| Welcome to Overnight Health Care! Monday is almost over, Congress is back in session, more insurance rate hikes were announced, and CMS kept us busy today with Medicaid news. We'll start in Kansas, where the Trump administration showed there is such a thing as too much flexibility in Medicaid requirements. Medicaid lifetime limits a bridge too far The Trump administration on Monday rejected Kansas's request to impose a three-year lifetime limit on Medicaid benefits. Why it matters: The Trump administration is drawing a line in the sand, saying that while work requirements in Medicaid are permissible, the extra conservative step of time limits on coverage is not. CMS Administrator Seema Verma explained her reasoning by saying the distinction is that people might need Medicaid again down the road, something that could be banned under a lifetime limit. "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them," Verma said. Read more here. But it's full speed ahead for work requirements New Hampshire on Monday became the fourth state to gain approval to impose work requirements as a requirement of Medicaid coverage. Under the newly approved plan, adults aged 19-64 will have to participate in 100 hours a month of "community engagement requirements," such as employment, education, job skills training or community service. If people don't meet the requirements, they will have their benefits suspended. Other states: Work requirements in Indiana, Arkansas and Kentucky have already been approved, and there are now seven states with pending applications, after Ohio submitted an application last week. The administration has yet to approve work requirements for states that have not expanded Medicaid. Read more here. Premium hikes putting ObamaCare back in the spotlight The newest round of insurance rate requests has Democrats on the offensive. Insurers in Maryland and Virginia have submitted their initial requests for premiums in the 2019 individual marketplace. And for the most part, they are pretty steep. Virginia: Two plans will see double-digit hikes. Cigna is proposing an average premium increase of 15 percent, and Group Hospitalization and Medical Services, operating as CareFirst BlueCross BlueShield, is asking for an average increase of 64.3 percent. Read more on Virginia here. Maryland: CareFirst BlueCross BlueShield, which is the largest insurer in the Mid-Atlantic, has asked state regulators for an average 26.4 percent increase. But if you're in a PPO, you could see a 91.4 percent increase. Kaiser Permanente requested a 37.4 percent increase on its HMO plans. The average rate increase was 30 percent. Why the big spike? The risk pool is getting increasingly older and sicker. Maryland Insurance Commissioner Al Redmer said the state's market is in a "death spiral." Premiums are rising because people are sicker, but the higher the premiums rise, the more the healthy people will drop coverage. And the Trump factor? The Trump administration is not helping, and many insurers cite policies promoted by the administration that help make the coverage pool more old and sick. The repeal of the individual mandate penalty, plus making it easier for insurers to sell cheap skimpy plans, all will contribute to removing the healthy people from the marketplace. Read more on Maryland here. Opioids update Walmart and Sam's Club pharmacies will soon limit the supply of first-time opioid prescriptions for acute pain to seven days. They're not the first to enact such a restriction. The effort comes as an increasing number of states and entities in the health care industry have placed limits on similar prescriptions. The opposition: The American Medical Association isn't a fan of such restrictions. The powerful group of physicians has argued that the limits are arbitrary and also impede a doctor's ability to individualize care for each patient. On the other hand: Supporters of the proposals have countered that such limits are important to stem overprescribing, lower the volume of painkillers available to be illegally diverted and decrease the potential for addiction. Read more here. Up tomorrow: Pharmaceutical distributors in the hot seat. They'll be testifying before a House Energy and Commerce subcommittee in a hearing billed as examining concerns about opioid distribution and diversion. Background: Cities, counties, tribes and other health care stakeholders have filed hundreds of lawsuits against manufacturers and distributors. They allege the companies didn't report suspicious quantities of opioids, and investigations have uncovered instances where millions of pills have gone to towns with very small populations. - In statements, the Healthcare Distribution Alliance has pushed back: "Given our role, the idea that distributors are responsible for the number of opioid prescriptions written defies common sense and lacks understanding of how the pharmaceutical supply chain actually works and is regulated. Those bringing lawsuits would be better served addressing the root causes, rather than trying to redirect blame through litigation."
What we're reading Trump calls on Congress to pull back $15 billion in spending, including on Children's Health Insurance Program. (The Washington Post) Drug plans drop after Trump official targets pharmacy-benefit managers ahead of speech (Bloomberg) Just who gets those big drug rebates? (CNNMoney) State by state Gubernatorial hopefuls look to health care for election edge (California Healthline) Many states don't restrict pot possession by childcare workers (Reuters) Hepatitis C cure eludes patients as states struggle with costs (NBC News) | 
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