with Paulina Firozi


There's a significant population of Medicaid recipients who would lose their health-care coverage if states began requiring them to work -- regardless of whether they got a job.

Seema Verma, administrator of the Center for Medicaid and Medicare Services, calls it “a subsidy cliff.” Others refer to it as “a Catch-22.”

Either way, thousands of low-income Americans lose their insurance. 

Here's the problem: Some of the states asking the Trump administration for waivers to add work requirements for Medicaid recipients did not expand the program to cover more people living below the poverty line as permitted by the Affordable Care Act. So, in those states only the extremely poor receive health care paid for by the government. 

Requiring those people to work a minimum of 20 hours a week, as states that didn't expand Medicaid have proposed, would almost surely make them ineligible for it in states with extremely low income limits. But work requirements would also most likely make them ineligible for subsidies through the ACA to buy insurance on the individual marketplaces.

It gets a little technical here, but stay with us. Subsidized coverage under the ACA is available for families with income between 100 and 400 percent of the poverty level. Because the ACA originally expanded Medicaid in every state to cover people up to 138 percent of the poverty level, there were no gaps in coverage. But after the Supreme Court ruled that the Medicaid expansion was optional, 17 states chose not to, maintaining their program for only the extremely poor. That meant the very thing the ACA was designed to fix --- create affordable coverage for people who made too much to get Medicaid and not enough to buy private insurance — remained a problem for low-income residents of those states. 

But now, if able-bodied adults in those states are required to work to stay on Medicaid they'll fall into that gap and have no affordable coverage option at all.

"The purpose is to encourage, incentivize to work more hours, go to a higher paying job. The problem in a state that hasn’t expanded Medicaid [is] there’s a gap  where there is no coverage available, so if they were going to increase the hours to comply then it puts them in a place where they’ll be uninsured," Jesse Cross-Call a senior policy analyst at the Center for Budget and Policy Priorities.

President Trump signed guidance in January giving states the autonomy to put strings on Medicaid. In that time, 11 states have submitted proposals and many more are working on them. 

Kentucky was one of the first states to receive approval for a work requirement, but a federal judge rejected the plan because it failed to consider the 95,000 people who would lose coverage because of it. It wasn't at first clear how the administration would respond, but on Wednesday CMS announced it was reopening public comments on Kentucky's same proposal to give it another chance. 

Our Post colleague Amy Goldstein called it an “unorthodox maneuver.” A CMS official told her it would “better inform any future decision” on renewing Kentucky's plan. 

If anything, the administration's decision on Kentucky suggests a strong desire to get these work requirements enacted. 

But the administration has not said how it will rule on waivers from states where Medicaid wasn't expanded.  But it signaled awareness of the problem. “Because there is no tax credit for them to move on to the exchanges, what happens to those individuals?” Verma asked at a May 1 news briefing. “We need to figure out a pathway, a bridge to self-sufficiency.”

Mississippi is the non-expansion state furthest along in its desire to add work requirements — though keep an eye on Alabama, South Dakota, Oklahoma and South Carolina to submit their proposals at some point. Seeing the trouble Kentucky has had with its waiver and the administration's wariness about creating a “subsidy cliff,” Mississippi officials recently tweaked their proposal, increasing from one year to two the extended coverage given to Medicaid beneficiaries who become ineligible. 

Joan Alker, a Georgetown University public-policy professor who is closely following the waiver submissions, told me the state's two extra years of coverage does not solve the greater problem of putting its poorest residents in a “damned if they do, damned if they don't” situation. 

In a report she wrote about Mississippi's waiver, she calculates that if Medicaid recipients were required to work at least 20 hours a week, at minimum wage that would be an annual salary of $7,540. To qualify for Medicaid in the state, a person has to make less than $5,000 a year. Moreover, she notes that low-wage workers rarely find employment that offers insurance to its workers, and if they do, they often can't afford the premiums. 

Of the people who rely on Medicaid in Mississippi, 91 percent are mothers, she says in her report. Additionally, putting aside worries about a coverage gap, the proposed waivers don't address other barriers to employment such as child care or transportation, she told me. 

“Just to be clear, I don't think these proposals are about encouraging work,” she said. “I think they're about speaking to the Trump base and secondly about cutting enrollment.”

Jeff Myers, president and CEO of Medicaid Health Plans of America, told me his organization has not deemed the work requirements good or bad, but rejects the criticism that they're just about kicking people off Medicaid. 

Myers believes there is value in encouraging people to work, but said the idea of people losing coverage does concern him. He said states need to examine closely the effect their plans would have on each individual and how those who might lose Medicaid can transition into alternative health-care options. 


— The Department of Health and Human Service’s Office for Civil Rights removed language from its website regarding sex discrimination and prohibition of sex discrimination at some point between March and August 2017, according to analysis released this morning from the Sunlight Foundation.

The report found that on web pages related to the ACA’s section 1557, which prohibits such discrimination, language was removed that specifically noted the prohibition based on gender identity, pregnancy termination, and sex stereotyping and information defining sex discrimination. The web pages also are missing mentions of “sex stereotyping” from a frequently asked question page about the section, from a question about whether the section specifically prohibits such discrimination, and from a list of what is prohibited under this part of the ACA.

The Sunlight Foundation’s Web Integrity Project, which published the report, compared versions of various web pages for HHS’s OCR using the Internet Archive’s Wayback Machine, according to the report. The changes were first brought to the Sunlight Foundation’s attention via the National Women’s Law Center.

Here are some of the changes below: 

“What’s now presented on this Web page is a narrow definition of sex discrimination,” Sunlight researcher Rachel Bergman told The Health 202. “Someone who now comes to this page is not going to see that sex stereotyping is a form of sex discrimination … it’s been removed explicitly that OCR can enforce harassment based on stereotyping, and they’ve removed even more language about discrimination based on gender identity.”

The changes follow a court-ordered nationwide injunction that prohibits enforcement of certain section 1557 provisions that prohibit discrimination related to gender identity or pregnancy termination. The Sunlight report indicates language was added to OCR’s pages to explain the injunction, but also suggests the “documented changes to the OCR website seem to go well beyond what the injunction requires.”

HHS did not respond to a request for comment.

Jocelyn Samuels, a former OCR director and now the executive director of the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy told Sunlight that such changes “’have a damaging impact, because the existence of this language … was intended to inform those subject to discrimination that they continue to have rights,’ regardless of ‘impressions they may have gotten about the injunction based on press releases.’”

In their first public appearance since their rescue from a flooded cave, the 12 Thai soccer players and their coach held a news conference on July 18. (Reuters)

AHH: In their first public remarks since their rescue from a flooded cave in Thailand, the group of young soccer players spoke yesterday in front of TV cameras after being discharged from the hospital, donning their team soccer uniforms, smiling and bowing, our colleagues Shibani Mahtani and Panaporn Wutwanich report.

The boys described being trapped for weeks deep inside the flooded cave. “The 12 boys persuaded their 25-year-old assistant coach, Ekapol Chanthawong, to bring them on a short trip into the vast Tham Luang cave system after soccer practice on June 23,” Shibani and Panaporn write. “They had no food with them, Ekapol said, and planned to stay there for just an hour and be home before nightfall.”

“When they arrived, water from seasonal monsoon rains had already begun pooling just beyond the cave’s mouth,” they continue. “They had planned to keep exploring, but they realized it was getting late and turned back, hoping to get out the way they came in. They quickly found that the floodwaters had blocked their exit.”

The coach said that the group “dug holes to find a way to escape and stopped when we were tired. We kept drinking water to fill our belly.”

OOF: Trump loyalists at the Department of Veterans Affairs have been cleaning house ahead of the likely confirmation of Robert Wilkie as the head, our Post colleague Lisa Rein reports.

More than a dozen career civil servants have been reassigned from VA leadership roles to “lower-visibility roles” in an effort to purge the department of staff who might be disloyal to the president and his agenda, Lisa writes. But she adds that “none say they were given reasons for their reassignments.” And the shifts are being carried out by political appointees led by acting VA Secretary Peter O’Rourke.

“The reshuffling marks a new stage in a long estrangement between civil servants and Trump loyalists at VA, where staff upheaval and sinking morale threatens to derail service to one of the president’s key constituencies, according to current and former employees,” Lisa writes. “Among those reassigned is an experienced scheduler who Wilkie told colleagues he wanted to work for him once he is confirmed by the Senate, according to former and current employees.”

Department officials insist the changes will improve the agency’s overall morale and performance. “Still, it is highly unusual for a leader in an acting, caretaker role — which began for O’Rourke on May 30 — to make such significant changes before a permanent leader arrives,” Lisa notes.

“Under President Trump, VA won’t wait to take necessary action when it comes to improving the department and its service to Veterans,” department spokesman Curt Cashour told The Post in an email.’

The New York Times’s Jacey Fortin writes some are concerned about political motives behind the reshuffling. Jacey writes Rep. Elizabeth Esty (D-Conn.), a member of the House Veterans' Affairs Committee, that the combination of departures under an acting secretary who was not Senate confirmed “does raise concern” adding “it is concerning not to have that institutional knowledge there.”  

OUCH: Deaths from liver disease have sharply increased in the United States, increasing 65 percent from 1999 to 2016. In that time, liver cancer-related deaths have doubled, according to a study published in the British Medical Journal. Our Post colleague Kate Furby reports the deaths are “predominantly by alcohol-induced disease.”

The research found that in the last decade, people ages 25-34 had the highest jump in cirrhosis death rates, an average of 10.5 percent each year.

Elliot Tapper, a liver specialist at the University of Michigan said the study signals “alcohol misuse and its complications” is impacting a new generation of Americans, Kate reports.

“Tapper said people are at risk of life-threatening cirrhosis if they drink several drinks a night or have multiple nights of binge drinking — more than four or five drinks per sitting — per week,” Kate writes. “Women tend to be less tolerant of alcohol and their livers more sensitive to damage.”

“The new study found that men were twice as likely to die from cirrhosis and nearly four times as likely to die from liver cancer as women,” she adds. “The study also found whites, Native Americans and Hispanic Americans are experiencing increased death rates for cirrhosis, along with people living in Kentucky, Arkansas and New Mexico. The one positive report from the study is the declining rate of deaths in Asian Americans from both cirrhosis and liver cancer.”


— As the Trump administration continues to target Obamacare, individual coverage is being increasingly determined at the state level, with states acting to either undo the changes or bolster the the law.

“The result is that the country is increasingly returning to a pre-ACA landscape, where the coverage you get, especially for people without employer-provided insurance, is largely determined by where you live,” the Wall Street Journal’s Stephanie Armour reports.

And this will likely continue as Republicans – including some who say it’s better for the states to handle how health care is provided – keep targeting the health-care law and red states that already had weaker regulations continue to dilute them with new permission.

“Maryland is restricting the expansion of cheaper health plans,” she adds. “In various ways, Hawaii, Rhode Island, Connecticut, California, Washington, Minnesota, New Mexico, New York and Colorado are all blocking GOP initiatives or publicly debating how much of the law to preserve… The states moving most aggressively to adopt the Trump-driven changes are those that had relatively relaxed regulations before the ACA. These states are moving to let insurers sell less-expensive plans, which can omit maternity care and other benefits, and charge higher premiums to people with pre-existing conditions.”

A graphic from the Journal, shown here tweeted via the New York Times’s Margot Sanger-Katz, shows a breakdown of the specific states are taking action to help bolster or chip at the ACA: 

— At least 70 infants have been summoned to immigration court since Oct. 1 over deportation proceedings after being separated from their families, Kaiser Health New’s Christina Jewett and Shefali Luthra report.

And the number of infants under the age of 1 has increased three times from the 24 infants who were required to appear before judges last fiscal year. Forty-six infants were summoned the year before that, Christina and Shefali write. Since Oct. 1 2015, there have been 1,500 “unaccompanied” infants up to age 3 called into immigration courts, per the report.

“These are children who need frequent touching and bonding with a parent and naps every few hours, and some were of breastfeeding age, medical experts say,” Christina and Shefali writes. “They’re unable to speak and still learning when it’s day versus night.”

“Officials who review such deportation cases say most children under 1 cross the border with a parent and their deportation cases proceed together,” they write. “But some of the infants were deemed ‘unaccompanied’ only after law enforcement separated them from their parents during the Trump administration’s ‘zero-tolerance’ immigration policy. The children were sent to facilities across the U.S. under the supervision of the Department of Health and Human Services.”

— As the Trump administration faces aJuly 26 deadline to reunite children ages 5 to 17 with their parents after being separated at the border, HuffPost’s Michelle Lou reports there were still 2,551 children in that age group in the administration’s custody, an HHS official said in court on Monday. Of those children, parents for 71 of them have not yet been identified.

Yesterday, HHS released a summary of its current reunification process and noted that HHS, the Department of Homeland Security and the Justice Department are “working rapidly to reunify children and their parents who are class members under the orders by District Judge Dana Sabraw of the U.S. District Court for the Southern District of California.”

The HHS news release detailed a five-step reunification process that included performing a criminal background check on the adults, reviewing a case file to identify “red-flags,” ensuring the adult is fit to take custody of the child, interviewing the adults in person, and finally moving the child to a reunification center and into the custody of DHS to meet with their parent or guardian.


— A group of more than 60 Democratic members of Congress are set to announce today that they’ve formed a Medicare for All Caucus, Vice News’s Alex Thompson reports. The group, comprised of more than a third of all 193 Democratic lawmakers, also expect more to sign on.

The launch of the caucus is the latest sign that the once-fringe liberal idea of universal health care is taking off among Democrats in office and those running for office this year. Here at The Health 202 we've been all over the "Medicare for all" trend, writing last month about Florida candidate Donna Shalala who is supporting a “Bernie Sanders-style" system that's fairly similar, and more recently about "Medicare for All" becoming a mantra for Democrats on the campaign trail this year.

The caucus will be co-chaired by Reps. Pramila Jayapal (Wash.), Keith Ellison (Minn.) and Debbie Dingell (Mich.), Alex reports. “The impetus for this caucus is to have a real discussion and work with our offices to see how a system would really work as we think about implementing it. It’s about a growing movement to bring a Medicare for All system into being,” Jayapal told Vice News.

— Democrats worrying about how their vote on Trump’s Supreme Court nominee will impact their reelection fight may be in the clear, according to a poll that the New Yorker’s Jane Mayer reported on this week.

“The question of whether centrist Democrats will pay a price for opposing Kavanaugh could be at the heart of which way the nomination goes,” Jane writes. She noted that a poll released by two left-leaning groups and conducted by Hart Research Associates found “Democratic senators may actually be better off politically, even in states that went overwhelmingly to Trump in 2016, if they cast votes against Kavanaugh.”

The poll found 54 percent of respondents in the battleground states of Indiana, Missouri, North Dakota, and West Virginia said they would approve of their Democratic senator’s move to oppose Trump’s pick “if it protected the independence of the Court as a check on Presidential power,” Jane writes. She also notes 53 percent of voters “said they would approve of their senator opposing any nominee who was ‘likely to overturn/eliminate protections’ in the Affordable Care Act for those with ‘pre-existing conditions, people over age fifty,’ and ‘women.’”

The poll also found two-thirds of respondents, as well as a majority of Republicans, want the high court to uphold health-care protections for individuals with preexisting medical conditions. 


— The insurance industry is increasingly working with data brokers that will soon have personal details about millions of Americans -- and that information is valuable. Information on your race, education level and online shopping habits will help insurers determine how much your health care will cost and, as some patient advocates are warning, that could lead them to jack up premiums. 

In an extensive story published by ProPublica and NPR, reporter Marshall Allen details how companies are taking on this new approach at using “lifestyle” data to make medical and insurance decisions. “Patient advocates warn that using unverified, error-prone ‘lifestyle’ data to make medical assumptions could lead insurers to improperly price plans — for instance raising rates based on false information — or discriminate against anyone tagged as high cost,” Marshall writes. “And, they say, the use of the data raises thorny questions that should be debated publicly, such as: Should a person’s rates be raised because algorithms say they are more likely to run up medical bills? Such questions would be moot in Europe, where a strict law took effect in May that bans trading in personal data.”


— The National Labor Relations Board is set to soon take on the case of a Planned Parenthood based in Colorado, where more than 150 members voted in December to form a union with the help of a local chapter of the Service Employees International Union.

But the clinic’s management called for a review from the NLRB, the Rolling Stone’s Matt Taibbi reports. “Management had argued against unionization before the vote,” Matt writes. “It now argued that it really wanted all of its offices to organize, and claimed the election was invalid because workers in its offices in New Mexico and Nevada did not participate in the election.”

“Workers are now at the mercy of the full five-member NLRB, which contains three Trump appointees,” Matt continues. “The workers believe the NLRB is likely to hand down a decision soon. “

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



  • The National Academies of Sciences, Engineering, and Medicine holds a workshop on the integration of health care and social services.
  • The House Energy and Commerce Subcommittee on Health holds a hearing on “21st Century Cures Implementation: Examining Mental Health Initiatives."

Coming Up

  • The Alliance for Health Policy holds an event on “State Responses to the Evolving Individual Health Insurance Market” on Friday.

Larry Nassar survivors honored at 2018 ESPY Awards:

More than 140 women took the stage at the 2018 ESPY Awards to shed light on sexual abuse and receive the Arthur Ashe Courage Award on July 18. (Amber Ferguson/The Washington Post)

House passes resolution backing ICE while Democrats withhold votes:

The House voted for a resolution backing U.S. Immigration and Customs Enforcement on July 18, with 133 Democrats voting "present." (U.S. House of Representatives)

What's causing all the 'orbs' in Trump's life?:

The orb went viral when President Trump was in Saudi Arabia in 2017, but why do orb-like objects keep finding their way into photos of him? (Allie Caren/The Washington Post)