The Washington PostDemocracy Dies in Darkness

The Health 202: Trump's executive order has a history. And the government says it's not all great.

Placeholder while article actions load

with Paulina Firozi


Want to understand health policy? Get stories like this here.

President Trump intends to sign an executive order this morning expanding association health plans. But 25 years ago, federal watchdogs concluded that such plans ripped off hundreds of thousands of Americans by refusing to pay their medical claims while violating state insurance laws and even criminal statutes.

Back in 1992, the Government Accountability Office issued a scathing report on these multiple employer welfare arrangements (known as MEWAs; they’re pronounced “mee-wahs”) in which small businesses could pool funds to get the lower-cost insurance typically available only to large employers.

These MEWAs, said the government, left at least 398,000 participants and their beneficiaries with more than $123 million in unpaid claims between January 1988 and June 1991.

Furthermore, states reported massive and widespread problems with MEWAs. More than 600 plans in nearly every U.S. state failed to comply with insurance laws. Thirty-three states said enrollees were sometimes left without health coverage when MEWAs disbanded.

In one of the most egregious cases, a California-based MEWA called Rubell Helm Insurance Services enrolled thousands of Florida residents without their knowledge but failed to pay any large claims.

“MEWAs have proven to be a source of regulatory confusion, enforcement problems and, in some instances, fraud,” the GAO wrote at the time.

Expect the president to describe such plans quite differently today after his expected signing of the executive order aimed at making it easier for association health plans to form, operate across state lines and duck coverage regulations under the Affordable Care Act.

Association health plans -- which are basically MEWAs that are tied to a trade association (such as the U.S. Chamber of Commerce) -- have been around for a long time, but had to operate in a single state and were subject to ACA regulations under Obama-era rules. Trump is seeking to broaden their ability to function by instructing a trio of Cabinet departments to rewrite the federal rules governing them. In these arrangements, a trade association acquires health coverage that small businesses, individuals or nonprofits could buy into.

Trump and some Republicans are billing these association health plans as a way to offer lower-cost options to consumers amid an otherwise toxic ocean of Obamacare regulations, which they’ve been unable to repeal and replace (read my rundown of them here.)

By purchasing insurance through associations, small businesses and individuals could potentially duck the ACA's coverage requirements — including its 10 “essential health benefits” — that don’t apply to large group plans. Republicans say this will lead to lower-cost health insurance and the ability of Americans to choose from a broader array of insurance options that better fit their needs.

Trump said this in an interview last night with Fox News' Sean Hannity, per Politico's Dan Diamond:

Of course, the details of the anticipated executive order will matter. One of the biggest problems with association plans – according to the GAO – is that they often flew under the radar of state insurance regulators.

“At the heart of regulation and enforcement problems is the fact that state regulators are often constrained by the inability to identify MEWA until after MEWA problems occur,” the report says.

Sometimes plans tried to duck regulations entirely, the agency found. Forty-two states said MEWAs had claimed exemption from state laws under the Employee Retirement Income Security Act (ERISA) of 1974, which had allowed MEWAs in the first place. Courts mostly sided with the states in these legal battles, but they still cost states large amounts of staff and time.

These problems are partly why the Obama administration actually cracked down on association health plans as it was implementing the ACA. In 2011 guidance, the Department of Health and Human Services said association plans must comply with the health-care law’s consumer protections just like any other individual or small group plan.

Yet Trump is now poised to rewrite the rules, turning to the 43-year-old idea of association health plans -- which the government has found some serious problems with in the past -- as his way of reshaping Obama’s ACA.

“What is old is new again,” as one health-care consultant told me.


AHH: Grubb's, Washington's oldest community pharamacy, has sent drugs by carload to the U.S. Capitol nearly every day for at least two decades in an arrangement so under the radar that even pharmacy lobbyists who regularly pitch Congress aren’t aware of it, Stat News reports.

"The deliveries arrive at the secretive Office of the Attending Physician, an elaborate medical clinic where Navy doctors triage medical emergencies and provide basic health care for lawmakers who pay an annual fee of just over $600," Erin Mershon writes. "Mike Kim’s tiny pharmacy — which, at its busiest, sends as many as 100 prescriptions to members in a day — is nestled among Capitol Hill’s stateliest row houses, less than four blocks from the Capitol building itself. Founded in 1867 and named for a previous owner, the pharmacy predates penicillin, the American health insurance system, and even the Lincoln Memorial."

"The pharmacy mostly serves the staffers, lobbyists, and families who make their home in the quiet, leafy neighborhood just to the east of the Capitol building, though Grubb’s five drivers will deliver prescriptions across the entire city," Erin continues. "The relationship between Grubb’s and the Capitol has gone nearly unchanged for decades, even as congressional leaders have pushed again and again to overhaul the nation’s broader health care system."

"For the most part, lawmakers get the same prescription delivery service that any other customer of Grubb’s does. The pharmacy still bills each lawmaker’s insurance plan, whether it’s Obamacare, Medicare, or a local plan back in their district. Grubb’s keeps credit card information on file for copays and other purchases. There aren’t any discounts, Kim said. No special treatment."

OOF: Fentanyl is becoming the new normal for heroin buyers in places like Chicago and Charleston, W.Va. It and other opioid painkillers are now the leading cause of overdose deaths nationwide, killing more than 21,000 people last year, BuzzFeed News reports. Prescription painkillers are increasingly accounting for the country's surge of drug overdose deaths, according to provisional CDC data. 

"Underneath the total increase is the surge in deaths dues to fentanyl and related synthetic opioids, more powerful relatives of heroin and morphine," Dan Vergano reports. "Widely tainting the illicit drug supply of heroin and counterfeit pain pills, these synthetic opioids doubled their share of the previous year's already alarming overdose toll, according to the new data, which is provisional, with final mortality figures expected in December."

"The increase is remarkable because fentanyl only arrived in the illicit drug supply in a noticeable way around 2012, and has now raced ahead of drugs usually responsible for overdose deaths," Dan writes. "Fentanyl is roughly 50 times more potent than morphine and about 10 times more potent than heroin."

OUCH: People who visit emergency rooms for routine medical care -- instead of going to a doctor's office -- contribute to the country's massive health-care spending, which far outpaces other developed countries. Major insurer Anthem is trying to shift behaviors by refusing to pay for non-emergency medical conditions treated in the emergency room in three states, Healthcare Finance reports.

The policy was rolled out in Georgia and Missouri this summer and has been in place in Kentucky since 2015, according to Anthem. The company said it's still evaluating how it will apply the policy in Ohio. The policy applies only to non-emergency care, where a primary care doctors is generally the most appropriate caregiver, Anthem said.

"The primary focus of this program is to promote appropriate care settings for members when they have a non-emergency medical condition," Anthem said in a statement. "It's about getting our members the right care at the right time. If a member feels he or she has an emergency, they should always call 911 or go to the emergency room."

Who's opposed? The American College of Emergency Physicians, which says members and doctors don't always know when a medical condition is a real emergency until after the patient is seen. One condition on Anthem's non-emergency list is unspecified chest pain, which be caused by something as mild as heartburn or as serious as a heart attack or stroke.


--Conservative activists attacked Senate Majority Leader Mitch McConnell (R-Ky.) for his lack of legislative accomplishments this year -- most chiefly, his failure to rally Senate Republicans around a plan to replace Obamacare.

"A constellation of conservative leaders issued a joint call for McConnell and his top deputies to step down, marking the latest round of criticism the Kentucky Republican has received from members of his party," The Post's Sean Sullivan, Karoun Demirjian and Michael Scherer write. "The developments, coming in the middle of a week-long Senate recess, raised new questions about the trajectory of the intensifying war for the soul of the Republican Party and further blurred the battle lines within it. The complex struggle is expected to affect not only the midterm campaigns, but also the ongoing GOP attempt at a sweeping rewrite of the nation’s tax laws.

In a letter to McConnell, six hard-right activists vented frustration with McConnell and his leadership team. “It is time for you and your leadership team to step aside, for new leadership that is committed to the promises made to the American people,” says the letter, signed by Media Research Center Brent Bozell, Senate Conservatives Fund president Ken Cuccinelli, Tea Party Patriots co-founder Jenny Beth Martin, FreedomWorks president Adam Brandon, For America president David Bozell and Richard Viguerie, the chairman of


Liberal groups are seizing on the insurance rollbacks in the GOP health-care bills and the Trump administration's move to exempt more employers from offering birth control coverage as they seek to galvanize women voters ahead of next year’s midterm elections, my colleague Elise Viebeck reports.

"Organizations such as Planned Parenthood Action Fund and Emily’s List believe the Trump administration handed them a potent political issue Friday when it carved out wide exceptions to the Affordable Care Act’s promise of no-cost contraception," Elise writes. "Activists plan to link this action to congressional Republicans’ repeated attempts to undercut the ACA in ways that could have caused millions to lose health insurance, as part of a broader strategy focused on defeating moderate GOP members and buttressing vulnerable Democrats."

President Trump's rollback of contraception coverage is rallying his opponents on the left to promote a pro-woman message in the 2018 elections. (Video: Jenny Starrs/The Washington Post)

--Democrats are eager to capi­tal­ize on women’s anger toward the Trump administration and congressional Republicans in a cycle that could be punishing for Democratic Senate incumbents, as the party defends 10 Senate seats in states won by President Trump — five in states he won by double-digits.

"By framing their message around health-care access, strategists hope to appeal to women voters who might not see themselves as part of the anti-Trump 'resistance,' but who opposed GOP health-care proposals this spring and summer," Elise writes. "Activists said the 2018 cycle is ripe for strong, pro-woman messaging in light of mounting sexual harassment scandals like the one engulfing Hollywood mogul Harvey Weinstein, which remind women of their continued vulnerability to discrimination, and Trump’s poor approval ratings with female voters."

Some more reads from The Post and around the World Wide Web:

Blackburn calls Twitter ad reversal 'our first Senate conservative victory' (Politico)


VA conceals shoddy care and health workers' mistakes (USA Today)

The fertility testing racket just got debunked by science (Vox)

FDA bans free samples of e-cigarettes (The Hill)


FDA Chief's Fans Hope He Gets Passed Over for Promotion (CQ)



  • The U.S. Chamber of Commerce holds an event on the opioid epidemic.

Coming Up

  • ​​​​​​​Axios hosts an event on what's next for health care with Sens. Lamar Alexander (R-Tenn.), Bill Cassidy (R-La.), and Tim Kaine (D-Va.) on October 18. 

See Seth Myers on Eminem's Trump ultimatum:

This drone has images of the California wildfires:

Putin gets a puppy for his birthday: