Democrats who hoped they'd have transformational new health legislation in place by next year could instead be facing one of the largest increases in the U.S. uninsured rate in recent history, Axios' Caitlin Owens writes.

Why it matters: Temporary pandemic-era reforms to Medicaid and the Affordable Care Act marketplaces caused enrollment in each to swell. But these policy changes are due to end soon, and millions of people could lose their health coverage.

What they're saying: "If continuous coverage in Medicaid ends and the extra ACA premium assistance isn't extended, we could see one of the biggest jumps in the number of people uninsured ever," said Kaiser Family Foundation's Larry Levitt.

State of play: The Medicaid changes are tied to the formal Public Health Emergency, which is currently scheduled to end April 15. The prevailing assumption is that it'll likely receive one more extension and then expire sometime this summer.

• States will then determine whether their Medicaid enrollees are still eligible for coverage — a huge undertaking that could result in millions of Americans being removed from the program.
• "Pretty clearly, this is going to be one of the biggest inflection points for health coverage that we've seen in a very long time — in a decade at least, and it's probably going to mean the largest reduction in Medicaid coverage in memory," said Matt Salo, executive director of the National Association of Medicaid Directors.
• Salo estimated some 10–15% of the Medicaid population — potentially more than 12 million people — will fall off the program rolls.

What we're watching: States will have a huge role deciding whether eligible people remain enrolled in Medicaid or are connected to other forms of coverage, including ACA plans.

Drinking alcohol — even just an average of a drink a day — is associated with reductions in overall brain volume, according to a study published today in the journal Nature Communications.

Why it matters: The study found the greatest risks with heavy drinking, but alcohol consumption was linked to reduced brain volume among far more moderate drinkers.

• The findings could throw cold water on other studies suggesting that lighter alcohol consumption has no impact on, or may even benefit, the brain.

Read the rest.

Approximately 33 million low-wage workers in the U.S. don't have access to paid sick days, creating all kinds of personal challenges for workers — and public health issues for everyone amid the pandemic, Axios' Emily Peck writes.

State of play: While most states still don't have guaranteed leave, a total of 15 states, as well as dozens of cities have passed sick leave laws.

• A new report, released this morning by advocacy group A Better Balance and provided exclusively to Axios, estimates those laws made guaranteed access to leave available to 55 million workers.

Go deeper.

Civica Rx, the nonprofit generic drug company created by a consortium of hospitals, announced Thursday that it plans to lower the cost of insulin by making it on its own.

Why it matters: Insulin — a critical drug that millions use, is cheap to make but often very expensive to buy — has been at the heart of the fight over unaffordable prescription drug prices.

• During his State of the Union speech Tuesday, President Biden lambasted high out-of-pocket insulin costs and proposed capping them.

Driving the news: Civica plans to manufacture and distribute three different kinds of insulin at a cost of no more than $30 a vial and no more than $55 for a box of five pre-filled pens.

• Civica will co-develop and manufacture the drug products, complete the clinical trials, and file the necessary applications for FDA approval. The plan is to have the first insulin available to purchase by 2024.
• The non-profit is among a number of companies looking to stabilize the price and availability of common generics in the U.S., including, most recently, billionaire Mark Cuban's online pharmacy.

💊 The Sackler family will pay up to $6 billion in an opioid settlement. (Axios)

✂️ Biogen began cutting jobs following the disastrous debut of its Alzheimer's drug Aduhelm (Boston Globe)

💉 Pfizer and Moderna expect combined vaccine sales of $51 billion this year (CNBC)

Meet Alexa, an adorable little hound in Arlington, Virginia, who is also a new mom recently rescued from Mississippi and now looking for her forever home.

• "My foster currently enjoys carrying my long, wiggly body out every morning and night and I have no problem with this ... I love cuddles from my human puppy as long as she's slow and easy going with me," the Wolf Trap Animal Rescue writes about her.
• Look at that face! If any of you Vitals readers end up adopting, please send pics so we can all share in the joy!