with Paulina Firozi


(This story has been updated.)

Thousands of low-income people living in Arkansas were stripped of their health-care coverage -- some without any idea they've lost it.

The state is the first in the nation to begin phasing in work requirements for so-called "able-bodied" adults receiving Medicaid, the health program for low-income people. And how Arkansas implements the new rules could serve as a test of whether they can be effectively applied in other states that want to do the same.

President Trump fiercely opposes the Affordable Care Act, which expanded Medicaid in 33 states in order to cover more low-income people without health insurance. After a GOP attempt to repeal and replace the law failed in Congress, the Trump administration has encouraged states to add work requirements and other eligibility conditions to its Medicaid programs. Critics argue such moves unfairly targets a vulnerable population. 

Here's how things are happening in Arkansas: Starting in June, childless adults between 30 and 49 years old  enrolled in Medicaid  were required to report to the government that they were working, volunteering, going to school or looking for job at least 80 hours a month, or ask for an exemption from the requirements. Next year, 18 to 29 year olds will have to do the same. If a Medicaid recipient fails to report this information three months out of the year, they lose their coverage. 

The Arkansas Democrat Gazette first reported Thursday that 4,574 people had not complied with the reporting requirements. 

As of last month, 5,426 people in Arkansas had not reported their status for June and July. They had until 9 p.m. last night to report for August or lose their coverage from September forward. Some folks are automatically exempted from the new requirements if the state already has data showing they are working or otherwise have a disability.

When Arkansas filed its waiver with the federal government to begin its work requirement program, it the state also instituted a "lock out" in which individuals kicked off Medicaid wouldn't be eligible to reenter it until Jan. 1, 2019, no matter when they lose coverage.

One big problem, say observers, is that Arkansans at risk of being kicked off Medicaid may not even be aware their coverage is at risk. Most of the correspondence about the looming reporting requirements were sent by regular mail, and there was no further outreach to ensure people received and understood what was coming. (See the letter here.) Some recipients may not have been able to properly read the letter or they could have limited access to a computer or the Internet — all the reporting has to be done online. 

"It’s clear from the data that folks on the ground don’t know what is going on," Joan Alker, a professor at Georgetown University, told me. "First of all, there’s almost nobody who is newly reporting work activities."

Arkansas Gov. Asa Hutchison said in statement to the Arkansas Democrat Gazette: "Personal responsibility is important. We will continue to do everything we can to ensure those who qualify for the program keep their coverage, but we will also make sure those who no longer qualify are removed. Otherwise, the taxpayers would be paying for health insurance premiums for those that are not eligible."

The official August numbers will be released by the state next week, but July data shows that of the estimated 46,025 Medicaid beneficiaries who are subject to the requirements, 30,288 people were automatically exempt because the state had wage data or disability information for them, according to data released by the state.

There were 12,722 who "did not satisfy reporting requirements," according to state data.

But, according to Alker, whose research focuses on health coverage for low-income children and families, what is most telling is that 844 people met the requirements in July, but only 145 people reported employment. Most of them, 639 beneficiaries, reported they were already meeting work requirements for the food stamp program. 

So, Alker says, if the whole point of the experiment is to get people working, only a sliver of the population actually did. 

Marquita Little Numan, health policy director of Arkansas Advocates for Children and Families,  said her organization has worked closely with doctors and hospitals to give them the tools to help their patients navigate the new rules. But she believes that when observers examine the fallout, the data will show that many people who lost coverage were actually working -- they were just unaware they had to prove it to the government.

"The biggest concern is that people are not even aware and don’t find out until they are at the point of service and that’s when they figure out their coverage is inactive," she said. "The great majority will simply lose coverage because they fall through the cracks because the complexity of the policy is difficult to understand and they will lose coverage unnecessarily."

After the expansion of Medicaid in many states under the ACA, many of the charity services for health care that used to exist for an undercovered population — those making between 100 and 138 percent of the federal poverty level, or about $16,000 a year— weren't needed anymore. So now options for access to health care for those people "are practically nonexistent," Numan said. 

Advocacy groups filed a lawsuit in August to halt the work requirements in Arkansas. They have already been successful in getting them blocked in Kentucky. They wrote in their complaint that the rule changes were "threatening irreparable harm to the health and welfare of the poorest and most vulnerable in our country.”

On-the-ground research by Jessica Greene, a professor of health policy at Baruch College, backs up that claim. Many Medicaid recipients she spoke to were either unaware of the requirements or overwhelmed by them. Writing in Health Affairs this week, Greene shared exchanges she had in Arkansas:

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year-old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.” Others echoed his surprise: “I’ve never even heard of it” and “I can’t believe I ain’t heard something about it on the news.”

Green wrote that half of the people she spoke to should have received the letter from Arkansas's Department of Health. Of that group, five weren't sure if they received a letter:

When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

"This is a major experiment where for leaders in Arkansas and the United States it’s important they be aware of the potential risk here," Numan said. "Because the risk is people’s lives."

Supreme Court nominee Brett M. Kavanaugh said Roe v. Wade has been "reaffirmed" multiple times. "I understand the importance of the issue," he said. (Reuters)

— Abortion rights emerged as a big line of questioning during Supreme Court nominee Judge Brett M. Kavanaugh’s second day of testimony before the Senate Judiciary Committee. Our Post colleagues Seung Min Kim, Ann E. Marimow and Elise Viebeck report Kavanaugh seemingly tried to put Democratic senators, namely California Sen. Dianne Feinstein, at ease with his testimony. He repeatedly insisted that the 1973 landmark ruling Roe v. Wade has been “reaffirmed” over the years.

“One of the important things to keep in mind about Roe v. Wade is that it has been reaffirmed many times over the last 45 years, as you know, and most prominently, most importantly reaffirmed in Planned Parenthood v. Casey in 1992,” Kavanaugh said.

He also said that he understands “the importance of the precedent set forth in Roe v. Wade.”

But our colleagues note Kavanaugh “did not say whether Roe was correctly decided — a punt that could give Democrats and abortion-rights supporters an opening to argue that the nominee could ultimately overturn the decision.”

Feinstein went deeper, referring to hundreds of thousands of women who died because of illegal abortions prior to the 1973 Supreme Court ruling, looking to press the nominee on what he meant by “settled law.” Feinstein told Kavanaugh that “how you make a judgment on these issues is really important to our vote as to whether to support you or not because I don’t want to go back to those death tolls.”

Kavanaugh responded that he understands “how passionate and how deeply people feel about this issue.” “I understand the importance of the issue. I understand the importance that people attach to the Roe versus Wade decision, to the Planned Parenthood versus Casey decision. I don't live in a bubble. I understand, I live in the real world. I understand the importance of the issue," he said.

Our Post colleague Amber Phillips writes Kavanaugh, like Justice Neil M. Gorsuch before him, was similarly mum about his opinion, only remarking on court causes that “had been decided decades ago.” “He said that the 1970s case legalizing abortion, Roe v. Wade, is ‘settled law’ but left himself wiggle room to uphold increasingly restrictive abortion laws in the states — and maybe even to rule against legalized abortion,” Amber writes, pointing out a particular exchange with said Sen. Richard Blumenthal (D-Conn.), who asked if Kavanaugh could commit that he would not overturn Roe v. Wade. “Each of eight justices on the Supreme Court now declined to answer that question,” Kavanaugh responded.

Kavanaugh also defended his dissenting opinion on the high-profile case involving a pregnant immigrant teen in federal custody. “Kavanaugh said the teen’s age was critical to his ruling and noted that the Supreme Court has upheld parental consent laws that can delay abortions,” our colleagues write.

“Had she been an adult, she would have had a right to an abortion immediately,” Kavanaugh testified.

The judge was first asked about health care by Sen. Sheldon Whitehouse (D-R.I.), who called on Kavanaugh for his views on the ACA, asking whether he would uphold Obamacare protections requiring insurance companies to cover preexisting conditions.

Kavanaugh suggested it would "be inconsistent with judicial independence" to remark on an issue that could come before the Supreme Court, and told Whitehouse he "can’t give assurances on a specific hypothetical."

Sen. Amy Klobuchar (D-Minn.) referred to the Texas lawsuit against the ACA -- the same day a federal judge heard oral arguments in the case -- and once again asked Kavanaugh whether he would uphold ACA protections. But Kavanaugh declined to comment on the case.

“Senator that’s a pending case so I cannot talk about it,” Kavanaugh said.

Members of the Senate Judiciary Committee questioned Supreme Court nominee Brett M. Kavanaugh on the second day of his confirmation hearing Sept. 5. (Sarah Parnass/The Washington Post)

AHH: A federal judge in Texas heard oral arguments yesterday as the ACA faced its latest legal challenge brought by 20 Republican states.

The coalition of GOP attorneys general representing the states called on U.S. District Judge Reed O’Connor to order a preliminary injunction to suspend the law, arguing that repeal of the individual mandate in the GOP tax policy makes the ACA unconstitutional.

The Post’s Amy Goldstein and Gayle Reaves report the judge “did not immediately rule or indicate when he would do so” but “asked more pointed questions of the parties arguing in favor of the ACA, while asking the opponents about the impact of a preliminary injunction or an outright ruling against the law.”

“Attorneys for the federal government, the defendant in the case, sat on the same side of the courtroom as the plaintiff’s lawyers during Wednesday’s hearing — a nod to their unwillingness to defend the law,” Amy and Gayle write. “A group of Democratic attorneys general, who have won standing in the case, were left to argue Wednesday for the law’s preservation.”

But they note that a deputy assistant AG, Brett Shumate, who argued on behalf of the Trump administration, asked the judge not to grant the injunction, warning it would “cause chaos in the insurance markets.”

The hearing also came as Kavanaugh faced his second day of confirmation hearings on Capitol Hill. “Advocates on both sides predict O’Connor’s eventual ruling will be appealed and could become the first ACA case to reach the high court with Kavanaugh as a member,” our colleagues write.

OOF: Rhode Island on Wednesday finalized 2019 rate hikes of up to more than 8 percent for Obamacare plans, the Washington Examiner’s Robert King reports.

The state’s two Obamacare insurers, Blue Cross & Blue Shield and Neighborhood Health Plan will increase their rates an average 7.5 percent and 8.7 percent, respectively. The state’s health insurance regulator cited the Trump administration’s efforts to undermine the ACA by creating uncertainty for insurers. “Critics have charged that the Trump administration has destabilized Obamacare's insurance exchanges by expanding access to cheaper plans with fewer benefits and by zeroing out of the individual mandate’s financial penalty in 2019,” Robert writes. “Rhode Island is the latest state to blame the Trump administration as drivers of higher insurance rates.”

Health Insurance Commissioner Marie Ganim said in a statement that Rhode Island “responded to these threats quickly to protect consumers as much as possible.”

OUCH: The Democratic Republic of Congo has recorded its first death in the city of Butembo, health officials said Wednesday. It’s one of the largest cities in Congo’s North Kivu province and a major trading hub, sparking concerns about the rapid spread of the virus and about efforts to control the outbreak, according to the Associated Press and Reuters.

Peter Salama, the U.N. World Health Organization’s head of emergency operations tweeted that as of this week, there have been 96 confirmed and 31 probable cases of Ebola, including 87 deaths, from the latest Ebola outbreak:


— In a new 30-second ad, North Dakota Senate Republican candidate Kevin Cramer goes after Democratic Sen. Heidi Heitkamp for supporting late-term abortion. The ad features Cramer’s two daughters, including one who is pregnant, who pan Heitkamp for voting against a 20-week abortion ban and features a clip of Heitkamp high-fiving Minority Leader Charles E. Schumer after the vote, The Atlantic’s Elaina Plott reports.

“She looked like she was celebrating,” Cramer’s pregnant daughter Annie says in the spot. “Late-term abortion, can you imagine?”


Following up on a Health 202 story from last month, Colby delved deeper into the story of how three Charlottesville consumers spent the better part of a year demanding answers from Optima to explain why their area had the most expensive health-care premiums for individuals in the entire country. 

Last year, Optima was the lone insurer in the Charlottesville rating area and they priced their plans extremely high for taking on the risk of the entire marketplace. The hikes didn't impact most consumers who receive government subsidies to buy insurance. But for the 700 individuals who don't, prices were three times more expensive in 2018 than they were in 2017. 

Optima has lowered its rates a bit for next year. A second insurer, Anthem, will cover the region as well in 2019. Optima has been working with the state on lowering its rates more, and in exchanges as recently as last week between the state and what had been the lone insurer, discussions about whether this year’s premiums could drop even more cited issues spotlighted by the Charlottesville consumers.

Even though rates are coming down, Dixon and the others are not letting up on their contention that Optima set last year’s rates too high. They continue to push state regulators about why they agreed to those rates and are seeking to recoup money from the insurer for residents who they assert overpaid.

“I’m convinced of the things we’ve alleged; I’m convinced we’re right on the facts,” Dixon said. “Our concern is that this could so easily happen next year. Anthem could easily leave again next summer. We could find ourselves back in this situation, and that’s why we want accountability.”

 — A new report from PhRMA, the top lobbying group for the drug industry, says hospitals are hiking prescription drug costs by an average of nearly 500 percent, Axios’s Bob Herman reports.

Based on an analysis of 3,800 hospitals, one in six had prescription prices that were at least seven times higher than what the hospital paid. At least one caveat is that the analysis focuses on the list price from the hospital, which is often not the actual cost paid for by insurance, Bob notes. He addsthat’s also a point out pharma “is quick to emphasize in debates about its own sticker prices.”

In a statement, the American Hospital Association chided the report as “typical finger-pointing by drug companies to try to divert attention away from their own skyrocketing prices.”

— First-time political candidate and former Celgene CEO Bob Hugin is looking to become New Jersey’s next senator at a time of peak concern over drug prices across the country.

Stat’s Damian Garde writes the 64-year-old pharmaceutical millionaire has branded himself as a “different kind of Republican,” trying to unseat incumbent Democratic Sen. Robert Menendez.

“The rising cost of prescription drugs, virtually the only issue that united President Trump [statnews.com] and Hillary Clinton, is something with which he has experience,” Damian writes. “Revlimid, Celgene’s banner cancer drug, costs nearly twice as much today as it did in 2010, the result of repeated price increases. On the eve of Hugin’s retirement, Celgene paid $280 million to settle charges that it defrauded Medicare to boost profits.”

Hugin’s wealth has turned the New Jersey Senate race into a surprisingly tight and immediately vicious campaign, one that doubles as a referendum on the drug industry’s place in the American psyche,” Damian adds. “While Hugin runs as a business leader devoted to winning a war on cancer, Menendez insists he’s a pantomime villain of pharmaceutical greed.”

— And here are a few more good reads:



  • Judge Brett M. Kavanaugh’s confirmation hearings continue before the Senate Judiciary Committee.
  • HHS Secretary Alex Azar is set to speak at the National Health Research Forum.
  • The House Energy and Commerce Subcommittee on the Oversight and Investigations holds a hearing on “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes."
  • The House Foreign Affairs Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations holds a hearing on fentanyl from China.

Bias, drugs and bots: Congress questions Twitter and Facebook:

Facebook’s Sheryl Sandberg and Twitter’s Jack Dorsey appeared before lawmakers on Sept. 5 and discussed foreign interference, political bias and drug sales. (Patrick Martin/The Washington Post)

Anonymous Trump official pens ‘resistance’ op-ed

An anonymous Trump official wrote a column published by the New York Times on Sept. 5, 2018, describing how senior officials are working to protect the nation. (Reuters)

When a protester interrupted a House hearing with Twitter CEO Jack Dorsey, Rep. Billy Long (R-Mo.) used an auction chant as the protester was removed:

When a protester interrupted a Sept. 5 House hearing with Twitter CEO Jack Dorsey, Rep. Billy Long (R-Mo.) used an auction chant as the protester was removed. (C-SPAN)