with Paulina Firozi


The Prognosis today is by Carolyn Y. Johnson. Paige will be back later this week.

Governors and insurance commissioners told lawmakers how to fix the Affordable Care Act exchanges last week. Today and Thursday, we’ll finally hear from some of the insurers as they testify before the Senate Health, Education, Labor and Pensions Committee, which is seeking a bipartisan plan to stabilize the Obamacare marketplaces.

It's these insurance companies that will truly determine the success or failure of the Obamacare exchanges by providing the plans and health coverage choices for millions of Americans. They weren't terribly involved in the GOP push to craft an Obamacare replacement, a break from their heavy participation in shaping the ACA leading up to its 2010 passage.

Now, insurers are going on the record with lawmakers. And they have their own demands and deadlines following the failure of the Republican-led Congress to pass its repeal-and-replace plan.

In testimony submitted last week, the powerful health insurance lobby, America’s Health Insurance Plans, laid out the urgency of the situation.

Two weeks from now, insurance companies will finalize their decisions about whether and where to sell insurance on the ACA exchanges next year, bringing to an end the ongoing saga about exactly how many counties will have little (or possibly no) choices next year.

In November, enrollment will launch for people to get insurance coverage for next year. And six weeks after that, by Dec. 15, insurers’ membership rolls for 2018 will be filled.

But health-policy watchers can't exhale after that — insurance companies will start crafting their plans for 2019 in about six months, if they haven't begun to already.

Large and small insurers will testify before HELP this week, including Kaiser Permanente and Anthem, to make their case for some kind of certainty in a political climate that has been far from stable.

I spoke yesterday with Susan Turney, the chief executive of the Marshfield Clinic Health System, which owns a health plan in northern Wisconsin with about 28,000 exchange members. Marshfield is one of the insurers that stepped forward at the last minute to fill a bare county next year, covering Menominee County in Wisconsin. And planning for 2019 is in full swing. Turney said that as early as two years before a plan year begins, companies must start making decisions about where and who they will cover.

Here are some of the things insurers want from lawmakers and the Trump administration as they determine how to move forward:

  1. Stop playing a game of chicken with federal subsidies that help lower-income people afford their deductibles and co-pays.

For months, the Trump administration has been threatening to stop paying obscure but important subsidies called cost-sharing reductions. They help defray the out-of-pocket costs, deductibles and co-pays for lower-income Americans. Cost-sharing reductions are one of the wonkiest parts of the ACA, but they have become headline news as a will-they-or-won’t-they drama unfolds each month about whether the payments will be made. Funding these payments – projected to be $10 billion next year -- is a top priority for many insurers. Turney said that about half her members benefit from the payments.Trump has opted to disburse the payments on a monthly basis -- but he's also made noise about stopping them.

  1. Extend a reinsurance program that provides payments to plans with high-cost members.

Turney said that these payments have been essential in keeping premiums down. Marshfield’s internal estimates show that premiums would have been 20 percent higher in 2014, 12 percent higher in 2015 and 6 percent higher in 2016 without the payments.

  1. Enforce the individual mandate, the requirement that people carry insurance, to make sure that it isn’t just the sick (and expensive) people who sign up for plans.

As one of his first acts as president, Trump signed an executive order that directed the government to relieve constituencies affected by the ACA — including consumers, doctors, insurers and hospitals. Experts think that the order allowed the administration to stop enforcing the individual mandate.

And, relatedly: Don’t pull back on the marketing and outreach to encourage people to sign up for insurance.

At the end of August, the Trump administration slashed grants to groups that help people sign up for insurance by 40 percent. AHIP noted that this was even more critical for 2018 because of a much earlier deadline to enroll — Dec. 15 instead of Jan. 1.

“In order to help our area residents afford coverage, we really have to make sure they understand this is available to them. It’s very complex, and it is very confusing, and we have to make sure we keep the navigator services,” Turney said.

Health insurers have plenty of other things on their wish lists. They'd like to abolish a tax that they say drives up premiums. They’d like to see states get greater flexibility and control over their marketplaces.

But the tricky thing about understanding the business of selling health insurance to individuals is that the situation can vary dramatically state by state and insurer by insurer. Some of the best-known names in health insurance — companies that didn’t traditionally focus on the business of selling individual insurance — dropped out of the marketplaces over the past year. Even as the financial outlook has been improving for those that have stayed, the insurers are buffeted by constant uncertainty and political rhetoric. Since the beginning of the month, Anthem has shrunk its participation in Missouri and Kentucky.

What insurers crave from politicians is certainty — a game with rules that won’t keep changing every time they think they’ve figured out how to play.

That still doesn't seem terribly likely.


AHH: The gang's all here. Sen. Cory Booker (D-N.J.) and Kirsten Gillibrand (D-N.Y.) became the latest Democrats to jump on board Sen. Bernie Sander’s (I-Vt.)’s “Medicare for All” bill -- otherwise known as a single-payer system -- being introduced this week.

Booker announced his support for the measure during an interview Monday with NJTV News (watch it above).

“You should not be punished because you are working-class or poor and be denied health care. I think health care should be a right to all. And I’m working on multiple pieces of legislation — Bernie Sanders, Medicare for All, I’m working with him on that to even some of my other senators who are just trying to get people opportunities to buy into Medicare," Booker said. “This is something that’s got to happen. Obamacare was a first step in advancing this country, but I won’t rest until every American has a basic security that comes with having access to affordable health care.”

Also on Monday, Sen. Jeff Merkley (D-Ore.) announced in a statement he would co-sponsor Sanders's bill. And Mic reported that Gillibrand intends to also become a co-sponsor.

"Health care should be a right for every single American, not a privilege reserved for the healthy and the wealthy,” Merkley said, adding that a single-payer system would "simplify health care and lower patients' costs."                                                           

Let’s refresh your memory on the latest news surrounding this plan: Sanders, who made single-payer health care a central promise during his presidential campaign, is set to unveil his measure on Wednesday. In the last two weeks, the defeated presidential candidate has gained the explicit endorsement of Sens. Kamala D. Harris (D-Calif.), Elizabeth Warren (D-Mass.) and now Booker, Merkley and Gillibrand.

What do these senators have in common? Many are considered top contenders to run for the Democratic presidential nomination in 2020.

The Post’s Aaron Blake included the five of them on his recent list of “The top 15 possible 2020 Democratic nominees, ranked.” In Aaron’s words, the single-payer dam is now breaking.

“This is about as far from a coincidence as you can get,” he wrote. "And it suggests the dam is breaking when it comes to the Democratic Party embracing government-run health care, also known as single-payer." The prominent endorsements, Aaron writes, "also [seem] to confirm that these senators have clear designs on running. The last thing any of them want is to see another candidate get to their left on this."

Meanwhile, Sens. Chris Murphy (D-Conn.) and Brian Schatz (D-Hawaii), have both come up with their own universal health-care plans following discussion with Sanders.

Post reporters have repeatedly written about the near-zero chance that a single-payer bill would pass in a Republican-run Senate. But nevertheless, there's a more-than-zero chance The Health 202 will continue to closely follow the Democrats who back it  as single-payer becomes a key litmus test in the 2020 sweepstakes.

OOF:  In a first-person piece for Vox, Elizabeth Brico writes about the setback that opioid addicts may face when a natural disaster like Harvey or Irma hits. Brico, a recovering heroin addict, is the author of Betty's Blog about living and parenting with PTSD. In her Vox essay, she notes that recovery for survivors of damaging storms isn't just about draining floodwater and repairing homes -- but access to methadone doses that help addicts stay clean. 

“It's awful. I haven't dosed in 5 days,” a woman named Clair wrote on Brico's Facebook feed. It happened so fast and took a turn for the worst so fast we didn't have time to prepare… Keep us in your prayers.” And then: “Today is day 6. I’m very sick.” Brico wrote that Clair stopped responding to replies after the sixth day.

She wrote about the restrictions around methodone, a long-acting prescription opioid that patients are prescribed as a replacement when recovering from addiction.

“When a natural disaster hits, these strict standards often become impossible to maintain amid the chaos. With so many people in acute danger, methadone quickly becomes deprioritized. Though state authorities sometimes allow for shelters and hospitals to dispense doses, or for clinics to allow patients to take the drug home, protocols vary from location to location. The stigma that drives the strict regulations still exists during a disaster.

And methadone is just one drug. Countless other pharmaceuticals are necessary for people to stay healthy during natural disasters. Storms, floods, and wildfires create unforeseen complications that can prevent people from accessing needed medication. These stories are too often overlooked.” 

OUCH: Washington Post reporter Christopher Ingraham details a troubling trend that was found in the latest National Survey on Drug Use and Health (which The Health 202 cited last week). Although adolescent marijuana use has declined in the years during which pot has been ncreasingly legalized, it’s adult use that’s spiking.

One caveat, Christopher writes: “In and of itself, the increase in adult marijuana use isn't particularly alarming. Public-health researchers are typically more worried about adolescent drug use, which can derail a young person's life. If more adults are smoking marijuana once or twice a year — even once or twice a month — it's not really a huge concern.”

What is a big problem, is “the number of people who are getting high all the time,” meaning people who smoke daily or near-daily. That number is on a steep incline. In 2016, nearly 19 percent of marijuana users said they used it at least 300 days that year. That’s up by about 50 percent since 2002. Ingraham also puts this in context of people who have an alcoholic drink near-daily: "According to the federal survey data, marijuana users are far more likely to use daily than drinkers are to drink daily," he writes. (See the chart below for the comparison:)


 --A movement is brewing to try to convince Sanders (the single-payer champion) to lead a “People’s Party,” writes our colleague Dave Weigel. On Friday, which was Sanders’ 76th birthday, dozens of members of the People’s Convergence Conference gathered on the National Mall to march to the Capitol to deliver a petition to Sanders’s Senate office.

Here’s how Weigel described the recent gathering: “Very few members of the media were on hand as the Convergence kicked off. Brana’s campaign, which Sanders has repeatedly (albeit politely) rebuffed, is the best-organized of several efforts to turn progressives away from the Democratic Party. It has the endorsement of Cornel West, perhaps the 2016 Sanders surrogate most adamant about leaving the party; and it has two clear narratives, which suggest that to stay inside the nation’s major liberal party is to accept permanent decline.”

One of these narratives is that voters don’t feel an allegiance to Democrats, and another is that Democrats can be replaced by another party “in the space of one or two elections.”

Weigel continues: “In interviews, several participants in the march said they were following Sanders’s work on single-payer health care; some viewed the draft campaign as an outside strategy, complementing Sanders’s inside strategy, and keeping Democrats honest and scared.” 

-- Not gonna happen: Lawmakers rejected President Trump’s proposal to slash funding from the National Institutes of Health, the New York Times reports, a bipartisan effort that is likely to lead to an increase in the agency’s budget.

“Lawmakers from both parties have joined forces to increase spending on biomedical research — and have bragged about it,” the Times’s Robert Pear reported.

The Senate Appropriations Committee passed a bipartisan bill providing $36.1 billion for NIH for the next fiscal year. The president had initially proposed cutting the health institutes funding by $7.5 billion, or 22 percent. House appropriators were less generous but nonetheless provided a $1.1billion increase in funding.

Pear writes that: “The audience erupted in applause when Senator Lamar Alexander, Republican of Tennessee, announced the increase at a hearing of a separate Senate committee.”

Republican senators also pushed back on the administration argument that overhead funds to universities that contribute to health research should be slashed, explicitly prohibiting a change to the current funding formula paying for such "indirect costs."

-- Declaration wanted: A month after President Trump announced his intent to declare the opioid epidemic a “national emergency,” a group of Democratic senators are urging him to actually do something about it.

“Your administration has yet to make such a declaration, leaving another unfilled promise to provide relief to the individuals and communities who continue to suffer,” reads a letter led by Sen. Edward J. Markey (D-Mass.) along with nine other Democrats.

“The Commission on Combating Drug Addiction and the Opioid Crisis you created, as well as public health and substance use disorder experts, support declaring opioid epidemic a federal emergency among other important recommendations,” they wrote. “However, your lack of action — coupled with your support of policies that would make access to substance use disorder care and treatment more difficult for millions of Americans — causes us to question your commitment to ending the opioid use disorder and overdose crisis.”  

The lawmakers then asked the president a series of questions, including “How will you ensure that any emergency declaration effectively removes barriers to substance use disorder care and treatment, such as Medicaid’s Institution for Mental Disease Exclusion?”

Along with Markey, the letter was signed by Democratic Sens. Sherrod Brown (Ohio), Sheldon Whitehouse (R.I.), Richard Blumenthal (Conn.), Maggie Hassan (N.H.), Elizabeth Warren (D-Mass.) Jack Reed (R.I.), Tammy Baldwin (Wis.), Cory A. Booker (N.J.) and Jeanne Shaheen (N.H.).


--At least 35 hospitals were forced to close their doors and evacuate due to Irma over the weekend. STAT News has a list of the closures here.

--The Post’s Amy Ellis Nutt has a debrief on how Florida’s hospitals fared following Irma's impact over the weekend. She writes that “doctors, nurses and staff at hospitals up and down Florida’s Gulf and Atlantic coasts were nearly breathless with surprise and relief.”

Steve Sonenreich, chief executive of Mount Sinai Medical Center in Miami Beach, credited the survival of the facilities to the tens of millions of dollars invested to strengthen the buildings following several hurricanes in 2005. Changes included hurricane-proof glass, and generators placed in structures that can withstand 180-mph winds.

Ellis Nutt wrote that hospitals in the Florida Keys were beginning to assess what could be greater damages, and a lack of accessibility made such reviews challenging. 

--The raging wildfires in states across the West have released a thick layer of smoke into the air, causing harmful conditions in a number of states: The Environmental Protection Agency’s AirNow website indicates “unhealthy for sensitive groups” and “unhealthy” conditions in parts of Washington Oregon, Montana, Idaho and into Canada.

"There's smoke from Canada, smoke from Idaho, smoke from California and Montana. There's smoke everywhere," Greg Svelund, a spokesman for Oregon's Department of Environmental Quality, told NPR.

The smoky skies can pose a health risk for susceptible people, Dr. Gopal Allada of Oregon Health & Science University told NPR.

 “For most people, the risk of any serious complications, like chest pain, irregular heart beat or even heart attack, is minimal,” NPR reported. “But for people who have underlying heart conditions or respiratory illnesses — such as asthma or chronic lung disease — exposure to wildfire smoke can be serious. Other high-risk groups include people over 65, children (whose lungs are still developing) and pregnant women, because of the risk to the fetus.”

And here are a few more good reads from The Post and beyond:



  • The Senate Committee on Health, Education, Labor and Pensions holds hearings on how to stabilize the insurance marketplaces today and Thursday.

  • The Hill hosts an event on “Turning Genes into Medicine.”

  • The Senate Finance Committee holds a hearing on health care cost and coverage.

Coming Up

  • HealthAffairs holds a briefing on “Understanding the Value of Innovations in Medicine” on Wednesday.

  • The Hill hosts an event on the opioid epidemic on Wednesday featuring Sen. Rob Portman (R-Ohio) and Rep. Paul Tonko (D-N.Y.)

  • The House Energy and Commerce Subcommittee on Health will hold a hearing on FDA’s regulation of over-the-counter drugs on Thursday.

  • The House Energy and Commerce Subcommittee on Health holds a hearing on “Examining Workforce Programs Under the Public Health Service Act” on Thursday.


Fact Check: Has the House passed more bills than it did during any recent president's first year?


President Trump's full remarks in remembrance of 9/11:

President Trump pledges resolve to 9/11 victims' families:

How animals remained safe during Hurricane Irma: