with Paulina Firozi


The Trump administration’s move to dramatically slash Healthcare.gov advertising could translate to at least 1.1 million fewer people signing up this year, says the Obama appointee who ran marketing for the federal-health insurance website in 2016.

Josh Peck -- who served as Healthcare.gov’s chief marketing officer under the former president and now heads up the group Get America Covered -- estimated how many fewer Americans might enroll in the Affordable Care Act marketplaces in 2018. He did so by applying what he learned about past signup periods in which the Obama administration spent 10 times what the current administration says it will now invest.

“Surprise: advertising works!” Peck writes in a report provided to The Health 202.

The Department of Health and Human Services announced in August it will gut the marketing budget for enrollment in the marketplaces, spending just $10 million on promoting the law during the upcoming enrollment period that runs from Nov. 1 to Dec. 15. Officials argued the ACA's shortcomings and diminishing returns from the advertising justify the cuts.

Here’s the biggest consequence of those cuts, according to Peck: HHS won’t have enough money to buy national TV ads -- the most expensive method of advertising but also the most effective at convincing people to buy plans on Healthcare.gov. In the past, such advertising was responsible for nearly 40 percent of enrollments directly resulting from outreach, he writes.

Of course, there are web ads, too. Peck writes that in past years, about a quarter of outreach-driven new enrollments resulted from the online ads that pop up when people search for terms like “health insurance.” Given the budget HHS has outlined, the agency will have to dramatically scale back these kinds of ads as well, perhaps by 75 percent, Peck writes.

And fewer TV and digital ads will have a dampening effect on the most cost-effective forms of advertising, such as emails and phone calls. Together, they’ve been responsible for 30 percent of outreach-driven new enrollments, according to Peck.

If HHS collects fewer email addresses and phone numbers from new potential customers, it will have a harder time attracting first-time enrollees versus reminding existing customers to complete their enrollments. Peck estimated that compared to last year, emails and phone calls will be 85 percent as effective on returning customers and 60 percent as effective on new customers.

“Sending email and making calls costs very little, but both tactics are dependent on people coming to Healthcare.gov and signing up,” Peck writes.

On top of all this, the signup season is half the length of last year's – just six instead of 12 weeks – meaning call centers could receive a much heavier load.

The marketplaces were already struggling with premium spikes and fewer insurance options in a given area for customers -- but that was before these new challenges. The shorter enrollment period, combined with reduced HHS marketing and less dollars for health-care navigators (nonprofit groups that get grants to advertise the ACA) could translate into the perfect storm for the beleaguered law, which Republicans have tried and failed to repeal. President Trump has put further stress on the marketplaces by refusing to reimburse insurers for cost-sharing discounts for low-income Americans.

If Peck’s estimate is right – and 1.1 million fewer Americans sign up on Healthcare.gov this year – it would be a big setback for the marketplaces, where 9.2 million people chose coverage during the 2017 enrollment period. And the people who opt out of coverage are likelier to be the healthier ones who could improve the risk pools -- sicker people are thought to be more likely to actively seek coverage despite the lack of advertising.

Peck stresses that he’s not pulling that number out of thin air. Contrary to claims by the Trump administration, HHS closely measured the effects of outreach during prior signup periods, so the agency has a body of data to inform its present decisions.

The analysis “tells us what worked and how many enrollments were generated per dollar spent,” Peck writes. “Television, radio, digital ads, search advertising, emails, phone calls, mobile ads, direct mail and more drive enrollments.”

--PROGRAMMING NOTE: JOIN ME on Wednesday at 9 a.m. at The Washington Post as we kick off The Health 202 Live, a new interview series. Leading lawmakers and policy experts will talk about what’s next for health care reform and what it means for your coverage. RSVP here.


AHH: The uninsured rate is creeping upward again. A Gallup poll finds that 12.3 percent of the U.S. population lacks health coverage, up 1.4 percentage points since this time last year. It's first such rise since the ACA took effect in 2014, representing 3.5 million Americans who are either declining to buy coverage or unable to afford it.


OOF: Millions of Americans with ACA insurance could find themselves locked into health plans they don't want because of the Trump administration's schedule for auto-enrollment notices, The Post's Amy Goldstein reports. If current enrollees don't actively select a new plan, they'll be auto-enrolled in their current plan. But they won't be notified until after the sign-up season has ended.

"Auto-enrollment will occur immediately after the last day of the ACA sign-up season, which the Trump administration has shortened, leaving the vast majority of such consumers stranded without any way to switch to a plan they might prefer," Amy writes. "How the renewal of current customers in ACA marketplaces will be handled is one of several crucial questions about aspects of the imminent enrollment period that have remained murky as Nov. 1 approaches."

According to a CMS document, “Consumer Timelines,” obtained by Amy, the automatic re-enrollment will take place starting Dec. 16, the day after open enrollment ends. "That is the same date as the past three years, but before, when the sign-up period lasted until Jan. 31, consumers had time to go into HealthCare.gov, the website for the federal insurance exchange on which most states rely, and either shop for a more affordable plan or drop their coverage," Amy writes.

Administration officials didn't specifically confirm the auto-enrollment date but issued this statement: “Similar to Medicare’s open-enrollment period, if you miss the deadline to enroll in a plan of your choice, you will not be able to make any changes to your plan until the next coverage year” except for a small number of people eligible for a special enrollment period because of moves, marriages, new babies or other life changes."

OUCH: Trump blindsided his own administration when he publicly announced last week that he'd soon declare the opioid epidemic a national emergency, Politico reports.

"Officials are now scrambling to develop such a plan, but it is unclear when it will be announced, how or if it will be done, and whether the administration has the permanent leadership to execute it," Brianna Ehley, Josh Dawsey and Sarah Karlin-Smith report. "Trump’s off-script statement stunned top [HHS] officials, who said there is no consensus on how to implement an emergency declaration for the drug epidemic, according to interviews with officials from the White House, a half dozen federal agencies, state health directors and lobbyists.

"Trump had previously promised an emergency declaration in August, after his handpicked opioid commission headed by New Jersey Gov. Chris Christie made it an urgent recommendation," they write. "But the commitment quickly got bogged down in White House infighting and concerns about the order’s scope and cost...Members of Trump’s Domestic Policy Council, budget director Mick Mulvaney and former HHS Secretary Tom Price opposed the plan for months because of the multibillion-dollar price tag, legal issues and questions about how it would be implemented."

"Everyone wants opioids to be a priority, but there's a lot of resistance to calling it an emergency," one senior administration official told Politico. 


ON TAP THIS WEEK, NEXT MONTH OR MAYBE NEVER: An ACA marketplace stabilization bill that Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are trying to advance. The measure would fund extra subsidies (known as cost-sharing reductions) for two years and provide states with more flexibility to run their marketplaces in alternative ways. Democrats are lining up behind the bill: Senate Minority Leader Chuck Schumer (D-N.Y.) said yesterday that all 48 members of his caucus support it, and urged his GOP counterpart, Senate Majority Leader Mitch McConnell (R-Ky.), to bring it to the floor.

“This is a good compromise,” Schumer said on NBC's "Meet the Press." “It took months to work out. It has a majority. It has 60 senators supporting it. We have all 48 Democrats, 12 Republicans. I would urge Senator McConnell to put it on the floor immediately. It will pass, and it will pass by a large number of votes.”

McConnell said yesterday that he's ready to move on the bill -- but first needs clarity from Trump on what he is willing to sign.

“What I’m waiting is to hear from President Trump what kind of health-care bill he might sign,” McConnell said in an interview on CNN’s “State of the Union.” “I think he hasn’t made a final decision. When he does, and I know that we’re not just debating it, but actually passing something to be signed, I would be happy to bring it up.”

Watch McConnell's interview: 


--But Trump isn't providing the clarity McConnell wants. In an interview yesterday with Fox News, when asked whether he had "soured" on the Alexander-Murray bill, the president appeared to suggest the Health and Human Services secretary can already accomplish the bill's specifics. That is technically true --  except that Trump's own administration has cut off the CSRs, which was why Alexander-Murray was needed to begin with.

"I know that Lamar Alexander’s a fine man and he is really in there to do good for the people," Trump said. "We can do pretty much what we have to do without, you know, the secretary has tremendous leeway in the -- under the Obama plans."

"We can pretty much do whatever we have to do just the way it is," the president added. "So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare ... And I think we actually have the votes. People are criticizing me for saying that. I think we actually have the votes for that. You know, we were basically one short and I think we’re going to have the votes for that also, Maria."

Trump also promised a successful health-care vote via Twitter:

On Fox, Trump even suggested that getting a tax code rewrite will be easier because of the GOP's failure to repeal and replace the ACA.

"So we’ll see what happens but I do believe we have the votes for health care at the appropriate time," he said. "And I think we’re going to have the votes for taxes and I will say the fact that health care is so difficult, I think, makes the taxes easier. The Republicans want to get it done and it’s a tremendous tax cut. I mean, especially for the middle class and especially for business."

The White House also signaled that it wants Alexander-Murray to suspend enforcement of the ACA's individual mandate to buy coverage and the employer mandate to provide it, my colleagues Juliet Eilperin and Sean Sullivan scoop. If added, such changes would push the Alexander-Murray bill in a rightward direction that would almost certainly anger Democrats and jeopardize the bill's chances of passing.

"The individuals briefed on what the White House privately signaled to Senate Republicans ... said that nothing was final and that the negotiations were ongoing and could change rapidly," Juliet and Sean write. "While the moves were part of what could become a more extended negotiation, the White House requests — which also include providing states with broader leeway — could derail the carefully crafted bipartisan package unveiled this week."

The White House is also interested in adding language to expand “association health plans,” which the president has sought to expand through an executive order this month. Such plans could potentially allow individuals and small businesses to buy coverage that are exempt from some ACA regulations.

Alexander called the administration's requests a "normal legislative process with people of different views saying what they are for and against. "Something close to the Alexander-Murray proposal is likely to become law this year because the president himself asked us to develop this short-term solution so people aren’t hurt by a chaotic insurance market," he said in a statement.

But Schumer said the administration, which was involved in the Alexander-Murray negotiations, should support that bill instead of floating "other ideas that would further the sabotage both parties are trying to reverse.”

-- In the department of divided government, meanwhile, the IRS says it will return tax forms in which the filer doesn't disclose whether they are exempt from the individual mandate or plan to pay the penalty. From The New York Times: "Legal experts say the I.R.S. has been clear that the law was in effect, despite repeated efforts by Mr. Trump and Republican lawmakers to repeal it. Congress would have to specifically repeal the mandate, they say, even if the administration has significant leeway over how aggressively it enforces it."

A few more good reads:


POST PROGRAMMING: The Washington Post hosts a kick-off event on Wednesday for The Health 202’s Live series with an event featuring Sens. Bill Cassidy (R-La), Chris Murphy (D-Conn.), Gov. Matt Bevin (R-Ky.) and several other leaders in the health care community. Register here and sign up for a live stream notification here.


  • The Milken Institute hosts the “Future of Health Summit.”

Coming Up

  • The Hill hosts an event on America’s Opioid Epidemic on Aging and Addiction on Tuesday.
  • The House Energy and Commerce Subcommittee on Oversight and Investigations holds a hearing on HHS’s Public Health preparedness for and response to the 2017 hurricane season on Tuesday.
  • The House Energy and Commerce committee holds a hearing on federal effort to combat the opioid crisis on Wednesday.

Five former presidents took part in concert for hurricane relief efforts:

All five living former U.S. presidents attended a concert in Texas benefitting hurricane relief efforts on Oct. 21. (Reuters)

'Trump just keeps merrily going along': For Trump accusers, nothing has changed:

After Harvey Weinstein's fall, Trump accusers wonder why not him too. (Alice Li/The Washington Post)

Former presidents break tradition in denouncing Trump-era politics:

Former presidents make veiled criticisms of President Trump's leadership style. (Joyce Koh/The Washington Post)

Northern Michigan University offers first degree in marijuana:

Northern Michigan University is the first known university in the U.S. to offer a four-year degree in the study of marijuana. (Amber Ferguson/The Washington Post)