"It's complicated” is a good way to characterize the Trump administration's approach to the Affordable Care Act.

Much ink has been spilled on how the Department of Health and Human Services is trying to undercut the ACA by rolling back marketing efforts, highlighting its premium hikes and cutting off extra subsidies for cost-sharing reductions (CSRs). Former HHS secretary Tom Price publicly disparaged the law, as does Seema Verma, administrator for the Centers for Medicare and Medicaid Services. Republicans have spent seven years talking about the health-care law in such black-and-white terms that it's easy to view the federal agencies overseeing it as one big monolith. 

Feeding this whole narrative, President Trump has recently become fond of proclaiming the law “dead.” Just hours after his inauguration, he signed an executive order directing all the federal agencies to pare back Obamacare as much as possible within legal parameters.

The reality, however, is in shades of gray. Yesterday, the government rolled out a window-shopping feature on, allowing consumers to view plan options and prices ahead of time (although they won't actually be able to sign up until Nov. 1.) That feature, which was begun by the Obama administration but which HHS isn't required to offer, is a consumer-friendly move that won praise from even the administration's staunchest health-care critics.

“For the first time since the Trump administration came into office you have seen a commitment to customer service that I didn't know they were going to have,” Lori Lodes, former CMS communications director under Obama and spokeswoman for Get America Covered, told me.

From Lodes: 

CMS outlined some more details yesterday about its approach to the sign-up period, which will run from Nov. 1 to Dec. 15. Along with window-shopping, will continue to offer "waiting rooms" where shoppers can linger at high-traffic times when the website has reached its capacity. And will present consumers with a new option in which they can choose to have an agent or broker in their area contact them directly for assistance.

“This year CMS is taking a strategic and cost-effective approach to inform individuals about open enrollment,” the agency said in a statement yesterday. “CMS continues to use consumer feedback to drive improvements.”

There was also widespread speculation about whether the IRS would enforce the individual mandate for Americans to either buy coverage or pay a fine -- the least-popular part of the ACA and the most disparaged by Republicans. But the agency recently indicated that it's cracking down, posting an online statement last week that it won't accept tax returns that fail to indicate whether the filer met the coverage requirements or qualified for an exemption. 

The IRS under Obama had accepted tax returns without that information, although the agency had said that this year it would start returning forms that lacked the required details.

These actions reflect the fact that, despite Trump's top-line messaging about the ACA, multiple federal agencies with thousands of federal workers — most of them career employees not political appointees — all play a role in how the health-care law is implemented. The ACA's text gives wide latitude to the federal branch, and there is not one central philosophy governing how it's being carried out in all its various facets.

There's even an example of how the president's decision to cut off CSRs might lead to an unexpected -- and positive -- outcome for lower-income consumers. The loss of the payments is prompting insurers to hike premiums for mid-range "silver" coverage -- the type of plans consumers had to buy to get the cost-sharing discounts. Higher silver plan premiums translate to more generous premium subsidies, since that's how the subsidies are calculated. Shoppers between 133 and 400 percent of federal poverty can get their premiums partially subsidized.

From the New York Times's Margot Sanger-Katz:

From Business Insider's Josh Barro: 

From Larry Levitt, senior vice president of the Kaiser Family Foundation:

But the higher premiums are sharply affecting people who don't qualify for subsidies:


--Today, in an afternoon address from the White House, President Trump will order his health secretary to declare the opioid crisis a public health emergency but will stop short of declaring a more sweeping state of national emergency, Jenna Johnson reports.

The public health emergency designation means "the federal government will waive some regulations, give states more flexibility in how they use federal funds and expand the use of telemedicine treatment, according to senior administration officials who briefed reporters on Thursday morning ...

The last time that a national public health emergency of this scope was called was in 2009 in response to the H1N1 influenza virus. The emergency will last 90 days but can be repeatedly renewed."

--Not even Trump's top substance abuse official knew the plans yesterday. “We don’t have information about what the announcement will be, and so I can’t comment on it. I honestly don’t know,” Elinore McCance-Katz, assistant secretary of Health and Human Services for mental health and substance use, told Politico.

--Experts are concerned that more money won't be provided to fight opioid abuse, the AP reports. Without a long term financial commitment, another declaration won’t do much good, they warn. "If there's no new money to expand our treatment infrastructure, I don't know what the punch is going to be," Andrew Kessler, a lobbyist who represents substance abuse treatment providers, told the AP.

"An emergency declaration without significant new funds will likely be unsuccessful, said Becky Salay, director of government relations at Trust for America's Health. "The problem is enormous and requires a similar investment in a comprehensive strategy that includes primary prevention."


AHH: Of course, here's a not-so-positive side-effect of Trump and Republicans keeping the words "Obamacare repeal" constantly in headlines. Nearly a fourth of Americans think the law has already been partially repealed. And another 15 percent believe it’s been fully repealed, according to a new Morning Consult/Politico survey. Forty-five percent of respondents correctly identified that Obamacare is still the law of the land.

Rep. Mark Meadows (R-N.C.) acknowledged that his party prompted some confusion by making repeated promises it then didn't accomplish. “We’ve been campaigning on it for seven years,” Meadows told Morning Consult in a report about the poll results. “So I think some people believe that we’ve executed better than we have.”

OOF: We all know the health-care industry spends a hefty sum on lobbying -- more than any other industry in the United States, actually. But you might not realize all of this lobbying can raise health-care costs. Industry lobbying is closely tied to the political maneuvering that congressional leaders use in an effort to pass legislation, using targeted provisions known as earmarks or pork barrel spending, writes Dhruv Khullar for the New York Times.

"We all know earmarks and lobbying influence policymakers and policy. In health care, this has critical implications: who gets care, how much they get, how we pay for it," Dhruv writes. "But there’s little hard data on exactly who benefits and how large the effects can be. A new study illuminates the ways these political dynamics can change congressional and hospital behavior — and how they can increase health care costs for the rest of us."

Dhruv explains research by professors from Yale and the University of Wisconsin-Madison, who looked at Section 508 waivers that determined the rate at which Medicare paid individual hospitals. They found that hospitals in districts with GOP members of Congress who supported the 2003 Medicare Modernization Act (which authorized these waivers) were seven times more likely to receive a waiver, and those hospitals saw higher Medicare payments.

“If you told me in advance that we’d find this tight a link between Congress and hospitals, I would have been very surprised,” Yale's Zack Cooper told the Times.

“In the years between passage of the M.M.A., and its reauthorization in 2007, legislators in districts with a Section 508 hospital saw a 22 percent rise in total campaign contributions, and a 65 percent increase in donations from the health care sector specifically. In the end, a provision that budgeted $900 million over three years led to billions in extra spending for nearly a decade,” Dhruv writes. “Pork, it seems, is as bad for budgets as it is for waistlines.”

OUCH: California’s exorbitant housing costs are driving the hepatitis A outbreak in cities along the coast as their homeless populations skyrocket, The Post's Scott Wilson reports. "The hepatitis A outbreak in Los Angeles, Santa Cruz and San Diego, long considered a model of savvy urban redevelopment, is the extreme result of a booming state economy, now driving up home prices after years of government decisions that made low-cost housing more difficult to build," Scott writes.

Scott visited San Diego, a city where the economy is booming yet the homeless population has been rising sharply, outstripping the local government’s ability to manage its scope. "The number of people living on the streets rose 14 percent in the past year, tracing a hepatitis A outbreak that thrives in unsanitary conditions. Health officials believe an epidemic that has infected more than 500 people statewide since March began in San Diego County, where 19 people have died as a result of the disease, nearly all of them homeless."

The outbreak led California Gov. Jerry Brown (D) to declare a state of emergency this month. Hepatitis, spread when a person ingests food or water tainted by the feces of someone who is infected, is a virus that stalks the unclean places where the poor often live. It's extremely rare in the United States and rarely fatal when it does occur, causing symptoms such as fever, nausea and jaundice. 


--The bipartisan bill to stabilize the ACA marketplaces, negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would slash the deficit by $3.8 billion over the next decade, the CBO announced on Wednesday. The bill would also not affect the number of people with health insurance, our colleague Amy Goldstein reports.

“This nonpartisan analysis shows that our bill provides savings and ensures that funding two years of cost-sharing payments will benefit taxpayers and low-income Americans, not insurance companies,” Alexander and Murray said in a joint statement on Wednesday.

--The bill appears as necessary as ever, after a federal judge in California yesterday denied a request from 19 attorneys general across the country to force the Trump administration to resume funding of the CSR payments. The ruling leaves intact Trump’s decision earlier this month to immediately end the payments, which had prompted attorneys general from 18 states and the District to seek a temporary order that would have maintained the funding while the rest of the case is decided.

In his decision, Judge Vince Chhabria of the U.S. District Court for the Northern District of California wrote that resuming the payments to insurers “would be counterproductive," Amy and Juliet Eilperin report. Chhabria pointed out that most states’ insurance regulators had already prepared for a possible end to the money, by allowing companies to charge higher rates for the coming year. “Although you wouldn’t know it from reading the states’ papers in this lawsuit,” he wrote, “the truth is that most state regulators have devised responses.”

Yesterday, House Speaker Paul Ryan, made this candid confession: "I can't imagine' passing a health-care bill this year," he told Reuters:


ICYMI: Yesterday, The Health 202 kicked off our first live event. Here are some of the highlights from our spirited discussion with Sens. Bill Cassidy (R-La.) and Chris Murphy (D-Conn.) about the ACA marketplaces, repeal-replace efforts and mental health:

On the Republican response to bipartisan efforts to fix the system:

Murphy: “I haven’t taken a look at the Hatch-Brady bill in detail but it looks to me a lot like the skinny repeal bill that didn’t pass the Senate when it was first offered and would likely result in millions of people losing coverage. We have 60 votes for Alexander-Murray in the Senate right now. I don’t see why we don’t put that bill on the floor.”

Cassidy: “Even if we passed it in the Senate we would not pass it in the House and the president would not sign... an exercise in futility right now it seems better to kind of continue working through.”

On the Mental Health Reform Act that the senators co-authored: 

Cassidy: “Chris was great. I had worked with Tim Murphy on the House side and Chris approached me and said can we work on this together and we didn’t know each other that well but our staffs worked together… We got something really significant through and it shows we can work on a bipartisan basis and again I thank my colleague.”

On the cost of overhauling the system:

Murphy: “The fact of the matter is there has been nothing in any of the Republican plans that have been offered that truly attacks the issue of cost, the issue of price, the issue of price being passed down to consumers by an increasingly for-profit health care system.”

Cassidy: “There’s about five states in the nation that lost money under Graham-Cassidy, 19 states that substantially improve. But those five states are incredibly high cost, at which point it becomes a philosophical argument: Should the federal taxpayer be obligated to support a high-cost state?”

Watch the full discussion here:

And here are a few more good reads:

House Energy and Commerce hearing touches on 2016 law that diminished agency’s options.
Lenny Bernstein and Scott Higham
The greater use of such therapies, which combine medication and counseling, could help people reduce their illegal drug use, he testified.
Laurie McGinley
Insurers no longer will receive compensation for discounts offered to low-income members
Colby Itkowitz
The Trump administration had blocked the procedure under new policy for minors in custody
Maria Sacchetti and Ann E. Marimow

Coming Up

  • The NIHCM Foundation hosts a briefing on Capitol Hill on “Transforming Health Care to Drive Value” on Friday.

'Enough is enough.’ Congressman demands answers from DEA on opioid crisis:

Senate Chaplain Barry Black calls for "more patriots who will stand for right regardless of consequences" during his morning prayer: 

On the Late Show with Stephen Colbert, Gretchen Carlson talks about using her experience to inform others about sexual harassment:

On Late Night with Seth Meyers, Megyn Kelly explains why she spoke out about Bill O'Reilly's harassment: