It turns out the ballot box may not be a foolproof way of expanding Medicaid in GOP-led states. Voters in Utah, Idaho and Nebraska have approved Medicaid expansion, but efforts are afoot in two of those states to scale back the plans.

Republican lawmakers in Utah are advancing legislation to expand Medicaid to those earning only up to 100 percent of the federal poverty level, instead of the 138 percent threshold laid out in a ballot initiative approved by voters. And a conservative think tank is suing Idaho over a similar initiative, arguing it violates the state’s constitution.

These are perplexing moves, considering Republicans in Congress, the White House and around the country consistently emphasize state autonomy. The Graham-Cassidy bill to replace Obamacare that temporarily picked up momentum in the Senate would have given states more leeway in how to use Medicaid and individual marketplace dollars. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, has sought to loosen the perimeters around how states can run their insurance marketplaces and Medicaid programs.

Yet there’s less gusto, and even antagonism, among some Republicans and conservatives when it comes to whether to expand Medicaid under the Affordable Care Act — something 14 holdout states have yet to do.

In November, 6 in 10 Idaho voters said they wanted their state to expand Medicaid coverage, while in Utah a narrow majority approved such a plan. Despite the success of these ballot initiatives, the future of Medicaid expansion in these states is still being called into question. Andy Slavitt, who headed CMS under President Obama, called these sabotage efforts “the ultimate form of politics over what voters want.”

“Legislator and governors should be careful if they are considering overturning the will of the voters,” Slavitt told me. “Some believe that in a conservative state, they will not face consequences from voters if they overturn their will. I don’t think that’s a good bet.”

Utah Republicans on the state Senate’s Health and Human Services Committee voted Tuesday to recommend a measure creating a scaled-back version of Medicaid expansion — even though the ballot initiative specifically calls for people earning up to 138 percent of the poverty level to receive benefits as generous as current Medicaid enrollees. There are also questions around whether CMS would even allow partial expansion, something the agency hasn’t yet fully weighed in on.

Republicans have said a sales tax approved as part of the ballot initiative might not be enough to pay for the state’s 10 percent share of expansion, even though the tax rate was set specifically to cover the state’s estimated costs based on an analysis by the governor’s Office of Management and Budget.

Supporters of Proposition 3 are showing their frustration, with about 300 activists rallying in the state Capitol a day before the vote. Jonathan Schleifer, executive director of the Fairness Project, said legislators who vote for the alternative Medicaid expansion bill are “disrespecting the basic principles of representative democracy.”

“These politicians are trampling on the most fundamental principles of representative democracy,” Schliefer said.

Schleifer tweeted this:

Idaho’s new governor, Republican Brad Little, has notably said he will uphold voters’ will by supporting Medicaid expansion. But the state’s attorney general is defending the ballot initiative in a lawsuit brought by the Idaho Freedom Foundation. The state’s Supreme Court heard arguments on Tuesday.

Medicaid advocates thought they had hit upon a fresh way to get more Republican-led states to embrace the ACA’s vision of making the low-income insurance program more widely available. By collecting enough signatures, activists have been able to pose the question not just to voters in Utah and Idaho, but in Nebraska and Maine as well.

Maine voters approved expansion in November 2017, although the state has been slow in implementing it under opposition from former governor Paul LePage. Newly elected Gov. Janet Mills, a Democrat, has vowed to swiftly put an expansion program in place.

Utah, Idaho and Nebraska excited advocates for the ACA when they followed suit a year later. Yet the ballot questions don’t appear to have swayed many conservative Republicans, who have cited concerns about the burden of Medicaid on state budgets and generally dislike the idea of expansive government insurance programs.

But trying to circumvent voter intent could backfire. Republicans are in a tough spot, said Bill Pierce, a health policy expert at APCO Worldwide.

“Either they believe in returning decision-making to the people at the state level, even in cases where they may disagree policy-wise, or they don’t,” he said. “But to simultaneously hold both positions lacks credibility.”


AHH: New rules released by the Trump administration will expand veteran access to private health care, a move that could reduce the amount of time they wait for care but could also shift billions of dollars away from the Veterans Affairs health-care system.

Under a new policy set to take effect in June, veterans who can prove they need to drive 30 minutes or more to reach a Veterans Affairs facility will be able to seek both primary care and mental health services outside of the department’s system, the New York Times’s Jennifer Steinhauer reports. The new rules allow veterans given a wait time of 20 days or more at their closest VA facility to seek outside care, down from the current threshold of 30 days or more.

Veterans Affairs Secretary Robert Wilkie called the policy “the most transformative piece of legislation since the G.I. Bill” in an interview with the Times. “It gets us on the road to becoming a 21st-century health-care institution,” he said.

“The move has been anticipated for months, after congressional lawmakers passed legislation last spring that empowered the administration to make substantial changes to veterans health care,” Jennifer writes. “Critics fear that private health care, which tends to have higher costs than government-provided care, will force the department to cut corners elsewhere.”

While VA officials, including Wilkie, insist the current health system will remain a first choice for most veterans, “a shrinking veteran population over all in the United States and more reliance on private providers could lead to the closings of some government hospitals, some veterans groups and members of Congress warn," Jennifer writes.

OOF: Purdue Pharma -- the pharmaceutical company that made billions off sales of the potent opioid OxyContin -- also considered expanding into the business of opioid addiction treatment, according to once secret sections of a court document filed in a Massachusetts lawsuit against the company.

According to internal communication reported in this revealing story from ProPublica’s David Armstrong, co-published with Stat, company leaders discussed the “naturally linked” nature of opioid sales and the sale of addiction treatment, suggesting Purdue Pharma should expand to “the pain and addiction spectrum.”

In September 2014 the company began looking into a secret project it dubbed “Project Tango” to “join an industry that was booming thanks in part to OxyContin abuse: addiction treatment medication,” David writes. “Internally, Purdue touted the growth of an industry that its aggressive marketing had done so much to foster.” The team working on the project wrote this: “It is an attractive market... Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”

The report is based on a review of redacted portions of Massachusetts’s 274-page civil complaint, David reports, noting “these passages remain blacked out at the company’s request after the rest of the complaint was made public on Jan. 15.” A Massachusetts judge ruled this week the entire complaint should be released, but Purdue Pharma has until Friday to seek a further stay.


OUCH: President Trump and Republican lawmakers across the country criticized Virginia Gov. Ralph Northam (D) and other state Democrats after a video circulated of a state lawmaker defending a failed bill that would have expanded the ability for women to get late-term abortions.

A clip of Democratic Del. Kathy Tran defending her proposal sparked outrage after she acknowledged her bill would allow abortions up to the point of delivery when the mother’s health or life was at risk, which The Post’s Gregory S. Schneider and Laura Vozzella report is the same as current law.

In the clip, state House Majority Leader Todd Gilbert (R) asks Tran: "Where it's obvious that a woman is about to give birth, she has physical signs that she is about to give birth; would that still be a point at which she could request an abortion if she was so certified? If she's dilating?”

Tran first responded that it "would be a decision that the doctor, the physician, and the woman would make at that point." When pressed further by Gilbert, Tran responds: "My bill would allow that, yes."

"Late-term abortions are permitted in Virginia only when the mother’s life is at grave risk," Gregory and Laura write. "Tran’s bill would have lifted some restrictions. Instead of requiring three doctors to sign off on the procedure, it would have required only one doctor. It also would have removed language requiring that the danger to the mother be 'substantial and irremediable.'"

In a radio interview, Northam said the issue was being “blown out of proportion." After Republicans said he supported killing live babies, a Northam spokeswoman said the idea he would support killing infants was "disgusting." 

“I’m surprised that he did that. I’ve met him a number of times,” Trump told the Daily Caller about Northam’s remarks. He said he hadn’t heard Northam’s interview but saw the video of Tran's remarks.

“I thought it was terrible,” Trump said. “Do you remember when I said Hillary Clinton was willing to rip the baby out of the womb? That’s what it is. That’s what they’re doing. It’s terrible."

Sen. Marco Rubio (R-Fla.): 

Jim DeMint, the former senator from South Carolina and chairman of the Conservative Partnership Institute:


— House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.) and Rep. Diana DeGette (D-Colo.), the head of the panel’s Oversight subcommittee, sent a letter to major insulin manufacturers Eli Lilly, Novo Nordisk and Sanofi calling for an explanation of increasing prices.

“Despite the fact that it has been available for decades, prices for insulin have skyrocketed in recent years, putting it out of reach for many patients,” the lawmakers wrote.  "… No American should suffer because they could not afford their insulin. As one of the few manufacturers of insulin in the United States, your company is well-suited to shed light on these issues and offer potential solutions.” The Democrats called for further details by Feb. 13 on the average price of insulin products, the annual net profit from insulin products over the past decade and changes that have been made to the product over the last decade, along with an explanation for the cause of rising prices.


— The American Lung Association is calling out the federal government for not doing enough to combat youth vaping.

In the association’s 17th annual State of Tobacco Control report, the Food and Drug Administration received an F rating mainly for “lack of action,” the report’s author and the association's national director of policy, Thomas Carr, told CNN’s Susan Scutti. He added the lack of effort, especially related to youth vaping, is “putting the lives and health of Americans at risk.” "They've made a lot of announcements this [past] year, but there hasn't been a lot of concrete action," Carr added. "Yes, there has been an investigation of [e-cigarette giant] Juul, but that hasn't led to a lot of meaningful policy change."

On Wednesday, FDA Commissioner Scott Gottlieb tweeted that the agency is “fully committed” to reducing tobacco-related disease and death and mentioned that he met with the U.S. surgeon general to discuss e-cigarette-related risks.

— Meanwhile, a new study published by the New England Journal of Medicine found e-cigarettes are nearly twice as effective as nicotine replacement therapies in helping smokers quit. 

The research found 18 percent of e-cigarette users stopped smoking after a year, compared with 9.9 percent of those using nicotine-replacement products like lozenges or patches, The Post's Laurie McGInley reports. The participants in the study also received behavioral support to stop smoking. 

“But two editorials in the same publication threw some cold water on the trial’s results,” Laurie writes. “One editorial, by Boston University researchers, said e-cigarettes should be used only when Food and Drug Administration-approved treatments do not work... [Belinda Borrelli, a Boston University researcher] noted e-cigarettes pose some serious risks, including potential harm to the lungs caused by flavorings — as well as the possibility that some people will end up using both regular cigarettes and the electronic versions.” 

The other editorial in the publication called for a ban on flavored e-cigarettes that Laurie writes “would go far beyond FDA’s plans to sharply restrict sales of flavored e-cigarette products, other than mint and menthol,” warning about the increase in youth vaping.

— And here are a few more good reads: 

The 2017 assault took place in a dispute over lawn care between the two neighbors.
Michael Brice-Saddler
The moderate Republican from Maine says she will look at the president’s record as the contest draws closer.
John Wagner
Capital Weather Gang
Temperatures plunged to dangerous depths across several states. Norris Camp, Minn., dropped to minus-48 degrees Wednesday morning, making the city the coldest reporting location in the Lower 48.
Katie Mettler, Alex Horton, Amy Wang and Angela Fritz
Extra shelters have been opened in D.C. and outreach workers are on the streets.
Paul Duggan and Peter Jamison
There are endless variations of cold, pain and suffering that a person may experience on the long, dark slide from 0 to minus-40 and beyond.
Christopher Ingraham
During extreme cold, the blood rushes to the center of the body to protect vital organs, and the body temperature can fall to dangerous lows. The best advice is to stay inside, experts say.
New York Times
They’re rolling out a plan similar to a proposal in Congress.
There have been no reports of illnesses, officials said.
Kristine Phillips
The $935,000 settlement was announced Wednesday, and court documents detail the 2017 breach of patient confidentiality that led to the lawsuit and a multimillion-dollar class action settlement.
Sacramento Bee
Anthem will terminate its current pharmacy benefit manager contract with Express Scripts early and transition plan members to its new in-house PBM after it launches earlier than planned.
Modern Healthcare
The judge presiding over all the federal cases had hoped to settle them by now. But the behemoth litigation is only becoming more bloated, contentious and difficult to resolve.
New York Times


  • Kaiser Health News holds a live taping of its podcast "What The Health?" on Thursday.
  • The 2019 CMS Quality Conference continues in Baltimore. 

Rail crews in Chicago set parts of its commuter train tracks on fire to prevent damage from the extreme cold: