with Alexandra Ellerbeck

Democrats have spent the 2020 campaign – now in its final weeks – hyper-focused on the Republican-backed legal threat that could undo Obamacare's protections for patients with preexisting medical conditions. 

“They’re coming for you,” Sen. Kamala Harris (D-Calif.) said at Wednesday's vice presidential debate, referring to the high-profile lawsuit brought by Republican-led states and supported by the Trump administration that could result in the entire Affordable Care Act being struck down.

But the health-care law's Medicaid expansion played a bigger role in extending health coverage – and is now enrollment is surging amid the coronavirus pandemic. Coverage for Americans enrolled in this program is also threatened by the lawsuit, a detail getting far less attention on the campaign trail. 

Nearly 4 million more people enrolled in the health insurance program for the low income between February and June. 

Medicaid enrollment grew 6.2 percent over the spring and early summer, the Centers for Medicare and Medicaid Services reported this week. 

It’s an abrupt reversal of the direction enrollment had previously been moving as it trended downward over the last several years. Yet the surge isn’t terribly surprising, given the nation’s widespread job losses during the first wave of the pandemic and subsequent lockdowns. More than one in five Americans – about 75 million – now rely on Medicaid or the Children’s Health Insurance Program for their coverage.

Many states have seen double-digit percentage increases in their Medicaid enrollment during the pandemic. 

In Nebraska, enrollment climbed from fewer than 644,000 in February to about 731,000 through August, my colleague Amy Goldstein reported.

“That 13.5 percent increase places Nevada among at least three states, along with Kentucky and Minnesota, where the cadre of people on Medicaid has spiked that much,” Amy wrote. “But increases are widespread: Caseloads had risen on average 8.4 percent through July in 30 states for which researchers have enrollment information. And in 14 states with enrollment data through August, the average is 10 percent.”

Around 15 million of Medicaid enrollees nationwide are eligible for the program because of the Affordable Care Act, which gave states dollars to expand their programs to earners up to 133 percent of the federal poverty level.

The outcome of the ACA lawsuit could affect their coverage. 

Just days after the election, the court is scheduled to hear a lawsuit challenging the ACA’s constitutionality. The confirmation of conservative nominee Amy Coney Barrett – a process the Senate is embarking upon in 10 days – could increase the court’s chances of knocking down some or all of the 2010 health care law.

Some ACA advocates have noted the much broader impact of tossing out the health care law, beyond those with preexisting conditions.

Charles Gaba, an ACA analyst, has been tweeting out how many people in each state could get kicked off Medicaid expansion:

It’s understandable why Democrats are focusing on the preexisting condition protections over Medicaid expansion.

Preexisting condition protections are especially popular, with 72 percent of Americans saying it's “very important” they stay in place.

And were the court to toss out any part of the ACA, the preexisting condition protections would be the first to go. It’s harder to imagine the court ruling that the entire law including its Medicaid expansion must fall. 

Still, rarely does presidential nominee Joe Biden speak without mentioning preexisting conditions, and the phrase shows up constantly in Democrats’ campaign ads and speeches.

“We’ll show America which party stands with protecting Americans’ health care and protections for preexisting conditions and which party opposes it, it’s plain and simple,” Senate Minority Leader Chuck Schumer said on the Senate floor last week, after Republicans blocked him from advancing a bill that would have prevented the Trump administration from asking the court to knock down the law.

Even if Democrats had succeeded in passing their bill, which fell short of the 60 votes needed to advance it, the lawsuit wouldn’t go away. That’s because it’s GOP-led states bringing the lawsuit, not the administration, as University of Michigan professor Nick Bagley noted.

The impact of Medicaid expansion is steadily growing, as more states embrace it.

dozen states still refuse to expand Medicaid, but their ranks have been declining over the past few years.

Nebraska was one of three states in 2018 to approve Medicaid expansion through ballot initiatives. It kicked off enrollment on Oct. 1, and is expected to add 100,000 people to the program’s rolls. Voters in two more states – Oklahoma and Missouri – also passed ballot initiatives over the summer to expand it.

Ahh, oof and ouch

AHH: Trump has repeatedly downplayed the coronavirus since his release from the hospital.

Trump tweeted on Monday, while still in the hospital, “Feeling really good! Don’t be afraid of Covid.” Since his discharge from Walter Reed later that evening, he has doubled down on the message, repeatedly saying he feels better than ever and boasting about the possibility that he might be immune from the virus.

“I think I'm better, to a point where I'd love to do a rally tonight,” Trump said in an interview with Maria Bartiromo on Fox Business on Thursday. The president joked he was a “perfect physical specimen.”

Some who have lost loved ones to the virus have found the president downplaying it hurtful.

Fitness trainer Amanda Kloots whose husband, Broadway actor Nick Cordero, passed away from the coronavirus:

Trump also dismissed concerns that he could still be contagious from the virus. He insisted he will not debate Biden at a townhall event next Thursday after the Commission on Presidential Debates announced that it would be virtual out of concern over the coronavirus, including worries that the president could be infectious. The Trump campaign has proposed delaying the debate in order to hold it in person. 

Not all Republicans are on board with Trump’s message about the virus. Senate Majority Leader Mitch McConnell (R-Ky) said Thursday that he has avoided the White House for months because of concerns that the administration was not following public health protocols.

OOF: The antibody treatment Trump received relied on testing with fetal tissues.

Regeron’s experimental antibody cocktail was developing using a mixture of two antibodies from a genetically modified mouse and the ovary cells of a hamster. But it was tested on a fetal tissue stem cell line, a practice that his administration has clamped down on, The Post’s Amy Golstein reports.

Researchers tested the effectiveness of one of the antibodies in the therapy using a cell line derived from the kidney tissue of a fetus aborted in the Netherlands in the 1970s. The tissue line was adapted at Stanford in the 1980s and is widely used in biomedical research. It’s old enough that it falls outside of restrictions on federal funding of fetal tissue researched imposed by the Trump administration last year.

Several vaccines being developed to combat the coronavirus also use cells derived from fetal tissue, causing controversy among Catholic leaders and those opposed to abortion. While the Catholic Church has pushed for the medical system to end the use of fetal tissue, the Vatican has held that people can receive vaccines developed using historical cell lines in the absence of alternatives. 

OUCH: Democrats move to create a commission that could rule on the president’s fitness for office.

House Speaker Nancy Pelosi (D-Calif.) and Rep. Jamie B. Raskin (D-Md.) announced that they intend to introduce legislation on Friday that would create a panel called the Commission on Presidential Capacity to Discharge the Powers and Duties of Office, The Post’s Felicia Sonmez reports.

Trump's doctors have said the president is symptom-free after returning home from the hospital on Monday. He spent three nights there while being treated for a case of covid-19.

Yet the Democrats say such a body is called for in the 25th Amendment to the U.S. Constitution, which outlines procedures for the removal of a sitting president from office and the succession by the vice president if the nation’s leader dies or becomes incapacitated. 

The 25th amendment says that the vice president and a majority of principal officers of the executive departments “or of such other body as Congress may by law provide” can transmit to Congress “their written declaration that the president is unable to discharge the powers and duties of his office.”

“President Trump’s four-day hospitalization at Walter Reed National Military Medical Center after contracting the novel coronavirus forced the administration to answer questions about the 25th Amendment and succession,” Sonmez writes. 

Administration officials said that Trump remained on the job during his hospitalization and that there were no plans for Pence to assume temporary authority.

Trump's health

Walter Reed staff were required to sign nondisclosure agreements during the president’s 2019 medical visit.

The request for nondisclosure agreements rankled some personnel who said that they already took seriously their commitments of confidentiality. In addition to a professional oath to protect patient privacy, staff members who care for the president have top-secret clearance, The Post’s Carol D. Leonnig, Shane Harris, Ashley Parker and Lenny Bernstein report.

Reporters have questioned whether Trump’s November 2019 visit to the hospital was the ‘routine checkup’ that the White House has claimed.

“There were multiple signs that the visit was hastily arranged and did not follow the typical protocol for a planned presidential stop,” Leonning, Harris, Parker and Berstein write.

It’s uncertain whether staff who cared for Trump during his recent hospitalization for covid-19 were also asked to sign non-disclosure agreements. The White House has come under fire for a lack of transparency around Trump’s health, including a refusal say whether scans of the president’s lungs showed any damage. The White House has also refused to release the date of Trump’s most recent negative coronavirus test.

Less than a month to election

Health officials are scrambling to get drug-discount cards to seniors by election day. 

Health officials were caught off guard when Trump promised two weeks ago that he would deliver $200 cards to help Medicare beneficiaries pay for their drug costs. Now, they are working quickly to try to get the cards out before the election, Politico’s Dan Diamond reports.

“The administration is seeking to finalize the plan as soon as Friday and send letters to 39 million Medicare beneficiaries next week, informing seniors of Trump's new effort to lower their drug costs, although many seniors would not receive the actual cards until after the election,” Dan writes.

The White House has justified the $8 billion program as a “test” of whether the cards encourage beneficiaries to take their medicine more regularly, but critics have said that the proposal, which lacks a control group, is poorly designed as an experiment. Democrats have also raised questions about the timing of the proposal, casting it as a last-minute election gimmick.

The plan is being driven by White House chief of staff Mark Meadows and Centers for Medicare and Medicaid Services Administrator Seema Verma, who has pushed Medicare officials to finalize it before the Nov. 3 election.

“The plan to lower seniors' drug costs comes as administration officials grapple with Trump's falling support among older Americans, a significant threat to his re-election,” Dan writes. “Trump is currently lagging challenger Joe Biden by as much as 27 points in recent polls among Americans ages 65 and older, a major reversal from the 2016 campaign.”

Trump made another pitch to seniors on Twitter on Thursday.

“We're taking care of our seniors,” Trump said. “For this one thing, you are vulnerable. So am I," he added. Trump also promised that seniors would get free medications to combat covid-19.

Eight our of 10 Americans who have died from the coronavirus have been over the age of 65, and concerns over the administration's handling of the pandemic have cut into the president's support among this age group. 

Elsewhere in healthcare

  • The Trump administration has reversed course multiple times this week over an economic stimulus package. After urging White House and Congressional leaders to reach a compromise, Trump abruptly shifted course on Tuesday and called off negotiations with House Speaker Nancy Pelosi. On Thursday, the White House said that talks were back on, but it is unclear if the administration is pursuing a comprehensive deal or looking for a narrow package focused on stimulus checks, an airline bailout and small-business relief, The Post’s Erica Werner and Jeff Stein report.
  • A new survey from the Kaiser Family Foundation finds that the average annual health insurance premium for a family now tops $20,000, with workers paying over $5,000 on average. Deductibles have more than doubled since 2010, the New York Times’s Reed Abelson reports.
  • In an “unusual and unsigned” disposition, the Supreme Court put a hold on a Trump administration request to reimpose requirements that women seeking abortion visit a clinic or doctors office. The requirements were suspended by a Maryland federal judge during the pandemic, The Post’s Robert Barnes reports.

Sugar rush