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Virginia's state legislature appeared to make some progress yesterday toward adopting the Affordable Care Act's Medicaid expansion, which would cover some 400,000 people in the stare, per the AP.

Meanwhile, Medicaid expansion will officially be on the ballot this fall in Utah. The state certified the ballot initiative yesterday, after advocates submitted the required number of signatures last month.

• The referendum is competing with a partial expansion that has the support of Republicans in the state legislature, as well as Gov. Gary Herbert.
• The full expansion would cover roughly 70,000 Utah residents, according to the Salt Lake Tribune.

Advocates in Idaho also say they've collected enough signatures to get the expansion on the ballot. It would cover up to 62,000 people there.

Why it matters: There are only 14 states that haven't taken part in the ACA's Medicaid expansion. It gained new life in Virginia after Democrats made big gains in the state legislature, and ballot initiatives are one way — albeit not a sure-fire one — to advance the issue in deep-red states.

• If all three states ultimately sign on, more than 500,000 Americans could gain health coverage, and Medicaid could become even more politically difficult to cut.

Health care companies are in the midst of a real M&A bender right now, and they often say it’s all in pursuit of “value-based care.” But Axios’ Bob Herman flags a survey, conducted by consulting firm West Monroe Partners, in which health care dealmakers laid out their actual reasons:

• “Attractive” profit margins
• An aging population
• Overall growth in demand for care

Between the lines: There's no talk here about "patient-centered coordination" or "controlling spending growth." The responses suggest that dealmakers, especially those in private equity, know they can extract profit from companies that get a lot of revenue from government programs.

• But not too much: Almost three-fourths of respondents said they have walked away from a deal, due in part to concerns that a target company relies too heavily on Medicare and Medicaid, which pay less than private insurance.

HHS has now lost four lawsuits over its controversial decision to end a teen pregnancy program. A judge in Seattle ruled yesterday that HHS had not followed its own rules and procedures when it eliminated the program.

• “HHS’s failure to articulate any explanation for its action, much less a reasoned one based on relevant factors, exemplifies arbitrary and capricious agency action,” the court said.

The intrigue: Congress created the Teen Pregnancy Prevention Program in 2010, and provided more than $100 million for HHS to give out in grants. Seattle was among the cities that received a new round of funding in 2015, but in 2017 the new administration abruptly put an end to the program.

• NBC News, citing internal HHS notes and emails, has reported that “three appointees with strict pro-abstinence beliefs … guided the process to end a program many medical professionals credit with helping to bring the nation’s teen pregnancy rate to an all-time low.”

What’s next: The Seattle judge told HHS to reconsider the grant request, and make any relevant funding available by August.

Researchers are turning to smaller, more narrowly targeted clinical trials to test the next generation of medicines, The Wall Street Journal reports. Experts are divided over the shift: Smaller trials make sense for more personalized treatments, but incremental benefits often are only discovered with a lot of data.

By the numbers: The number of clinical trials funded by the National Institutes of Health fell by 41% from 2005 to 2015, according to the WSJ, largely because trials have gotten more expensive.

What they’re saying:

• New therapies “are trying to match drugs to individual patients’ features, so the sorts of trials we need will look much different than the large clinical trials,” Nicholas Schork, a professor at the Translational Genomics Research Institute, told the Journal.
• “I think that we are throwing away a lot of good drugs and a lot of good diagnostics because our trials are too small,” sad Larry Norton, a breast-cancer specialist at Memorial Sloan Kettering.