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Obamacare’s sixth open enrollment kicks off. Open enrollment has started today for healthcare.gov where people can buy health plans subsidized by the federal government. There are a few changes ahead; People who are uninsured in 2019 will not face a fine, and customers will have the option to buy short-term health insurance, which omits coverage for medical care such as maternity coverage or treatment for chronic illnesses, but can be less expensive for certain customers. That’s not true across the board, though. In some states Obamacare plans will come with premiums as low as $0 a month for people who are subsidized. How is your experience with the exchange this year? Send us a tip at [email protected].

Welcome to Philip Klein’s Daily on Healthcare, compiled by Washington Examiner Managing Editor Philip Klein (@philipaklein), Senior Healthcare Writer Kimberly Leonard (@LeonardKL) and Healthcare Reporter Robert King (@rking_19).  Email [email protected] for tips, suggestions, calendar items and anything else. If a friend sent this to you and you’d like to sign up, click here. If signing up doesn’t work, shoot us an email and we’ll add you to our list.

As Medicaid expansion kicks in, Virginia moves toward work requirements. Virginia officials are moving to limit eligibility for Medicaid via work requirements, even as the state is set Thursday to make more poor Virginians eligible to sign up for the government-funded health insurance program. The state will file a waiver with the Trump administration by Friday that would require certain people in Medicaid to work or train for work as a condition of staying enrolled in the program, just after opening the program to low-income residents a day earlier without such conditions attached. Virginia’s Democratic Gov. Ralph Northam signed the Medicaid expansion into law after a five-year fight, begun under his predecessor, with the GOP-controlled legislature. Northam’s campaign had largely centered on the promise to expand Medicaid, and the agreement to add work requirements was a compromise to get enough Republicans on board in the state House to make it happen. Under the planned work requirement, certain Medicaid enrollees would need to work, volunteer, or take classes, and log their hours with the state. People would also have to pay premiums of up to $10 a month, depending on their income. If they were to skip the requirement for three months in a row, they would be knocked out of Medicaid. Republicans in the state Senate believe the requirement that has come together is a watered-down version of what was promised. “We don’t consider it to be a work requirement,” said Jeff Ryer, press secretary for Virginia’s Senate GOP caucus. “It has got exemptions you can drive a truck through. … We refer to it as a ‘work suggestion.’”

Trump administration approves Wisconsin Medicaid work requirement. Wisconsin will begin requiring people on Medicaid to work or train for work as a condition of staying enrolled in the program, despite a legal battle in Arkansas over a similar program. The Trump administration approved a Medicaid waiver for the state on Wednesday.

The approval came through less than a week ahead of Election Day as Republican Gov. Scott Walker, who backed the requirements, is neck-and-neck with his Democratic challenger, Tony Evers. Wisconsinites will need to work for 80 hours a month to maintain benefits, and if they fail to do so for 48 months in a row then they will be locked out of Medicaid for at least six months. “This is a thoughtful and reasonable policy, and one that is rooted in compassion,” Verma wrote in a blog post.

Wisconsin waiver includes health incentives, but no drug test. The Trump administration did not approve Wisconsin’s request to drug test all Medicaid beneficiaries. But people will undergo a health risk assessment that will include asking about drug use. The plan will cover residential treatment for substance abuse disorder, and beneficiaries will be able to reduce their premiums by making healthy lifestyle choices such as wearing a seatbelt, maintaining a healthy weight, and not smoking.

Verma tweets ‘scariest Halloween costume’ — a ‘Medicare for all’ shirt. “This year’s scariest Halloween costume goes to…,” Verma tweeted Wednesday afternoon, along with an image of a “Medicare for all’ T-shirt. Verma has been vocal in her criticism of “Medicare for all.” Earlier this month, she said the proposal is not something the country can afford, and said expanding Medicare will threaten seniors’ security. In the evening, Verma followed up with another tweet: “Did I get your attention? Good. Medicare for All isn’t a joke. It’s a multi-trillion dollar drain on the American economy that will bankrupt future generations. It’s government controlled healthcare that will strip choice away from millions. It’s a bad idea. And it IS scary.”

Trump tweeted about the leading topic in healthcare this election cycle: Pre-existing conditions. “Republicans will protect people with pre-existing conditions far better than the Dems!” he wrote Wednesday.

House Republican calls on Senate to take up abandoned Obamacare repeal bill. Rep. Michael Burgess, R-Texas, isn’t shying away from the Obamacare repeal bill that the House passed last year, a stark contrast from some of his colleagues facing tough re-election races this fall who are struggling to defend their votes for the bill. Burgess said in a video released Wednesday that he hopes the Senate will take up the American Health Care Act, which the House passed in May 2017, in the lame duck session. It is extremely doubtful the Senate will take up the bill during the lame duck.

Bill Cassidy also defends Republican moves on pre-existing conditions. GOP Sen. Bill Cassidy of Louisiana outlined a theory in a CNN op-ed that Democrats are saying Republicans don’t support pre-existing condition protections because they want to “protect the status quo created by Obamacare and set the stage for a single-payer healthcare system.” Cassidy said that Congress should give states “flexibility to customize their programs while protecting people with pre-existing conditions.” The statement was an oblique reference to Cassidy’s own failed Obamacare repeal bill that he wrote with Sen. Lindsey Graham, R-S.C. The bill converted Obamacare funding into block grants and distributed them to states. But that bill too came under fire for not doing enough to protect people with pre-existing conditions, on the grounds that it allowed states to erode regulations that protect people with pre-existing conditions. The bill said that states that waived these regulations had to “maintain access” to adequate and affordable insurance, but didn’t specify what that meant.

Voters divided over what ‘Medicare for all’ should look like in new poll. A new survey pinpoints what Americans think that ‘Medicare for all’ means. The Survey Monkey and Axios poll found that 52 percent of voters surveyed think that ‘Medicare for all’ refers to a single-payer, government-run system where Medicare covers everyone in America. The plan would likely resemble the one sponsored by Sen. Bernie Sanders, I-Vt., the poll said. But voters are far more divided over whether they actually want single payer, as 34 percent said they would prefer a single payer system. Another 33 percent would prefer an optional public plan alongside private insurance, which would resemble the “public option” that was considered for Obamacare but was eventually scuttled.

State Department weighs barring terms including ‘sexual and reproductive health.’ The State Department is considering barring U.S. diplomats from the terms “sexual and reproductive health” and “comprehensive sexuality education,” among others, according to a new report. The suggestion is included in a memo that still requires approval from Secretary of State Mike Pompeo, amid the urging of several conservative political appointees in the State Department and other federal agencies, Politico reports. The terms would be replaced by “reproduction and the related health services” in official communications of U.S. officials, a source familiar with the issue said.

E-cigarette companies contrite about youth vaping in meetings with FDA. Major e-cigarette makers were contrite about youth vaping in meetings with Food and Drug Administration Commissioner Scott Gottlieb, Gottlieb said Wednesday, with some companies in favor of moving the minimum age to buy tobacco from 18 to 21. The five major e-cigarette companies met with Gottlieb separately in recent weeks as they face a massive crackdown from the FDA on minors using their products. Gottlieb has hinted about possibly banning sales of e-cigarettes in convenience stores to help stem the skyrocketing use of e-cigarettes among adolescents.

Express Scripts sales grow as Trump weighs upending business model. Express Scripts revenue surged in the three months through September, even as speculation mounted that the Trump administration will try to revamp a key piece of its business model. The Trump administration is expected to take aim at the current drug rebate system, under which benefit managers like Express Scripts receive a portion of the discount they negotiate with drug companies. The industry has pushed back against allegations the rebates lead to higher drug prices, with CVS Health’s top executive calling the claim “entirely false.”

340B advocates cheer long-delayed rule finally coming out. Advocates for the drug discount program called 340B are cheering the Trump administration’s decision to finally release rules that prevents drugmakers from overcharging hospitals for discounted products in the program. The 340B program requires drugmakers to provide discounts to safety-net hospitals that cover a certain level of care for low-income people. The rules, first issued more than eight years ago, would stop drugmakers from overcharging hospitals for drugs covered under the program.

“These rules were ordered by Congress more than eight years ago based on clear, documented evidence of overcharging by drug companies of 340B hospitals, clinics, and health centers,” the group 340B Health, which is made up of more than 1,000 hospitals, said in a statement. “The time for delay is over and now it is time for action.” The rules officially go into effect on Jan. 1, 2019.

Lower medical costs, higher premiums spur gains for mega insurer Cigna. Cigna increased its full-year profit target on Thursday after lower medical costs and higher premium revenue drove profit growth in the third quarter. Chief Executive Officer David Cordani said the company expects to continue driving innovation, growth and value” in its merger with Express Scripts, which has been approved by the Justice Department and should be completed by the end of this year.

Insurer Molina plans to expand back into Obamacare markets. Health insurer Molina Healthcare Inc. on Wednesday projected optimism about participating in the Obamacare marketplaces. The insurer will be selling healthcare plans again in Utah and Wisconsin for 2019, after leaving the states this year, and Joe Zubretsky, the company’s president and CEO, said on an earnings call that it hoped to expand further in 2020. “We are pretty comfortable that our strategy in the marketplace… will hold and that will position rates in 2019 that will allow us to grow in 2020,” he said. The company had scaled back participation, raised premium rates by double digits, unloaded technology that wasn’t delivering on lower costs, and changed which doctors and hospitals it contracted with. For 2019 it will sell Obamacare plans in nine states.

RUNDOWN

Axios More ACA competition comes with a catch for consumers

The Hill Democrats close campaign by hammering GOP on healthcare

Politico MacArthur, Kim debate Trump policies, but steer clear of Trump

New York Times In Congo’s Ebola outbreak, experimental treatments are proving effective

Reuters Privacy, drug price bills have a fighting chance in lame duck session

Kaiser Health News Pricey precision medicine often financially toxic for cancer patients

Cleveland Plain-Dealer Ohio Medicaid program to treat patients with hepatitis C earlier