THE PROGNOSIS

Republicans argued passionately this year about scrapping Obamacare’s health coverage requirements. Turns out they didn’t really need to, as the Trump administration is moving on its own to allow states to scale back the mandatory benefits.

Let’s just say that if we were waiting for the other shoe to drop, it may just have done so. A humongous, 365-page rule proposed late last week by the Centers for Medicare and Medicaid Services is the agency’s biggest attempt to put a conservative stamp on the Affordable Care Act by rewriting its rules in a way that gives insurers and states as much leeway as possible from the law’s mandates.

The proposed rule, which suggests an array of changes to how the individual and small-business marketplaces are run, most notably gives states wide latitude in carrying out the ACA’s “essential health benefits” — 10 categories of care that individual market insurers must cover to ensure consumers can access a full range of benefits.

These essential health benefits (or EHBs) are among the Obamacare regulations that Republicans have blamed for skyrocketing premiums in the marketplaces, as they mean that everyone buys plans with benefits they may not need or want.

As the House and then the Senate were struggling to pass bills overhauling the ACA — an effort that has stalled -- the EHBs emerged as a major flash point in the fights. Conservatives insisted they had to go, while moderates said they represent important consumer protections and ensure that everyone “pays in” to the system.

Here’s how EHBs work: States must select a “benchmark” plan to set the standard for how generously insurers must cover essential benefits, which include categories such as maternity care and mental-health services. The benchmark plan is typically chosen from among employer-sponsored plans in order to ensure individual plans are comparably generous.

Marketplace insurers must provide the same value of services within each of the 10 categories as the benchmark plan. So if the benchmark plans covers treatment for autism or speech-language therapy, for example, insurers must cover that too, or substitute a service with equivalent value. You get the idea.

If CMS goes ahead with its proposed changes, states won’t have to choose from a limited, fixed menu of benchmark plans. Instead, they can select a la carte. For example, Ohio could choose the maternity care standards from one benchmark plan and the mental-health services from another. Wisconsin could choose the benchmark plan from North Dakota or New Jersey or Virginia.

For states that opt to take this approach, it will be like choosing their EHBs out of a hat, University of Michigan health law professor Nick Bagley writes at the Incidental Economist. They’ll be essentially stapling together all sorts of plans, which could result in a much-reduced set of benefits for consumers.

“This definitional change, combined with the choose-your-own-adventure option to devise a benchmark, means that states will have wide authority to water down the essential health benefits requirement,” Bagley writes.

Bagley wonders whether the proposed rule is even legal, because it could allow essential health benefits to be watered down beyond what the ACA intended:

And that’s not all CMS is suggesting. The rule would also allow insurers to shift benefits across the 10 categories — not just within them. So if an insurer wanted to scale back, say, prescription drug coverage, it could do so, as long as it ramped up coverage in another category at an comparable level. In doing so, insurers could potentially make plans less appealing to someone they don’t want to cover — like someone with long-term conditions like diabetes or arthritis, for example.

Now, the CMS rule hasn’t been finalized. And the jury’s still out on how many states would adopt lighter coverage requirements. And indeed, leaner plans would cost less, which could in turn attract younger, healthier customers to the ACA marketplaces.

“There is an interest in creating a cheaper product that has the potential opportunity to bring more people into the market,” Michael Adelberg, a principal at Faegre Baker Daniels Consulting, told me yesterday.

But the overall aim of the changes, CMS wrote, is to free up states and insurers from as many ACA regulations as legally possible in compliance with President Trump’s executive order for his administration to scale back the ACA where able.

“This proposed rule is intended to increase flexibility in the individual market, improve program integrity and reduce regulatory burdens associated with the [PPACA],” the proposed rule says.

STATE SCAN

--HAPPY OPEN ENROLLMENT EVE. Tomorrow, the ACA’s fifth sign-up season kicks off for a period of six weeks. The season is already off to a rocky start, with some ground-level disruptions on Healthcare.gov and, of course, higher prices and fewer options, my colleagues Amy Goldstein and Juliet Eilperin report. Federal health officials confirmed that until Friday night the window-shopping version of the federal marketplace contained an error in calculating subsidies for certain family situations. And there are fewer resources on the ground to hep people sign up: state organizations charged with helping people find ACA insurance plans have faced layoffs, and some resources in states have been cut all together.

“The greatest challenges are a messy mix of higher prices and fewer options, plus less time to sign up, less assistance for doing so and far less government promotion of the opportunity to enroll,” Juliet and Amy write. “The net effect is rampant public confusion, surveys show. And there is a broad expectation that when sign-ups end — on Dec. 15 in all but several states that run their own ACA marketplaces — fewer Americans will have gotten ACA coverage.”

Experts have predicted significant drops in enrollment numbers. America’s Health Insurance Plans President Marilyn Tavenner, who used to run CMS, predicted a drop of at least 1 million people from the 12.2 million who signed up in 2017. A Standard & Poor's analysis forecast a decrease of between 800,000 and 1.6 million.

For the first time, federal health officials have no forecast of their own for the number of people who will be insured through the ACA next year. When asked whether such calculations have been made internally, federal officials sidestepped the question, Amy and Juliet report. The Trump administration also didn't provide last month an expected quarterly update on how many people were paying their premiums to keep coverage effective with their current ACA plans. The most recent figures available show that 10.3 million people were covered in March.

The remaining uninsured are woefully ignorant of the fact that sign-ups start tomorrow, per the Kaiser Family Foundation: 

With fewer resources available for outreach, ACA advocates are trying to supplement. Former CMS acting administrator Andy Slavitt: 

From millennial advocacy group Young Invincibles: 

Democrats who watched the ACA make progress in reducing the uninsured rate over past few years are deeply frustrated at the situation. Rep. Mike Quigley (D-Ill.): 

AHH, OOF and OUCH

AHH: Grandparents, extended family and close friends are crucial in caring for about 2.5 million children in the United States, some whose parents struggle with drug addiction. This type of "kinship care" is becoming more common amid the opioid crisis, Vox's Mac Schneider explains. "While opioid abuse might be a recent cause, kinship care has always been common. Since it often occurs informally, many people might be surprised to learn it has a dedicated name recognized by local, state, and federal authorities," Mac writes.

"Instead of living with a stranger, relative caregivers tend to provide a safer and more stable home for children in need. Nonetheless, kinship caregivers who have chosen not to become licensed foster parents can struggle to find the support and services they need to raise a child. Unlike most nonrelative foster parents, kinship caregivers might lack legal custody of a child, which can be limiting when it comes to enrolling a child in school, making caregiving decisions, or accessing medical services that children of addicted parents often need."

Last month, Mac visited a support group of kinship caregivers to learn more about their experience:

Last week, The Courier Journal reported on a group of kinship caregivers who are urging the state of Kentucky to restore a program that provides financial resources to relatives who care for children.

OOF: Little data exists on the extent of opioid abuse among college students, even as the opioid epidemic ravages the nation. But it's driving a need for more recovery programs on campuses. "Already on campuses, recovery programs are expanding and multiplying, populated by students who have struggled with dependence on Percocet (oxycodone) and Vicodin (hydrocodone), as well as those who have moved on to fentanyl and heroin, which are far cheaper on the street than prescription pills," the New York Times' Kyle Spencer reports. 

Kyle describes the struggle with opioids for 22-year-old Julie Linneman, who got her first pills, Vyvanse and Adderall, from a boy in high school before moving on to Percocet and then to heroin when she left for college. Linneman eventually dropped out of Northern Kentucky University and enrolled in a rehabilitation center in New Jersey before she went to Villanova and became a resident of the Haven, housing for students in recovery.

"Little data exist on the extent of the problem among college students," Kyle writes. "But according to a 2016 national survey of them by the University of Michigan, 7 percent of 870 respondents said they had misused opioid painkillers; 4 percent had done so in the previous year. For 19- to 22-year-olds who hadn’t gone to college or had dropped out, which is common when struggling with addiction, close to 13 percent said they had misused painkillers."

Kyle notes that data reported via the Kaiser Family Foundation shows opioid-related deaths among Americans age 24 and under nearly doubled from 2005 to 2015, as did the number of opioid-related hospital visits. Misuse is most common on competitive campuses, where students are wealthier and have more access to prescribed pills. Campus users are most likely to be athletes engaged in high-contact sports; white; live in fraternity or sorority houses; and have lower GPAs. 

OUCH: Yesterday, members of the D.C. Council said they were “gravely” worried about patients’ safety at the District’s only public hospital at a tense hearing on the same day as The Post published an account of the death of Warren Webb, a 47-year-old nursing home resident with AIDS. Webb died Aug. 25 at United Medical Center of a heart attack after being left on the floor for at least 20 minutes by his caregivers. My colleague Peter Jamison obtained an audio recording of Webb crying out repeatedly for help in the run-up to his death.

"The D.C. Council health committee hearing focused on the performance of Veritas of Washington, a firm led by campaign donors to Mayor Muriel E. Bowser (D), which has managed United Medical Center for a fee of $300,000 per month since 2016," Peter writes. "The council must decide in the coming weeks whether to renew the contract...Veritas and UMC executives defended their handling of the incident in their testimony, saying they had undertaken 'an exhaustive review' of the case and reported it to the appropriate regulatory authorities. They declined to say what specific steps they had taken to discipline the nurses involved, citing employee confidentiality."

And here are some other good reads from The Post and beyond:

The Puerto Rican government has prioritized getting power back to hospitals. Many clinics and doctors' offices, like other small businesses on the island, still don't have electricity.
NPR
HEALTH ON THE HILL
But his Toronto trip was light on real-life exposure to the Canadian system’s challenges.
HuffPost
SECOND OPINION
"There is a great deal of fear among whistleblowers."
Joe Davidson | Columnist
INDUSTRY RX
Medicare Advantage is an alternative to traditional Medicare that is run by private insurers.
Judith Graham
Trump’s choice for assistant health secretary for policy has a long association with the insurance industry.
Politico
A close look at Celgene's practices shows why President Trump is so angry at the pharma industry — and may also help explain why he hasn't moved against it.
Stat News
MEDICAL MISSIVES
And too often people with alcohol issues don’t seek treatment.
Nathaniel Morris
DAYBOOK

Today

  • The Senate Health, Education, Labor and Pensions Committee holds an event on the implementation of the 21st Century Cures Act.
  • The National Coalition on Health Care holds an event on “Prevention Across the Lifespan.” 

Coming Up

  • The Council for Affordable Health Coverage holds an event on the cost of health care on Wednesday.
  • The Edward M. Kennedy Institute holds an event on the national opioid epidemic with Sens. Rob Portman (R-Ohio), Sheldon Whitehouse (D-R.I. and Jeanne Shaheen (D-N.H.) on Thursday.
  • The Brookings Institution holds an event on policy approaches to the opioid crisis on Friday.
SUGAR RUSH

Is the White House haunted? 

President Trump and First Lady Melania Trump welcome trick-or-treaters to the White House on Halloween eve: 

From The Late Show with Stephen Colbert: "'Tis The Season For Treason: A Very Mueller Christmas:"

From The Daily Show with Trevor Noah: "It's Mueller Time:"