Axios Vitals

Almost 22.4 million seniors and people with disabilities are enrolled in Medicare Advantage plans for 2019 — up 6.8% from the same point last year, Axios' Bob Herman reports, based on preliminary federal data.

Why it matters: The growing enrollment total is in line with what the Trump administration expected and continues a decade-long trend of moving more of the traditional Medicare program into a privatized version run by health insurers.

Winners: Most insurers are winners to some degree, considering MA is "a friendly environment" right now for the industry. And the biggest companies are getting even bigger.

By the numbers: Together, 3 companies control more than half of the MA market.

• UnitedHealth Group: 5.7 million enrollees, up 9%
• Humana: 3.9 million, up 11%
• Aetna (now owned by CVS Health): 2.1 million, up 23%

The big picture: The federal government is expected to pay MA insurers $250 billion this year. With profit margins hovering around 4% or higher for many companies, that equals billions of dollars of profit.

Yes, but: Federal prosecutors and auditors are scrutinizing the coding practices of MA insurers and may be willing to claw back overpayments soon.

• Many enrollees also may be unaware of the program's shortcomings.

What's next: February's enrollment data will provide an even clearer picture of how much the Medicare Advantage program grew for this year.

The manufacturers of OxyContin not only engaged in a high-pressure, no-holds-barred marketing barrage, but also sought to shift the blame to the people who became addicted to their highly addictive drug, according to a new filing from Massachusetts Attorney General Maura Healey.

Driving the news: The document adds new details to the emerging public image of Purdue Pharma and its former president, Richard Sackler.

• "The launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition. The prescription blizzard will be so deep, dense, and white ..." Sackler said at a launch party for the drug, according to the filing.
• That blizzard happened, thanks in part to aggressive marketing efforts and partnerships with prominent teaching hospitals.

Among the most damning accusations in the Massachusetts filing: Accusations that the Sackler family, faced with evidence of how powerfully addictive their product was, shifted the burden back to patients — reinforcing a stigma that public health officials are still trying to combat.

• "We have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals," Richard Sackler said in a 2001 email, according to the legal filing.

The other side: Purdue, in a statement to Boston's WBUR, accused Healey of trying to "vilify a single manufacturer whose medicines represent less than 2 percent of opioid pain prescriptions rather than doing the hard work of trying to solve a complex public health crisis."

Kentucky’s plan to impose Medicaid work requirements is being re-challenged in court, after it was re-approved by the Trump administration this past November.

Flashback: Kentucky was the first state to win approval for Medicaid work requirements last year.

• A federal judge stopped those rules from taking effect, saying the Health and Human Services Department hadn’t made a compelling enough case that work requirements align with Medicaid’s stated purpose.
• In response, HHS reopened the window for public comments on Kentucky’s proposal, then quickly re-approved basically the same policy.

A new class-action lawsuit filed on behalf of 16 Kentuckians says the re-approval is still illegal.

• It accuses HHS of “working to effectively rewrite the Medicaid statute, ignoring congressional restrictions, overturning a half century of administrative practice, and threatening irreparable harm to the health and welfare of the poorest and most vulnerable in our country.”

The big picture: Medicaid work requirements are arguably the most substantively significant piece of health policy the Trump administration has implemented.

• The policy would substantially curb enrollment — Kentucky estimates more than 90,000 people would lose their coverage there — and help redefine a health care program as a form of welfare.

Go deeper: Kentucky's health care microcosm

Democratic governors and state legislatures are pushing forward on a range of plans to expand public health care coverage, especially for the uninsured — a cause the industry can get behind.

• But in the past, public insurance plans have been seen as a way to bring prices down throughout the system. And if Democrats start to go there, the industry will fight back, Axios’ Caitlin Owens writes this morning.

What they’re saying: “I’d expect substantial health industry pushback to the idea of expanding publicly-sponsored insurance. The industry will see it as threatening, and the camel’s nose under the tent,” the Kaiser Family Foundation’s Larry Levitt said.

• Industry killed the public option in the Affordable Care Act, and also beat back attempts at cost control last year in California.

Why it matters: There’s a lot of energy on the left right now around health care, and these plans are all a reflection of that fact. But polls also show that cost control is voters’ biggest concern; it ranks above coverage expansion even among Democrats.

• “I think we’ll be able to evaluate how much of a cost containment caucus there really is, either at the state or federal level," Democratic health care strategist Chris Jennings said.

UnitedHealth Group recorded $17.3 billion in operating profit in 2018, which does not include interest expenses or taxes, the conglomerate said Tuesday.

• 20% of those earnings ($3.6 billion) came from OptumRx, UnitedHealth’s pharmacy benefit manager, Bob reports.

Between the lines: Health insurance still makes up a majority of UnitedHealth’s bottom line. But the company’s Optum businesses, and its pharmacy benefit manager in particular, have silently driven more of UnitedHealth’s profitability over the past few years.