THE PROGNOSIS

Want more inside information on health care policy in the Trump era? Get it here.

You’ll hear two competing narratives over the next six weeks, as Americans without employer-sponsored coverage buy plans on Healthcare.gov and state-run marketplaces during the Affordable Care Act’s fifth signup season. Here they are:

Narrative 1: Obamacare was working beautifully until President Trump and his Republican cronies sabotaged the law, pushing up premiums, driving insurers away and confusing people about whether the ACA even exists anymore.

Narrative 2: Obamacare is in an unavoidable death spiral because it’s a fundamentally flawed law, forcing up premiums and reducing choices for consumers who are losing out big time under it.

The truth is, neither narrative is entirely correct, despite what you might hear from relatives around the Thanksgiving table a few weeks from now.

The Trump administration — according to the way it has framed this year’s diminished options and higher premiums — would have you believe the situation is unavoidably out of its control. The sharp contrast between how it's handling things and how the Obama administration approached the marketplaces has been clearer than ever over the past few days.

Were the prior administration around, the Department of Health and Human Services would be stressing that most consumers are sheltered from premium hikes because of federal subsidies. Its top officials would be fanning out across the United States to hold outreach events. But this week, representatives of HHS and the Centers for Medicare and Medicaid Services didn’t respond to questions about whether their leaders — Eric Hargan and Seema Verma — have events planned today to mark the first day of open enrollment.

Democrats, dismayed at the prospect that recent coverage gains under the ACA could be reversed, are accusing the administration of hurling a wrecking ball at an otherwise healthy individual market. Several groups that have sprung up to defend the law from GOP attacks — many of them run by Obama appointees or Democratic operatives — are heaping blame on Trump for unaffordable premiums.

“While many Americans will pay more due to President Trump’s sabotage, millions of Americans can still find affordable health coverage,” Protect Our Care Director Brad Woodhouse said in a statement yesterday.

Let’s eat some reality pie: The truth lies somewhere in the middle. The administration could be doing a lot more to support the marketplaces. But the marketplaces have also failed to attract the healthy mix of enrollees needed to keep prices lower.

Here are three things to watch during enrollment season (which starts today and ends Dec. 15):

1. The enrollment number to beat (or fall short of) is 12.2 million. That’s how many people selected a marketplace plan during 2017 enrollment.

Most experts have predicted that sign-ups will be significantly less this year — perhaps by as much as 1 million — given the administration’s cuts to advertising and outreach and only six weeks for consumers to enroll instead of three months.

2. Obamacare is getting cheaper for people whose low income qualifies them for premium subsidies. About 80 percent of marketplace enrollees will qualify for the federal assistance, up from 71 percent last year, according to numbers from CMS.

This seems counterintuitive, right? After all, Trump cut off extra cost-sharing payments for insurers, prompting them to raise premiums even more to make up the difference. But that’s precisely why the premium subsidies are getting more generous. They’re based on the cost of a mid-level “silver” plan. And because silver premiums are rising, subsidies are, too.

3. But fewer people ineligible for subsidies are buying individual plans. They could drop off even more as premiums go up because these folks aren’t sheltered from the increases.

This year, 5.4 million people bought their health insurance outside the ACA marketplaces. You can’t get subsidies off the exchanges, so these shoppers were presumably higher-income earners who can’t get the federal assistance anyway.

But this number has been declining dramatically. Even though the marketplaces got 3.8 million new enrollees for 2017, individual market enrollment actually fell by 12 percent overall, according to a July report by Mark Farrah Associates.

The moral of the story? Obamacare coverage is totally affordable if you get help from the federal government in buying it. But if you don’t get help, buying that coverage is a lot harder.

AHH, OOF and OUCH

AHH: Trump's opioid commission will issue a final report today calling for big boosts in substance-abuse treatment programs but stopping short of urging the funding officials would need to implement changes, Politico reports. Led by New Jersey Gov. Chris Christie (R), the report will recommend the administration increase access to addiction treatment and recovery programs, expand the availability of medication-assisted therapies and strengthen the power of first responders to administer the life-saving overdose reversal drug, naloxone, according to a draft obtained by Brianna Ehley and Sarah Karlin-Smith.

"The commission’s final meeting and report come just one week after Trump declared the opioid epidemic a public health emergency — a move seen as a largely symbolic gesture that provided no new funding," Brianna and Sarah write. "Administration officials have characterized the declaration as a jumping off point and said the president would incorporate recommendations from the commission."

"While the panel acknowledges that lack of funding is the main barrier to implementation, it doesn't lay out a figure, project how long money will be needed or where it should come from," the two write. "The report says, for example, the 'principal factors' limiting the expansion of drug courts are insufficient funding, treatment and supervision resources, not a lack of interest....It also emphasizes the need for 'significant funding,' to increase the number of doctors trained in addiction medicine and to fund research on new pain, overdose reversal and addiction treatments."

OOF: Republicans control the House and the Senate. Oh, and the White House, too. But why not keep blaming Democrats for blocking them from repealing Obamacare? That's the message in a new RNC ad, which points to the ACA's "skyrocketing" insurance premiums and says Democrats blocked “a better plan to repeal and replace Obamacare once and for all — obstructing our president just to score political points with the radical left.”

"President Trump will fix it," says the ad, which appeared nationwide yesterday. "He wants what's best for the American people. Top-quality health-care you can afford. Tell Washington Democrats, end the obstruction."

Reality check: Republicans didn't need any Democrats to sign onto their various Obamacare repeal bills because they were using a special process requiring just 50 votes in the Senate instead of 60. The Senate failed to pass a health-care bill not because Democrats objected but because they couldn't get moderates and conservatives Republicans to back it.

OUCH: Aetna's doing great financially -- except when it comes to the ACA marketplaces. The company’s CFO Shawn Guertin said on a Tuesday earnings call that Aetna is continuing to experience underlying losses from covering marketplace enrollees, even after the company scaled back marketplace participation in 2017, the Washington Examiner reports. Once covering nearly 1 million marketplace enrollees, the company lost $700 million from 2014 to 2016. It was projected to lose $200 million in 2017.

Still, the company exceeded third-quarter earnings expectations with a net profit of $838 million compared with $604 million for the third quarter in 2016, per Healthcare Finance News. And it lowered its medical benefit ratio (the percent of premiums spent on claims) for its commercial business to 81.4 percent, from 83.8 percent a year earlier.
 

HEALTH ON THE HILL

JUST SAY NO: Republicans will not try to repeal the ACA's individual mandate to buy coverage as part of their tax overhaul, despite requests from some conservatives. House Ways and Means chairman Kevin Brady (R-Tex.) rejected a plan from Sen. Tom Cotton (R-Ark.) to include the repeal, warning that it could “kill” the tax revision.

“Look, I love these ideas from senators on health care, but what my constituents are looking at are for action on health care from our senators...I’m still hopeful they can find a way forward. What I don’t want to do is to add things that could again kill tax reform like health care died over there,” Brady told radio host Hugh Hewitt yesterday.

Cotton said he wanted to use repeal of the mandate to raise money for a tax package, telling reporters earlier this week he had the support to include it in the tax plan. "Almost every colleague with whom I have spoken is favorably disposed toward repealing the individual mandate of Obamacare as part of that tax package," Cotton said Monday, per the Washington Examiner.

But Brady suggested that wasn't likely, given how the Senate's various health-care bills have fared so far. “Look, I want to see that individual mandate repealed,” Brady said. “I just haven’t seen, no one has seen 50 votes in the Senate to do it.” But Brady did say he'd support adding the individual mandate repeal once a tax bill got to the Senate floor.

--Democrats are still opposing GOP-led legislation to fund the Children's Health Insurance Program (CHIP) for five years and community health centers for two years, the  Hill reports. The House plans to pass the bill this week on a party-line vote, after the parties failed to reach an agreement on how to pay for the extension after weeks of negotiations.

Under pressure from Democrats, Republicans removed language to charge wealthy seniors higher Medicare premiums. But they replaced it with a something Democrats also dislike by pulling more money from a public-health fund set up under the ACA. The bill would also shorten the grace period for Obamacare enrollees who fail to make premium payments -- a change that could result in between 259,000 and 688,000 people losing their insurance, according to analysis by the left-leaning Center on Budget and Policy Priorities.

A Democratic aide told the Hill that the changes make the bill even worse. “It is a further example that this has become a vehicle to sabotage the Affordable Care Act,” the aide said.

A GOP aide called the bill "reasonable" and "responsible." "[Chairman Greg Walden] has worked closely with Republican leadership and members of the conference to put together a responsible package that funds health care for children, extends important public health programs like community health centers, and is paid for with reasonable and responsible offsets," the aide told the Hill.

STATE SCAN

--Texas has joined a multi-state investigation into a group of pharmaceutical companies for potentially illegally contributing to the opioid crisis, including one company -- McKesson Corporation -- that received a nearly $10 million grant from the state last year, the Texas Tribune reports.

Gov. Greg Abbott (R) had worked with McKesson, which brought almost 1,000 jobs to North Texas. But some are now criticizing him for awarding the company a grant from the state’s Enterprise Fund, which the Texas Tribune’s Jim Malewitz and Edgar Walters described as “the controversial deal-closing incentives program created in 2004.”

“There needs to be better oversight here,” state Rep. Joe Moody, a Democrat from El Paso, told the Tribune. “You’re in the middle of the opioid crisis, and we’re issuing an enormous grant that comprises a significant amount of grants this company is getting across the country.”

In June, Texas AG Ken Paxton announced that the state joined the 41-state investigation. Some counties in Texas have already filed lawsuits against the drug companies, including McKesson. One such suit argues that the corporation and other distributors “did nothing” to address “alarming and suspicious” overprescription of the opioids, Jim and Edgar report.

A McKesson spokeswoman told the Tribune that its “partnership with the state remains strong.” “We certainly agree that the opioid epidemic is a national public health crisis, and we’re cooperatively having lots of conversations with AG Paxton and the others involved in the multistate investigation," the spokeswoman said.

Here are a few more readables:

Vermont declared an emergency over the opioid crisis — and actually did something about it.
Vox
With more and more states going after pharmaceutical companies over the opioid crisis, New Jersey is getting in on the action.
Bloomberg
MEDICAL MISSIVES
Here are reasons to be utterly grateful you didn't have surgery in Victorian times.
William Wan
U.S. officials say they consider the undocumented 10-year-old, who has lived in Texas with her parents for years, an unaccompanied minor.
Maria Sacchetti
Mumps symptoms include fever, headaches, muscle aches, and swollen or tender glands.
Sarah Larimer
REPRODUCTIVE WARS
The university is taking advantage of new Trump administration rules allowing exemptions to the Obamacare contraceptive mandate.
Vox
DAYBOOK

Today

  • The Council for Affordable Health Coverage holds an event on the cost of health care.

Coming Up

  • 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 Hillary Clinton president? In Trump world, it sounds like it:

New York mayor calls vehicle attack an ‘act of terror:’

Stephen Colbert addresses New Yorkers after the attack in Manhattan: 

Seth Meyers offers up questions he would ask White House press secretary Sarah Huckabee Sanders: