In November, Montana voters will get to choose whether to increase taxes on all tobacco products to fund Medicaid expansion and other health programs. Advocates of the "Healthy Montana Initiative" argue that smoking contributes to a range of illnesses, so the industry producing them should help bear the burden of increased health-care costs.

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Under the Affordable Care Act, states are allowed to expand their Medicaid programs to cover people earning up to 138 percent of the federal poverty level, or about $16,000 a year. The federal government paid 100 percent of expansion costs through 2016. Since then, federal funding has been tapering off and by 2020 the states will have to pay 10 percent of the cost of any Medicaid expansion.

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Montana didn't expand Medicaid until 2015 and then, to make the growth palatable to conservatives, did it as a sort of trial run for several years, allowing the expansion to sunset in 2019. If the program is not renewed, close to 100,000 Montanans are at risk of losing their coverage. For perspective, there are only 1 million people in the entire state.

Advocates of the ballot initiative -- which would raise the taxes on a pack of cigarettes by $2 and 33 percent on other tobacco products like e-cigarettes -- say that the Medicaid expansion has helped provide health coverage to many Montanans who otherwise would not have it.

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"It's one of the best things to happen to Montanans and the only way to sustain that is through a source of revenue," said Jonathan Schleifer, executive director of the Fairness Project, which is working to "improve the economic lives of everyday Americans" in states by raising the minimum wage, increasing paid sick leave and expanding Medicaid.

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Earlier this year, with no sign that the state legislature would act to reauthorize the Medicaid expansion, a number of health organizations, including the American Heart Association, the American Cancer Society Cancer Action Network, the Montana Hospital Association, as well as providers across the state, collected enough signatures to secure a ballot initiative known as I-185 that allows voters to determine the future of the Medicaid program.

But the groups' decision to make the tobacco industry pay for permanent expansion put them up against a powerful adversary. The initiative is expected to generate more than $74 million each year by 2023, the Associated Press reported in April.

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A political action committee created to launch an opposition campaign against the ballot initiative, called Montanans Against Tax Hikes, is almost entirely funded by tobacco companies like Altria, Inc., which is the parent company for Phillip Morris. In its most recent state campaign finance filing, which covers the period from July 28 to August 27, Altria had given the PAC more than $7 million.

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Montanans Against Tax Hikes doesn't have its own Internet presence, and the treasurer on its campaign filings is Chuck Denowh, a GOP consultant in the state. The Health 202 couldn't reach him for comment but, in August, Denowh issued a statement to Montana Public Radio after refusing a reporter's request for an interview about the campaign:

"I-185 is a massive new tax increase that permanently expands Medicaid but does not allocate enough money to pay for it, leaving all Montanans on the hook for tens of million of dollars per year. Montanans Against Tax Hikes plans to run a campaign and make sure voters understand why they should reject I-185."

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Advocates of the ballot initiative say the tobacco industry is using a well-worn playbook to mislead voters. The tax is only on those who use tobacco products. And a study conducted by the Bureau of Business and Economic Research, a research department within the University of Montana, examining the Medicaid expansion's economic impact on Montana found it ultimately saved the state money.

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"While the state pays a nominal amount for these benefits, the costs to the state budget are more than offset by the savings created by Medicaid expansion and by the revenues associated with increased economic activity," the authors of the study wrote.

Healthy Montana, the group created to organize the campaign to keep Medicaid expansion, needs to convince voters of that against an onslaught of critical messaging. So far, the group has raised $2 million -- almost five times less than the tobacco-backed group.

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Amanda Cahill, director of government relations for Montana's American Heart Association chapter, said they "thought long and hard" about the challenge of taking on the tobacco industry.

"It’s intimidating but we expected them to come out with a lot of money," Cahill said. "So I think we’re probably seeing a lot of what we expected. It doesn’t make for an easy campaign, but we think it’s worth it."

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Those supporting the initiative have seen some successes already. They beat back a tobacco industry-funded lawsuit to change the language on the measure. On Monday, Montana's campaign regulator ruled that two tobacco companies, Altria and RAI, parent company of RJ Reynolds Tobacco, had violated some state campaign finance laws.

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With one in 10 Montanans benefiting from Montana's Medicaid expansion, the issue is personal for many. It's an issue, Schleifer said, that drew people from across the political spectrum -- "those wearing MAGA hats and those people wearing Bernie Sanders t-shirts" -- to sign the petition to get Medicaid expansion on the November ballot.

"In Montana, they’ve experienced the benefits," he said, "and saying 'hell no' to having it taken away from them."

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AHH, OOF and OUCH

AHH: Sen. Joe Manchin III (D-W.Va.) is really fired up about the anti-Obamacare lawsuit brought by a number of Republican states, including his own.

In a new ad, the senator points a shotgun at a copy of the Texas lawsuit and blows it away. Manchin, who is in one of the more difficult reelection battles this fall, faces West Virginia Attorney General Patrick Morrisey (R), who is among 20 state attorneys general supporting the lawsuit.

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The lawsuit claims the Affordable Care Act should be ruled unconstitutional because the GOP tax bill eliminated the penalty on the individual mandate, which bringers of the suit argue makes the whole law unconstitutional. Critics argue if the lawsuit is successful then many of the ACA's most popular provisions would also fall, including protections for preexisting conditions. It's an issue Democrats have made central to their midterm campaigns.

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In the ad, Manchin says his opponent is “just dead wrong, and that ain’t gonna happen,” before shooting a copy of the lawsuit.

The spot is reminiscent of a 2010 Manchin ad that showed him shooting a climate change bill.

“I might be a few years older but I’ll still take on anyone that messes with West Virginia,” he says in the ad.

OOF: There are a scarcity of comprehensive addiction training programs available at medical schools across the country. But an effort in the last decade by doctors, medical school students and patients to “legitimize addiction medicine is resulting in blips of change around the country,” the New York Times’s Jan Hoffman reports.

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“A handful of students has begun to specialize in the nascent field, which concentrates on prevention and treatment of addictions and the effect of addictive substances on other medical conditions,” Jan reports. “While most medical schools now offer some education about opioids, only about 15 of 180 American programs teach addiction as including alcohol, tobacco and other drugs, according to Dr. Kevin Kunz, executive vice president of the Addiction Medicine Foundation, which presses for professionalization of the subspecialty.”

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Jan noted there’s also a federal effort to push for further training. In June, lawmakers approved a bill that would reimburse education costs for providers working in addiction-affected areas.

Jan highlights the work being done at Boston Medical Center at Boston University, where addiction training is integrated into four years of study. “I really enjoy working with these patients,” one medicine fellow, Dr. Bradley M. Buchheit said during a training session at the university where students learned about pain patients. “They have often been kicked to the curb by the formal medical system. They don’t trust us. So for them to walk into a room and have a doctor say, ‘It’s great to see you, thank you for coming in,’ is very powerful. And then you can see them get better with treatment. It can be very rewarding work.”

OUCH: Confidential records obtained by ProPublica Illinois reveal details about 99 children who were separated from their parents at the U.S.-Mexico border under the Trump administration’s “zero-tolerance” immigration policy.

According to the records, these children, who were all taken to shelters in Illinois, were younger and some more traumatized by their detention experiences, – some threatened to “harm themselves or others,” Jodi S. Cohen, Melissa Sanchez and Duaa Eldeib report. Seven of the 99 children have yet to be reunited with their families.

“One of them, a 12-year-old boy named Erick — in custody nearly four months after immigration officials took him from his father — became so depressed that he was admitted to a psychiatric hospital for a week, diagnosed with adjustment disorder,” they write. "In June, an 11-year-old boy from Guatemala, housed at a Heartland shelter in suburban Des Plaines, cried inconsolably and said, ‘I want to die here,’ the records show. Employees there told him ‘he needs to live to see his family.’”

Now, a federal class-action lawsuit is calling for the government to pay for the mental-health treatment the separated children will need in the aftermath of the trauma. “The damage inflicted was not something that went away because of the reunification,” Jesse Bless, one of the attorneys who filed the claim told ProPublica Illinois. “We are starting to see signs that there could be long-term effects.”

STATE SCAN

— Michigan on Monday became the latest state to seek federal approval for Medicaid work requirements.

The proposal would require low-income adults who receive Medicaid benefits under the Healthy Michigan Plan that provides expanded Medicaid to work for at least 80 hours a month to remain covered. Any beneficiaries who fail to meet the requirement or who don’t otherwise meet certain exemptions for three months out of the year will lose coverage.

If the waiver is approved, Michigan would be allowed to impose work requirements starting in 2020, The Detroit News reports, a rule which could impact 540,000 able-bodied adults.

HEALTH ON THE HILL

— Add these lawmakers to the list of Democrats publicly opposing Trump’s pick for the Supreme Court: Sens. Jeanne Shaheen (N.H.), Maggie Hassan (N.H.) and Sheldon Whitehouse (R.I.) on Monday joined their colleagues who have said they will vote against Judge Brett M. Kavanaugh, a list that expanded following the nominee’s confirmation hearings last week.

Here’s what they had to say:

"While much of Judge Kavanaugh’s record remains a mystery, what we do know is extremely troubling and dangerously out of step with the American people, particularly on critical issues including executive power, abortion rights and pre-existing conditions," Shaheen said in a statement.

"We need to be clear that Judge Kavanaugh, the people who have promoted him throughout his career and who precleared his nomination, and President Trump could all lead us down a path toward further criminalizing abortion," Hassan wrote in a Medium blog post about her opposition to Kavanaugh.

“The Supreme Court needs to stand alone, tall and independent, and Americans should feel confident their cases will be decided on the merits. ... Judge Kavanaugh has failed to give Americans that assurance, and he will not get my vote," Whitehouse wrote , also on Medium.

OPIOID OPTICS

— New research suggests doctors don’t always give a good reason when they prescribe opioids, NBC News’s Maggie Fox reports.

The research from Harvard Medical School and Rand Corp. found that from 2006 to 2015, doctors gave no explanation for writing an opioid prescription in 29 percent of cases, per the report.

“The findings help support criticism by the Centers for Disease Control and Prevention, the Food and Drug Administration and others that say inappropriate prescribing practices have helped drive the opioid crisis, in which 42,000 people died in 2016 alone,” Maggie writes. The research, based on tens of thousands of medical records, and 31,000 physician surveys that included opioid prescriptions found two-thirds did include a pain diagnosis, with 5 percent of prescriptions written for cancer-related pain.

“At visits with no pain diagnosis recorded, the most common diagnoses were hypertension, hyperlipidemia (high cholesterol), opioid dependence and ‘other follow-up examination,' ” researchers wrote, according to Maggie.

— And here are a few more good reads:

REPRODUCTIVE WARS

MEDICAL MISSIVES

INDUSTRY RX

DAYBOOK

Coming Up

Thursday. The House Veterans Affairs Subcommittee on Health holds a legislative hearing on

Thursday. The House Energy and Commerce Subcommittee on Health holds a hearing on “Examining Barriers to Expanding Innovative, Value-Based Care in Medicine” on

Thursday. AHIP holds a webinar “Redesign your Payment Integrity Model to Achieve Savings” on

Thursday and Friday. The National Committee on Vital and Health Statistics holds a committee meeting on

SUGAR RUSH

From The Fact Checker: Did Brett Kavanaugh offer a ‘dog whistle’ to abortion foes?| Fact Checker