with Paulina Firozi


Want more stories like this on health care? Read Paige Winfield Cunningham.

Here’s the health-care takeaway from Tuesday’s elections: Voters across two states resoundingly sided with Medicaid expansion, sending a clear rebuke to Republicans who spent the past year trying to whittle down spending on the program.

Up in Maine, voters said “heck, yeah,” to growing the low-income health insurance program, making their state the first in the nation to embrace via the ballot box Obamacare’s vision of Medicaid coverage for Americans earning slightly above the federal poverty line.

And across the river in Virginia — a state where the GOP-led House of Delegates had for years blocked Medicaid expansion despite efforts by Gov. Terry McAuliffe (D) — voters overwhelmingly sided with a whole slate of Democratic candidates who pressed for finally adopting that part of the Affordable Care Act.

“All the folks who fought me on Medicaid expansion, they all got blown out,” McAuliffe said at the election-night party for Gov.-elect Ralph Northam, who promised throughout his campaign to lead the state in expanding the program.

Maine Gov. Paul LePage (R) has vowed to throw roadblocks in the way as much as he’s able, and there’s still a chance Republicans will be able to stymie Democrats if they retain a slim majority in the Virginia House. According to the most recent vote counts, there are 51 Republican seats and 49 Democratic seats in that body; that could shift toward Democrats as several close races are recounted over the next few days.

Paul Goldman, a longtime Virginia Democratic strategist, told me he thinks Medicaid expansion is a “done deal” in Virginia, even if Republicans retain their slim majority.

“All you need is a couple of Republicans, and the question is who is going to stand up and block it,” Goldman said. “It’s inconceivable to me that Medicaid expansion won’t happen.”

Regardless, the Maine and Virginia outcomes signal a trajectory toward an even broader embracing of the ACA by states, even as congressional Republicans cling to dimming hopes they will one day be able to dismantle President Barack Obama’s 2010 health-care law.

House Budget Democrats did some gloating:

Center on Budget and Policy Priorities' Jacob Leibenluft previewed the takeaways in a tweet last month:

The Post's Greg Sargent:

Rep. Jim Cooper (D-Tenn.):

With the addition of Maine and Virginia, the number of states offering their low-income residents expanded Medicaid would reach 34. Activists who organized the Maine vote are trying to pull together similar efforts in Utah and Idaho.

“I would think the Republicans would take a sober second look after these election results,” said Tim Jost, a health law professor at Washington and Lee University and a member of the Virginia Organizing Project’s health-care committee.

Here’s something else that should give Republicans pause. Health care was the top concern by far for Virginia voters even though it didn't get a lot of airtime during the campaign. Thirty-nine percent said a candidate’s position on health policy was the top factor in deciding how they’d vote, according to exit polls. Gun policy was the next-biggest issue, but only 17 percent of voters picked that as their biggest concern.

Connecticut Sen. Chris Murphy (D), a fierce gun-control advocate from the state where the Newtown school shooting occurred:

And don’t forget that marketplace premiums are through the roof in Virginia. Even with that situation, a majority of voters sided with Northam, who embraced the ACA, over his opponent Ed Gillespie, who had talked about trying to reduce premiums and out-of-pocket expenses.

These are “health-care voters,” writes actor Blake Cooper Griffin, who urged Americans in a HuffPost op-ed to make health care their No. 1 issue in next year’s midterm elections.

“After everything Trump and congressional Republicans have thrown at us, and as we saw in last night's election results, we have taken on a new role — health-care voters,” Griffin wrote.


--We're into Week 2 of the ACA's open enrollment period. In this section, we're featuring letters from readers who have been enrolling in marketplace coverage. Here's today's:

"I was born with Cerebral Palsy, but was able to work for over 26 years...Since my state didn’t expand Medicaid, I applied on the Healthcare.gov exchange and have been using the ACA for insurance ever since. Since I am low income, I receive a subsidy. I became depressed and suicidal when Donald Trump won the election, because I knew eliminating the ACA was at the top of his agenda. After many months of anxiety, and after my 2017 health insurance company left the market this year, I have another plan for 2018 and pay only $50.34 a month on premiums and have a $100 deductible. My heart goes out to those who do not get the subsidy. I know the uncertainty and the elimination of the [cost sharing reduction payments] have made premiums and deductibles much higher. My premium went from $612 last year to $1,243 this year. The subsidies need to be expanded to everyone until the cost of healthcare and insurance goes down. I will be eligible for Medicare in October of 2018 but the ACA has been a life saver."        --Patricia Cox, Nebraska


AHH: The drug naltrexone might be highly effective at helping people break their heroin addictions -- even more so than the mainstay drugs buprenorphine and methadone used to treat addiction by substituting for heroin in the brain. Use of naltrexone -- which instead halts opioids from binding the opioid receptor, thus making drug use less rewarding -- gave somewhat better results for opioid-addicted patients in a study at the Norwegian Center for Addiction Research, The Post's Keith Humphreys reports.

Researchers observed patients suffering from opioid addiction who were either treated with a daily dose of buprenorphine or monthly injections of the extended-release naltrexone. After three months, most patients receiving either type of treatment had stopped using opioids, but the rate of abstinence was statistically higher for patients on extended-release naltrexone, Keith reports.

The findings are depicted in the chart below:

Additionally, patients using naltrexone were also more satisfied with their care and more likely to recommend treatment as the drug “made them feel protected against relapse and overdose," Keith writes. 

OOF: Humana plans to slash about 2,700 jobs in a cost-cutting measure that comes as many insurers continue to grapple with uncertainty over the future of the health-care industry.  The Louisville-based company’s CFO Brian Kane said yesterday on a third-quarter earnings call that the move would save “hundreds of millions of dollars,” The Courier Journal reported. 

Humana is working on a turnaround after steep losses from selling individual policies under Obamacare and a scrapped plan to merge with industry rival Aetna, although CEO Bruce Broussard said the cuts were part predated the failed merger. 

OUCH: Repealing Obamacare's individual mandate to buy coverage would save less money than previously estimated by the Congressional Budget Office -- now just $338 billion over a decade instead of the agency's previous estimate of $416 billion. That's because the CBO now considers the mandate less effective at convincing people to buy coverage than it had previously estimated. 

The agency says 13 million fewer people would be uninsured without the mandate, down from 15 million people under previous projections. Fewer people getting coverage means fewer people accessing government subsidies to help cover the costs. And that translates to less government spending. 

This creates an uncomfortable situation for Republicans, who had previously blasted CBO for overestimating the mandate's effects. But now, just when they're considering using repeal to help fund a tax overhaul, the CBO is responding to their concerns and thus scoring rolling back the measure accordingly. If you want to read more about how all this works, check out Tuesday's The Health 202, where I previewed the CBO's shift.


— The story around the attack on Sen. Rand Paul over the weekend gets curiouser and curiouser (as Winnie the Pooh would say, per my toddler). The Kentucky Republican tweeted yesterday that he's recovering from six broken ribs (not five, as initially reported) and fluid has built up around his lungs:


Initially, the New York Times and others pointed to landscaping as the root cause of the altercation between Paul and his next-door-neighbor, Rene Boucher. Boucher tackled Paul at his home last Friday, leaving him with his injuries. The Times cited three Kentucky Republicans who said the attack was the result of a landscaping dispute, although a friend who visited Paul on Saturday also told the Times that Paul was "still unsure why he was attacked."

Then, yesterday, Paul's chief strategist, Doug Stafford, appeared to call the landscaping theory into question, tweeting a link to a Breitbart story that casts doubt on it:

Boucher's motive is still unclear, even though he has basically admitted to the attack, my colleague Aaron Blake writes. Aaron lays out a number of puzzling questions that neither Paul nor Boucher nor their attorneys have answered. Like what the dispute Boucher's attorney described as “trivial” was really about — and why they couldn't explain whether it really is trivial. Stafford sure didn't seem to describe it as trivial. “It is a pending, serious criminal matter involving state and federal authorities,” Stafford said. “We won’t have any further comments at this time.”

“The wording there — 'involving state and federal authorities' — is also somewhat intriguing,” Aaron writes. “Why are the federal authorities going to be involved? We only know so far of the arrest warrant in Kentucky. Is it just because Paul is a U.S. senator and they are inherently involved? Federal law, for what it's worth, makes attacking federal officials like members of Congress punishable by up to 10 years in prison if 'personal injury results'...There are a lot more questions than answers right now. And the whole thing seems to be getting more opaque rather than less.”

—Boucher is due to appear in court today to face charges, my colleague Ed O'Keefe reports. He was charged with fourth-degree assault and released last Saturday on $7,500 bond. Kentucky State Police said Monday that Boucher may face more serious charges given the extent of Paul’s injuries.

Read the Breitbart piece as well as one in The Washington Examiner, which posits a political theory of the case.

— Do Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) feel like broken records yet? Maybe, but they're continuing to petition Congress to pass legislation funding the extra Obamacare payments to insurers to cover their cost-sharing discounts for the next two years — payments the Trump administration has ceased making. Alexander took to the Senate floor yesterday to again make his case, pointing to skyrocketing marketplace premiums in his home state of Tennessee. Congress should pass the bipartisan measure before President Trump returns from his stint in Asia, he urged.

“I hope that when the president returns from Asia, he will go to his desk and find a nice package there with a bow on it, presented by Senator Murray and me, 24 of us in the United States Senate, Republicans, Democrats, that does exactly what the American people I think want us to do — lower premiums, avoid chaos, work together, take a step in the right direction, and let's see if we can help the American people in that way,” Alexander said.


—Yesterday, a group of abortion-opposing lawmakers and activists pressured leaders in Congress to include language in a year-end spending package allowing health-care providers to sue if they’re pressured to perform an abortion over their personal objections. Existing law already prohibits discrimination against any health-care providers who won’t participate in abortions, but the Conscience Protection Act would enable providers to also take legal action if they feel coerced or face discrimination for not participating in the procedure, The Hill reports.

Rep. Diane Black (R-Tenn.), chair of the House Budget Committee, urged swift action on her legislation. “It is time for this comprehensive, reasonable and modest bill to be voted on so we can allow millions of Americans who believe as I do in the sanctity of life to abide by those beliefs without having them trampled on by their own government,” she said.

March for Life President Jeanne Mancini said this: "It is un-American for someone to be forced to go against what they know in their conscience is wrong. I can’t think of anything more un-American than forcing a person – especially a health care professional who is responding to a life saving mission ---to take part in the destruction of life."

A few more select reads from The Post and beyond:



  • 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.

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.


What if Hillary Clinton had won? From The Post's Depatment of Satire:

Watch Rep. Steve Scalise (R-La.) challenge Rep. Sam Johnson (R-Tex.) to a scooter race:

Former President Bill Clinton chats with Conan O'Brien:


Watch the official trailer for Steven Spielberg's movie about The Post: