with Paulina Firozi


You know those cheaper but leaner health insurance plans the Trump administration has been busy expanding? It took things a step further yesterday, announcing that for the first time Obamacare subsidies could be used to buy such plans — a dramatic departure from the vision laid out under the 2010 health-care law.

Centers for Medicare and Medicaid Services Administrator Seema Verma is inviting states to go further in seeking changes to the subsidized marketplaces that cover around 11 million Americans, as she seeks to peel away Affordable Care Act requirements and reshape the law in a way that pleases its opponents.

Via guidance issued yesterday, CMS promised states more flexibility to change how insurance subsidies are distributed and the types of plans that are sold, billing the changes as a way to relieve consumers of what the administration views as an overly prescriptive and top-heavy law. States can obtain permission for these changes by applying for “1332 waivers,” named after a section of the ACA allowing for state innovation.

“Today, we are continuing our efforts to mitigate the damage caused by Obamacare,” Verma told reporters. “These waivers … allow states to get out from under the onerous rules under Obamacare.”

The administration is essentially expanding what are known as “guardrails” around how 1332 waivers can be used. The Obama administration had a much narrower understanding of these guardrails, refusing to grant a waiver if it would lead to less-comprehensive coverage or lower insurance rates among people in every income group.

The new guidance broadens those guardrails, allowing such waivers to be approved as long as people still have access to at least one comprehensive health plan and as long as states can show coverage rates wouldn’t decline in the aggregate.

Larry Levitt, senior vice president of the Kaiser Family Foundation:

The effects of the new guidance would be to permit ACA subsidies to be used for short-term health plans and association health plans that don’t cover the full range of health benefits — two types of coverage that President Trump directed his administration to expand as a way of making cheaper plans available to those who want them. These plans often don’t include coverage of certain “essential” benefits such as mental-health services and prenatal care, and they can refuse to cover people with preexisting conditions.

Not surprisingly, Democrats leaped to criticize the move. They’ve already been hammering Republicans on the campaign trail for undermining protections for those with preexisting conditions, and CMS’s announcement yesterday infused their attacks with fresh energy.

“Every day, Republicans further expose their brutal agenda to destroy Americans’ health care,” top House Democrat Nancy Pelosi (Calif.) said in a statement. “President Trump is once again cynically pushing families into shoddy junk plans that can discriminate against pre-existing conditions and that do not cover essential health benefits, while making dependable health coverage more expensive for everyone else.”

Yet it’s important to note these changes don’t do away with all the ACA’s protections for people with preexisting conditions, despite what you’re hearing from Democrats.

Consumers with serious medical conditions will still have access to marketplace plans that are required to cover them and can’t charge them higher premiums. Trump has sought to do damage control, tweeting this last week:

However, health-policy wonks have expressed legitimate concern that these leaner plans could draw healthy people away from the marketplaces, resulting in higher premiums for those remaining — a population that would presumably include many Americans with preexisting conditions. Allowing subsidies to flow to these leaner plans could make them even more attractive to the healthy, further exacerbating the problem.

Andy Slavitt, CMS acting administrator under President Obama and a top ACA advocate, told me he’s concerned that expanding the waivers will make it harder for people to find affordable coverage.

“You can make the guardrails narrower but you can’t make them broader,” Slavitt said.

Tweets from Slavitt:

This isn't the only type of change CMS wants states to seek under Obamacare. Verma noted that while eight states have obtained 1332 waivers, all but one of the waivers have permitted reinsurance programs (which can bring premiums down as I explained in this Health 202). She urged that states should blaze new trails with how waivers can be used in different kinds of ways to improve the marketplaces.

Seeking to draw a contrast between their approach vs. the Obama administration, CMS is dubbing them "State Relief and Empowerment Waivers." Verma told reporters that as a former Medicaid consultant in Indiana, it was extremely difficult to get such waivers approved. She slammed the prior administration's approach, saying it hampered states from finding creative solutions.

"Today, in response to numerous state requests, the administration is reversing that mistake and giving states the flexibility they need to provide choice for their citizens," Verma said.

Several wonks suggested to me that CMS had an eye toward Iowa in rolling out this new guidance. Last year, Iowa sought permission for a "stopgap" proposal to prevent the ACA marketplaces there from unraveling. It would have used federal subsidy money to help residents buy coverage outside the marketplace, eliminated the ACA’s cost-sharing subsidies and replaced tiers of coverage with a single level of insurance.

But when CMS indicated the proposal went beyond what could be permitted via waivers, Iowa withdrew its proposal. It’s possible, however, Iowa's proposal could be approved under the new guidance, although officials didn’t mention specific states yesterday.

One thing is for sure — this move is bound to further accent the growing divide between Republican-led states that are shying away from Obamacare and Democrat-led states that have embraced the law’s tenets. Red states have been more likely to reject Medicaid expansion and some have also applied for waivers to enact work requirements for Medicaid — another major way Verma has been seeking to put a conservative stamp on federal health-care programs.

President Trump reacted Oct. 22 to reports that say his administration is considering defining gender solely by a person's biological framework. (The Washington Post)

AHH: Trump said yesterday his administration is “seriously” considering changes to how transgender people are treated under the law, our colleagues Laura Meckler, Samantha Schmidt and Lena H. Sun report, “confirming what administration officials describe as a debate about whether to define a person’s sex as a biological fact determined at birth.”

The president confirmed the administration was considering some policy changes, but was not specific about the alternative approaches being considered. “We’re looking at it. We have a lot of different concepts right now. They have a lot of different things happening with respect to transgender right now,” Trump said. “And we’re looking at it very seriously.”  The potential changes were first reported over the weekend by the New York Times.

At HHS, the agency’s director of civil rights Roger Severino is leading the task. Severino has been critical of the previous administration’s expansion of transgender rights. Marchers rallied outside the White House and calls to the Trans Lifeline crisis hotline had doubled in the 24 hours after the news.

OOF: The Trump administration continues to consider new immigration policies in the hopes of deterring Central Americans from crossing the border into the United States (including in the much-maligned caravan originating in Honduras). One such plan involves essentially be voluntary family separations, the New York Times’s Miriam Jordan, Caitlin Dickerson and Michael D. Shear report.

“Each of the policies, which range from a new form of the widely criticized practice of family separation to stricter requirements on asylum, would face significant legal and logistical challenges,” they write. “But the White House is applying strong pressure on federal immigration authorities to come up with a solution to secure the southwest border.”

“The most talked-about alternative would be a variation of the family separation policy,” they add. “Parents would be forced to choose between voluntarily relinquishing their children to foster care or remaining imprisoned together as a family. The latter option would require parents to waive their child’s right to be released from detention within 20 days.”

At least six children have been diagnosed with a rare polio-like illness called acute flaccid myelitis or AFM, according to the Minnesota Department of Health. (Reuters)

OUCH: The Centers for Disease Control and Prevention says there are now 155 patients being investigated for possible cases of acute flaccid myelitis, the rare paralyzing, polio-like condition that has seen a sudden spike of cases.

There have been 62 confirmed cases out of the 155, CNN’s Michael Nedelman reports.

The number of cases under investigation has increased from the 127 reported patients last week.


— Meanwhile, HHS is considering a shakeup of its refuge resettlement program at the direction of Secretary Alex Azar after the department came under heavy criticism as it cared for separated children and then tried to reunited them with their families under court order.

Lynn Johnson, the agency’s assistant secretary for family support, has not made any personnel decisions yet, but she's examining the leadership of Scott Lloyd, director of the Office of Refugee Resettlement, Politico’s Dan Diamond reports. "Lloyd gained attention earlier this year for his efforts to prevent teen migrants from getting abortions," Dan writes, noting that Azar removed Lloyd from day-to-day operations amid the public scrutiny.

“Her review has taken on new urgency as Trump rails against the caravan of Central Americans heading across southern Mexico toward the U.S. border,” Dan writes. “The refugee resettlement office came under fire last summer after the White House and the Homeland Security Department began separating families at the border.”


— Vox’s Dylan Scott has a great break down of all the ways Medicaid is on the ballot in two weeks. Here are the key things to know:

  • Republicans running for House and Senate may re-up the effort to repeal Obamacare. That’s important because “the fundamental feature of the Republican health care bills was an overhaul of Medicaid,” Dylan writes. “The GOP wanted to place a federal spending cap on the program (a fundamental restructuring) and roll back Obamacare’s Medicaid expansion.”
  • From ballot initiatives to critical gubernatorial races in states where Medicaid has yet to expand, voters could have a direct influence on the program.
  • New governors can also mean some states implement Medicaid work requirements. “Arizona, Kansas, Michigan, Ohio, South Dakota, and Wisconsin currently have applications pending with the Trump administration to set up a work requirement,” Dylan writes. “New Hampshire has already had one approved… All seven of those states have competitive governor’s races.”

— There are various ways that states are spending the emergency money allocated by Congress to address the opioid crisis. A new analysis from the Associated Press’s Carla K. Johnson and Nicky Forster found that states that expanded Medicaid spent that funding more slowly compared with states that did not expand it under the ACA.

That’s in part because for the states that expanded Medicaid, “the insurance program already covers addiction treatment for nearly everyone who is poor and needs it.”

The report found states that did not expand Medicaid spent an average of $2,645 per patient on opioid addiction treatment, compared with $1,581 on average spent per patient in expansion states. Non-expansion states spent 71 percent of grant money received in the first year, compared with 59 percent spent by expansion states.

“The emergency money from Congress was part of a two-year, nearly $1 billion grant program,” they write. “States spent the money at different paces and on different services, the AP found. In total, states used the money to provide treatment to nearly 119,000 people with opioid addiction, including nearly 3,000 pregnant women. More than 33,000 people received recovery services, such as training and housing.”


— A new survey conducted by Gallup found record support for marijuana legalization. It showed that for the first time, 66 percent of American adults support legalizing marijuana, compared with 64 percent in the survey last year.

The poll comes on the heels of another survey from the Pew Research Center that found 62 percent of American adults are in favor of legalization, which was double what support was in the Pew poll in 2000.

That support also comes as voters will have a chance to expand marijuana legalization next month. Michigan and North Dakota will vote on ballot initiatives to legalize pot for recreational use while Missouri and Utah will vote on legalizing medical marijuana, as Paulina wrote for The Health 202 this week.

— And here are a few more good reads: 



  • The Medicaid and CHIP Payment and Access Commission holds a public meeting starting Thursday.
  • The American Enterprise Institute holds an event on postelection analysis for 2018 and beyond on Nov. 8.

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on Nov. 28.

Defining gender: What a narrow framework could mean for the transgender community:

Reports say the Trump administration is considering defining gender solely by a person's biological framework. Here are some of the changes in approach. (Adriana Usero/The Washington Post)