THE PROGNOSIS

Health insurers heading into the 2018 Affordable Care Act enrollment season say they’re staying laser focused on maximizing sign-ups, even as Republicans remain in disarray and even denial over the seven-year-old health-care law.

A big funding infusion that could help lower ACA premiums is in flux just 12 days before enrollment starts. There's an array of possible outcomes here: Congress could vote to fund the cost-sharing reduction payments, known as CSRs, possibly through passing a compromise measure crafted by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.). It was embraced by two dozen Senate Democrats and Republicans yesterday, although there's significant pushback among conservatives in the House.

Or, a federal judge could rule next week that the Trump administration is required by law to resume the payments, in a court challenge filed by 19 states. The Department of Health and Human Services had cut them off last week, saying it didn’t have constitutional authority to pay them without an appropriation from Congress.

Yet insurers are moving forward. They're more immediately worried about consumer confusion stemming from the debate over halting the CSRs, especially given the administration’s recent cuts to outreach and advertising.

“They’re focused on open enrollment and how do we ensure in this environment, where we’ve had so much uncertainty, that consumers know where to get their plans,” said Kristine Grow, spokeswoman for America’s Health Insurance Plans. “That’s kind of job No. 1 as we’re standing here today.”

Individual insurers expressed similar sentiments to me. Neil Heller, vice president of sales and marketing for Piedmont Community Health Plan -- which covers about 5,000 marketplace customers in Virginia -- acknowledged the possibility the payments could be restored, either through court order or congressional action. But present reality must govern the company’s actions, given the political volatility, he said.

“Until we hear differently, that’s really the only course of action that we can undertake,” Heller said. “In the absence of any new information, we are executing on what has been approved and what are the current requirements.”

Trump appeared to tout an alternative reality this week, insisting on multiple occasions that the ACA no longer even exists.

“It’s dead. It’s gone. It’s no longer — you shouldn't even mention. It’s gone,” Trump said in the Rose Garden on Monday.

At a Tuesday White House news conference, Trump called the ACA “virtually dead” and “in its final legs.” “There’s no such thing as Obamacare anymore,” the president said.

The marketplaces certainly aren’t dead, as Trump has claimed. But they’re not as healthy as in prior years, either. Almost all of the big, publicly traded insurers have bailed under heavy losses, leaving the not-for-profit plans remaining, some of which are the only insurer in the more rural U.S. counties.

When the marketplaces first opened in 2014, three out of four shoppers had access to at least three plans, according to data from the Kaiser Family Foundation. Just six percent had only one plan to choose from. This year, just 58 percent of shoppers had at least three plans to choose from. More than one in five (21 percent) had only one option.

Trump’s claims that Obamacare has collapsed — coupled with months of headlines about dismantling the ACA and the possibility the administration would cut off the CSRs — mean insurers are encountering even more consumer confusion than usual about their coverage options.

“Whenever our members hear in the media that these things are going away, their immediate thought is ‘Oh my gosh, does this affect me now?’” said Melanie Coon, a spokeswoman for Premera Blue Cross, which participates in Alaska and Washington state’s marketplaces.

“So we try to think from that perspective: What are our members going to do when all they hear is their subsidies are going away and their costs are going up?” Coons said.

Fortunately for Premera, it had already submitted to regulators a set of premium rates assuming the CSR payments would be cut off. Insurers have said they’re generally raising premiums by 15 to 20 percent to account for the loss of the subsidies, which compensate them for discounting costs for the lowest-income marketplace enrollees.

The Trump administration has yet to release final rates and insurer participation for HealthCare.gov. So far, no insurers have decided to exit the marketplaces last-minute, even though they now appear to be losing the subsidies. But all the uncertainty could take its toll in 2019, said Ben Isgur, head of PwC’s Health Research Institute.

“You’re really kind of sitting there with a lot of uncertainty,” Isgur said. “For some insurers who are sitting on the bubble, maybe they haven’t been doing very well in the exchanges, this may be the last door for them to exit.”

The situation could further worsen after the 2018 enrollment period, which some have described as a perfect storm, with fewer enrollment dollars, a halved time frame and heightened uncertainty. That’s why insurers say for now, they’re just focusing on the next two months.

“I think the truest answer from any insurer is we can only approach this a year at a time,” Heller said.

AHH, OOF and OUCH

AHH: There's an unintended consequence of halting the CSR payments that Trump may want to consider. Because insurers are raising premiums to compensate for the loss, the government must shell out more in premium subsidies. And that would actually make certain plans more affordable for some marketplace shoppers.

It's kind of like pushing on a see-saw: you push down on one end and the other end goes up. "The subsidy for premiums is designed to increase with the rising price of insurance," the AP explains. "So government spending to subsidize premiums would jump." And then the counting gets weird. The Urban Institute has estimated that "richer premium subsidies could entice up to 600,000 more people to sign up for health law coverage. That depends on how insurers and state regulators adjust, which isn’t totally clear yet."

So cutting off the CSRs "would have the unintended consequence of making free basic coverage available to more people, and making upper-tier plans more affordable," the AP writes. "The unexpected assessment comes from consultants, policy experts, and state officials, who are trying to discern the potential fallout from a Washington health care debate that’s becoming even more complicated and volatile."

OOF: Some of the biggest American and international pharmaceutical companies were offering substantial kickbacks and free medication to Iraq's health ministry while a group of terrorists engaged in violence against U.S. interests were running it, alleges a lawsuit that has just hit the federal courts. The lawsuit, which involves subsidiaries of the largest medical brands in the world: AstraZeneca, General Electric, Johnson & Johnson, Pfizer and Roche, claims such actions were violations of the Anti-Terrorism Act.

The 203-page suit, filed in the U.S. District Court for the District of Columbia on behalf of 108 plaintiffs, seeks to hold the corporations responsible for the deaths and injuries of U.S. service members between 2005 and 2009, The Post's Kyle Swenson reports. The businesses "obtained lucrative contracts from that ministry by making corrupt payments to the terrorists who ran it," the complaint argues. "Those payments aided and abetted terrorism in Iraq by directly financing an Iran-backed, Hezbollah-trained militia that killed or injured thousands of Americans."

In those first years following the defeat of Saddam Hussein, the walls of the health ministry headquarters in Baghdad were covered with hundreds of photos of scowling Shiite clerics. "Banners proclaimed 'Death to America and Israel' and 'we must destroy the occupiers,'" Kyle writes. "Death squads commandeered the ministry’s ambulances for missions to hunt Sunnis. Assault rifles were stacked in offices. The morgues were used for torture...The government office was so thoroughly infested that in 2007 Gen. David Petraeus, then in command of U.S. forces in Iraq, admitted Sadrists had 'effectively hijacked the Ministry of Health. And yet at the same time, American and international pharmaceutical companies were regularly doing business with it.

OUCH: A North Korean official apparently believes Trump is mentally ill, according to NBC correspondent Kier Simmons. “He quite plainly said he believes President Trump is mentally ill,” Simmons told “Morning Joe” co-hosts Mika Brzezinski and Joe Scarborough on Thursday, referring to a lieutenant colonel he'd interviewed. 

 “They [North Korean officials] are saying what a lot of people are thinking, that the president is mentally ill. It's considered inappropriate to say,” responded Brzezinski, who Trump publicly insulted a few months ago.

HEALTH ON THE HILL

--Yesterday, Democrats pressed to advance the Alexander-Murray bill to fund CSR payments amid a new show of cooperation, even as Republican leaders suggested they would need greater concessions before bringing it up for a vote, my colleagues Sean Sullivan and Juliet Eilperin report. The duo said there are 12 Republican and 12 Democratic co-sponsors for their measure. 

"Many conservative Republicans, including congressional leaders, have expressed skepticism about passing legislation that would roll back the ACA in a meaningful way," Juliet and Sean write. "Although the bill does make it easier for states to obtain federal waivers to change the way their markets operate and allows ACA consumers ages 30 and older to buy catastrophic health plans, it preserves the law’s core mandates....Speaking on the floor Wednesday, Alexander said those conservatives were ignoring the 'chaos' that could ensue if the federal government did not provide the cost-sharing reduction payments that Trump cut off this month."

“What’s conservative about unaffordable premiums?” he asked.

Even as Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) announced their sponsors — which included conservatives and liberals, as well as centrists from both parties — No. 2 Senate Republican John Cornyn (Tex.) argued that the plan must undergo changes and win the clear support of Trump before it can succeed.

“It takes the president’s support, would be the first thing it would take,” Cornyn said. “I know they’ve got bipartisan co-sponsors. Senator Alexander is a very methodical, very thoughtful guy. He understands that there are going to need to be changes to be — before [the bill is] going to get a critical mass of support.”

Meanwhile, Trump suggested that he was “open” to authorizing the payments — but had not given up his goal of repealing the ACA. Alexander said Trump called him twice yesterday and both times encouraged him to continue working on a deal. The president told reporters that although he prefers providing federal health funding in a block grant to states, he is open to a different approach for a finite period.

“We will probably like a very short-term solution until we hit the block grants, until that all kicks in,” Trump said. “And if they can do something like that, I’m open to it, but I don’t want it to be at the expense of the people. I want to take care of our people; I don’t want to take care of our insurance companies.”

REPRODUCTIVE WARS

While abortion is still a common experience — with one in four women undergoing it by age 45 — rates have fallen by 25 percent in recent years, The Post's Ariana Eunjung Cha reports. In 2008, there were 19.4 abortions per 1,000 women ages 15 to 44. By 2014, the number had dropped to 14.6 per 1,000.

During that period, numerous states — including Indiana, Kansas, Texas and North Carolina — enacted new restrictions, waiting periods or mandatory ultrasounds for women considering abortions in those states, Ariana reports. In other parts of the country, the ACA's Medicaid expansion helped women who might not otherwise have been able to get an abortion get insurance coverage for one.

But the Guttmacher Institute, a research group that supports abortion rights, suggests the decline in abortion was driven by improvements in contraceptive use. “Definitive data on unintended pregnancies for that period isn't available yet, but there are other indicators that support this theory,” Ariana writes. “The teen birthrate, for one, has been declining, hitting an all-time low in 2014, according to Centers for Disease Control and Prevention data. Experts have credited better access to contraception and more convenient and reliable contraception than in the past. They have also suggested that many teens may be having less sex.”

Some more reads from The Post and beyond:

MEDICAL MISSIVES
Top Republicans trying to push a partisan agenda are running smack into another complication: the sheer age and health issues of some senators.
Stat News
The Department of Veterans Affairs inspector general has reported launched a criminal investigation.
Samantha Schmidt
Susan G. Komen will hold its fundraising event in January aboard a cruise ship after pulling its gala from President Donald Trump’s Mar-a-Lago club.
Palm Beach Post
SECOND OPINION
The law simply requires warning before shutting down an opioid distributor.
Orrin Hatch
DAYBOOK

Coming Up

  • The House Natural Resources Committee is scheduled to hold an oversight hearing on Puerto Rico's recovery on October 24.
SUGAR RUSH

Watch George W. Bush's full 'Spirit of Liberty' speech:

The Melania Trump impostor rumor, according to the Internet:

Listen to Trump's conversation with a Gold Star family:

The Daily Show's Trevor Noah takes on President Trump's feuds with Gold Star families: