THE PROGNOSIS

INDIANAPOLIS, Ind. – Indiana is emerging as a test case of whether it’s possible to enact Medicaid work requirements without also prompting widespread confusion and coverage losses in the health program for low-income Americans.

The state's former governor Mike Pence and consultant Seema Verma found a creative way to expand Medicaid under the Affordable Care Act when many other red states rejected it. Now, with Pence as vice president and Verma as the head of the federal Medicaid and Medicare programs, Indiana is again blazing its own path on health care, with the Trump administration’s avid encouragement.

Like other states, Indiana recently imposed work requirements on some of the state’s 1.4 million Hoosiers who receive benefits under Medicaid. But the state says the requirements are so limited in scope that only a fraction of those Medicaid recipients, estimated at 70,000 people, will actually be affected. And officials stress the implementation is so gradual that they'll have plenty of time to comply.

In fact, Indiana's secretary of health has made a bold promise that not a single person will lose coverage under its “Gateway to Work” program.

“We don’t want to hurt anybody, we’re just making progress in Indiana in improving our health outcomes. We don’t want to change that — that trajectory is important,” Indiana Family and Social Services Administration Secretary Jennifer Walthall told me in a recent interview in her offices in Indianapolis.

Unlike Kentucky, Arkansas and New Hampshire, Indiana isn’t facing massive pushback against its version of work requirements — so far, there have been no legal challenges against it, unlike the ones that resulted in rulings barring their implementation in other states.

And so far there has been no massive drop-off in coverage like in Arkansas, where ultimately more than 18,000 enrollees — about one-fourth of those subject to work requirements there — were booted before a federal judge ruled against the state.

The Trump administration is appealing those rulings as it seeks ways to curtail parts of the ACA following Congress’s failure to repeal and replace it. Work requirements surrounding Medicaid, which expanded dramatically under the ACA, are one way administration officials are seeking to put their stamp on the U.S. health-care system. While President Obama refused to sign off on work requirements, Verma’s Centers for Medicare and Medicaid Services has approved them in nine states.

Walthall says her goal in implementing Indiana’s work requirements isn’t to lock people out of safety-net services but to instead prompt them to seek out such services.

“We have to build a program that actually delivers those services, not makes it harder to get them,” Walthall said.

If Arkansas and Kentucky were heavy-handed in imposing their work requirements, Indiana’s program is more like a tap on the shoulder, advocates argue.

“We are so different than those other states,” said Susan Jo Thomas, executive director of Covering Kids and Families of Indiana, a leading group promoting enrollment in safety-net programs. “This is not your Arkansas work requirement, this is not your Kentucky work requirement.”

As the battle over the ACA rages at the federal level, several Republican-led states are heeding calls from Verma to impose new work and volunteering requirements on Medicaid recipients for a program that covers 65 million low-income Americans. The Trump administration says the requirements encourage personal responsibility, but judges have blocked them as tens of thousands of people saw their coverage jeopardized or dropped entirely.

But Indiana officials say the state is taking a different path, with Walthall vowing that the requirements, which technically went into effect in January, will be rolled out so gradually that no one currently receiving coverage will lose it.

Walthall argues the purpose of work requirements is to identify the Medicaid enrollees who can take the next step toward self-reliance and give them a push in that direction. The idea — one Verma frequently touts — is that higher levels of employment and education are linked to better health and increased well-being.

“Can people access more education than they thought they would, can they access employment that they didn’t think they could, can they be more engaged in their community and can that end up with improved health outcomes?” Walthall said. “That’s what we want to evaluate.”

Not everyone buys that argument. Fran Quigley, director of the Health and Human Rights Clinic at Indiana University’s law school, said he believes work requirements will cause people to lose coverage and won’t improve their overall health.

“Let me just be real blunt about this . . . this is a politically motivated lie,” he said. “They are inevitably going to cut people in Indiana off of their health care.”

Others argue work requirements are a means of increasing political support for Indiana’s Medicaid expansion under the ACA. Republicans who dominate both state legislative chambers in Indianapolis are generally wary of anything related to Obamacare.

To gain GOP support for expanding Medicaid in 2015, then-governor Pence added a requirement for enrollees to contribute a monthly premium pegged to their income and shut them out of the program for up to six months if they failed to pay it.

“There are political trade-offs being made here,” said Kosali Simon, a health economics professor at Indiana University. “What are ways to get business done in Indiana in a way that is politically successful?”

Indiana’s work requirements will affect only about 5 percent of its Medicaid population: Some who are in Indiana’s expansion program under Obamacare, called the “Healthy Indiana Plan” (HIP). There are more than a dozen exemptions, including for pregnant women, those who are too sick to work and caregivers of young children.

Officials say many of those who would be affected may already be employed or involved in other activities that satisfy the requirements, including job searching, job training, volunteering or taking college courses.

The state is also implementing the requirements slowly. Although the conditions went into effect in January, enrollees didn’t have to start reporting partial hours until July. A full 80 hours of eligible work will need to be reported a year from now to qualify for Medicaid coverage in the HIP program. Participants would lose coverage only if they fail to meet those requirements five or more months out of the year.

Furthermore, there is no “lockout” period for failing to meet the requirements, which would prevent someone who loses coverage from immediately reentering the program once they comply with it.

Walthall says she’s afraid enrollment in HIP will drop just because of “fearmongering” about work requirements.

No one has yet sued Indiana over the new limits — perhaps reflecting its go-slow approach. Verma said she wouldn’t address Indiana specifically, given her work there in the past. She said letting states implement work requirements in different ways is crucial to discover how to do it well.

“There’s different ways to approach this, and I think that’s why it’s important to allow different states to do this,” Verma told reporters in August.

“There are some lessons Indiana has definitely learned because we’ve had a slow ramp up by watching what was done wrong in those [states],” added Mark Fairchild, director of policy for Covering Kids and Families of Indiana.

It’s too early to tell whether Walthall will be able to keep her promise that no one will lose coverage, as enrollees have until year’s end to report their work hours. Jim Gavin, a spokesman for Indiana’s Family and Social Services Administration (FSSA), said “thousands” have reported working so far but the state isn’t ready to share specific figures.

Officials insist they’ve make sure everyone is aware of the new requirements. The FSSA communications team says it has sent 1.2 million emails to Medicaid expansion enrollees and disseminated digital and print ads specifically targeting them.

Medicaid plans themselves are also involved in the effort. Kevin O’Toole, president of Managed Health Services, one of four plans in Indiana that covers Medicaid patients, said his agency has mostly relied on email blasts to educate consumers.

O’Toole stressed that just 15 percent of his plan’s 67,000 HIP members will be subject to the requirements. Of those, an estimated one-third are fulfilling the requirements already. He said the state seems receptive to suggestions, with officials including an exemption for homeless people at his group’s request.

“When you look at how this program has been rolled out, there has been a great deal of advance communication and there’s a tremendous amount of attentiveness,” O’Toole said. “They’re really not trying to exploit people.”

Work requirements still don’t belong in the ideal world for Thomas or Fairchild, who worry about any barrier to people who depend on safety-net programs. But both said they’ve been impressed by the state’s slow ramp-up and state officials’ willingness to consider their concerns. They meet with Walthall on a near-weekly basis to share feedback.

“By their statement of no one losing coverage, they’ve taken on a pretty massive burden to make sure that happens, and that’s something they’re going to be held accountable for,” Fairchild said.

AHH, OOF and OUCH

AHH: The Sackler family that owns Purdue Pharma and has made billions because of its prescription painkiller OxyContin could end up holding on to most of its personal fortune in a legal settlement that’s under negotiation, our Post colleagues Lenny Bernstein, Aaron C. Davis, Christopher Rowland and Renae Merle report.

Under the plan, in which the Sacklers would give up control of the company, the family “could raise most, if not all, of their personal share of the $10 billion to $12 billion agreement by selling their international drug conglomerate, Mundipharma, according to the documents and those close to the talks,” our colleagues write.

Purdue would become a trust to help address the opioid crisis – for example, it would develop anti-addiction medication and overdose antidotes to be doled out to the public. While the company would be out of the pharmaceutical business, the family would maintain its wealth, and also may be able to keep billions of dollars that state attorneys general allege they pilfered from the company.

“The assumptions that undergird the $12 billion figure reveal why some of the plaintiffs are uncomfortable with aspects of the deal and why some have pledged flatly to oppose it,” our colleagues write. “…But the documents also indicate that if settlement talks fail and the Sacklers vote to send Purdue into Chapter 11 bankruptcy, the plaintiffs might get as little as $1.2 billion from an auction of the business’s components.”

OOF: Sen. Bernie Sanders plans to release a new proposal to cancel $81 billion worth of medical debt Americans are struggling to pay off, our colleage Sean Sullivan reports. Sanders is seeking the Democratic presidential nomination on promises of enacting Medicare-for-all, wiping away student loan debt and aggressively combating climate change, initiatives that together would cost an estimated $48 trillion or more over a decade, Sean writes.

Sanders' proposal on medical debt, which he plans to roll out next month, would spur the federal government to negotiate and pay off all past-due medical bills in collection that have been reported to credit agencies.

“We are introducing legislation that would end all medical debt in this country,” Sanders told reporters in Florence, South Carolina on Friday after campaigning at an outdoor festival. “And the bottom line is, it is an insane and cruel system which says to people that they have to go deeply into debt or go bankrupt because of what? Because they came down with cancer or they came down with heart disease or they came down with Alzheimer’s or whatever.”

OUCH: Ahead of Hurricane Dorian’s possible shift toward Florida, nursing homes and relatives in the state struggle with whether to move patients out of harm’s way – some recalling tragic events where elderly or vulnerable patients were killed during previous storms.

In Florida, officials are concerned with the safety of residents living in the 683 nursing homes and 3,100 assisted-living centers, our Post colleagues Tim Craig, Emily Wax Thibodeaux and Lori Rozsa report. “On Friday, Gov. Ron DeSantis (R) noted that 120 nursing homes still had not submitted proof that they have generators, as is required by law,” they write. “By Sunday afternoon, DeSantis said nursing home operators had worked throughout the weekend to make sure all nursing homes in eastern coastal communities have at least temporary generators or a plan to evacuate should they lose electricity.”

Some residents in the state, with relatives living in state rehabilitation and nursing centers, recalled the last hurricane that threatened southern Florida. In 2017, 12 people who were staying at a nursing home in Hollywood Hills died, an incident that led to new regulations and emergency plans for such facilities, including requiring generators.

The governor said there would be site checks and that the state would inspect nursing homes after a storm to make sure they had the necessary resources.

Kathryn Hyer, a professor and director of the Florida Policy Exchange Center on Aging at the University of South Florida, has studied the impact that hurricanes Katrina, Rita, Gustav, Ike and Irma had on vulnerable populations and told our colleagues that whether or not vulnerable patients are evacuated, “the impact of a storm increases the likelihood of hospitalizations and death.”

AGENCY ALERT

— A Veterans Affairs pathologist made 3,000 errors or misdiagnoses dating back to 2005, our Post colleague Lisa Rein reports in this chilling story.

Over more than a decade, Veterans Affairs failed to stop Robert Morris Levy, a longtime chief pathologist at Veterans Health Care System of the Ozarks in Fayetteville, Ark. Officials there did not respond to early warnings about Levy’ intoxication and patient endangerment – he was only fired after he was arrested from driving under the influence in spring 2018, Lisa reports, based on internal VA documents, court filings and interviews with 20 congressional officials, veterans and current and former VA employees.

Last week, federal prosecutors charged the 53-year-old Levy with three counts of involuntary manslaughter in the deaths of three veterans. And VA officials now acknowledge his misdiagnoses lead to the death of at least 15 patients and harmed 15 others.

“The mistakes of a physician they never saw have sowed anger among an aging population of veterans whose illnesses Levy was charged with diagnosing and monitoring. Many had cancers he missed. Others were told they were sick when they were healthy — and mistakenly given invasive treatment,” Lisa writes. “Prosecutors say Levy concealed his errors by altering patient records and evaded detection by swallowing a dangerous substance that gave him a quick and powerful high, but that was indiscernible on common drug and alcohol tests.”

“It’s hard to fathom how a physician sworn to do no harm could be so reckless, and the fact that his behavior continued for some time is testament to his shameless duplicity,” VA Secretary Robert Wilkie said in a statement to The Post, adding: “Like all health care providers, VA occasionally experiences unexpected adverse outcomes in a small percentage of cases. When that happens, we hold ourselves accountable.”

—The Trump administration is reportedly walking back a move to eliminate protections for immigrants allowing them to avoid deportation while they or their relatives are receiving lifesaving medical treatment.

Last month, the United States Citizenship and Immigration Services eliminated the “deferred action” program without notifying the public, the New York Times’s Miriam Jordan reports, a move that was swiftly met with public outrage and criticism from the medical community.

But on Monday, the Homeland Security agency “said in a statement that while limiting the program was ‘appropriate,’ officials would 'complete the caseload that was pending on August 7,’” Miriam writes. “The statement said that deportation proceedings had not been initiated against anyone who had received the letter. However, it did not say whether it would continue to grant immigrants extensions to stay in the country or whether the program would be continued after current applications are processed.”

HEALTH ON THE HILL

— The latest mass shooting in West Texas over the weekend has re-upped the pressure on lawmakers to address gun legislation when they return to Washington next week.

After the shooting that left seven dead and 19 wounded – the incident increased the number of people killed in mass shootings in the United States to more than 50 in August alone – congressional Democrats and 2020 presidential candidates are renewing criticism of the president and Republican lawmakers for inaction on gun safety measures, our Post colleague Felicia Sonmez reports. 

“The biggest lies that the president has told include that he would do something about universal background checks,” Julián Castro, a candidate and former San Antonio mayor said in an interview on NBC’s “Meet the Press.”

Other presidential candidates spoke about the latest issue and gun violence on the campaign trail over the weekend, our Post colleagues Cleve R. Wootson Jr. and Chelsea Janes report. Former vice president Joe Biden conceded tackling the issue may mean a lack of bipartisan compromise. "I think there’s no compromise,” Biden said. “This is one where we are going to just have to push and push and push and push and push. And the fact of the matter is, I think it’s going to result in somebody being defeated.”

“Enough is enough,” House Speaker Nancy Pelosi (D-Calif.) said in a Saturday statement. “The Republican Senate must end its obstruction and finally pass the common-sense, bipartisan, House-passed gun violence prevention legislation that the country is demanding.”

Meanwhile, Trump said the latest incident did not change his assessment on tougher background check legislation. “This really hasn’t changed anything,” Trump told reporters on Sunday. “We’re doing a package, and we’ll see what it all — how it comes about. . . . A lot of people are talking about it, and that’s irrespective of what happened yesterday in Texas.”

Trump said his administration is “committed to working with Congress” to stop mass shootings and added “our goal must be to identify severely disturbed individuals and disrupt their plans before they strike.”

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

REPRODUCTIVE WARS
Cutbacks have hit health clinics that lost federal dollars over Trump abortion rules.
Politico
INDUSTRY RX
The execs are using their personal wealth to fund GOP lawmakers playing key roles in the Senate’s ongoing consideration of a bill to lower drug costs.
Stat
MEDICAL MISSIVES
The surge in cases comes as the Trump administration sets out to eradicate HIV transmission by 2030.
Politico
Health
THC is increasingly the focus, but officials say they can’t rule out nicotine products.
Lena Sun and Laurie McGinley
A review of patient records finds startling differences, but critics say a clinical trial must be done.
New York Times
One out of every 13 older Americans struggles to find enough food to eat while the federal program intended to help hasn’t kept pace with the graying population.
Kaiser Health News
Health
The disease, which can have devastating consequences, is almost entirely preventable.
Lindsey Bever
DAYBOOK

Coming Up

  • The American Enterprise Institute holds an event on “The Fair Care Act and the 2020 campaign plans” on Sept. 10.
  • The American Enterprise Institute holds an event on alternatives to the individual mandate on Sept. 16.
  • The Acting FDA Commissioner Ned Sharpless gives a keynote address at the 8th Annual Blueprint for Breakthrough Forum on Sept. 18.
SUGAR RUSH

They’ve been told to evacuate, but some Floridians are staying put for Dorian: