with Paulina Firozi


Arkansas is going where no state has gone before with Medicaid. Yesterday, it got federal permission to not only require work from enrollees but to go a step further by locking them out of health coverage for the remainder of the plan year if they don’t comply.

This type of a “lockout period” — previously allowed only for Medicaid transgressions such as failing to pay monthly premiums – will be applied for the first time to work requirements under Arkansas’ waiver request approved yesterday by the Centers for Medicare and Medicaid Services.

It’s yet another way the Trump administration is embracing a slew of new regulations and requirements for state Medicaid programs as part of a broader philosophy that poor Americans should have more incentives to find employment and Medicaid should be treated only as a temporary program to give people a leg up.

“This is not about punishing anyone,” Arkansas Republican Gov. Asa Hutchinson said at a news conference with CMS Administrator Seema Verma. “It’s about giving people an opportunity to work. It’s to give them the training that they need. It’s to help them to move out of poverty and up the economic ladder.”

Sen. Tom Cotton (R-Ark.): 

The New York Times's Abby Goodnough: 

Arkansas is the third state to gain permission for work requirements after CMS approved waiver requests for Indiana and Kentucky this year. Work requirements can be satisfied in a number of ways: by getting a job, of course, but also by volunteering or undergoing vocational training. Being disabled or caring for small children are among a number of ways Medicaid enrollees could be exempted.

Critics of work requirements have charged that they’ll result in shutting more people out of Medicaid because of the extra paperwork involved.

“These Medicaid requirements actually make it harder for lower-income people to find a job and stay at work, and really have only one aim: denying people coverage,” Brad Woodhouse, director of the Protect Our Care Campaign, said in a statement.

A health-policy expert at the liberal Center on Budget and Policy Priorities: 

From the associate director of the Kaiser Program on Medicaid and the Uninsured: 

In Arkansas, the work requirements will apply to only the 30 percent of new Medicaid enrollees who were wrapped into the program after it was expanded under the Affordable Care Act. And this is a group of people who for the most part have jobs (their income is closer to the federal poverty line or even slightly above it).

The Department of Health and Human Services has estimated about 39,000 Arkansas residents ages 30 to 49 would be affected this year, although that number will rise next year when the requirement is also imposed on those ages 19 to 29. The state has about 930,000 Medicaid enrollees.

The idea of lockout periods is a popular with conservatives, who argue for more serious consequences for those ignoring Medicaid rules. But Hutchinson and his staff could also have been seeking to reduce churn in the program if people are employed for only part of a plan year. The problem of churn has been raised by Medicaid plan officials, who say they don’t want patients constantly ducking in and out of the system.

Patti Boozang, a senior managing director at Manatt, Phelps & Phillips, LLP who helped Arkansas with its alternative Medicaid expansion, said there is more “administrative simplicity” to cutting off coverage for the rest of a plan year rather than allowing people to come in and out.

“It’s a straightforward ‘you’re out’ and then back in with everyone else,” Boozang said.

Even as CMS gave Arkansas the nod on work requirements and a lockout period, it said “no” to something else: the state’s request to roll back its Medicaid expansion but continue getting increased federal dollars for the remaining population.

It was sort of like Arkansas was trying to get the best of both worlds, at least from a Republican perspective.

Under the ACA, the federal government covered 95 percent of states’ costs for expanding Medicaid to those earning 133 percent of the federal poverty level (although the match phases down to 90 percent by 2020). Arkansas had asked permission to cut down its Medicaid expansion to those earning just 100 percent of the federal poverty level while still getting the enhanced federal rate for its remaining enrollees.

Had the Trump administration approved Arkansas’ request, it would have been an even more dramatic reshaping of the world envisioned by the ACA. Many more Americans would have lost their Medicaid coverage and had to buy subsidized private plans on the marketplaces, and many other GOP-led states probably would have followed suit.

Politico's Rachana D. Pradhan: 

So why didn’t CMS go this route? Perhaps because its lawyers decided the legal authority was lacking. Or maybe officials realized it would be more expensive for the federal government to subsidize this population on the marketplaces rather than pay for their Medicaid benefits.

“I really do think the decision would have been pretty momentous,” Boozang told me.

Either way, it's clear from the administration’s Arkansas choices that that Trump officials are eager to remold Medicaid in an image preferred by conservatives. But there seems to be a limit on how far they will go.


AHH: FDA chief Scott Gottlieb said yesterday he wants to more than double the number of packages his agency inspects for illicit drugs, with the goal of reducing the deadly flow of opioids that increasingly runs through international mail disguised as other drugs and supplements, the Associated Press reports.

"At a time of massive growth in shipments of packages from China as a result of e-commerce, the FDA, the U.S. Postal service and other government agencies are struggling to intercept shipments of opioids such as fentanyl to U.S. buyers," the AP writes. "International shipments processed by the postal service nearly doubled in just three years, to 275 million in fiscal year 2016 from 150 million in 2013."

Gottlieb wants more staffers who can inspect 100,000 packages per year flagged as suspicious by customs agents, up from the agency's current capacity of roughly 40,000 packages. "That would require more than doubling FDA staff, which now consists of 23 staffers dispersed between the nation’s nine international mail facilities," the AP writes. "That number has tripled since September, when the agency had just seven full-time staff assigned to the posts nationwide."

“We’re finding an increasing number of opioids coming in through those facilities,” Gottlieb told the AP in an interview. “In some ways the FDA is the last line of defense.”

OOF: Roll Call’s Andrew Siddons has a deep dive into the chronically underfunded Indian Health Service, which has struggled for years as Native Americans face a higher rate of health problems. The disparities are troubling: Native Americans are 60 percent more likely to commit suicide than the general U.S. population; 50 percent more likely to have substance use disorder; twice as likely to die during childbirth; three times as likely to die from diabetes and five times more likely to die from tuberculosis. Overall, they die an average of five years sooner than other Americans.

The Trump administration has vowed to do more to improve IHS, Andrew writes. After calling for a $300 million budget cut last year, the White House's latest budget proposal calls on lawmakers to provide $3.8 billion in one-time funding for the agency's facilities and construction projects. Lawmakers on the House Energy and Commerce Committee have launched a task force to examine the service.

"Some think that IHS needs direct hire authority, more competitive pay scales and expanded loan repayment programs," Andrew writes. "Republican bills in the Senate and House would do that, plus address concerns about low-performing staff by giving the service the ability to terminate employment more easily. Committees in both chambers have held hearings on the bills. But it’s unclear whether they will find room on the legislative calendar."

OUCH: While the opioid crisis continues to get worse, it’s not the only lethal drug Americans need to worry about. A recent study found cocaine is the No. 2 killer and leads to the death of more African Americans than heroin, Austin Frakt reports for the New York Times. From 2012 to 2015, cocaine overdoses claimed the lives of 7.6 black men for every 100,000 compared with heroin overdoses, which claimed 5.45 lives for every 100,000. Rates of cocaine overdoses exceeded heroin overdoses for black women as well, though they use both drugs at lower rates than men. 

The study, by researchers for the National Cancer Institute and the National Institute on Drug Abuse, also revealed drug-related deaths increased across all racial groups and for both men and women. Here are some of the other startling data points from the new research, per Austin:

  • Overdose deaths from any drug for Americans ages 20 to 64 jumped 5.5 percent from 1999 to 2015.
  • From 2012 to 2015, heroin-related deaths of men increased more than from any other type of opioid.
  • Opioid medication-related deaths were the most common for women. 

--Yesterday, Health and Human Services Secretary Alex Azar gave his broadest outline yet of how he plans to restructure the health-care system, a notoriously complicated and murky maze that often leaves patients confused about how much treatments and medicines cost and too often generates profits for middlemen without bringing value to consumers.

Addressing the Federation of American Hospitals, the new secretary didn't shy away from blaming hospitals for some of the problem. Azar said all sections of the health-care industry -- from providers to insurers to drugmakers -- need to more quickly become increasingly transparent about prices and outcomes. Acknowledging payment reform was "taken seriously" by the Obama administration, Azar vowed HHS will also prioritize it under his leadership.

"This administration is calling on not just doctors and hospitals, but also drug companies and pharmacies, to become more transparent about pricing and outcomes of their services and products," Azar said. "And if that doesn’t happen, we have plenty of levers to pull that would help drive this change."

Azar shared his own troubling experience several years ago when he went to a hospital to get an echocardio stress test and tried to ferret out its cost. After initially being told the information wasn't available, he was told by a manager that it would cost $5,500, but he'd have to pay just $3,500 under the negotiated rate with his insurer. Azar said he discovered the procedure would have cost just $550 had he received it in a doctor's office.

"Now, there I was, the former deputy secretary of Health and Human Services, and that is the kind of effort it took to find out how much I would owe for a procedure. What if I had been a grandmother? Or a 20-something with a high-deductible plan?" Azar said. "This is simply wrong. It cannot continue if, as most people in America agree, we want some degree of a consumer market when it comes to healthcare."

--Azar is expected to deliver similar remarks to the major health insurance lobby, America's Health Insurance Plans, on Thursday.


—Lawmakers are weighing legislation that would create a three-digit suicide and mental-health hotline. Sen. Orrin Hatch (R-Utah) introduced such a bill last year that the Senate passed unanimously in November, and the House Energy and Commerce Committee is working on an identical bill with bipartisan backing, CNN’s Jen Christensen reports.

“The bill would require the Federal Communications Commission to work with the Health and Human Services Department and the Department of Veterans Affairs to study the existing system, suggest ways to improve it -- and recommend a new three-digit number,” Jen writes.

Hatch said the existing national suicide hotline number 1-800-273-TALK is ”not an intuitive or easy number to remember, particularly for those experiencing a mental-health emergency.”

John Madigan, vice president of public policy at the American Foundation for Suicide Prevention, said "three digits, if you are in crisis, would help,” but warned funding and infrastructure would be needed to improve a currently “overwhelmed’ system.  


--Google Cloud is trying to help aggregate medical data, such as labs, medical records or X-ray imaging, CNBC reports. Using a new application, the company says it can pull together the top health-care data types used by various hospitals and clinics. It's also working with several hospitals, including Stanford School of Medicine, on an early-access program.

Google has tried to take on the problem of clunky health-care data sharing before with Google Health, which shut down in 2011 for a variety of reasons. But doctors have made significant progress since then in transitioning from paper to electronic records.

Yet it's still challenging to transfer records from one health system to another, and Google's cloud business is competing with Amazon Web Services and Microsoft Azure. "Health care is particularly attractive to these companies, as it's one of the few remaining industries that hasn't fully yet transitioned to the cloud," reporter Christina Farr writes. (Amazon co-founder and CEO Jeffrey P. Bezos owns The Washington Post.)

—Lyft and Allscripts want to give you a ride to your doctor, too. Days after Uber announced a new dashboard to let health-care providers schedule rides for patients, Lyft said it will provide a similar service. The ride-hailing company is partnering with Allscripts, an electronic health record company, to get its system into 2,500 hospitals, 45,000 practices and 180,000 physicians in an effort to reach about 7 million patients, USA Today’s Marco della Cava reports. Lyft’s new desktop program will allow medical facilities to call multiple cars for patients at once, send patients details by text message and cover the cost of the transportation.

What’s the upside for health-care providers? These ride services are more cost effective than taxis or shuttles and offer an opportunity to get more patients to appointments, which is a plus for the patients that will also save hospitals money and improve their ratings in the long run, Marco writes.

--A few more good reads from The Post and beyond:



  • Avalere holds a webinar on Medicaid.
  • Roll Call Live and CQ News host Health Care Decoded.
  • Brookings Institution holds an event on the individual health insurance market.
  • The House Judiciary Subcommittee on the Constitution and Civil Justice holds a hearing on Intermediate Care Facilities for Individuals with Intellectual Disabilities.

Coming Up

  • AHIP National Health Policy Conference begins on Wednesday.
  • The Center for American Progress holds an event on “How Cities and States Are Leading the Way on Mental Health” on Wednesday.
  • HHS Secretary Alex Azar speaks at the AHIP National Health Policy Conference on Thursday.
  • The Senate Health, Education, Labor and Pensions committee holds a hearing on the opioid crisis on Thursday.
  • George Washington University hosts an event on the seate of the health care system in the EU on Thursday.
  • The National Coalition on Health Care holds an event on alternative payment models on March 16.

Here's why the debate on DACA is not over: 

The Washington Post’s David Nakamura explains why the debate on DACA, an Obama-era program shielding young undocumented immigrants from deportation, isn’t over. (The Washington Post)

Late-night host Stephen Colbert dedicated more than 10 minutes of his show to talk about former Trump aide Sam Nunberg. Here are the highlights:

Late-night comedian Stephen Colbert dedicated over 10 minutes of his show on March 5 to talk about former Trump aide Sam Nunberg. Here are the highlights. (The Washington Post)

In case you missed it, here are some of Jimmy Kimmel's funniest moments from the Oscars: 

Presenter Jimmy Kimmel addressed Hollywood’s sexual harassment reckoning and offered nominees a free Jet Ski for the shortest acceptance speech. (The Washington Post)