with Paulina Firozi


There was a clear loser in last night's elections: Medicaid work requirements in Kentucky and Virginia.

To accomplish its goals for Medicaid, the Trump administration needs the help of state political leaders – and election results in Kentucky and Virginia yesterday made that less likely as Democrats widened their control in those states. Meanwhile, a Republican won in Mississippi, keeping it in the camp of states aligning themselves with the administration’s vision for the health insurance program for the low income.

In all three of these states, Medicaid work requirements and its expansion through the Affordable Care Act were on the line. The Trump administration can only do so much in carrying out its vision for the Medicaid program, which includes requiring able-bodied enrollees to work or volunteer and generally trying to limit further dependence on public benefits by discouraging Medicaid expansion. It’s up to governors and legislators to decide whether to expand Medicaid under the 2010 health-care law and what types of eligibility requirements to impose.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, has made clear what she’d like states to do. She has made requiring work or volunteering of some Medicaid enrollees a top priority. She has also said the health-care law is subpar and that reducing the population enrolled in Medicaid – currently one in four Americans – is a good thing.

But because Medicaid is a program run by the states, state elections are deeply relevant to how each state’s program is run and who it covers. Here’s what happened last night, and what it means for Medicaid’s future:


Incumbent Republican Gov. Matt Bevin appears to have narrowly lost to opponent Andy Beshear, son of former governor Steve Beshear -- although Bevin hasn’t yet conceded the race. Beshear was leading statewide by about 5,000 votes, dominating in many urban and suburban communities, according to the latest reporting by my colleague Tim Craig.

“Appearing at his victory party shortly after 10 p.m., Beshear vowed to be a ‘governor for everyone.’ He said the election’s outcome should be viewed as a sign that voters are tired of partisan division,” Tim writes.

“With all the partisan bickering and nastiness that we are seeing in politics, we have an opportunity to do better right here in Kentucky,” Beshear said. “I ran on kitchen-table issues, and I will govern, focused on those same challenges of good jobs, health care for every Kentuckian, protecting and funding our pensions and always supporting public education.”

Beshear is likely to pull back on the state’s Medicaid work requirements, which Bevin championed. Those work requirements were blocked by U.S. District Judge James Boasberg earlier this year as Bevin was about to implement them. Bevin had planned to appeal to the Supreme Court if the federal appeals court in D.C. also ruled against them.

“We’ll win at the U.S. Supreme Court, but it takes time, and there’s people that are hoping to wait me out, hoping I won’t be around to push this,” Bevin told my colleague James Hohmann earlier this week, before the election results were in. “But I’m telling you, we’re going to win. And this will be the first entitlement reform of any significance in America since the mid-‘90s. And it is needed.”

Democratic strategist Christine Pelosi, daughter of House Speaker Nancy Pelosi (D-Calif.): 

Anthony Wright, executive director of Health Access California:

Politico's Alice Miranda Ollstein: 

MSNBC's Joy Ann Reid: 

Joan Alker, executive director of the Center for Children and Families at Georgetown University: 


Lt. Gov. Tate Reeves, a Republican, defeated Attorney General Jim Hood, in a race where Medicaid expansion was one of their clearest differences. The result: the state will remain among the 14 states that still haven’t expanded Medicaid.

Mississippi is also a top state with some of the worst health indictors, including rates of obesity, diabetes and heart disease, and one of the country’s highest uninsured rates.

While Hood said he’d expand Medicaid to 100,000 uninsured Mississippi residents, Reeves opposed it on “philosophical grounds,” saying he doesn’t think it’s good public policy to put tens of thousands more low-income people on “government health care.”

President Trump tweeted congratulations to Reeves:

Daniel Nichanian, fellow at The Justice Collaborative:


Democrats flipped Virginia’s state legislature, gaining at least five House of Delegates seats and at least two Senate seats.

Democratic Gov. Ralph Northam succeeded in expanding Medicaid in the state two years ago. But he was forced to concede some ground in the form of work requirements to Republicans, who held a two-seat advantage in both chambers. The new Democratic majorities could mean the party has enough votes to roll back those requirements.

“The sweep completed a dramatic political conversion, from red to blue, of a Southern state on Washington’s doorstep,” my colleagues Gregory Schneider and Laura Vozzella write.

“Both of Virginia’s U.S. senators, a majority of its congressional delegation and all three statewide officeholders are Democrats,” they note. “The state was carried by Democrats in the past three presidential elections. Republicans have not won a statewide contest since 2009.”

Pollster Matt McDermott: 


AHH: A settlement in the bankruptcy case against Purdue Pharma could be key in the attempt by the Purdue-owning Sackler family to repair its legacy.

Under the proposed settlement, the Sackler family business would be turned into a public interest trust to address addiction and overdose deaths.

“The Sackler family business would be transformed from a maker of a well-known prescription narcotic into an entity focused on manufacturing and distributing overdose antidote drugs free or at a low cost to communities hit hard by addiction,” our Washington Post colleague Christopher Rowland reports. “Court filings indicate the company and its owners seek to use the plan not just to settle a tidal wave of litigation, but also to promote a counternarrative to years of criticism by public health officials and political leaders.”

Up to 25 state attorneys general who have sued the OxyContin manufacturer have opposed the settlement. And some government officials and health care experts worry the public trust element of the settlement is meant to inflate the value of the settlement and circumvent the call for the Sackler family to pay billions more.

“They are trying to win a PR war,” Connecticut Attorney General William Tong told Christopher. “I think this is scorched-earth wealth preservation.”

OOF: It could be the end of the road for House Speaker Nancy Pelosi’s (D-Calif.) drug plan. The White House believes her proposal to enable Medicare to negotiate drug prices is "unworkable,” the Associated Press’s Ricardo Alonso-Zaldivar reports.

President Trump is planning to back the bipartisan plan from Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.), which requires drug companies to pay rebates to Medicare if they raise prices faster than inflation. It would also cap what seniors pay out of pockets for prescriptions. While Pelosi’s plan includes both of those proposals, the Grassley-Wyden bill does not allow Medicare to negotiate.

A senior White House official told the AP that although Trump "is not ideologically opposed to Medicare negotiating prices for medicines, Pelosi’s approach can’t be quickly retooled.”

Notably, Pelosi aides say her bill “would give Trump precisely what he had asked for as a presidential candidate, when he broke with other Republicans to back negotiating authority for Medicare,” Ricardo adds. “Under the legislation that created Medicare’s prescription drug program, price negotiations are handled privately by insurers and their pharmacy benefit managers.”

The White House is working with Grassley and Wyden on improvements to their bipartisan measure, adding provisions to tackle high insulin costs and monthly out-of-pocket limits for Medicare beneficiaries.

OUCH: There are 49,000 vacant positions across Department of Veterans Affairs facilities nationwide. And a report from VA’s inspector general found 96 percent of VA facilities say there’s at least one “severe occupational shortage,” The Post’s Joe Davidson writes.

It’s a signal of a troubling level of staff shortages at VA, even as there’s been a 12 percent decline in severe staffing shortages from 2018 to 2019.

“There are two main reasons for the shortages — low salaries and a lack of qualified applicants, with the former leading to the latter,” Joe writes. “…Highly skilled individuals work for the federal government when they could make more elsewhere because of their public service drive and the sense of purpose their agencies provide. VA attracts many employees, including a high percentage of veterans, who appreciate that role and the sacrifice those in uniform have displayed for the nation. But let’s be real, that only goes so far.”

House Veterans’ Affairs Committee chairman Rep. Mark Takano (D-Calif.), said lawmakers “need to know what actions VA is taking to address long-standing staffing challenges and the extent to which VA has made full use of numerous new [hiring] authorities Congress has authorized in recent years . . . We need to understand why VA is struggling to use this and other tools Congress has provided.”


— The White House canceled numerous meetings this week with groups that advocate for vaping, which groups worry is a sign that the administration is readying its ban on flavored e-cigarettes, Bloomberg’s Gerald Porter Jr. and Josh Wingrove report.

Paul Blair, the director of strategic initiatives at Americans for Tax Reform, who supports e-cigarettes, tweeted that the Office of Management and Budget canceled a meeting meant to be about the planned guidance from the Food and Drug Administration.

“The FDA has been working on drafting guidance concerning the sale of flavored vaping products since September, when Health and Human Services Secretary Alex Azar said the agency would clear the market of all such products except those that taste like tobacco, amid a surge in youth e-cigarette use,” Gerald and Josh write. “Since then, there have been signs that the administration may allow menthol vaping cartridges and pods, and potentially other flavors, to remain on the market.”

The agency did not say what the timing would be on announcing the guidance.

— Americans believe marijuana to be less harmful than alcohol, tobacco or e-cigarettes, a new poll from Politico and Harvard’s T.H. Chan School of Public Health found.

Notably, views on marijuana have not taken a plunge in response to the almost 2,000 cases of vaping-related lung illnesses, including at least 37 deaths,” that have been reported nationwide – the Centers for Disease Control and Prevention say more than 80 percent of the products linked to the illnesses contained THC – the psychoactive component of marijuana.

The poll found 20 percent of Americans find Marijuana for recreational use to be harmful, compared with 41 percent who said alcohol was harmful, 52 percent who said the same about e-cigarettes and 80 percent who said the same about tobacco cigarettes.

“Understanding that THC is part of marijuana and how that could be put in a product traditionally used for nicotine takes a longer time and takes a lot of messaging,” Politico’s Natalie Fertig reports.

“If news stories said, ‘Oh, there was marijuana in it,‘ people would get it. But they’re using three letters,” Harvard professor Robert Blendon, who conducted the poll, told Politico. “I think they just haven’t made the link.”

— And here are a few more good reads: 






Coming Up

  • The Senate Special Committee on Aging holds a hearing to examine “veteran scams, focusing on protecting those who protected us” on Wednesday.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the response to lung illnesses and youth e-cigarette use on Nov. 13.
  • The House Veterans' Affairs Subcommittee on Technology Modernization holds a hearing on cybersecurity challenges and cyber risk management at the VA Department on Nov. 14.


The numbers add up on paper. But whether they are realistic is open to question. (The Washington Post)