THE PROGNOSIS

Want more stories about how health-care policy affects you? Read Paige Winfield Cunningham.

Americans are flocking to Healthcare.gov in greater numbers than ever before in a development that runs precisely contrary to the doom-and-gloom everyone had predicted for this enrollment season.

I think it’s safe to say that last year, the Obama administration would have pretty much killed for the shockingly brisk pace of Obamacare signups in the first four days the federal health insurance website opened for business.

The Centers for Medicare and Medicaid Services announced yesterday that more than 600,000 people selected plans from Nov. 1 through 4. Those figures appear quite a bit higher than last year, when just over a million people selected plans in the first dozen days (the best comparison available at this point). More than one in five of those people — 137,322 — were new enrollees.

That’s despite the Trump administration’s much cooler attitude toward Healthcare.gov and Obamacare more generally. It seems certain the administration was trying to undercut enrollment figures by halting TV and radio advertising for the open enrollment season, chopping off navigator fund for groups that help people sign up and doing only the bare minimum to let people know they can start shopping.

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

Former acting CMS head under President Obama:

I should emphasize that it’s still just the very beginning of the six-week signup period -- and way too early to know how this year will turn out in comparison to years past. But the initial trajectory is one that virtually no one predicted.

 Let’s explore a few reasons why this might be:

1. More Americans can get more generous subsidies this year.

This is a phenomenon stemming from Trump’s decision to cut off extra payments to insurers for cost-sharing reductions they must offer.

We elaborated on this effect in Monday’s The Health 202, but here’s the quick-and-dirty explanation: To make up for losing the payments, many insurers hiked prices for their mid-grade “silver plans.” And because premium subsidies are based on silver plan prices, the subsidies are going up too, making bronze and gold plans even cheaper for many low-income people.

“I really believe the availability of these very low-cost plans could be a game changer,” said Josh Peck, who served as Healthcare.gov’s chief marketing officer under Obama and now heads up the group Get America Covered.

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

2. People with a Healthcare.gov account are still getting reminder emails.

I know this because I created an account several years ago. I’ve received at least four reminder emails in the last week, telling me I should visit the website to search for a plan. So have others:

NYT's Margot Sanger-Katz:

Over the last four years, the Obama administration created a large database of email addresses for past and current enrollees. Even though it appears the Trump administration isn’t using some of the email messaging strategies that were effective in years past – like telling people they could find cheaper plans on Healthcare.gov if they shopped around – email remains a major way Americans remember to sign up.

3. Maybe brokers are kicking butt.

Before the Obama administration instituted more restrictions on the role of private brokers, they’d helped enroll an estimated 40 to 50 percent of marketplace customers. In California, brokers accounted for 43 percent of new enrollments on the state’s Covered California exchange during the second year of enrollment.

The Trump administration reversed the crackdown in a rule last spring, allowing brokers to once again enroll people in marketplace plans through their own websites. This could lead to brokers filling a hole left by the administration’s refusal to promote the law.

EHealth, one of the largest online brokers licensed to sell marketplace plans in all 50 states, said the new rules allow the company to once again find it profitable to help people sign up for marketplace coverage.

“Web-based entities bring younger and healthier participants in the system,” the company’s CEO Scott Flanders told me. “So it's very healthy for the viability of ACA for web-based brokers to bring in a higher share of enrollees.”

4. Advertising drives enrollment near the end of signup season, not the beginning of it.

If the reduced advertising dollars do have a dampening effect on enrollment, that effect won’t be apparent until near the end of the signup season, Peck told me. Outreach is less important at the very beginning of the season because that’s when the most motivated customers are signing up. Last year, the Obama administration didn’t run any TV ads during the first week of open enrollment, Peck said.

“Outreach has an outsize effect the last week or two weeks of open enrollment,” Peck said.

AHH, OOF and OUCH

AHH: There’s an expensive big fight brewing between two powerful lobbies -- hospitals and drug makers -- around an obscure drug discount program called 340B, Politico's David Pittman reports. The program is supposed to help rural and charity hospitals by offsetting the cost of medicines for these low-income providers with discounted drugs. But 340B has grown exponentially, now comprising $16 billion worth of medications dispensed in hospitals every year.

"Drug companies have gone on offense," David writes. "In paid advertising, messaging through an army of lobbyists and on-the-record briefing of reporters, the pharmaceutical industry has crafted a message that hospitals are taking nearly $6 billion in drug discounts and using it to enrich themselves rather than help poor patients. They say the 340B cash has even played a role in hospitals buying up doctors’ offices, causing a rise in health care costs that more than cancels out any benefit of the drug discounts."

“It seems to be a perversion of this program that patients might be paying more today than they would have prior,” Lori Reilly, PhRMA executive vice president, told reporters recently. “The goal of 340B was to lower costs to patients, not increase them.”

"Hospitals deny that characterization," David continues. "But it’s caught the attention of at least some on the Hill. Congressional offices are drafting bills that would more tightly limit how hospitals use the discounts...The lobbying has escalated fast. Nearly 160 organizations, almost all drug companies, hospitals and community health centers, reported lobbying on 340B last quarter, spending a combined $41.8 million, according to a review of lobbying disclosure forms."

OOF: A provision in the annual defense authorization bill has sparked a fiery debate over whether the Pentagon should be allowed to authorize the use of unapproved drugs and medical devices for combat soldiers, our colleague Laurie McGinley reports.

Under existing law, the FDA is the only agency that can authorize the use of medical products -- but the Defense Department can request that the FDA grant approval if there's a threat of a chemical, biological, radiological or nuclear agent on the battlefield. The new measure would allow the secretary of defense to authorize non-FDA-approved drugs and devices in emergencies in order “to reduce the number of deaths or the severity of harm to members of the armed forces . . . caused by a risk or agent of war.”

The two sides: The FDA and lawmakers say troops could be exposed to dangerous products. The Pentagon and leaders of defense committees say such medicines could potentially be cutting-edge and life-saving treatments.

OUCH: "God only knows" how Facebook is affecting children's brains, the website's co-founder Sean Parker told Axios in an interview published yesterday. Parker said he and the website's other creators purposefully tried to make it addictive. With each like and comment, Facebook is “exploiting” human psychology on purpose to keep users hooked on a “social-validation feedback loop,” Parker said, adding that it is “exactly the kind of thing that a hacker like myself would come up with.”

Parker, the billionaire Napster co-founder who later served as Facebook's founding president, also called himself "something of a conscientious objector," The Post's Ellie Silverman reports. “I don't know if I really understood the consequences of what I was saying, because [of] the unintended consequences of a network when it grows to a billion or 2 billion people and . . . it literally changes your relationship with society, with each other. . . . It probably interferes with productivity in weird ways,” Parker said.

Although Facebook is a social networking site, it also has immense impact as an advertising platform and news distributor, reaching 2 billion people each month. Parker said that when he was helping Facebook get off the ground in 2004, he and others involved thought: “How do we consume as much of your time and conscious attention as possible?”

“And that means that we need to sort of give you a little dopamine hit every once in a while, because someone liked or commented on a photo or a post or whatever," he said. "And that's going to get you to contribute more content, and that's going to get you . . . more likes and comments.”

TRUMP TEMPERATURE

--President Trump, who has blamed China for Americans' increased access to fentanyl, said yesterday he discussed reducing the flow of drugs into the United States with Chinese President Xi Jinping. Trump said that he and the president would be "focusing on it very strongly," without elaborating further.

“Every year drug trafficking destroys millions and millions of lives,” Trump said standing alongside Xi, Reuters reported. “Today President Xi and I discussed ways we can enhance coordination to better counter the deadly drug trade and to stop the lethal flow of poisonous drugs into our countries and into our communities," the president said. He added that a ‘special emphasis” would be placed on fentanyl, the synthetic painkiller that is 50 to 100 times more addictive than heroin.  

Secretary of State Rex Tillerson later added that Xi "committed to taking new actions including agreements to control the export and movement of fentanyl precursors, sharing intelligence on drug trafficking, and exchanging trafficking information." But last week, China’s drug control agency denied Trump’s claim that most fentanyl is produced in China.

-- Meanwhile, the DEA announced yesterday it's taking steps to make it easier to prosecute fentanyl traffickers by temporarily scheduling all fentanyl-related substances on an emergency basis. That classification will let prosecutors charge people trafficking substances similar to fentanyl with the same charges as fentanyl, The Hill reported.

Late last month, President Trump declared opioid abuse a public health emergency, after first announcing his intention to declare a national emergency in August. The move allows the federal government to give states more flexibility in putting resources toward treatment.

STATE SCAN

--Like last year, Uber is running its own campaign aimed at urging its contract workers to enroll in Obamacare. Starting today, the company will host events to help drivers sign up for marketplace plans in more than two dozen cities from Los Angeles to Indianapolis, Reuters reported. 

The company, which employs about 600,000 U.S. drivers, said nearly 150,000 drivers had looked for 2017 insurance plans through its partnership with the consultant group Stride Health. "This year we’re doubling down on that,” Uber spokeswoman Meghan Joyce told Reuters. The company heavily relies on freelance and contract workers -- a key target population for marketplace enrollments.

--Jimmy Kimmel facetiously celebrated the huge Healthcare.gov enrollment figures for finally allowing him and the president to agree on something.

"I have taken issue with a great many things Donald Trump has done as president but I have to admit, it hasn’t all been bad. In fact, yesterday I was looking at the White House website, healthcare.gov specifically, and I have to admit the health care plan there isn't bad. It's actually pretty good,” Kimmel said on his show Wednesday night.

Kimmel cited The Post’s coverage of record sign ups for what he dubbed "Trumpcare" and read out loud messages on social media thanking him for bring “on Trump’s side for once.” Of course, the Trumpcare Kimmel is referring to is still President Obama's Affordable Care Act that Trump keeps promising to repeal.

“If you care about health care, go to Donald Trump’s website, Healthcare.gov," Kimmel added.

HEALTH ON THE HILL

--Health and Taxes: The Senate version of a tax bill, which Republicans rolled out yesterday, preserves the popular medical expense deduction that its House counterpart would ditch, the Hill reports. The deduction allows people with hefty medical costs, who spend more than 10 percent of their gross income on care, to deduct certain qualified expenses like surgery, dentists, eye care, addiction treatment programs or transportation used primarily for or essential to medical care.

"There’s always a sense that it’s a good thing to continue,” Sen. Bill Cassidy (R-La.) told reporters.

The House tax bill has gotten pushback for getting rid of the tax break, which largely benefits low-income families. The Joint Committee on Taxation has said that 70 percent of the people who claim the deduction make less than $75,000 a year.

From our colleague Glenn Kessler:

--Say whaaat? A top adviser to Sen. Rand Paul (R-Ky.) said yesterday that the senator had not had a conversation “in many years” with the man who allegedly assaulted him at his Kentucky home last week, per Politico. 

“Last week Sen. Paul was vigorously assaulted by someone in his neighborhood. This is a serious criminal matter involving serious injury, and is being handled by local and federal authorities," Doug Stafford said in a statement. "As to reports of a longstanding dispute with the attacker, the Pauls have had no conversations with him in many years."

Stafford added that Paul spoke with his attacker only after his ribs were broken. "This was not a 'fight,' it was a blindside, violent attack by a disturbed person. Anyone claiming otherwise is simply uninformed or seeking media attention," Stafford said.

Earlier this week, Stafford and Paul both tweeted a link to a Breitbart story that cast a doubt on a report by the New York Times that pointed to landscaping issues as the origin of the altercation:

Paul's 59-year-old neighbor, Rene Boucher, pleaded not guilty to a misdemeanor assault charge yesterday. He faces the potential for much more serious federal and state felony charges as the investigation into the incident continues, Ed O’Keefe and Brandon Gee report, and a pretrial conference was set for Nov. 30. Meanwhile, we can all continue speculating around the Twitterverse:

HuffPost’s Jennifer Bendery:

From CNN's Chris Cillizza: 

A few more good reads from The Post and beyond:

MEDICAL MISSIVES
The study challenges some big assumptions about acute pain treatment in emergency settings.
Vox
INDIANAPOLIS (AP) — Alison Wrenne was making waffles for her two young children one morning when abdominal pain forced her to the floor. A neighbor who is a physician assistant ur
AP
Doctors release postmortem findings for former Patriots tight end who hanged himself in prison.
Adam Kilgore
DAYBOOK

Coming Up

  • 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

Late-night hosts responded to the allegations of sexual misconduct against Louis C.K.:

Stephen Colbert says there's now one more reason not to elect Roy Moore:

See FLOTUS Melania Trump visit a Panda enclosure in Beijing: