THE PROGNOSIS

There’s a sort of a Robin Hood situation this year for Americans buying health coverage on their own: The poor are getting richer, and those who have more are getting poorer.

This situation has become clearer than ever in the five days since Healthcare.gov and the other state-run marketplaces set up under the Affordable Care Act opened for the 2018 enrollment season. If you qualify for government assistance to buy a plan, you’re probably finding more affordable options than ever before. If you don’t qualify for government help — watch out.

We’ve touched on this phenomenon in The Health 202, but let’s dig a little deeper since the issue affects the 22 million people who buy plans on their own without the help of an employer. Of this population, earners below 400 percent of the federal poverty level ($98,400 for a family of four) can get subsidies to help defray the monthly cost of a marketplace plan; those earning more cannot.

Let’s start with the unsubsidized. Over the past few days, I’ve received emails from some deeply unhappy consumers who are finding their premiums have skyrocketed far beyond what they can reasonably pay. These folks earn a comfortable income, but not enough to contribute more than $1,000 a month toward health insurance (and that’s even before costs for their deductible and co-pays for any care they actually receive).

“I’m still reeling by the figures that I saw,” Virginia resident Melissa Davis, 51, wrote me.

Melissa lives in Lake Monticello, a private, gated community about 15 miles away from Charlottesville. Her county has just one marketplace insurer, Optima, after Anthem decided to exit Virginia for next year.

Melissa said she’d been paying $765 a month for an Anthem “silver” plan to cover herself and her teenage son. But now her only options would cost almost triple and even quadruple that figure. She could buy an Optima “bronze” plan for nearly $2,000 a month. She could buy the company’s “silver” plan for more than $2,500 a month. Both plans cost more than her housing expenses.

“Needless to say, we cannot afford to spend twice as much on health insurance as we do on our house payment, so I will soon join the ranks of the uninsured for the first time in my entire life,” Melissa wrote me.

Bob LoPinto, a 61-year-old self-employed resident of Rockville, Md., also earns slightly above the 400 percent federal poverty threshold for subsidies. He said he’d paid $825 a month for a Kaiser Permanente marketplace plan, but the premium jumped to $1,084 and will now cost $1,397 next year. And that's with a hefty $12,400 deductible.

“We’re getting hammered with Obamacare and have been since inception,” Bob wrote, adding that he feels like the media and members of Congress don’t “get it.”

“Everyone can blame it on this person or that, but in the meantime we little folks are getting caught in the crossfire,” Bob wrote. “I voted for Obama but didn’t expect that he would place the burden on my back to finance health insurance for so many others.”

The hefty premiums faced by people like Melissa and Bob are driving many to forgo coverage altogether. Even though the ACA marketplaces lured 3.8 million new enrollees in 2017, individual market enrollment actually fell by 12 percent overall, according to a July report by Mark Farrah Associates.

But here’s the flip side of the coin. More marketplace shoppers will get more generous subsidies next year, despite the Trump administration's significant moves to undermine the marketplaces after congressional Republicans failed to kill the ACA.

Enrollees eligible for subsidies will get $555 next year on average to offset the price of their plan — up 45 percent from this year’s $382 average credit, according to the Department of Health and Human Services.

This is partly because of a counterintuitive side effect of Trump halting extra payments to insurers for the cost-sharing discounts they must offer. To make up for losing these payments, many insurers are hiking the cost of their mid-grade “silver plans.” And because premium subsidies are based on the price of the second-lowest-cost silver plan, subsidies are going up, too.

The premium subsidies are so generous that the lowest-income marketplace shoppers in nearly every U.S. county will be able to receive the lowest-grade “bronze” plan free, according to an analysis released last week by Avalere.

The firm found that nearly 98 percent of counties using Healthcare.gov will have a bronze plan available free to those earning less than 150 percent of the federal poverty level ($36,900 for a family of four). These consumers will also have access to free silver plan options in 18 percent of the counties and free gold plan options in 10 percent of the counties, Avalere found.

“The dramatically higher subsidies mean consumers could be getting much better deals for bronze and silver plans for 2018,” Avalere senior manager Chris Sloan said.

But those subsidies won't help individuals earning more than $48,240 (400 percent of the federal poverty level). It’s expensive to be poor, as they say. But when it comes to Obamacare shopping, it's also pretty costly to be middle and upper class, too.

AHH, OOF and OUCH

-- AHH: It’s been nearly a year since the World Health Organization declared Zika is no longer a public-health emergency. Indeed, the mosquito-borne virus seems to be in retreat, with just 300 cases reported in U.S. states this year compared to about 5,100 cases last year, Aimee Cunningham writes for The Post. In Puerto Rico, Zika cases hit nearly 35,000 in 2016; this year, fewer than 500 cases were tallied as of the middle of October. Local transmission seems to have come to a standstill, with one suspected case in Texas and one case confirmed in Florida. There are also far fewer cases in the most heavily affected areas in south and central America:

  • Brazil had more than 216,000 probable cases in 2016; as of early September, the new cases for 2017 were around 15,500.
  • Colombia tallied more than 106,000 suspected and confirmed cases from 2015 to the end of 2016. This year, new cases have plummeted, with around 1,700 by mid-October.
  • Mexico went from about 8,500 confirmed cases in 2015 and 2016 combined to around 1,800 by early October of this year.

But the drop-offs don’t mean the virus has been wiped out all together. Scientists say these diseases tend to be cyclical because of herd immunity. “Zika came in like a bulldozer,” Yale epidemiologist Albert Ko told Aimee. Many people in the Americas who coexist with Aedes mosquitoes, which transmit Zika, were infected. Now that “there are so many people who’ve already been exposed to the virus and are presumably immune, it kind of protects indirectly the people who haven’t been infected," he said.

OOF: Opioid-related deaths have increased for every racial group in the United States -- although not at the same rate, Axios reports. Reporter Andrew Witherspoon pulled data from the Centers for Disease Control to create some cool graphics showing how deaths have risen across racial and age groups to varying degrees. He notes a few especially interesting points:

--In 2015, white people ages 15 to 64 age were 61.9 percent of the population but accounted for 80.2 percent of all opioid-related deaths. Native Americans were the only other racial group with a higher share of deaths (1.1 percent) than their share of the population (0.9 percent).

--Black people were the only racial group where the death rate was higher in progressively older age groups. The oldest age groups (45 to 54 and 55 to 64) had the highest death rates (26.1 and 26.5 per 100,000 people).

--White people ages 55 to 64 years had the largest increase in death rates from 1999 to 2015 (488 percent). Next were Native Americans aged 45 to 54 (380 percent) and white people ages 25 to 34 (339 percent).

OUCH: Literally. Sen. Rand Paul (R-Ky.) suffered five fractured ribs after a neighbor assaulted him at his home in Bowling Green on Friday, Politico reports. Police say the senator was left struggling to breathe and bleeding from cuts around his mouth, after his neighbor, Rene Boucher, tackled him from behind on Friday afternoon. Boucher has been charged with one count of fourth-degree assault, a misdemeanor that can carry up to one year in prison. It's not yet clear why he attacked Paul.

Staffers for Paul said over the weekend that he'd been “blindsided" and it's unclear whether he'll be able to return to D.C. this week due to the extent of his injuries.

“Senator Paul has five rib fractures including three displaced fractures,” Paul's chief political strategist, Doug Stafford, said in a statement Sunday. “This type of injury is caused by high velocity severe force. It is not clear exactly how soon he will return to work, as the pain is considerable as is the difficulty in getting around, including flying.”

TRUMP TEMPERATURE

--A lone gunman killed 26 people yesterday at a First Baptist Church in Sutherland Springs, Texas, opening fire on people as they worshiped in the pews, in the latest mass shooting likely to feed the debate over gun control. Twenty-six-year-old Devin Kelley,  who used a Ruger assault-style rifle, eventually came under fire from a local man and fled, sparking a car chase before running off the roadway where he was found dead, The Post's Peter Holley, Kristine Phillips and Mark Berman report. Authorities said they found multiple weapons in his vehicle.

Trump, who is traveling abroad in Japan, declared that the shooting was not “a guns situation,” saying instead he believed that “mental health” was the problem, my colleague Ashley Parker reports. Trump’s comments came at a news conference in Tokyo, when he was asked about the shooting at a South Texas church and if stricter gun laws were the answer.

“I think that mental health is your problem here,” Trump said. “Based on preliminary reports, a very deranged individual, a lot of problems for a long period of time.”

“But,” Trump added, “this isn’t a guns situation.”

Kelley's full mental state has yet to be determined, authorities say. A Texan who enlisted in the Air Force in 2010, he was court-martialed in 2012 for assaulting his wife and child, and received a bad conduct discharge from the military in 2014.

“This is a mental health problem at the highest level,” Trump said. He added that the church shooting might have been even deadlier, but for the fact that, “fortunately, somebody else had a gun that was shooting in the opposite direction.”

HEALTH ON THE HILL

--Will the GOP try again to repeal the individual mandate? House Republicans met yesterday to consider some changes to their tax plan, which is supposed to get a markup today, our colleagues Ed O’Keefe, Damian Paletta and Mike DeBonis report. Adding in a repeal of the ACA's individual mandate to buy health insurance would give them a little wiggle room to pay for other costly changes like increasing the limit on the mortgage-interest deduction and making more business owners eligible for a lower tax rate. Of course, it's also the least popular part of the health-care law and the part Republicans have criticized most fiercely.

House Speaker Paul Ryan (R-Wis.) said on the Sunday talk shows that he and colleagues are still debating the idea.

“We have an active conversation with our members and a whole host of ideas on things to add to this bill,” Ryan said in an interview on Fox News Sunday. “And that’s one of the things that’s being discussed...We’re listening to our members about what we can do to add to this bill to make it even better. So that’s among the ideas that a lot of members are suggesting that we could add to this bill to make it even better."

House Ways and Means Chairman Kevin Brady (R-Tex.) acknowledged he had received pressure from Trump to insert a repeal of the individual mandate.

“The president feels very strongly about including this at some step before the final process,” Brady said at a Friday event hosted by Politico. ”He’s told me that twice by phone and once in person.”

But Brady's worried about dooming the bill’s chances in the Senate by adding in elements of health-care -- the very topic that enough Republicans couldn't agree on earlier this year to pass a bill repealing the ACA. “Importing health care into the tax reform debate has consequences, especially when the Senate has yet to produce 50 votes on anything related to health care that I’m aware of," Brady said. "Clearly you’re bringing a whole new element into pro-growth tax reform.”

--More than a month after funding for the Children's Health Insurance Program technically expired, the House passed a bill 242-174 on Friday funding the program for five years. To pay extending the program, which covers 9 million children, the bill would increase premiums for the wealthiest beneficiaries og Medicare (those earning more than $500,000 a year), remove some lottery winners from Medicaid and cut $6.35 billion from an ACA fund to pay for public-health initiatives.

Rep. Frank Pallone, top Democrat on the House Energy and Commerce Committee, called the bill a “false choice." “In one hand it strips health care away from upwards of 680-thousand Americans and guts the Prevention Fund...and then in the other hand it reauthorizes these important programs,” Pallone said on the House floor, per the Hill.

But the committee's top Republican, Rep. Greg Walden (R-Ore.) called the criticism “ironic and cynical." “It is a tragedy this is not a bipartisan bill, as it always has been,” Walden said on the floor.

--When I ran into Walden at Costco later in the day (near the bulk granola bar section, I should add), we chatted a bit about the vote -- and he noted that in the past, many Democrats have supported some of the bill's funding mechanisms, particularly charging higher premiums to the wealthiest seniors. These seniors, who are in the top 1 percent of income earners, already pay somewhat higher premiums but Congress has long toyed with the idea of asking them to pay more to finance various initiatives.

REPRODUCTIVE WARS

--Every month, Vice President Pence will be getting a letter from Planned Parenthood saying an anonymous donation has been made in his name, compliments of Mila Kunis. The actress told Conan O'Brien last week that it's not supposed to be a "prank" but instead it's her way of peacefully protesting Pence's views on abortion.

"As a reminder that there are women out there in the world who may or may not agree with his platform, I put him on a list of recurring donations that are made in his name to Planned Parenthood," Kunis told O'Brien. "Every month, his office—he gets a little letter that says 'an anonymous donation has been made in your name.' "

--Susan B. Anthony List is countering by inviting donors to give to the anti-abortion cause in the vice president's name. SBA List President Marjorie Dannenfelser tweeted this on Saturday:

Pence responded with support and gratitude:

MEDICAL MISSIVES

--Check out this reporting by my colleagues Lena Sun and Melina Mara, who traveled to the Congo Republic with CDC scientists who are studying monkeypox, a rare and fatal disease. "A cousin to the deadly smallpox virus, the monkeypox virus initially infects people through contact with wild animals and can then spread from person to person," Lena writes. "The disease produces fever and a rash that often turns into painful lesions that can feel like cigarette burns. It kills up to 1 in 10 of its victims, similar to pneumonic plague...there is no cure."

"Over the past year, reports of monkeypox have flared alarmingly across Africa, one of several animal-borne diseases that have raised anxiety around the globe," she continues. "The Congolese government invited CDC researchers here to track the disease and train local scientists. Understanding the virus and how it spreads during an outbreak is key to stopping it and protecting people from the deadly disease."

Some other great reads from The Post and beyond:

Getting rid of tax breaks could complicate budgeting for medical, adoption and business expenses.
Carolyn Y. Johnson
Rosa Maria Hernandez was detained in Texas when she was on her way to have surgery for gall bladder.
Maria Sacchetti
INDUSTRY RX
The American Hospital Association said it was "concerned" about that provision
Axios
Anthem CEO Joseph Swedish will step down, The Wall Street Journal reports, citing people with knowledge of the matter.
CNBC
DAYBOOK

DON'T MISS THIS: The Post and Live Nation will bring the “Can He Do That?” podcast to a live audience at the Warner Theatre on Tuesday. In this live taping, political reporters Bob Woodward, David Fahrenthold and Karen Tumulty will join host Allison Michaels to review the past year in President Trump’s White House and the biggest moments that made people wonder “Can He Do That?” Tickets can be purchased now at Live Nation. Attendees will also receive a free 30-day digital subscription to The Washington Post.

MORE POST PROGRAMMING: The Washington Post hosts Secretary of Veterans Affairs David Shulkin for a discussion that will include his department’s efforts to curb the veterans’ suicide rate, address post-traumatic stress disorder and other health concerns on Thursday.

Today

  • The American Enterprise Institute hosts an event on Puerto Rico after Hurricane Maria.

Coming Up

  • The Hill hosts an event on the opioid epidemic featuring Sen. Jeanne Shaheen (D-N.H.) and FDA commissioner Scott Gottlieb on Tuesday.
  • Kaiser Health News holds an event on advance care planning on Wednesday.
  • Axios hosts an event on a new era in cancer innovation with former Vice President Joe Biden and former first lady Jill Biden on Wednesday.

  • The House Education and the Workforce Subcommittee on Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Development hold a joint hearing on opioids on Wednesday.

  • The House Energy and Commerce Subcommittee on Health holds a hearing on MACRA and alternative payment models on Wednesday.
  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on Nov. 13.

  • STAT holds an event on the FDA on Nov. 13.

SUGAR RUSH

Watch as SNL takes on the Mueller indictmets:

SNL gives Sarah Huckabee Sanders the Sean Spicer treament, writes The Post's Aaron Blake: 

This growing list of women allege sexual harassment, assault against Harvey Weinstein:

Watch actress Uma Thurman's response when asked about the spate of sexual misconduct allegations: