THE PROGNOSIS

Typically by August, the state of the upcoming Obamacare enrollment season is pretty evident – that is, what health insurance rates will look like and how many insurers will participate in the marketplaces created under the Affordable Care Act. But not this year. A picture of the 2018 marketplaces is slowly emerging -- but everything is volatile under Republican rule.

The Kaiser Family Foundation has released the clearest look yet at how the ACA's state-based marketplaces – which recently escaped an attempted revamp by congressional Republicans – are faring. While they’re not in meltdown mode, as President Trump has been gleefully predicting, neither do they look too pretty for some of the 10 million or so Americans likely to seek coverage there starting Nov. 1.

Out of 20 states (including the District of Columbia) that have released enough information to analyze, insurers in 15 of them have proposed rate hikes in the double digits. In Albuquerque, N.M., for example, average monthly premiums will increase 34 percent to $346 for a mid-range “silver plan.” Average proposed hikes for the same type of plan are 29 percent in Seattle, 25 percent in Baltimore, 23 percent in Philadelphia and a whopping 49 percent in Wilmington, Del.

Further darkening the picture, insurer participation in the marketplaces is down somewhat. Kaiser found that among those same 21 states, an average of 4.6 carriers intend to sell plans compared to 5.1 carriers this year and 6.2 in 2016. Generally speaking, residents of more urban areas will have several insurance options while consumers in rural areas will have fewer or perhaps none at all.

The situation isn’t final -- some insurers have until the middle of next week to file final rates and there’s some wiggle room for them through the rest of August and into September. States with rural counties facing the prospect of no insurers have been working behind the scenes to fill in the holes, with Ohio most recently announcing it had found an insurer for all but one of its previously “bare” counties.

An important point to remember is that people earning up to 400 percent of the federal poverty level can get marketplace subsidies to blunt their costs. But according to Kaiser, those directly bearing the cost hikes include about 1.6 million marketplace enrollees who earn too much for subsidies and another 5.1 million people who chose to buy individual coverage off the marketplaces (likely because they wouldn't be eligible for subsidies there anyway).

Analysts say things are likely to move in a worse, not a better, direction, unless President Trump and Republicans in Congress step in quickly to guarantee long-term payment of extra subsidies on which insurers are depending to cover cost-sharing discounts.

Kaiser researcher Cynthia Cox told me she wouldn’t be surprised to see insurers request even higher premium hikes this month, or announce they’re withdrawing from certain marketplaces completely. There’s already been news on that front this week; major insurer Anthem announced Monday it’s paring back offerings in Nevada and Georgia.

“By this point in the process, we’d normally have a good sense of where the premiums are going to be next year. But this year -- because there is so much uncertainty insurers are facing -- I think many of them will go back and request even higher rates in the next week or so,” Cox said.

About all that uncertainty: It remains unclear whether the administration will make the August payment of the cost-sharing subsidies that aid low-income Americans in buying insurance. Trump has threatened he’ll halt them as part of an effort to sink the marketplaces and watch the collapse of Obamacare – and it may be up to Congress to fund them in the long-term anyway.

Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor and Pensions Committee, is planning a series of hearings next month aimed at crafting bipartisan legislation to fund the subsidies and potentially other small health-care tweaks. But the timeframe is extremely tight. Once Congress returns from summer recess the week of Sept. 4, it would have only a few weeks to approve legislation before insurers’ drop-dead date to file contracts to sell marketplace plans next year. (currently set for Sept. 27, although the administration could extend that deadline).

“In some ways, it’s really too late for Congress to act in a way that would change premiums for next year. But it might not be too late to change whether insurers participate,” Cox said.

To be fair to Republicans and their criticism of the marketplaces, insurers would still be hiking 2018 rates even with assured payment of the subsidies. They did last year, too, forcing the Obama administration into the awkward position of defending the marketplaces even as some suffered under heavy cost increases.

When I asked the Department of Health and Human Services about the Kaiser report, spokeswoman Alleigh Marre offered this statement:

"This analysis confirms what we already knew - Obamacare is flawed, failing, and harming the American people. Inaction is not an option. The Trump Administration is committed to repealing and replacing Obamacare and will always be focused on putting patients, families, and doctors, not Washington, in charge of healthcare."

But insurers are threatening even greater hikes without the payments, which total around $7 billion this year. Some insurers submitted two sets of rates; one assuming the subsidies are continued and one assuming they’re discontinued. According to Kaiser’s tally, they’ve estimated cost increases of anywhere from 2 to 23 percent without the payments.

It's fully within Republicans' power to assure insurers that the administration has got their backs. Instead, Trump has been tweeting threats. Remember these?

Trump is facing pressure not just from Alexander but other leading Republicans as well to fund the cost-sharing subsidies:

The Hill's Peter Sullivan noted the position of Ways and Means Chairman Kevin Brady (R-Tex.):

From Sen. Jeanne Shaheen (D-N.H.):

And don't forget another factor also contributing to rate hikes next year – the ACA’s-health insurance tax.

In January, the levy on insurance premiums is set to resume after Congress suspended it this year. Insurers have been lobbying heavily for repealing it, arguing they’ll be forced to raise premiums in order to cover it. UnitedHealth Group and a coalition of other groups against the tax have been circulating research from Oliver Wyman estimating that premiums will rise 2.6 percent next year if the tax is allowed to go into effect.

The tax would have been erased in both the House and Senate bills overhauling the ACA. It’s just one of many questions Republicans must grapple with, now that they’ve massively failed to wipe out even small portions of their longstanding political nemesis (aka Obamacare). 

Programming note: The Health 202 is going on vacation next week and we’ll be back in your inbox on Aug. 22. We hope you get some time off too!

AHH, OOF and OUCH

AHH: If Congress can't come together to improve heath care, at least health-care wonks are. Top names in health-care policy from both the left and the right are uniting in an unusual partnership to urge Congress to strengthen health insurance by continuing to pay all the federal subsidies provided under the ACA and to help Americans enroll in coverage. Participants included former Families USA Director Ron Pollack (who was instrumental in getting the ACA passed); Gail Wilensky and Lanhee Chen, who have both worked for Republican officials and candidates; and a half dozen other prominent health-care experts.

The group laid out a five-point set of principles yesterday, which include paying the cost-sharing subsidies and allowing states latitude to merge the funding of health-insurance programs for people who are poor, The Post's Amy Goldstein reported. The coalition also said the government must continue strong incentives for Americans to carry health insurance and quickly bring health plans to about two dozen "bare" counties with no marketplace insurers.

OOF: States are enacting strict limits on the number of powerful prescription painkillers doctors can prescribe, a move that many believe will help fight the opioid crisis but has raised alarms among some physicians, The Post's Katie Zezima reports.

"At least 17 states have enacted rules to curb the number of painkillers doctors can prescribe," Katie writes. "Some, including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio, have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Others are passing dosage limits. In Kentucky, a law went into effect last month capping opioid prescriptions for acute pain to three days.

"The Centers for Disease Control and Prevention last year issued guidance for providers, recommending shorter durations for opioid prescriptions, stating that three days should be sufficient and a course of more than seven days 'will rarely be needed,'" Katie continues. "According to a CDC study, patients who use such painkillers for longer periods of time are more likely to end up addicted to them."

OUCH: It's the disease's fault. That's what Sen. Ron Johnson (R-Wis.) essentially suggested yesterday when he raised that idea that Sen. John McCain (R-Ariz.) sunk the GOP's "skinny repeal" bill in the middle of the night because he isn't feeling well.

Johnson told Chicago radio station AM560 that Speaker Paul D. Ryan (R-Wis.) had absolutely assured Senate Republicans the House wouldn't pass the "skinny repeal" bill but it would instead go to a conference committee for revisions -- a promise McCain had insisted on in order to support it. But then McCain gave the thumbs-down anyway.

"Again, I'm not gonna speak for John McCain -- he has a brain tumor right now -- that vote occurred at 1:30 in the morning, some of that might have factored in," Johnson said.

"Really?" the radio host responded.

"Again, I-I-I don't know exactly what -- we really thought -- and again I don't want speak for any senator," Johnson answered. "I really thought John was going to vote yes to send that to conference at 10:30 at night. By about 1, 1:30, he voted no. So you have talk to John in terms what was on his mind."

McCain's office responded a few hours later, per CNN's Andrew Kaczynski:

A few hours after that, Johnson walked back his remarks. "I’m disappointed I didn’t more eloquently express my sympathy for what Sen. McCain is going through. I have nothing but respect for him and the vote came at the end of a long day for everyone," he said in a statement.

TRUMP TEMPERATURE

--Is there an all-out war brewing between President Trump and Senate Majority Leader Mitch McConnell (R-Ky.), which seems a pretty bad fight for the president to pick? The president is turning his fury at Congress's failure to repeal Obamacare upon the GOP leader, who at the end of July guided his members through a series of votes all aimed at the ACA -- all of which failed. Trump's tweet this morning:

And this, yesterday:

Trump was referring to comments McConnell made Monday at a Rotary Club meeting in Kentucky, where the Senate leader said Trump’s lack of political experience had created “excessive expectations” for passing major legislation. 

"Our new president, of course, has not been in this line of work before," McConnell said. "I think he had excessive expectations about how quickly things happen in the democratic process....Part of the reason I think people think we're under-performing is because of too many artificial deadlines unrelated to the reality of the legislature which may have not been understood."

"The back-and-forth was the latest sign of strained relations between Trump and Republicans in Congress, who have had few victories since January, despite the GOP's control of the White House and both the House and Senate," my colleague John Wagner writes. "Since the collapse of a health-care bill, Trump has belittled GOP senators as looking like 'fools' and suggested they change the chamber's rules to make it easier to pass bills.

White House social media director Dan Scavino Jr. joined the McConnell-bashing:

Former GOP congressman Joe Walsh jumped in too:

HEALTH ON THE HILL

Sen. Shelley Moore Capito (W.Va.), one of the Republican moderates who disliked the cuts to federal assistance in the Senate's health-care bill, says she'd back a plan to get rid of Obamacare's mandates but keep its subsidies -- like the one offered by GOP Sens. Bill Cassidy of Louisiana and Susan Collins of Maine.

"There is still going to be a lot of passion, at least I'm seeing it at home, on protecting certain parts of Obamacare," Capito told the Washington Examiner yesterday.

Capitol added that any health-care bill must include funding for opioid abuse prevention, which is a raging problem in her state of West Virginia "That's one of the things my state is talking about all the time," Capito said. "We have the highest overdose rate in the country."

 

McCain held a Facebook Live event yesterday, where he further explained his vote against "skinny repeal," saying he still thinks it's possible to repeal and replace the ACA.

"I still believe we can do that," McCain said."I still believe we must do that. One of the reasons Obamacare failed was because it was rammed through the Senate without any Republican consideration. So, what did we do nine years later? ... The same thing to the Democrats. That's not the way the Senate should function."

"I campaigned on repeal and replace," he said. "And I also expected to play a role in the Senate with amendments, with debate and all of the aspects of the formulations of legislation which is characteristic of the Senate."

McCain added that treatment for his brain cancer -- which he's undergoing over August recess -- is "going fine."

"I'm feeling fine," McCain said. "This is a rough disease, let's be very honest about it. That's straightforward. I've always been straightforward...I have to beat it. Fortunately, they found it early, and the treatment is going extremely well. I have another week and a half of this kind of treatment that I'm getting, then they will check it out and see if there's anything ... additional that needs to be done."

And McCain insisted, with his trademark humor, that he's coming back to Washington.

"Look, my friends, this is a very malicious disease," he said. "But I've had other challenges in my time as well. I don't mean to be repetitious, but to my Democrat friends and some of my Republican friends: I'm coming back.”

"Even those that want me to die don't want me to die right away, so that's good," he added.

Some other good reads from The Post and beyond:

He has created a task force and touted the border wall, but he has also proposed cuts to Medicaid that could affect access to treatment.
Nicole Lewis
The department’s secretary intends to use the authority given to him in a new law that makes it easier to fire deficient employees.
New York Times
MEDICAL MISSIVES
Baltimore Health Commissioner Leana Wen worries about what this means for teen pregnancy rates.
Ariana Eunjung Cha
INDUSTRY RX
One in 12 doctors has received money from drug companies marketing prescription opioid medications, according to a study released Wednesday afternoon.
Katie Zezima
STATE SCAN
United Therapeutics alleges that a 2013 FDA decision on its Orenitram drug was unlawful.
Aaron Gregg
DAYBOOK

Today

  • The House Committee on Veterans Affairs will hold a hearing on veteran care in rural areas.
  • The Center for Global Development holds an event on implementing clinical trials during epidemics. 
  • Ravina Daphtary, director of state strategies at All* Above All moderates a panel on abortion rights at the Netroots Nation conference in Atlanta. 
  • Congress is on recess until September 5. 
SUGAR RUSH

Why was there a giant inflatable chicken outside the White House?:

Why tiny Guam is in North Korea's crosshairs:

Stephen Colbert teases that Anthony Scaramucci will be a guest on his show on Monday: