with Paulina Firozi


Some Americans allowed to enroll in Medicaid under Obamacare could now get kicked off the low-income health-insurance program. 

Here’s why: The Trump administration has given states unprecedented leeway to erect all sorts of new enrollment barriers, if they agree to accept their federal Medicaid dollars in a lump sum instead of per enrollee.

The Department of Health and Human Services was abuzz yesterday as Secretary Alex Azar and top officials announced that states can now seek permission to rewrite their rules around who can enroll in Medicaid. It’s the administration’s latest move to reconfigure Medicaid to discourage enrollment by able-bodied adults and prioritize care for the most vulnerable.

Under this “block grant” approach, states can agree to receive a lump-sum payment to finance care for adults who became eligible for Medicaid when the 2010 health-care law expanded it. In return, they can make a range of changes to the program, some of which weren’t allowed previously. These changes could include:

  • Restricting drugs Medicaid covers by setting up a list of covered medications.
  • Capping total enrollment.
  • Charging premiums or co-pays that total no more than 5 percent of an enrollee’s income.
  • Limiting the program only to people with particular medical diagnoses.

The administration has branded the initiative “Healthy Adult Opportunity,” billing it as a way for states to run Medicaid as they see fit and ensure the program prioritizes care for the most vulnerable, such as children, pregnant women or the disabled.

Nick Bagley, a health law professor at the University of Michigan:

“Officials portrayed it as a ‘groundbreaking opportunity’ for states to upgrade care, limit the program’s strain on their budgets, and gain more freedom to shape Medicaid to local needs,” my Washington Post colleague Amy Goldstein explains.

The new guidance — which the Centers for Medicare and Medicaid Services explained in a letter sent yesterday to every state Medicaid director — is a “groundbreaking new policy that holds the potential to transform the Medicaid program,” CMS Administrator Seema Verma told an invited crowd of health-care stakeholders at the Hubert H. Humphrey Building in Washington.

“Our administration is committed to protecting and improving the lives of Medicaid recipients,” Verma said.

Yet opponents say it would do the opposite by limiting opportunities for people to sign up for Medicaid. This population, while slightly better-off than traditional Medicaid enrollees, is less likely to have access to workplace coverage enjoyed by higher-income Americans.

A doctor asked Vice President Pence in Iowa (which holds its caucuses in the presidential race Monday ) about the Medicaid announcement, per this tweet that went viral:

“It really is going to harm the adults in the expansion population,” said Jerry Vitti, founder of Healthcare Financial, a company that connects people with public benefit programs.

“They are really going after the Obamacare expansion population as they have done throughout the administration,” Vitti told me. “There’s a line between the AHCA failure years ago and going for the hatchet now.”

Vitti was referring to the American Health Care Act, a bill to replace Obamacare passed by the GOP-majority House back in 2017. That measure, and a Senate bill like it, would have shifted the Medicaid program to a system where states got limited funding through either block grants or per capita caps.

At the time, Republicans got huge pushback from health-care advocates and Democrats who said it would hurt Medicaid enrollees — and they ultimately abandoned the whole repeal-and-replace effort.

There was a similar reaction yesterday, as Democrats portrayed the move as more evidence the administration is trying to undermine the Affordable Care Act and constrict Medicaid.

Oregon Gov. Kate Brown (D):

Sen. Martin Heinrich (D-N.M.):

“Even after people across the country spoke out and pressed Congress to reject President Trump’s plan to gut Medicaid … he’s still charging forward with harmful policies that will hurt the many families who rely on Medicaid,” said Sen. Patty Murray (Wash.), the ranking Democrat on the Senate Health, Education, Labor and Pensions Committee. 

“After being stopped in the Congress from repealing the health care law and destroying the lifeline of Medicaid, the Trump administration has decided to ignore the law and steal lifesaving health care from seniors and families anyway,” House Speaker Nancy Pelosi (D-Calif.) said in a statement.

The new rules are likely to spark court battles, just like the administration’s previous guidance allowing states to incorporate work or volunteering requirements into their Medicaid programs.

And the administration could find it even harder to defend these block grants. Christen Linke Young, a health fellow at the Brookings Institution, told me that changes to payment structures aren't among the things the federal government can let states experiment with, under the Social Security Act. Beyond that, the administration may also need to justify to courts why a block grant would further the objectives of the Medicaid program.

Administration officials seemed aware of how their announcement might be received. They notably avoided using the polarizing term “block grants.” Azar stressed the approach “isn’t mandatory or top-down reform,” noting that states could take or leave it.

And while states could decide to restrict enrollment, they couldn't slash the benefits Medicaid plans cover. Plans will still have to comply with the ACA's requirements to cover 10 services deemed “essential,” such as maternity and emergency-room care. 

It could be risky for states to ask for block grants, because that could result in less federal funds. But it would also help states lighten their own spending load. Medicaid currently consumes 16 percent of all state spending, according to the Medicaid and CHIP Payment and Access Commission.


AHH: The new commissioner of the Food and Drug Administration, Stephen Hahn, defended the Trump administration’s partial e-cigarette ban but also pledged to take tougher action as needed, our Post colleague Laurie McGinley reports. 

The ban, which is set to take effect on Feb. 6., will ban sales of most flavored e-cigarette products but does not bar the sales of menthol or tobacco-flavored pods. Critics have argued young people will just switch products. 

“Hahn, who was confirmed in mid-December, disagreed, saying in an interview that the sales restrictions will target the products most popular with young people. But the FDA will closely monitor the situation, and if minors do switch to menthol-flavored vapes or other e-cigarette products, the agency will take further action to curb vaping, he said,” Laurie writes. 

“The good thing about this policy is we have the ability without jumping through a lot of hoops to change our enforcement prioritization based on the data we are getting in,” Hahn told Laurie. 

OOF: A grand jury is deliberating in the criminal investigation of at least 11 deaths being linked to improper insulin injections at a West Virginia Veterans Affairs hospital, our Post colleagues Lisa Rein and Matt Zapotosky report. 

Investigators believe a former nursing assistant at the hospital “gave the elderly veterans, most of whom were not diabetic, multiple, unauthorized injections of insulin that led to their deaths of severe hypoglycemia, or low blood sugar,” they write. “The deaths, which are being investigated as homicides, are another potential embarrassment for leaders of the sprawling and long-troubled VA system, which President Trump promised to reform. Reverberations from the case have reached the highest levels of the Justice Department.” 

Veterans Affairs Secretary Robert Wilkie and Sen. Joe Manchin III (D-W.Va.) have publicly criticized how long it took hospital leaders to determine what happened after initially saying the deaths were due to natural causes. In an email to The Post, Manchin said: “A year and a half after these deaths, no one has been charged with a crime and we have yet to learn the details that led to these horrible deaths … Family members and Veterans across West Virginia deserve answers.”

The World Health Organization declared the coronavirus outbreak a "public health emergency" on Jan. 30. (Reuters)

OUCH: The World Health Organization declared the coronavirus outbreak a “public health emergency,” a designation it has given to just six other outbreaks. The declaration sets off a global coordination to curb the spread of the virus that has surpassed the number of people infected with the SARS outbreak in 2002-2003. 

In the United States, federal health officials confirmed a sixth case, which also marked the first time there was a person-to-person transmission of the virus in the United States. 

“The patient is a Chicago resident who was infected after being in close contact with his wife, who had traveled to the central Chinese city of Wuhan. The Chicago woman was the second confirmed case in the United States,” our Post colleague Lena H. Sun reports. There are now five countries — Germany, Japan, Vietnam, China and the United States — that have had human-to-human transmission, as has the self-governing island of Taiwan.

Meanwhile, scientists are working at record pace to get a vaccine ready to work against the coronavirus. Scientists at the National Institutes of Health are working with a Massachusetts biotech company, Moderna, and hope to have a vaccine ready for human testing by April, our Post colleague Carolyn Y. Johnson reports. 

— Rep. Ami Bera (D-Calif.), chairman of the House Foreign Affairs subcommittee on Asia, the Pacific and nonproliferation, announced that his panel will hold a hearing next week on the coronavirus outbreak.

Bera has invited witnesses from the Centers for Disease Control and Prevention and the State Department to brief lawmakers on steps they’re taking to limit the spread of the virus abroad and in the United States. 

“While the threat of the coronavirus is relatively low in the United States at this time, we must be vigilant and prepared,” Bera said in a statement. “I look forward to hearing from our expert witnesses on ways in which we can plan and respond to this virus. Congress needs to ensure the administration has the tools it needs to respond to and limit the outbreak. As a doctor and public health expert, I know that we must take every step necessary to ensure the health and safety of every American."


President Trump commented on the global coronavirus outbreak at a USMCA celebration speech in Michigan on Jan. 30. (The Washington Post)

— Trump is under increasing pressure to respond to the coronavirus outbreak with a coordinated federal response, especially given concerns over the economic consequences of a global health crisis in an election year, our Post colleagues David Nakamura, Yasmeen Abutaleb and Josh Dawsey report. 

So far, the administration has tried to project confidence and competence, one strategy to push back against criticism from Democrats. 

“Yet the vast uncertainty over the contagiousness and lethality of the coronavirus, which originated in the Chinese city of Wuhan, and the complicated geopolitics given Beijing’s poor record of transparency in handling infectious diseases, have increased the stakes for the Trump administration,” our colleagues write. “So has the president’s interest in an election year of restoring more normal trade relations with China after years of tariff battles.” 


— The Virginia House and Senate have approved legislation to undo GOP-backed abortion restrictions. 

On Wednesday, the state's Senate passed a bill undoing requirements for women to undergo a 24-hour waiting period, an ultrasound and counseling before getting an abortion. The bill would also roll back a requirement for an abortion to be performed by a physician, opening the door to nurse practitioners and physician assistants to perform them. The legislation is backed by Democratic Gov. Ralph Northam.


— Sen. Bernie Sanders (I-Vt.) is considering dozens of executive orders he'd issue if elected president, including expanding access to cheaper prescription drugs and reversing the Trump administration's rules blocking abortion providers from the family planning program.

The list of potential executive orders, which the senator is still reviewing, include unilaterally allowing the importation of prescription drugs from Canada, directing the Justice Department to legalize marijuana, and reversing rules blocking federal funding to groups that provide abortion counseling, our Post colleagues Jeff Stein and Sean Sullivan write. 

“The unilateral actions considered by Sanders’s campaign are likely to be fiercely opposed by conservatives and even moderate liberals,” they write. “Sanders could face criticism for moving to take more power away from the legislative branch amid ever-expanding executive authority, although he has been a vocal proponent of giving Congress more power over the country’s wars and military interventions. Many Democrats and some Republicans have criticized Trump for the numerous executive orders he signed in the early part of his presidency.” 

— And here are a few more good reads:






Coming Up

  • The House Foreign Affairs Committee holds a hearing on “Unique Challenges Women Face in Global Health” on Feb. 5.
  • The House Veterans' Affairs Subcommittee on Oversight and Investigations holds a hearing on how the Veterans Affairs Department supports survivors of military sexual trauma on Feb. 5.
  • The House Ways and Means Subcommittee on Health holds a hearing on “Overcoming Pharmaceutical Barriers” on Feb. 5.


President Trump criticized Democrats over impeachment efforts during a Des Moines rally on Jan. 30. (The Washington Post)