with Paulina Firozi


President Trump believes that Obamacare is "imploding." And his administration could be doing a lot to hasten its demise in the wake of the failure by Senate Republicans to pass a bill overhauling the seven-year-old health-care law.

The interesting thing, however, is it's not.

With the congressional failure, the Obamacare spotlight has now shifted to how Tom Price, Trump's secretary of the Health and Human Services Department, is approaching the Affordable Care Act. And while you might think Price would be trying to shoot holes in the measure he’s long criticized, his agency’s approach – at least so far – is far from clear cut.

Health policy observers -- many of them former Obama administration officials who helped implement the ACA -- say Trump’s fiery rhetoric doesn’t match the more measured approach HHS appears to be taking toward the law, at least for now.

“I think they’ve done some things to undermine the law and I think they’ve done some things to move forward in the normal way,” Joel Ario, who was the first director of HHS’s Office of Health Insurance Exchanges, told me.

That doesn't mean Price and his appointees are cheerleading Obamacare from behind the scenes -- in fact, they often highlight the shortcomings of its insurance marketplaces. But they also haven’t made administrative rule changes -- ones that are well within their power to implement -- that could severely cripple the ability of insurers to participate in the ACA marketplaces or dramatically reduce the rolls of Americans getting coverage there.

Let's first take a look at a set of marketplace changes that HHS finalized in April, which included a number of stricter rules that insurers had said are necessary to help them stabilize the individual markets next year and beyond.

If people want to enroll outside the sign-up season, they must first prove they’re eligible (those who qualify would be people with life changes like a divorce or a new baby). Insurers had argued for tightening verification rules around eligibility outside the enrollment season, arguing that too many people were trying to game the system.  The Obama administration actually wanted to tighten the eligibility requirements, and HHS simply finalized some of those plans.

“It was a very important thing that the ACA doesn’t require,” said Mike Adelberg, a former top director at the Center for Consumer Information and Insurance Oversight at HHS’ Center for Medicare and Medicaid Services.

“Frankly, if they were really trying to kill the program this is something they could have thrown the brakes on,” Adelberg told me.

In May, HHS issued a new policy making it easier for online brokers to sell Healthcare.gov plans to their customers. During the next sign-up season that starts Nov. 1, individual and small-business shoppers can sign up for subsidized coverage through popular Internet companies like eHealth and HealthSherpa instead of being directed to the federal website.

Some ACA supporters have raised concerns that online brokers might not present consumers with their full range of options. But even they admit the strategy could boost enrollment numbers by giving shoppers even more venues from which to sign up.

"I think some brokers play a very helpful role and it is a helpful way of extending information about what opportunities people have," said Ron Pollack, a longtime health-care activist who formerly led Families USA before retiring earlier this year.

On Monday, the agency released guidance finalized in mid-July indicating (among other things) that it will continue the Obama administration’s practice of re-enrolling patients if they don’t actively select a different plan for the new year. The ACA doesn’t require this approach by HHS; if Price chose, he could end auto-enrollments and even refuse to notify people they need to renew coverage or their plan will end Dec. 31. That would undoubtedly remove a lot of people from the rolls and make the program smaller by default.

And then there are the things HHS could have done to undercut the marketplaces, but hasn’t (yet). Here are a few examples:

-- Insurers pay the federal government a fee to use the marketplaces; it’s this money that largely funds the day-to-day operations of Healthcare.gov. HHS could either lower the fee -- thus cutting off the flow of funds to even run the marketplaces -- or dramatically increase it, thereby chasing insurers away. HHS has done neither.

-- Marketplace plans must cover ten essential benefit categories (like prescription drugs and maternity care). HHS can’t entirely sweep those categories away. But it could give states even greater latitude to define them or use its waiver authority to approve alternative rules altering the benefits. It has not released any rules doing so.

-- Both HHS and the IRS can exempt people from the individual mandate to buy coverage if they are in certain extenuating circumstances. The agencies could broadly expand these “hardship exemptions,” like excusing people in hundreds of counties expected to have just one marketplace option next year. But HHS has not taken this path either, at least publicly.

Of course, all this doesn’t mean Price is suddenly showering love on the ACA. His agency still won’t answer questions about whether it will advertise Healthcare.gov during the enrollment season, which runs Nov. 1 through Dec. 15. It’s worth noting that the agency slashed in half the sign-up season, which used to run through the end of January.

Some state insurance officials complain they’re not hearing as much from the Trump administration unlike the communication they had with Obama's government. Tennessee Insurance Commissioner Julie Mix McPeak, whose state’s marketplace has just three insurers participating next year, said communication with HHS and the Centers for Medicare and Medicaid Services feels “quieter.”

“I think they’re still fairly responsive to us and other states, but there is less outreach,” McPeak told me. “We have to reach out more to them than we have in the past.”

But remember that the vast majority of HHS staff are career employees, not political appointees. Of the agency’s nearly 80,000 workers, just 161 have been or will be selected by Team Trump. That means hundreds of staff supporting the marketplaces through the Obama era are pressing forward with their jobs despite the changes at the top.

“It’s almost like there are decisions that get bumped up to a political level and the political people do what the political people do and there are administrative matters that wouldn’t make a sexy headline in The Post that are getting done,” Adelberg said.

Here’s something to watch in the next week or so: Whether HHS awards the third and final year of “navigator” grants to nonprofit and medical groups for doing enrollment outreach. Navigators in Alaska and Texas told The Health 202 they’re expecting the awards will be doled out in early September, as in the last two years. The agency didn’t respond to a question about it yesterday.

Likewise, insurers and regulators say they don’t have any evidence that Price and his team will try to dramatically undermine the marketplaces next year -- and until they do, they’re hoping for the best.

“The way we approach it is we come to it with the conviction that CMS is going to fulfill its responsibility and uphold the letter of the law,” said Kristine Grow, a spokeswoman for the influential insurer association America’s Health Insurance Plans.

Of course, Trump’s tweets and statements about allowing the marketplaces to collapse and his refusal to give insurers certainty about extra subsidy payments known as cost-sharing reductions give stakeholders pause. But things seem to be chugging along behind the scenes at HHS, according to the National Association of Insurance Commissioners.

“They are doing everything they have done in the past to make sure the exchange is up and running and everything is loaded,” said a spokesperson for the NAIC.

The administration’s approach might seem confusing given that Price has for years insisted the ACA was harming Americans by ruining insurance markets and destroying jobs. But the former Georgia lawmaker now presides over the agency that runs Obamacare's biggest programs. Price is facing a hard reality pitting politics against practicality.

“I think HHS and the administration find themselves in a precarious position because on one hand they want to keep up the political rhetoric but they still can’t let the markets crater,” said former Republican Senate Finance Committee staffer Chris Condeluci.


AHH: About half a million more Americans had health coverage in this year's first quarter, a tiny and statistically insignificant uptick from the year prior, providing the latest evidence the ACA's progress has stalled in reducing the uninsured rate.

About 28.1 million people still lack health insurance in the United States  -- 8.8 percent of the population -- according to a report released yesterday by the Centers for Disease Control and Prevention. That's still a lot of people. But at least it's far below the 48.6 million people (16 percent of Americans) who lacked coverage when President Obama signed the ACA in 2010.

OOF: Cries have grown louder to dismantle monuments to J. Marion Sims, the “father of gynecology,” a white 19th-century doctor who established New York's first hospital for women in 1855 but also performed surgical experiments on enslaved black women without anesthesia, The Post's DeNeen L. Brown reports.

Amid efforts around the country to remove statues of Confederate leaders, New York City is considering whether to remove the Sims statue as part of a 90-day review of “symbols of hate” on city property, New York Mayor Bill de Blasio announced last week. New York City Council Speaker Melissa Mark-Viverito has denounced the memorial, describing Sims’s work as “repugnant and reprehensible” and a “stain on our nation’s history.” The New York Academy of Medicine has also called for the statue’s removal. Some activists vandalized the statue over the weekend. “RACIST” was spray-painted on the Central Park monument, and splotches of red paint were used to deface the statue’s eyes and neck.

"Sims, who practiced medicine in Alabama from 1835 to 1849 before moving to New York, invented the speculum and other instruments still in use today. He pioneered surgery for fistula, a condition that left women incontinent after giving birth; historians say the treatment revolutionized the field of gynecology. He also performed the first successful gallbladder surgery and the first successful artificial insemination," DeNeen writes. "But to make those advances, Sims performed experimental surgeries on enslaved women, raising disturbing ethical questions. His legacy has long been questioned by those who believe he used black women as medical guinea pigs without their consent."

OUCH: Opioid overdose deaths nearly doubled between 2009 and 2015 in the United States, according to a new study in the Annals of the American Thoracic Society, dramatically increasing the need for emergency care related to opiate addiction.

"The paper is believed to be the first to quantify the impact of opioid abuse on critical care resources across the country," Time's Amanda MacMillan writes. "For the study, researchers from Harvard Medical School, the University of Chicago, and Ben-Gurion University of the Negev analyzed nearly 23 million hospital admissions over a seven year period, at 162 hospitals in 44 states....Almost 22,000 patients were admitted to intensive care units because of overdose from opioids—including prescription medications, methadone (which can be used to treat opiate addiction) or heroin."

"From 2009 to 2015, the number of opioid-related ICU admissions increased by 34 percent," Amanda writes. "During that same period, the number of ICU patients who died from opioid-related causes nearly doubled. The death rate rose at roughly the same rate per month throughout the study period, but climbed higher beginning in 2012. In other studies, the researchers note, similar increases have been linked to more prescriptions being written for painkillers—which may lead to more addiction and overdoses in the following years."


--Secretary Price told reporters last night that Trump's "heart goes out" to the people whose lives have been devastated by Harvey. The president's "passion and his love for the American people and concern about their welfare is unending," Price told reporters aboard Air Force One, according to Bloomberg News

Trump spent much of his visit to Texas yesterday applauding the government's response efforts, but some said he missed opportunities to strike a sympathetic note for the multitudes who are suffering. He visited both Corpus Christi — near where the storm made landfall — and state officials in Austin. At one point, he shouted a message to a crowd outside a fire station in Corpus Christi.

“This is historic, it’s epic what happened. But you know what, it happened in Texas and Texas can handle anything,” he told the crowd, which applauded his remarks and cheered more loudly when he waved the Texas state flag.

"What a crowd, what a turnout," President Trump said as he addressed people in Corpus Christi, Tex., on Aug. 29 while touring the damage from Hurricane Harvey. (The Washington Post)

--Authorities said yesterday that more than 13,000 people had been rescued from floodwaters and at least 22 have been confirmed dead. The Post's Kevin Sullivan, Arelis R. Hernandez and David Fahrenthold report: "After more than 50 inches of rain over four days, Houston was less of a city and more of an archipelago: a chain of urbanized islands in a muddy brown sea. All around it, flat-bottomed boats and helicopters were still plucking victims from rooftops, and water was still pouring in from overfilled reservoirs and swollen rivers."

Between 25 and 30 percent of Harris County — home to 4.5 million people in Houston and its near suburbs — was flooded by Tuesday afternoon, according to an estimate from Jeff Lindner, a meteorologist with the county flood control district. That’s at least 444 square miles, an area six times the size of the District of Columbia.

The visuals are unbelievable. From Storyful's David Clinch:


--The Democratic Congressional Campaign Committee is launching a new Facebook ad campaign -- aimed at nearly all of its 80 GOP targets -- that highlights the Republican health-care bill most of them voted for, Roll Call reports. The ads highlight higher costs for seniors under the GOP plan, which would have allowed insurers to charge older people more relative to young people. A DCCC spokesman declined to comment on how much the committee was spending on the Facebook ads. 

The sponsored post shows a picture of two seniors in a hospital room with the text, “The Republicans’ health care bill would add an age tax to older Americans, allowing them to be charged five times more than younger people. And [lawmaker's name] supported it.” The last sentence will not appear in districts where the GOP House member voted against the health-care bill, or in districts with open seat races. The push is part of Democrats’ effort to turn the unpopular legislation into a useful political tool as they look to flip 24 seats and win back the House in 2018.

A few more good reads from The Post and beyond:



  • President Trump will travel to Missouri to talk tax reform.
  • The Paralyzed Veterans of America holds its annual summit through Thursday

Coming Up

  • Sen. Ben Cardin (D-Md.) holds a town hall to discuss the nation’s health care on Thursday.
  • The New York Times hosts the first event in its TimesTalks D.C. series featuring House Speaker Paul D. Ryan on September 7.



How presidents react to natural disasters:

President Trump visited Texas Aug. 29, after Hurricane Harvey struck parts of the state. Here’s how his predecessors handled natural disasters. (Victoria Walker/The Washington Post)

President Trump to Harvey responders: ‘The world is very impressed with what you’re doing’:

President Trump congratulates responders for their rescue efforts amid historic flooding in Texas. (The Washington Post)

Politicians react to Harvey's devastation: 

As waters keep rising from Hurricane Harvey, President Trump, administration members and Texas officials weigh in on the federal government's role. (Jenny Starrs/The Washington Post)

Watch dogs and cats being rescued from floodwaters in Texas:

From dogs and cats rescued from floodwaters to a hawk that refused to leave a cab driver's vehicle, these are moments that captured our hearts. (Claritza Jimenez/The Washington Post)