Last month, there was a flurry of headlines when the Centers for Medicare and Medicaid Services reopened Kentucky's Medicaid work requirements waiver for public comment after a federal judge sent the state's proposal back to the agency for further review.

What didn't get any attention is that on the same day it also quietly reopened comments on Mississippi's waiver. 

Both states are seeking permission from the federal government to require low income, "able-bodied" adults to work, volunteer or train for a job to maintain their health benefits through Medicaid.

What makes these two states different is their Medicaid populations. Kentucky is one of the nearly three dozen states that accepted the Affordable Care Act's offer to expand Medicaid to cover more people. Mississippi is not.

As we explained recently here at The Health 202, instituting work requirements in non-expansion states means the absolute poorest Americans, who are largely single mothers, would be caught in a catch-22 where working could earn them too much money to qualify for Medicaid, but not working would also make them ineligible for the benefits.

The new comment period, which ends when Kentucky's does on Aug. 18, seems to be a result of Mississippi amending some parts of its waiver application.

Mississippi first submitted its application in January shortly after the Trump administration issued a guidance encouraging work requirements and was waiting for a response. Then, the state recently updated its request with several important changes. Most notably, it extended from one year to two a transitional Medicaid period available for people who comply with the work requirements every month but fall into the catch-22 scenario.

Mississippi also removed language from its waiver related to the state's desire to save money. These waivers are designed for states to propose new concepts for their Medicaid programs, not as a way for the state to control costs. 

Joan Alker, a Georgetown University public-policy professor who follows these waivers very closely, believes the changes are an attempt to make the plan more palatable, so the federal government can reasonably approve it.

"To me," she said, "the Trump administration is looking for way to get to yes on these proposals."

If the government struggled to get Kentucky's waiver past a judge, many assume the challenge for non-expansion states will be much greater. Even those who support work requirements in theory have their doubts. Thomas Miller, health policy expert at the conservative American Enterprise Institute, told MedPage Today this week that "it's unlikely that imposing work requirements on a non-expansion, 'old' Medicaid population can thread the legal needle to withstand a court challenge."

Alker says giving extremely low-income people an extra year of coverage on the condition they work or volunteer 20 hours a week just delays the problem, but doesn't fix it.

The state projects the population who will fall into the catch-22 category and be eligible to receive the additional 24 months of coverage is only 1,280 people, or, by Alker's calculations, 2 percent of the parents or caretakers who have Medicaid. Alker said the administration's contention has been that Medicaid should be "preserved for the truly needy."

"That’s exactly who is hit by these proposals," she told me. "If they were to approve one of these [non-expansion states] it would really lay bare the hypocrisy of what they’re saying."

Mississippi has some of the country's most restrictive eligibility for Medicaid already, allowing only families who earn up to 27 percent of the poverty level. For a family of three, that's an annual income of less than $6,000. Most of those people are African American mothers living in rural areas, data analysis shows. 

The Mississippi Division of Medicaid did not respond to a request for comment. Neither did CMS.

But shortly after a judge ruled the Kentucky's waiver did not adequately address the consequences of tens of thousands of people likely losing coverage, CMS Administrator Seema Verma told reporters that her agency was working with Mississippi and other non-expansion states to help them address any potentials issues of adding work requirements to their Medicaid programs. 

Yet Roy Mitchell, the executive director of the Mississippi Health Advocacy Program, said the state and CMS kept the changes to the waiver and the reopened comment period "under the radar."

"Why isn’t there more transparency on this if it’s such a great program?" he asked. "If you're going to implement this and you’re serious, you have to talk to us. There’s going to be nothing short of panic when you implement this. I already have people calling here asking me questions because there hasn’t been an open dialogue." They include: "How's this going to work?" (He doesn't know) and "What does this mean for Medicaid for my children?" (They're still covered). 

At the end of July, Mitchell's group traveled the state talking to community health groups about what's at stake if Mississippi's waiver is approved and actually goes into effect. The extra layer of bureaucracy and confusion alone will cause some Medicaid recipients to fall off the rolls. 

Advocates like himself and Alker also point out that the state isn't offering additional resources to assist these mothers with child care or transportation, which are two common barriers to employment. 

"If CMS approves it, I won’t be surprised," Mitchell told me. "Mississippi is a worst-case scenario, and you can expect to hear the worst-case stories of people being harmed."

As a related aside, proponents of work requirements say self sufficiency leads to healthier lives. Work requirements are then, in their view, in line with the overall mission of Medicaid to help promote the health of the poorest Americans. But the Kaiser Family Foundation released a comprehensive review of research on the intersection of employment and health this week and found insufficient evidence to conclude that working would improve health outcomes for Medicaid beneficiaries. 

The reasons: Most studies that assess work and health are surveying a wide swath of the population, and not just individuals who may be in low-wage, poor-quality jobs. While there is a correlation between unemployment and bad health, Kaiser researchers caution against using that as evidence that work would then be the cure without considering other variables. Moreover, when someone takes a job or volunteers out of fear of losing needed benefits, it may not have the same positive effects as doing so of their own volition, the Kaiser analysts wrote. 

"Given the characteristics of the Medicaid population, research indicates that policies could lead to emotional strain, loss of health coverage, or widening of health disparities for vulnerable populations," they concluded in their report. "As debate considers the question of whether policies to promote health—versus health coverage—are the aim of the Medicaid program, the question of whether work requirements will promote health also will remain key to the ongoing debate over the legality of work requirements in Medicaid."


AHH: A new study found pregnant women who were induced at 39 weeks were less likely to need a C-section compared with women who waited to let labor begin spontaneously. The research, based on 6,000 women in 41 hospitals, found 18.6 percent of induced women and 22.2 percent of women who waited for spontaneous labor needed C-sections, our Post colleague Ariana Eunjung Cha reports.

“The outcomes for the babies were similar for the two groups: They had statistically equal rates of infection, need for respiratory support, hemorrhage, stillbirth, newborn death or other major complications,” Ariana writes. “The study's authors characterize the research as a game-changer for women suffering from discomforts of later-term pregnancies and for those who want to be able to schedule their deliveries for convenience's sake or to make sure their loved ones can be present.”

But she notes that the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have insisted while the research suggests it’s “reasonable” for inductions to be offered as an option, the ACOG’s guidance is that “induction without a medical reason should not be attempted before 39 weeks (when the baby's lungs tend to be underdeveloped), and induction should be recommended after 41 weeks (when the risk of problems related to the placenta, amniotic fluid, umbilical cord go up for the baby and the risk of a condition known as preeclampsia goes up for the mother,” Ariana reports.

OOF: Rep. Chris Collins (R-N.Y.), one of the president’s earlier congressional supporters, was charged yesterday with insider trading and accused of scheming with his son to avoid losses on an investment in a biotechnology company, Innate Immunotherapeutics.

Collins, his son and another individual were charged with 13 counts of securities fraud, wire fraud and false statements related to the scheme. Collins, who was on the board of the Australian drug company, is accused of tipping off others about a failed trial of a drug to treat multiple sclerosis, our Post colleagues Renae Merle and Mike DeBonis report.

“Basically, prosecutors allege that Collins passed along nonpublic information about the trial and that Collins’s son, Cameron Collins, and others unloaded millions of shares of stock before that news became public,” our Post colleague Aaron Blake explains. (Read more from Aaron on the five key parts of the indictment).

Collins, who pleaded not guilty yesterday on the charges, helped others avoid more than $700,000 in losses, prosecutors said.

Collins couldn’t save himself, however. Because he was on the company’s board, Collins couldn’t unload any of his own stock, and lost about $16.7 million over the failed trial, Aaron reports.

“The charges could turn into a headache for several House Republicans, who invested in Innate Immunotherapeutics with Collins' encouragement,” Renae and Mike write. “Prosecutors did not allege in the indictment that Collins tipped off any of his colleagues in Congress about the failed drug trial before it was made public, but Democrats pounced on the charges and said those lawmakers would have to answer tough questions about their investments in Innate.”

OUCH: Two Democratic lawmakers who sit on appropriations panels called this week for more information about sexual harassment policies as well as settlements reached by the National Institutes of Health over the last five years. Sen. Patty Murray (D-Wash.) and Rep. Rosa L. DeLauro (D-Conn.) criticized a “lack of engagement” at the agency that it said “largely failed” to hold its institutions accountable for stopping sexual harassment and ensuring a safe environment.

We write to express deep concern regarding harassment in the workplace and to obtain information on how the National Institutes of Health (NIH) is working to address the issue both within the agency and in research facilities that receive NIH funding,” they wrote in a letter to NIH director Francis Collins. “Federal funding should not support laboratories and institutions where workplace harassment is allowed to continue unaddressed… This lack of engagement from NIH is particularly unacceptable in light of disturbing news reports that cases of sexual harassment in the academic sciences often involve high profile faculty offenders whose behaviors is considered an ‘open secret.’”

The lawmakers called for more information about “ongoing discussions, plans, and actions within the agency aimed at protecting researchers and establishing a safe working environment free from harassment.”


— New government data released yesterday suggests migrant families were undeterred by the Trump administration’s controversial policy that led to the separation of thousands of parents and children, our Post colleague Nick Miroff reports.

“U.S. border agents arrested 9,258 family members along America’s southwest border last month, down slightly from 9,434 in June and 9,485 in May,” Nick reports.

He notes some defenders of President Trump’s “zero tolerance” policy moves, if given more time, would have blocked people from attempting to cross the border into the United States. “But the July arrest totals released Wednesday suggest the separations made little difference,” Nick writes. “While families continued to arrive at roughly the same rate, the number of unaccompanied minors taken into custody dropped from 5,093 in June to 3,938 in July, even though that group wasn’t a target of the ‘zero tolerance’ crackdown.”

“Trump officials Wednesday attributed the declining arrest totals in June and July as proof their tougher approach is working,” he added.

— California Attorney General Xavier Becerra filed a Freedom of Information Act request yesterday calling for more information from the Trump administration’s “zero tolerance” policy.

The request asks for records “related to the creation of this policy” from the Department of Health and Human Services, the Department of Homeland Security, the Justice Department, the Office of Management and Budget and the White House and information about whether the administration considered the mental and physical well-being of children.

For the months the Policy was in effect, the forcible separation from their families according to numerous medical experts, likely caused trauma and lasting harm to these children. Even with the issuance of the Executive Order, hundreds of these children are still separated from their families,” the request reads. It also refers to testimony from HHS official Jonathan White, who was “concerned about the effect of the Policy on child welfare and was uncertain of its ability to care for large numbers of detained children.”


— Senate Democratic candidates are focusing heavily health care in their advertisements this year, another signal of just how much attention the left is giving the issue ahead of midterm elections.

According to analysis from USA Today of data from Kantar media, Democratic candidates for Senate seats have dedicated more than 40 percent of television ads to health care. The data found that from January to July, Democratic candidates and outside groups aired 70,000 spots about health care. Meanwhile, Republican candidates have focused more on Trump as well as on the GOP’s tax overhaul. The analysis found Republican candidates aired 45,000 pro-Trump ads and 43,000 ads on tax cuts.

“The sharp focus on health care from Democrats stands in contrast to a more diffuse message on the GOP side,” Deirdre Shesgreen and Maureen Groppe write. “In hotly contested races across the country, Republicans and the GOP-leaning groups have divided their ad dollars on a broader set of issues – spending about $10.5 million on spots embracing President Donald Trump, $14 million on ads touting the GOP tax law and $7.6 million on commercials highlighting a hard line on immigration.”


— The Justice Department has reportedly found no competition issues in the potential merger of CVS Health Corp. and Aetna Inc., Bloomberg’s David McLaughlin and Robert Langreth report, a finding that will allow the pharmacy giant to avoid the antitrust hurdle that AT&T faced in its takeover of Time Warner Inc.

“The investigation by the Justice Department’s antitrust division hasn’t turned up vertical-competition concerns from the merger,” David and Robert report, citing people familiar with the confidential review. “Instead, the government is focused on competition between the companies in the prescription-drug market, the people said…. CVS’s $68 billion deal to buy Aetna was announced on the heels of the Justice Department’s unsuccessful lawsuit to block AT&T Inc.’s takeover of Time Warner Inc., a vertical deal that combined a pay-TV distributor with a programmer. That case was a warning shot that enforcers were suddenly taking a tougher stand on such tie-ups.”

Yesterday, the American Medical Association came out against the merger, warning that it could lead to higher prescription prices. “The CVS-Aetna deal is popularly described as a vertical merger involving two companies that don’t operate in the same markets,” AMA President Barbara L. McAneny said in a statement. “But in fact, CVS and Aetna do operate as rivals in some of the same markets, raising substantial concerns that are specific to horizontal mergers. A merger of these two rivals would risk a substantial reduction of competition in the stand-alone Medicare Part D prescription drug plan market and the pharmacy benefit management (PBM) services market.”

— In other CVS news, chief executive Larry Merlo sent shares of the company’s stock rising Wednesday after he told analysts that rebates from drugmakers are expected to account for just 3 percent of adjusted earnings this year.

That is particularly notable because the rebates, which are negotiated between drugmakers and pharmacy benefit managers, have become a target of criticism from drugmakers, lawmakers and the Trump administration for driving up the rising costs of prescription drugs. And the administration, including Health and Human Services Secretary Alex Azar, has suggested rebates could even be eliminated.

CVS Health says it passes well over 90 percent of its rebates on to its customers, and Merlo added Wednesday that the idea that what it retains affects prescription drug prices is ‘entirely false,’” the Associated Press’s Tom Murphy reports.


— The Food and Drug Administration says the large E. coli outbreak from tainted romaine lettuce may have been the result of water from a large cattle farm, USA Today’s Zlati Meyer reports.

“A concentrated animal feeding operation, or CAFO, is near a canal whose water came in contact with the affected romaine lettuce from the Yuma, Arizona, growing region, the FDA said. The water may have been used for irrigation, and sample testing revealed in June that it was tainted with E. coli O157:H7 that had the same genetic fingerprint as the outbreak strain,” Zlati writes.

The outbreak, which sickened 210 people and killed five, was the largest experienced in the United States in a dozen years.


— Vaccinations to treat the latest outbreak of Ebola in Congo began yesterday. Three thousand doses of the experimental vaccine are making its way from Kinshasa, the capital, the Associated Press’s Al-Hadji Kudra Maliro and Carley Petesch report.

Thirty-six people have died in the region of hemorrhagic fever, but health officials in the Congo have been unable to confirm them as Ebola deaths thus far. Health workers, including the Beni region's chief doctor and medical staff, were the first to receive the vaccination. Others who will be among the first to receive the experimental vaccine include contacts of people with confirmed cases of Ebola as well as contacts of those individuals, “in what is called a ring vaccination campaign,” the Associated Press reports.

“At least 43 people are believed to have been infected in North Kivu province, including 36 who have died, Congo’s health ministry said on Tuesday,” our Post colleague Max Bearak reports. “Sixteen of the cases were confirmed to be Ebola.”

“This is Congo’s 10th Ebola outbreak since the 1970s, and some health officials are worried it might be the hardest to contain,” Max notes. “The new outbreak is centered on a thickly populated stretch of Congo’s eastern border with Uganda — an area that is also the epicenter of decades-long clashes between dozens of militias that have forced millions into squalid refu­gee camps.”

— And here are a few more good reads: 

Juul puts a cool new gloss on smoking that teenagers might find, well, addicting.
Lavanya Ramanathan
And male doctors do better when they have more female colleagues.
The Atlantic
AstraZeneca agreed to pay $110 million to settle allegations of illegally marketing two drugs, causing Texas Medicaid to overpay for the medicines.
The deal was supposed to solve several challenges facing the two companies in a retail landscape turned upside down by consolidation and digital innovation.
The New York Times
The state "has not explained why these drugs are necessary."
Mother Jones
Collins was indicted on insider-trading charges, a strange turn in the New York congressman's involvement with Innate Immunotherapeutics.
The Americas
The country, considered one of the most progressive in Latin America, was deeply split on the issue.
Max Radwin and Anthony Faiola
Planned Parenthood Action Fund is launching an ad campaign as part of a broader effort by progressive groups to highlight personal stories of individuals who could be affected if President Trump's nominee, Brett Kavanaugh, is confirmed.
The Hill

Coming Up

  • FDA Commissioner Scott Gottlieb speaks at an event hosted by the National Health Council on Friday.

Prosecutors announce criminal charges against Rep. Chris Collins:

Rashida Tlaib could become one of the nation’s first Muslim congresswomen: