump administration could find challenging to defend before a judge.

For one thing, a majority of Medicaid recipients already have jobs, opponents of work requirements say. About three-quarters of Medicaid recipients live in a family with at least one part-time or full-time worker, according to the Center on Budget and Policy Priorities.

Rather than prompting unemployed Medicaid recipients to find jobs, work requirements could have the opposite effect of causing them to drop health insurance entirely. Indeed, Kentucky has projected that 95,000 fewer people would be enrolled in its program at the end of five years (although some of that could be from people finding jobs that provide health coverage).

And while Congress enacted work requirements for TANF, it has not done so for Medicaid. The Medicaid statute says nothing about requiring enrollees to have a job. Nor does the Affordable Care Act, which allows states to expand Medicaid, mention anything about beneficiaries working.

As Verma laid out her case yesterday, she pointed to a troubling statistic — that labor force participation among men ages 25 to 54 has declined dramatically over the past 60 years.

But is it Medicaid’s job to try to fix that? The jury’s still out. has been up and running for a full week, and we're expecting an enrollment snapshot from the Department of Health and Human Services soon. Stay tuned, because initial reports of sign-up figures indicted they're surprisingly robust, even given the reduced marketing and outreach efforts.

It's unclear exactly what is driving the interest, although it could be partly due to the increased role that outside brokers are able to play this year due to an HHS rule change. My colleagues Juliet Eilperin and Colby Itkowitz checked in with the handful of states running their own marketplaces to get a sense of how the first few days of enrollment went for them.

Here are some highlights:

--Washington Health Benefit Exchange: Chief marketing officer Michael Marchand said the mixed messages and doomsday forecasts leading up to Nov. 1 may have actually helped increase marketplace visitation — which is up 20 percent — because it forced people to ask themselves how the changes will affect them personally.

--Covered California: Executive Director Peter Lee said people who tend to sign up for coverage as enrollment starts tend to need insurance the most, and the critical question is how many young, healthy Americans will enroll some weeks from now. While federal enrollment this year lasts just 45 days, several states are allowing residents to sign up for ACA plans into January. Roughly 5,900 Californians selected plans last Wednesday, a 25 percent increase over last year.

--New York: Department of Health spokeswoman Erin Silk said more than 140,000 people visited the state’s website and 73,000 placed calls to its customer service line the first three days.

--HealthSource R.I.: Director Zach Sherman said enrollment this year is five times higher in the first week than it was last year. An early outreach campaign by the state seems to have paid off with more than 500 people enrolling, compared to 109 people in the first week last year.

--D.C. Health Link: The District’s marketplace has seen the highest volume of first-week activity since the first year of enrollment. On just the first day last week, nearly 9,300 people visited the DC Health Link website to shop for plans, compared to 6,727 last year and just over 2,000 in years two and three.


--Yesterday, I invited readers of The Health 202 to send me stories about their experiences with and the other state-run marketplaces -- and you responded! Over the next five weeks of open enrollment, I'll feature one or two of your letters every day. Please keep 'em coming -- the good, the bad and the ugly. (I also accept mild sedatives for my 3-year-old and awesome cocktail recipes.)

Today's letter:

"I am so grateful someone is finally noticing the families like us who make "too much" to qualify for a subsidy under Obamacare. We make just slightly over the limit to qualify, and here in Northern Colorado, the least expensive plan for our family of four is a Kaiser Bronze plan with a $13,000 family deductible and 50% co-insurance.  The premium is $1,574, which sounds reasonable until you consider we are paying 50% of all costs after the $13,000 deductible.

"What is most frustrating for us is why we need Obamacare: My husband, an engineer, lost two jobs to outsourcing in the last 10 years. Now all he can find is 'contract work' that doesn't offer benefits. My company was acquired by a Canadian hedge fund, and I was 'downsized' too. Our COBRA runs out in mid-December. I'm still looking for a permanent position that will offer enough hours to qualify for health insurance. Many companies offer part-time work, contract work, or hours that are just below the limit to get health benefits. Let's face it, companies do not want to offer employees health insurance anymore. It's expensive for them too. Between the outsourcing, downsizing and insurance costs, we feel like we are falling further and further behind every year."  --Denise DeVore, Loveland, Colorado


AHH: Yesterday, the D.C. Council narrowly voted 7-6 not to extend a multimillion-dollar contract for the company running the District’s only public hospital, United Medical Center, after a string of stories by The Post's Peter Jamison exposing recent incidents raising questions about patient safety. 

"The vote came after an intense flurry of last-minute lobbying by the Bowser administration on behalf of the firm, whose leaders were political donors to the mayor in 2014," Peter writes. "Veritas, a company that has been in business less than three years, was awarded a no-bid contract to run United Medical Center — at a fee of $300,000 per month — in the spring of 2016."

Scrutiny of the hospital grew in August, when the city’s health regulators abruptly shut down the hospital’s nursery and delivery rooms without disclosing a reason. The Post obtained, and published, a letter from D.C. Department of Health Director LaQuandra Nesbitt showing that regulators had uncovered dangerous medical errors in the treatment of pregnant women and newborns.

The following month, The Post reported that at the time of its most recent contract review, Veritas was falling short in 41 percent of its performance metrics and had generated just $1.07 million of the $9 million in revenue the firm anticipated by altering hospital operations.

Then in October, Peter reported on the case of Warren Webb, a 47-year-old resident of UMC’s on-site nursing home who died of a heart attack after calling out for help and being left on the floor by his nurse. The hospital also did not report key details of that incident to regulators.

OOF: The 26-year-old alleged gunman who opened fire on a Texas church over the weekend escaped from a mental health facility in 2012 while he was in the Air Force, our colleagues Eli Rosenberg, Mark Berman and Wesley Lowery report. That was just one of the warning signs in the life of Devin Kelley, who'd also been convicted for beating his then-wife and stepson, charged with animal cruelty and investigated for domestic assault and threats against his family members.

"Interviews and police and military documents depict Kelley as a distressed — and at-times, violent — man in the years before authorities said he walked into the First Baptist Church in Sutherland Springs, Tex., and fired round after round into the congregation gathered for Sunday morning services," Eli, Mark and Wesley write.

"Police in El Paso reported that five years before the church massacre, officers were dispatched to a bus terminal after Kelley escaped from a nearby behavioral facility," they continue. "Officers wrote they were told Kelley, who was serving in the Air Force, 'was a danger to himself and others' at the time and 'was also facing military criminal charges.' While it is unclear why Kelley was at the behavioral facility and whether he ever faced military discipline for the threats, he was court-martialed that same year and convicted of abusing his wife and stepson."

--The report about Kelley's stint at a mental health facility follows President Trump's comments Monday on the shooting where he insisted that “mental health is our problem here," not access to guns. But some experts have been warning against always assuming that mental health is directly tied to violence. "It really hurts a lot because one of the things we always have said in the aftermath of these kinds of tragedies is, you cannot equate mental illness with violence," Paul Gionfriddo, the CEO of Mental Health America told Axios.

--And The New York Times studied the links between various factors and mass shootings and found that the highest correlation by far is the amount of guns in the a certain country. The United States has more guns -- 270 million -- that any other nation in the world, and the highest number of mass shooters from 1996 to 2012. 

OUCH: Trump’s nominee for a top health post at the Pentagon yesterday called it "insane" that a civilian is able to purchase a semi-automatic weapon, even as he acknowledged his comments might get him in trouble with Republicans.

"I'd also like to — and I may get in trouble with other members of the committee — just say, you know, how insane it is that in the United States of America a civilian can go out and buy ... a semi-automatic assault rifle like an AR-15, which apparently was the weapon that was used," Dean Winslow, a physician and nominee to be the assistant secretary of defense for health affairs, said during his Senate Armed Services confirmation hearing, per Politico. "I think that's an issue not as much for this committee, but elsewhere.”

Texas officials have described the weapon used by the gunman as a Ruger AR-556, an assault-style rifle that is a variant of the AR-15 and similar to what is used by the military.

Winslow, a retired Air Force colonel, was answering a question by Sen. Jeanne Shaheen (D-N.H.) about whether he believed the Texas gunman should have received a “dishonorable discharge” instead of the less severe “bad conduct” discharge. After his remarks, Sen. John McCain (R-Ariz.) warned: “Dr. Winslow, I don’t think that’s in your area of responsibility of expertise.”


--Man, Maine. Yesterday, the state became the first in the nation to accept the Affordable Care Act's Medicaid expansion through a ballot question. Voters -- by a nearly 20-percentage point margin -- said they want to expand the program, in a pretty clear rebuke to their Republican Gov. Paul LePage, who had five times vetoed legislation to do so.

"What happened in Maine could provide momentum for progressives to get voters in other states to expand Medicaid, such as Alaska and Idaho, where groups have already started similar Medicaid expansion ballot initiatives next year," The Post's Amber Phillips reports.

“This will send a clear signal to where the rest of the country is on health care,” Jonathan Schleifer, executive director of the Fairness Project which helped put together the ballot initiative, told Amber. Schleifer said his group had spent the past year in Maine — and some $2 million — laying the groundwork.

“Looking at what progressives were able to accomplish by ballot initiatives in 2016, we asked ourselves what do we do for biggest challenge out there, which is the threat to Affordable Care Act,” Schleifer said. “We asked ourselves: What can we do to not just hold the line but to advance things?”

From Politico's Dan Diamond:

Organizing for Action communications director Jesse Lehrich:

Think Progress's Judd Legum:

--The Medicaid vote just about guarantees the state's Republican senator, Susan Collins, will never vote for a bill repealing and replacing the ACA if it rolls back Medicaid expansion. Collins had already been highly skeptical of all the GOP health-care bills; now Maine's decision to join the ranks of Medicaid expansion states could make it impossible for her Senate colleagues to ever sway her.

Matt Viser, Washington bureau chief for the Boston Globe:

--Medicaid expansion may soon become more likely in Virginia, with major victories by Democrats yesterday. Democrat Ralph Shearer Northam, a pediatrician, incidentally, won a hard-fought race to become Virginia’s 73rd governor, beating Republican Ed Gillespie 54 to 45 percent. Democrats also seized the lieutenant governor and attorney general offices and made significant gains in the House of Delegates, perhaps even winning the majority depending on the outcome of several ongoing recounts.

Voters said health care was what they most cared about, according to an NBC News poll, despite the fact it wasn't a top issue for the candidates. Thirty-seven percent of respondents cited health care as the most important issue to their vote, followed by gun policy (17 percent), immigration (14 percent) and taxes (14 percent) and abortion (9 percent). 

A few other good reads from The Post and beyond:

Senator Ted Cruz of Texas is pushing to keep alive the idea of including a repeal of Obamacare’s individual mandate in the tax overhaul plan, even as House Republicans struggle with how to address an issue that threatens to complicate the tax debate.
Groups representing older people and patients are trying to save the medical expense deduction targeted for repeal by GOP tax writers.
The administration is moving ahead with the requirement to post calorie counts in restaurants, supermarkets, convenience stores and pizza delivery chains.
Four mumps cases have been confirmed at Catholic, which has changed communion distribution during Mass on campus.
Sarah Larimer
Too many people of color suffer depression and anxiety in silence, says Nikki Webber Allen. Her D.C.-based non profit is bringing the problem into the open.
Mary Hui

POST PROGRAMMING: The Washington Post hosts Secretary of Veterans Affairs David Shulkin for a discussion that will include his department’s efforts to curb the veterans’ suicide rate, address post-traumatic stress disorder and other health concerns on Thursday.


  • Kaiser Health News holds an event on advance care planning.
  • Axios hosts an event on a new era in cancer innovation with former Vice President Joe Biden and former first lady Jill Biden.

  • The House Education and the Workforce Subcommittees on Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Development hold a joint hearing on opioids.

  • The House Energy and Commerce Subcommittee on Health holds a hearing on MACRA and alternative payment models.
  • Rep. Chris Smith (R-N.J.) will host a press conference on the Conscience Protection Act of 2017 this morning with several other lawmakers.

Coming Up

  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on Nov. 13.

  • STAT holds an event on the FDA on Nov. 13.


Republicans are trying humor to promote their tax plan:

House Speaker Paul Ryan says "enforcing the laws we got on the books" on guns is the solution:

Here’s what happened in Virginia’s 2017 election:

Stephen Colbert said Ed Gillespie would lose in Virginia thanks to Donald Trump Jr.: