Red state governor races could bring Medicaid expansion to millions Presented by

Editor's Note: This edition of Free Morning Pulse is published weekdays at 10 a.m. POLITICO Pro Health Care subscribers hold exclusive early access to the newsletter each morning at 6 a.m. To learn more about POLITICO Pro's comprehensive policy intelligence coverage, policy tools and services, click here.

ACA open enrollment is in two days. The midterms are in seven days.

But first: A closer look at the fate of Medicaid expansion.

RED STATE GOVERNOR RACES COULD BRING MEDICAID EXPANSION TO MILLIONS — There are at least half a dozen states next week where a Democratic supporter of Medicaid expansion has a fighting chance of replacing a Republican who opposes it, POLITICO's Alice Miranda Ollstein reports.

— The states to watch: The outcome of races in Florida, Georgia, Kansas, Oklahoma, South Dakota and Wisconsin could flip the status of those holdout states that have so far refused Obamacare's Medicaid expansion — though Republican legislatures are not likely to make it easy.

Meanwhile, four more states deep in Trump country — Idaho, Utah, Nebraska and Montana — have Medicaid expansion questions on their ballot. Maine voters also will choose between a Republican who has vowed to continue departing Gov. Paul LePage’s crusade to block its implementation and a Democrat who says she will immediately move expansion forward.

— What's at stake: The “blue wave” many experts are predicting could drive the biggest enrollment spike in Medicaid since the early years of Obamacare’s implementation.

It also could mark a sharp rejection of the Trump administration and congressional Republicans’ efforts to roll back the Affordable Care Act.

— What Stacey Abrams is telling voters in Georgia: The Democratic candidate for governor, who's made health care a central focus of her campaign, brought that message to a church in the closing days of the race.

“When we help the least of these, we help everyone,” Abrams said, pointing her finger in the air, as audience members swayed in their chairs, raised their hands and called out in assent. “Republicans are too mean and too cheap to take the money. But we know that health care is not a privilege in America. Health care is a right in America, and that is why I’m running.” Keep reading: More for Pros.

— What the WSJ editorial board is saying: Reject 'ObamaCare’s Red State Trap.' The board is arguing that voters should reject Medicaid expansion in the four states considering such ballot initiatives next week.

"Every state that has expanded Medicaid has blown the budget by spending more money on more people," the board writes. "The cost overruns are more than double on average." More.

A message from PhRMA: Today, there are several promising vaccine candidates in stage three clinical trials. These trials have tens of thousands of participants, from every walk of life. From development to robust clinical trials, and throughout manufacturing, these vaccine candidates follow the same rigorous process of other vaccines that have saved millions of lives. More.

TRUMP'S NEXT TARGET ON DRUG PRICING: MEDICARE PART D? — HHS on Friday submitted a proposed rule to OMB on the Medicare outpatient drug program, just days after proposing an overhaul of how Medicare pays for physician-administered drugs in Part B, POLITICO's Sarah Karlin-Smith reports.

The proposed rule, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out of Pocket Costs ," is marked as economically significant and is generating a lot of buzz downtown, Sarah writes.

— What's in the rule? One clue could be Trump’s drug pricing blueprint, which called for a simultaneous five-part plan to modernize Part D and was first described in the White House’s 2019 budget.

That plan would (1) establish an out-of-pocket maximum for patient spending in Part D; (2) let Medicare Part D plans cover just one drug per category or class in their formularies, instead of two; (3) increase health plans' liability for drug costs in the catastrophic phase of Part D and (4) simultaneously reduce taxpayers' portion. Another major component (5) would require Part D plans to share at least part of drug companies' rebates with patients at the point of sale.

— Another question: Could HHS really make so many changes to Part D without Congress butting in?

That's unlikely, Kim Monk of Capital Alpha Partners suggested in a note to clients, given the implementation challenges. (Monk also notes the failure of the Obama administration's own drug pricing reforms.)

“The administration might peel off one or more components, like capping out-of-pocket beneficiary costs, to make a populist splash ahead of the election," Monk wrote.

THIS IS PULSE — Where your author is going to check out this exhibit of gun ownership and its effects curated by TIME (time permitting).

PULSE is in the capable hands of Rachel Roubein for tomorrow's issue; find RR at [email protected]. Your regular author will be back on Thursday; flag him at [email protected].

Election Day is almost here. Have you made your POLITICO Playbook Election Challenge picks yet? Don’t miss your chance to compete against the nation’s top political minds in the POLITICO Playbook Election Challenge by correctly picking the winning candidates in some of the most competitive House, Senate and gubernatorial races in the country . Win awesome prizes and eternal bragging rights. The contest closes at 6 a.m. on Nov. 6. Sign up today. Visit politico.com/playbookelectionchallenge to play.

POLITICO Pro announces dedicated California coverage: On Nov. 7, there will be a new authority on California politics and policy. Just in time to help policy professionals and business leaders in the Golden State navigate the twists and turns of a new administration, POLITICO California Pro is the only tool that will arm you with a team of state-level experts. Learn more.

Senate Democrats urge FDA to immediately remove 'kid-appealing' e-cigs from the market. Fifteen senators on Monday called on the agency to yank some flavored products that have proven to appeal to teenagers, warning that they are "unconvinced that voluntary, self-policing by e-cigarette companies will be sufficient."

FDA Commissioner Scott Gottlieb last month threatened to pull some flavored e-cigarettes from the market, giving companies 60 days to come up with plans to combat teen use. But the Democrats are pushing for even more aggressive action.

"As a result of its inaction, FDA has placed a cohort of teens at risk for a lifelong addiction, as well as put them at increased risk for using cigarettes," the senators wrote, led by Sens. Ron Wyden, Dick Durbin and Patty Murray. "The FDA needs to take action, and fast." Read letter.

Health care tops priorities for freelance workers. Forty percent of independent contractors, part-time employees and other freelancers named health care as the most important issue facing the country, according to a Fiverr/VIGA survey released today.

The poll of more than 1,000 U.S. freelancers, timed to gauge voter preferences in the growing “gig economy," found health topped the list for both Republicans (32 percent) and Democrats (47 percent).

… Freelancers were more likely than the general public to support Obamacare (54 percent, with a sharp partisan divide of support from 74 percent of Democrats and just 18 percent of Republicans). Seventy-five percent of respondents agreed the federal government should increase spending for Medicaid. And 59 percent expressed support for a single-payer health system.

California: Increase in dubious 'medical' vaccine exemptions. Health officials are frustrated by the increase in the number of parents seeking medical exemptions and doubt many of the claims, according to an American Academy of Pediatrics study.

Researchers conducted the interviews in response to a 2015 California law eliminating the “personal belief” exemption seen as too expansive. State officials found the rates of medical exemptions — which are supposed to be limited to health issues attested to by a physician — increased by 250 percent in 2017-2018.

… Health officials told the study authors that sometimes the doctors who signed the exemptions didn’t appear to treat children or charged a fee, and they were frustrated by the lack of authority they had under the law.

Lobbying groups set record: $111 million to fight California dialysis measure. That's the most ever spent on a state referendum, surpassing the $110 million that pharma spent two years ago to beat back a measure to curb state drug spending.

This year's spending was led by two for-profit dialysis companies, DaVita and Fresenius. The ballot measure would cap profits for dialysis clinics. More from Pro's Victoria Colliver here.

By Rachel Roubein

In another example of how health care is playing out in the midterms, GOP Rep. Martha McSally, vying for an Arizona Senate seat, said she was “getting my ass kicked” for her vote to repeal and replace Obamacare, alleging “it’s being misconstrued by the Democrats,” The Arizona Republic reports. More.

According to The Washington Post, the NIH is temporarily pausing testing an experimental stem cell therapy for heart failure “out of an abundance of caution” -- and after recent news of allegations of fabricated data from researcher Piero Anversa. More.

The New York Times profiles Anversa, who says he did nothing wrong and a “rogue colleague” altered data. More.

Writing in Health Affairs, David Anderson details the factors that could contribute to sign ups on the Obamacare exchanges set to open for business this week More.

Gun-related injuries are sending about 8,300 children to the emergency room each year, the Associated Press reports, citing a new study published in JAMA Pediatrics. More.

Follow us on Twitter Joanne Kenen @joannekenen



Adriel Bettelheim @abettel



Jason Millman @jasonmillman



Lauren Morello @lmorello_dc



Sara Smith @sarasmarley



Dan Diamond @ddiamond



Zach Brennan @ZacharyBrennan



Adam Cancryn @adamcancryn



Tucker Doherty @tucker_doherty



Brianna Ehley @briannaehley



Dan Goldberg @dancgoldberg



David Lim @davidalim



Susannah Luthi @SusannahLuthi



Alice Miranda Ollstein @aliceollstein



Sarah Owermohle @owermohle



Carmen Paun @carmenpaun



Mohana Ravindranath @ravindranize



Rachel Roubein @rachel_roubein



Darius Tahir @dariustahir