In just over a week, voters in four conservative states will decide whether to expand health coverage to hundreds of thousands of people.

Idaho, Utah and Nebraska voters will choose whether to expand Medicaid under the Affordable Care Act through a ballot initiative. In Montana, where Medicaid expansion was adopted in 2015, voters will decide whether to extend the program's expansion, which is set to expire next year.

Just as health care has become a central theme of this year's midterm elections, the fate of Medicaid -- and whether it will continue to fill the gaps in the health system -- is also on the ballot next Tuesday. The health program for low-income Americans is a flashpoint for partisan criticism over Obamacare, which allowed expansion of Medicaid in order to cover the millions of Americans without health insurance.

But not all states chose to expand Medicaid when the ACA was enacted, arguing the costs would be too heavy a burden. So pro-Obamacare activists are increasingly supporting ballot initiatives to put the issue directly to voters.

Utah, Idaho and Nebraska are among the 17 states that have not yet expanded Medicaid, which provides federal funding to states that do so by covering adults up to 138 percent of the federal poverty level. Currently, 33 states and the District of Columbia have taken the plunge.

Supporters of expansion point to the number of people who could gain health coverage and the fact the federal government would foot at least 90 percent of the bill. Opponents argue that expanding the program shifts an unmanageable burden onto states that can't pay for it and may disrupt the quality of care for those already receiving benefits from the program.

There are also competing numbers.

A new analysis from liberal think tank Center for American Progress concluded that if all the holdout states expanded Medicaid, more than 14,000 lives would be saved every year. In Idaho, Utah and Nebraska, CAP found that more than 600 lives a year would be saved if Medicaid was expanded. If the ballot measure passes in Utah, the campaign behind the initiative says expansion could cover up to 150,000 more people. In Nebraska, expansion would provide coverage for another 90,000 low-income residents and in Idaho, 62,000 people could be covered, according to the state campaigns.

 But David Barnes, policy manager for Americans for Prosperity, a Koch-backed political group, argued that in states where the program has expanded, “costs are higher than expected, enrollment is higher than expected, the cost per person is generally higher.”

“People have been looking at it like it’s some free lunch from the federal government, which is not necessarily the case,” he said, adding that the addition of “largely working-age, able-bodied people … dilutes public dollars from the most vulnerable in society.” AFP is working to oppose the ballot initiatives in Utah and Nebraska.

Sara R. Collins, vice president for the health-care coverage and access program at the Commonwealth Fund, said expanding Medicaid makes “tremendous fiscal sense from a state perspective.”

She said that in some cases, the savings generated by expanding Medicaid can bring the state’s contribution of 10 percent even lower.

“Let’s use the example of pregnant women in Nebraska,” Collins said. “The state is spending a larger share relative to the federal government for care for that particular population. Under expansion, that group of women becomes eligible for expansion and the state’s share of the cost for their care goes down.”

Here’s how that breaks down: According to one estimate by the Nebraska state legislature that Collins shared with The Health 202, the total cost for Medicaid expansion in 2021 would be about $635 million, with federal funding accounting for nearly $572 million. That leaves the state paying about $63 million, or 10 percent for the costs of expansion.

With Medicaid expansion, pregnant women and other groups such as women with cancer and behavioral-health patients would be eligible for expansion funding. The savings for these groups for the state could be about $30 million, which would essentially cut in half the amount of money the state would have to pay for expansion, Collins said.

Collins noted that other estimates predict lower savings but that overall “on the fiscal side, there’s obviously a strong argument that it’s a good thing for states.”

Patricia Boozang, a senior managing director for consulting firm Manatt Health, said that the biggest issue on the ballot when it comes to Medicaid expansion is the state's share of the costs. That'swhat made expansion a “hot-button issue” in states such as Maine, which voted to pass Medicaid expansion via ballot initiative last year.

Despite the fact that voters overwhelmingly approved the initiative, Republican Gov. Paul LePage has done what he can do avoid expanding the program, citing funding concerns.

Some states seem to have learned a lesson from that experience. In Utah, voters will be asked next week about whether there should be an increased sales tax on nonfood items to pay for the state’s share of expansion. In Montana, voters will get to choose whether to increase taxes on tobacco products to fund growth in the program.

Jonathan Schleifer, executive director of the Fairness Project, which has spent about $5 million to support expansion efforts, said success at the ballot box next week could push the momentum forward even more.

Boozang said adding to the map of expanded states would be “significant.”

“I think it reflects the fact that expansion is popular among the electorate in many states and has become more popular over time,” she said. “I think the despite the fact that the electorate wants it, and even in some cases you have a governor or a key house of the legislature in the state that are supportive, it’s been challenging to move forward in some states, because of the politics around the ACA and around Medicaid.”

That politicization is partially why advocates have taken this issue straight to voters.

“Health care has become simultaneously the most important issue of the day and the most partisan issue of the day,” Schleifer said. “With ballot initiatives, you go around the partisanship, around the politics and go straight to the voters and ask them what they want.”


AHH: Some Republican candidates on the road have been misleading voters by claiming that their opponents received Four Pinocchios from the Fact Checker team at The Post for their attacks regarding the GOP’s undermining of protections for people with preexisting conditions. Our colleague Glenn Kessler says the team found at least seven politicians who have done this, “twisting an unrelated fact check and are misleading voters.”

Glenn calls out Illinois Reps. Peter J. Roskam and Rodney Davis, as well as GOP Reps. Mike Kelly (Pa.), Erik Paulsen (Minn.), John Faso (N.Y.), Jeff Denham (Calif.) and Dave Brat (Va.). He breaks down here the date or instance in which they made the claim and the reason it’s misleading.

“We asked these lawmakers whether they would be willing to withdraw the citation of the Pinocchios. None agreed to do so,” Glenn writes. “That’s dismaying. These lawmakers have been put on notice that they are peddling a falsehood — and politicians who care about their reputation should acknowledge they made a mistake and offer an apology.”

OOF: The Trump administration acknowledged late last week that it had miscounted the number of children in its custody after they had been separated from their families at the border. There were 14 migrant children that have been in the custody of the Department of Health and Human Services and who have been overlooked for months, Politico’s Dan Diamond reports.

The information was revealed during an additional review of the HHS Office of Refugee Resettlement’s records. According to a filing in federal court last week, ORR “recently completed another review of case management records to ensure that its categorizations of certain children in ORR care remain accurate,” Dan reports.

The filing acknowledged that there were 2,668 separated children, not the previous count of 2,654.

“The discrepancy stemmed from the haphazard way that the Trump administration tracked migrant families after it imposed the ‘zero-tolerance’ strategy that led to separations at the border,” Dan writes. “Neither Homeland Security nor HHS was prepared to implement the policy, government investigators reported this week. Border Patrol agents also did not track families consistently as they were separated and as children were remanded into HHS custody.”

Reuniting the 14 newly identified separated children won’t be easy, either. The filing notes that seven of them have parents with criminal histories.

OUCH: A federal judge approved an injunction to permanently ban an Ohio doctor from prescribing controlled substances or practicing medicine anywhere in the country after federal prosecutors said he doled out painkillers to people without a medical need.

“U.S. Attorney General Jeff Sessions highlighted federal prosecutors’ civil action against [Michael P. Tricaso] in August during a visit to Cleveland as among the ways the federal government is trying to curb the opioid epidemic,” the Akron Beacon Journal’s Amanda Garrett reports. “The Justice Department said at the time a temporary restraining order against Tricaso was among the first obtained against a doctor accused of illegal prescription practices under the Controlled Substances Act.”

“For the first time, the Department of Justice is going to court to use civil injunctions to stop the spread of opioids to our communities,” Joseph H. Hunt, assistant attorney general of the Justice Department's Civil Division said in a Friday statement. 'Today’s injunction means that this doctor — who allegedly sold and prescribed dangerous opioids without a legitimate medical purpose — no longer presents a risk of harm to patients or the community.' ”


— Consumers may face a lot of confusion when they begin shopping this week for insurance plans under the ACA. There will be more options, including short-term plans recently approved by the Trump administration with leaner benefits. But what consumers will also have is limited help from “navigators,” unbiased insurance counselors who guide people in finding plans, the New York Times’s Robert Pear reports.

“Insurers are entering or returning to the [ACA] marketplace, expanding their service areas and offering new products,” Robert writes. “But the budget for the insurance counselors known as navigators has been cut more than 80 percent, and in nearly one-third of the 2,400 counties served by, no navigators have been funded by the federal government.”

There will be nearly 800 counties served by that won’t have navigators for this enrollment year, Robert reports, citing an analysis of federal data by the Kaiser Family Foundation. “That is a sharp increase from 2016, when 127 counties lacked such assistance,” he adds.

For its part, the Centers for Medicare and Medicaid Services defended its strategy toward outreach and marketing ahead of open enrollment.

CMS said it would implement “similar marketing tactics from last year and focus funding and attention on the most strategic and efficient ways to reach consumers.”

“This year’s outreach and education campaign will target people who are uninsured as well as those planning to re-enroll in health plans, with a special focus on young and healthy consumers,” the agency said in a fact sheet posted Friday to its website. CMS called last year’s enrollment period “the agency’s most cost effective and successful experience for consumers to date.”


— Campaign finance filings reveal that Sen. Heidi Heitkamp collected a lot of cash after she said she would vote against the confirmation of Judge Brett M. Kavanaugh to the Supreme Court. The North Dakota Democrat raised a whopping $12.5 million in 17 days, most of which came following the decision to oppose Kavanaugh, the New York Times’s Catie Edmonson and Rachel Shorey report.

“Before Ms. Heitkamp’s announcement, ActBlue was processing approximately $80,000 in donations for her every day,” Catie and Rachel report. “But when she announced on Oct. 4 that she would vote against Justice Kavanaugh’s confirmation, donations poured in, reaching $1.6 million on that day, and nearly $2 million the next. By Oct. 17, when the pre-election filing period closed, Ms. Heitkamp had raised more than $12 million in 14 days, of which more than $7 million came from donors giving under $200.”

“To put that haul in context, Ms. Heitkamp raised about $15 million between her last election, in 2012, and Sept. 30 of this year,” they add.

Catie and Rachel write the windfall came in part because of the “deeper emotional resonance for donors in the senator’s decision and accompanying statement to vote against confirming the judge.”

“After Christine Blasey Ford testified that she was sexually assaulted by a teenage Justice Kavanaugh, Ms. Heitkamp wrote that she had ‘heard the voices of women I have known throughout my life who have similar stories of sexual assault and abuse.’ ”


— Research shows pollsters have not found a good way to assess what people actually think about abortion, BuzzFeed News’s Ema O’Connor reports.

Ema examined 14 polls on abortion rights from the last four years and concluded: “All of the researchers and most of the polls agreed: The public’s opinion on abortion is much less binary and significantly more complex than the national conversation about abortion makes it seem, and that accurately polling on abortion is particularly tricky.”

“There are many reasons for this, researchers told BuzzFeed News, but three in particular: the intense emotional and political charge of the subject, the extreme knowledge gap surrounding the issue, and the lack of clarity on how opinions on abortion affect voting behavior,” Ema writes.

For example, Janine Beekman of consulting and research firm Ipsos explained to BuzzFeed that it can be all about wording. In some cases, changing just one word in a poll question can generate opposite results. “They also found that asking people questions about what they think of specific abortion laws… often had little bearing on how those people actually felt about abortion itself, or on how they vote,” Ema writes.

So why poll at all? “Interest groups and candidates on both sides of the abortion issue use polling data to persuade people that their position is what the rest of America believes, and that those who disagree with them are going against the views of the people”, Ema writes.

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

Eleven people were killed on the morning of Oct. 27, when a gunman opened fire inside a Pittsburgh synagogue. Here are the stories of those who died.
Moriah Balingit, Kristine Phillips, Amy B Wang, Deanna Paul, Wesley Lowery and Kellie B. Gormly
There’s talk of cutting taxes again, which could usher in spending cuts to Medicare, Social Security and Medicaid.
The New York Times
A rural county in Washington declared the opioid epidemic a life-threatening emergency. They use a multi-agency coordination group straight out of FEMA's playbook to respond to the crisis.
Health & Science
Study shows the virus can survive for over an hour on surfaces--and in the air.
Seema Lakdawala and Linsey Marr
Health & Science
Anti-addiction medicine can really help, but most emergency care doesn’t include it. That’s starting to change.
Christine Vestal
A ninth child has died of a viral outbreak at a New Jersey health care facility, the state department of health said Sunday.
NY Daily News
Within months, Lori Yearwood lost her house, her family and business, and wound up, traumatized, on the streets of Salt Lake City. She spent two years enduring brutality as a homeless woman before she found the strength to pull herself out.
Lori Yearwood, Victoria Adams Fogg and Mark Miller
Democrats and Republicans are launching new criticisms over the Affordable Care Act and pre-existing conditions coverage.
Wall Street Journal
Maryland Politics
Industry players are frustrated by silence surrounding marijuana commission’s decision.
Steve Thompson
The Trump administration’s new plan to lower drug prices quickly set off a war with the drug industry after it was unveiled Thursday.
Health & Science
Article probes little-known story on how war, personalities and research resources affected a forgotten scientist’s work on diabetes.
Erin Blakemore

Coming Up

  • The Heritage Foundation holds an book talk on “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” on Tuesday.
  • The National Press Club hosts an event on next-generation broadband and telemedicine on Wednesday.
  • HHS Advisory Committee on Heritable Disorders in Newborns and Children holds a meeting on Thursday and Friday.
  • The FDA holds a joint meeting of the Psychopharmacologic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee on Friday.

'Wicked act of mass murder': Trump condemns deadly Pittsburgh shooting:

Politicians respond to 'evil' synagogue shooting