with Paulina Firozi


Utah Republicans seeking to scale back a Medicaid expansion plan approved in 2018 by voters are taking a big gamble on the Trump administration going along with it.

Under two similar bills — one passed by the Utah state Senate on Monday and another on the floor of the state House today — Utah would ask the Centers for Medicare and Medicaid Services for permission to do something completely new: accept the Affordable Care Act’s offer of Medicaid expansion, but only for residents earning up to 100 percent of the federal poverty level, not 138 percent as envisioned by the health-care law.

It’s a bold and controversial move by the state’s Republicans to water down, or even completely reverse, a ballot initiative accepting full Medicaid expansion that voters approved (albeit somewhat narrowly) in November. Medicaid expansion is a core way the ACA extended coverage to lower-income Americans, even though the Supreme Court later said states could opt out if they wished.

“It’s completely crazy and it’s something voters are really angry about,” said Colin Diersing, press secretary for the Fairness Project, a national group that seeks to advance welfare programs through ballot initiatives.

The Utah legislation certainly hinges on a shaky assumption, as it’s not at all certain that CMS will allow the state to expand Medicaid only partially. There’s currently a heated debate within the agency over whether to allow partial expansion at all. CMS Administrator Seema Verma is reportedly in favor of the idea, while other officials have expressed concerns it would only motivate more GOP-led states to expand Medicaid — something many Republicans frown upon.

The question cuts into a deeper issue around the Republican-led administration’s approach to Medicaid, a state-federal program typically championed more by Democrats. Verma is allowing states to implement stricter requirements on the program’s low-income enrollees, saying her aim is to help pull people out of poverty rather than have them rely on the program indefinitely. Her approach has highlighted stark intraparty differences over what Medicaid should look like and how many people it should cover.

As conservative health wonk Chris Jacobs wrote last month, CMS staffers have been feeling out conservatives on how they would respond were the agency to give permission for partial Medicaid expansion. Arkansas and Massachusetts have also asked the agency to go forward with partial expansion, so its decision will affect more states than just Utah.

Paul Edwards, a deputy chief of staff to Utah Gov. Gary Herbert (R), told the New York Times that the governor and other state officials have been speaking with officials at the White House and CMS but that “no one has put anything into writing.”

But if CMS didn't grant approval, Utah is poised to either spike Medicaid expansion entirely or be forced to pay more for the new enrollees, depending on which bill Herbert might sign into law.

Under the state Senate version, expansion would be canceled entirely without federal permission. Under the state House version, the state would still expand Medicaid but would cover more of the costs itself. That’s because the federal government pays for 90 percent of the costs for people covered under expansion, but a much smaller share for the traditional Medicaid population.

It’s unclear at this point which version will win out. House lawmakers may work to amend their bill today, in hopes they could send it over to the Senate for passage and then straight on to the governor. Proponents of the effort also hope to achieve two-thirds support in both chambers because that would prohibit activists from passing a future ballot initiative undoing the state bill.

The whole thing is creating a lot of uncertainty for the state’s health department, which oversees the Medicaid program. The agency has been forced to follow multiple iterations of legislation as it moves through the state legislature and consider the different scenarios the bills lay out, all while preparing to implement full expansion by April 1 as required under the ballot initiative.

Nathan Checketts, director of the Utah Department of Health's Medicaid division, told me he and his staff are in regular communication with CMS in preparation for full expansion. But they’re also preparing to change plans quickly if needed.

“It creates a lot of work on our side to be able to consider these multiple options,” Checketts said. “Our teams have been doing a lot of work over the last couple of months to consider these different options.”

The Supreme Court voted 5-4 to block a Louisiana law that would enforce new regulations on abortion clinics. (Reuters)

AHH: The Supreme Court ruled 5-to-4 to block Louisiana from enforcing an abortion law requiring doctors to have hospital admitting privileges that may leave the state with a single doctor eligible to perform abortions. Chief Justice John G. Roberts Jr. joined the four liberal justices in granting a stay of the lower court decision, our Post colleague Robert Barnes reports, adding the majority did not give a reason for its decision, which is customary.

The law in question would require a doctor providing abortion services to have admitting privileges at a hospital within 30 miles of the procedure. “The court’s most conservative members said they would have allowed Louisiana to begin the process of enforcing the law,” Robert writes.

The court found a similar Texas law unconstitutional in 2016. “In the court’s 2016 decision, it said the admitting privileges requirement ‘provides few, if any, health benefits for women, poses a substantial obstacle to women seeking abortions, and constitutes an ‘undue burden’ on their constitutional right to do so,’” Robert reports. “The Whole Woman’s Health decision was the court’s most important one on abortion in a quarter-century. But it was decided by a very different eight-member Supreme Court in the wake of conservative Justice Antonin Scalia’s death.”

In that ruling, Justice Anthony M. Kennedy joined the high court’s liberal justices to strike down the Texas provisions, while Chief Justice John G. Roberts Jr. and Justices Clarence Thomas and Samuel A. Alito Jr. dissented.

“The Supreme Court has stepped in under the wire to protect the rights of Louisiana women,” president and CEO of the Center for Reproductive Rights Nancy Northup said about the Thursday ruling. “The three clinics left in Louisiana can stay open while we ask the Supreme Court to hear our case. This should be an easy case—all that’s needed is a straightforward application of the court’s own precedent.”

In a statement, Marjorie Dannenfelser, president of antiabortion group SBA List said the Supreme Court "continues a disappointing trend of avoiding their responsibility on decisions concerning abortion."

OOF: Veterans are taking their own lives in parking lots of Veterans Affairs hospital facilities. The Department of Veterans Affairs says there have been 19 suicides on VA campuses from October 2017 to November 2018, seven in parking lots, our Post colleague Emily Wax-Thibodeaux reports.

“While studies show that every suicide is highly complex — influenced by genetics, financial uncertainty, relationship loss and other factors — mental-health experts worry that veterans taking their lives on VA property has become a desperate form of protest against a system that some veterans feel hasn’t helped them,” Emily writes.

Preventing suicides has been a top priority for the Trump administration, she reports. In a 2018 executive order, the president sought to make sure all veterans could receive mental-health services in the first year after returning from military service.

A large majority — 62 percent — of veterans depend on the VA hospital system, Emily adds. But that can mean dealing with the complicated bureaucracy that comes with it.

Eric Caine, director of the Injury Control Research Center for Suicide Prevention at the University of Rochester, said veterans who take their own lives on VA campuses often want to send a message.

Emily reports in a note left by 55-year-old Jim Turner, the most recent veteran to take his own life in a parking lot, he wrote: “I bet if you look at the 22 suicides a day you will see VA screwed up in 90%.”

John D. Dingell Jr., who was the longest-serving member of Congress in U.S. history, was awarded with the Presidential Medal of Freedom in November 2014. (White House)

OUCH: John D. Dingell Jr., the longest-serving member of Congress in U.S. history, died at his home in Dearborn, Mich. yesterday. The Michigan Democrat was 92.

"He will be remembered for his decades of public service to the people of Southeast Michigan, his razor sharp wit, and a lifetime of dedication to improving the lives of all who walk this earth,” Rep. Debbie Dingell (D-Mich.), Dingell’s wife and successor said in a statement.

Dingell became chairman of the House Energy and Commerce Committee in 1981, and our Post colleague Emma Brown writes he used to define the committee's jurisdiction by pointing to a photograph of Earth taken from space.

“He introduced legislation that created a Civil Rights Division in the Justice Department and became an indefatigable proponent of health-care reform, annually sponsoring the national health-care legislation that his father introduced in 1943,” Emma writes. “He presided over the House when Medicare was passed in 1965, and lent the gavel he had used that day to then-Speaker Nancy Pelosi (D-Calif.), who used it when the House passed the 2010 health-care overhaul.”

President Trump on Feb. 7 said the U.S. must “build a culture that cherishes the dignity and sanctity of innocent human life." (The Washington Post)

— President Trump received a standing ovation from religious leaders at the National Prayer Breakfast after he declared: “All children, born and unborn, are made in the holy image of God.”

“Every life is sacred, and every soul is a precious gift from heaven,” Trump added.

The remarks follow his comments during his State of the Union speech criticizing recent legislative efforts in New York and Virginia to loosen restrictions on the procedure. The comments “highlighted discomfort around the topic, including among some of the president’s Democratic political adversaries,” our Post colleague Anne Gearan reports. But the president did not refer specifically to his SOTU remarks at the prayer breakfast, she adds.

 "I will never let you down," Trump told the audience. "As president I will always cherish, honor and protect the believers who uplift our communities and sustain our nation.”


— Democratic lawmakers announced a bill that would authorize Medicare to negotiate drug prices and would take patent exclusivity away from drugmakers if  companies refuse to negotiate.

Sen. Sherrod Brown (D-Ohio) and Rep. Lloyd Doggett (D-Tex.) introduced the bill. Sens. Tammy Baldwin (D-Wis.) and Amy Klobuchar (D-Minn.) and Reps. Peter Welch (D-Vt.) and Elijah Cummings (D-Md.) are original co-sponsors of Senate and House versions of the legislation. 

“We know the power of the drug industry,” Brown said at a news conference. “We know the White House looks like a retreat for pharmaceutical executives.”

But he said the bill would help lower drug prices for 45 million Americans “because either drug companies play ball with the former CEO, the secretary of HHS … or we have a free-market alternative. It works for consumers, it works to make the drug industry actually more competitive.”

Doggett said in a statement that lawmakers were calling on “President Trump to follow the advice of Candidate Trump,” referring to Trump’s previous support during his campaign for the government to negotiate lower drug costs for Medicare beneficiaries.

The bill will face an uphill climb in the Republican-controlled Senate. Senate Finance Committee Chairman Chuck Grassley (R-Iowa) has expressed opposition to the government negotiating directly with drug companies. "I don't want to mess with the government negotiating prices with the private sector," Grassley told reporters last month.

— A Health and Human Services official told members of Congress yesterday that he warned three Trump officials about the potential health risks related to separating migrant children from their families at the U.S. border with Mexico. During testimony before the House Energy and Commerce oversight subcommittee, career public health official Cmdr. Jonathan White also said no one at HHS would have ever supported such a policy.

"I do not believe that separation of children from their parents is in the best interest of the child," he said. “Neither I nor any career person in (the Office of Refugee Resettlement) would ever have supported such a policy proposal.”

During the hearing, Democrats grilled HHS officials on how many children were separated and how the agency was involved in the Trump administration's "zero tolerancy" policy.  “We need to know what role HHS leaders played in formulating this policy, whether they made any effort to stop it and whether they raised any concerns about the harm it would do to the children who were separated," said subcommittee Chairwoman Diana DeGette (D-Colo). "There is no evidence that HHS ever tried to stop this abhorrent policy,”


— Johnson & Johnson will be the first drugmaker to share the list price of its prescription drugs in television ads.

The pharmaceutical company announced it will start with a commercial on its popular blood thinner, Xarelto, the Associated Press’s Linda A. Johnson reports. “By late March, commercials will give the pill’s list price plus typical out-of-pocket costs,” she writes. “The information will appear on screen at the end of the commercial and include a website where people can enter insurance information to get more specific costs.”

The announcement follows an October proposal from the Trump administration to require drugmakers to disclose standard prescription list prices in advertisements.

— A new study has found medical problems contribute to 66.5 percent of all bankruptcies, a rate that has mostly remained the same since before the ACA passed.

The study published in the American Journal of Public Health found before the ACA went into effect, 65.5 percent of people in debt cited medical concerns contributing to bankruptcy, compared with 67.5 percent in the three years after the health care law was implemented.

It found 530,000 families deal with bankruptcies related to illness or medical bills.

Bankruptcy debtors said medical bills contributed to 58.5 percent of bankruptcies and income loss related to illness contributed to 44.3 percent of bankruptcies, the study found.

“The ACA was a step forward, but 29 million remain uncovered, and the epidemic of under-insurance is out of control,” said the study’s senior author Dr. Steffie Woolhandler, a physician and professor at CUNY’s Hunter College. She called for a move toward a single-payer health care system that “assures first-dollar coverage for everyone.”

— And here are a few more good reads: 


Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on managing pain during the opioid crisis on Feb. 12. 
  • The House Energy and Commerce Subcommittee on Health holds a hearing on the ACA and protections for preexisting conditions on Feb. 13. 

Mounting scandals rock Virginia's Democratic Party:

A cascade of scandals rocked the Democratic Party in Virginia in 2019 after a racist photo was discovered on Gov. Ralph Northam’s medical school yearbook page. (Lee Powell, Patrick Martin, Joyce Koh/The Washington Post)