with Paulina Firozi


Are you shocked by the huge Obamacare sign-ups of the last two weeks? Guess what -- the Trump administration is scratching its head, too.

Officials with the Centers for Medicare and Medicaid Services seem unsure of exactly why so many Americans are flocking to buy health plans on Healthcare.gov despite spending a lot less money this year on advertising and outreach, several insurance brokers who visited the agency Tuesday told me.

“I got the sense that they were prepared to take quite a bit of blowback if the enrollment numbers were bad,” said Michael Keegan, senior vice president of Health Agents for America, a group that represents independent health insurance brokers. “I think they are pleasantly surprised that the enrollment numbers were as strong as they were.”

“Strong” could be an understatement. Healthcare.gov enrollment has surged at least 47 percent higher than during the same period last year, CMS announced yesterday. Nearly 1.5 million Americans selected plans on Healthcare.gov in the first 11 days of the sign-up period — a shockingly high number that has surprised just about everyone, given that the administration whittled down the advertising budget touting the open enrollment window by 90 percent.

Kaiser Family Foundation VP Larry Levitt tweeted a good side-by-side:

Which leads to the next question: What really drives people to buy health-care plans, anyway? If the sign-up surge continues — although I should note it may not — does that call into question the importance of television, radio and web-based ads, and the navigator groups engaged in the sign-up effort who were spotlighted for losing grant funding?

“What we all thought was important doesn’t seem to be all that important,” one health-care lobbyist told me. “If people think that getting insurance is something that is good for them, they’re going to sign up. Ultimately people are going to vote with their feet.”

Sen. Maggie Hassan (D-N.H.):

Rep. Adam Schiff (D-Calif.):

Although there certainly are fewer Healthcare.gov ads going around, there is one group of people fueling sign-ups whose participation appears to have remained steady this year: health-care brokers who help consumers select a marketplace plan. These include big online companies, such as eHealth or Health Sherpa, and brokers who work on their own.

In the past, CMS estimated that brokers are responsible for between 40 and 50 percent of total marketplace enrollees, even though they generally haven’t gotten nearly as much attention as nonprofit and health groups with federal navigator grants (who, incidentally, have signed up fewer than 1 percent of total enrollees, at an average cost of nearly $5,000 per person).

Brokers insist they’re much more effective than navigators at enrolling people because they’re already trained and licensed – and they don’t cost the federal government anything. They point to a 2014 Urban Institute survey in which 84 percent of marketplace enrollees said they found insurance agents or brokers helpful in signing them up, a little better than the 77 percent who said they found navigators to be helpful.

“I don’t think the advertising and outreach does anything at all,” said Bill Stapleton, chief executive of HealthPlanOne, a company that sells mostly Medicare and employer plans. “People can either afford it or they can’t. Are there a small amount of people getting it free? A broker will find that person.”

Brokers are responsible for about the same share of enrollees this year, CMS officials told Keegan and HAFA President B. Ronnell Nolan on Tuesday. The two met with Randy Pate, head of the CMS office that oversees Obamacare implementation, and senior adviser Lisa Wilson to discuss how brokers can keep helping with enrollments.

In the past, brokers felt undermined by the Obama administration and other ACA advocates, who cast doubt on whether they would present consumers with the full range of available options because they’re paid a commission for selling some plans but not others.

“I kept saying let’s work together,and navigators were like, ‘No, CMS says ya’all are bad people,” Nolan told me. “If we would have worked together, there's no telling what we could have done.”

Until the Trump administration loosened rules for brokers this past spring, brokers had to ping-pong between their own websites and Healthcare.gov when helping people enroll. Financial aid verification took place directly on the federal website before the enrollment process could be completed, a step that brokers complained was cumbersome.

This year, brokers can complete enrollments through their own websites without visiting Healthcare.gov. CMS even created a new “Help on Demand” feature on the federal website, where shoppers can enter their contact information and get a call back from a licensed broker.

Brokers are now facing other challenges, such as the increasing refusal by marketplace insurers to pay them commissions on the plans they sell. Twenty-nine percent of respondents to a 2016 Kaiser Family Foundation survey said that insurers they worked with reduced marketplace commissions during the enrollment period.

UnitedHealthcare and several Blue Cross Blue Shield plans have stopped compensating brokers for enrollments in their marketplace plans, while other insurers have reduced the payments.

Even so, it’s clear the Trump administration is counting on brokers to play a bigger role this year than in the past — even if it doesn’t yet have a clear picture of what is driving the high-speed sign-ups.

If Pate knows exactly why sign-ups look so good, he didn’t let on this week, Keegan said. Pate raised a possible factor many point to — people may be rushing to sign up sooner because the enrollment season is only half that of last year's period. Pate is not necessarily counting on the strong enrollment to continue throughout the remaining four weeks, according to Keegan.

“I think ultimately nobody expects it will continue at this rate,” Keegan said. “I don’t think they’re assuming they’ll come out ahead.”


--We're seriously starting to have deja vu with the GOP tax effort, as some of the same conservative and moderate senators who jeopardized the health-care bills speak out against the Senate's tax overhaul. Yesterday, Sen. Ron Johnson (R-Wis.) said he opposes both the Senate and House measures because they benefit corporations at the expense of smaller companies, while Sen. Susan Collins (R-Maine) said Republicans shouldn't have tacked on a repeal of the ACA's individual mandate, which requires every American to have health insurance or pay a fine, The Post’s Damian Paletta and Mike DeBonis report.

Johnson said Trump is also concerned, via CNN's Ryan Nobles:

--Johnson eventually came around to the Senate's health-care bills. But Collins, one of the key Republicans who voted against every single version of those measures, said getting rid of the mandate on its own while leaving the rest of the law intact is a bad idea. Because it would inflate premiums, she notes the move would also cancel out the tax cut that middle-income Americans would get from the tax plan.

“I am no fan of the individual mandate and I very much want to see tax reform,” she said, Talking Points Memo reported. “But I believe taking a particular provision from the Affordable Care Act and appending it to the tax bill greatly complicates our efforts. One of my concerns is that it will cause premiums in the individual markets to go up as healthier, younger people drop out.”

Collins shared more of her reasoning with NBC's Chuck Todd, via NBC News's Kailani Koenig:

The Intercept's Ryan Grim agrees that this is starting to look familiar:

Bloomberg's Sahil Kapur:

If Johnson and Collins oppose the tax bill, every other Republican senator would have to support it for success, leaving no room for error (and still potentially forcing Vice President Pence to cast a tie-breaking vote). Neither senator’s concern can be easily addressed without changes that could drive other Republicans to oppose the revamp, Mike and Damian write.

"Adding additional tax breaks for smaller businesses could appease Johnson, but it could force the GOP to raise taxes elsewhere," they write. "Leaving the Affordable Care Act alone could make the measure more attractive to Collins and other moderates. But it would run against the wishes of many conservatives and Trump and create other challenges in making the bill comply with Senate rules allowing passage with fewer than 60 votes."

And we're still waiting on a final word from Sen. John McCain (R-Ariz.) -- who gave an infamous thumbs-down in July to sink a final Senate health-care bill -- on whether he would vote for a tax bill removing the individual mandate. Sen. Bob Corker (R-Tenn.) also voiced concerns yesterday, though he wouldn't say whether he plans to vote for the bill, the New York Times reports.

--The House is expected to pass its own tax overhaul today, after President Trump visits Capitol Hill this morning to deliver a pep talk to Republicans right before they hit the chamber. Majority Whip Steve Scalise (R-La.) said yesterday the vote count was “looking real good." Of course, the House bill doesn't repeal the individual mandate -- and differs from the Senate version in several other ways -- so the two bills would have be a merged for success. The Senate Finance Committee hopes to pass its bill this week, with the full Senate voting after Thanksgiving.

--The GOP’s proposal to use the tax overhaul to gut the individual mandate may bring Republicans the political win they’ve been searching for. But long term, the plan could backfire for upper-middle class people who pay full price for individual health plans, our colleague Carolyn Johnson reports.

The short-term benefits: Getting rid of only the penalty (and not the rest of the ACA) would bring relief to the 6.5 million people who paid a fine for the 2015 tax year; insurers would not be able to deny covering preexisting conditions; Medicaid expansion would remain and federal subsidies to help pay for premiums would continue.

But the long-term upshot: The Congressional Budget Office says premiums would increase without the mandate because fewer healthy people would buy coverage. Now, the federal government would cover the balance for the 8.7 million Americans who qualify for tax credits and thus only pay a percentage of their income toward premiums. But it’s the 6.7 million Americans who don’t qualify for government assistance and pay full price for individual ACA plans that would end up paying a lot more.

Why is this important for Republicans? Carolyn points out that this would affect Trump's own middle-class supporters. 

Here's what the public says: A small majority of Americans favored repealing the individual mandate until they were given additional details about the consequences, according to a new poll by the Kaiser Family Foundation. But after respondents were told the consequences of repealing the mandate, their opposition jumped from 42 percent up to 62 percent.

Here's a chart depicting the poll, from Levitt: 

--What about CSRs? Sen. John Cornyn (R-Tex.) told reporters yesterday that senators would likely include cost-sharing reduction payments in the year-end government funding bill. (These are payments cut off by the Trump administration that compensate insurers for cost-sharing discounts they must give the lowest-income marketplace consumers.)

The No. 2 Republican senator added he bipartisan Alexander-Murray bill -- which provides the CSRs to insurers for two years -- “has merit,” but thinks it makes more sense to couple it with a repeal of the individual mandate (presumably to get conservatives on board), The Hill reported.

--Meanwhile, Democrats are furious that Republicans are taking a bipartisan plan and attaching it to a highly partisan measure. Top Senate Democrat Chuck Schumer (N.Y.) said Democrats won't vote for Alexander-Murray if it’s tied to the tax bill. "The Republicans cannot expect to pass their own separate ideological health-care provision and then turn around and ask Democrats to vote to pass Alexander-Murray," Schumer said.

Sen. Patty Murray (D-Wash.) herself criticized the idea. “First — let’s be clear about the policy: Tacking Alexander-Murray onto the partisan Republican tax reform effort is like trying to put out a fire with penicillin. It will not do anything to help," she said.


AHH: Sen. Tom Cotton was a key figure behind the Senate's surprise decision to add individual mandate repeal to the tax bill. For days, the Arkansas Republican was working behind the scenes to convince GOP leaders that inserting repeal into the already-contentious tax fight was a good idea, Politico's Jen Haberkorn and Seung Min Kim report.

“I am with you 1,000 percent on this,” Trump told Cotton over the phone earlier this month. The conversation "illustrates how the GOP rank-and-file methodically coaxed their leadership to embark on what seemed — and could still become — a fool’s errand to try again to take down Obamacare," Jen and Seung Min write. 

“Hesitant would be kind,” Cotton told the reporters, asked about leadership’s initial reaction to his pitch. "In an interview with POLITICO, Cotton said he became convinced that the GOP had to target the individual mandate during an Oct. 26 meeting with Senate Finance Committee members. Republican senators detailed what Cotton described as a 'parade of horribles' — a series of popular tax breaks they would need to rescind — that would result absent the hundreds of billions in savings from nixing the health care requirement," they write.

“I started seeing the looks of hesitancy and outright terror on the faces of my colleagues,” Cotton said. “[I] spoke to some of them over the next few days and just realized that if we wanted the tax bill to work within the constraints of the budget, we had to repeal the mandate.”

OOF: A new Rand Corp. study finds the U.S. health-care system is unprepared to cope with the Alzheimer’s crisis, even if there were a treatment in the near future, Carolyn reports. The study found that people would have to wait a year and a half for access to treatment if it did exist (as of 2020) because of a shortage of specialists and equipment to diagnose and treat the disease. An estimated 2.1 million people could develop dementia while waiting for treatment over the next two decades it found.

"The researchers found shortages: not enough specialists who would be able to screen and diagnose the early stages of the disease, a lack of imaging scanners that would be needed to confirm the diagnosis, and insufficient infusion centers where patients would receive a drug by IV," Carolyn writes. "The study found the wait time would shrink over time — to a little over a month by 2030. But those bottlenecks in access matter when a disease is progressive, and the study highlights that the scientific challenge of developing a safe, effective drug is only the first step. Access to a future Alzheimer’s drug will depend on insurers paying for it and patients being able to afford it."

OUCH: Christopher and Michelle Briggs are facing a deeply troubling problem as they shop for coverage on Virginia's marketplace -- not a single plan available covers their 4-year-old daughter Colette's chemotherapy treatments at Inova Fairfax Hospital. For years the Briggs family had purchased insurance from Anthem, but this year the carrier isn't selling in their home county of Loudoun, The Washington Post's Colby Itkowitz reports.

"To watch the bubbly preschooler play, a perma-smile on her cherub face, no one would know she was sick. But for half of her young life, since the day a Lyme disease scare uncovered aggressive leukemia, she has been in and out of chemotherapy treatments," Colby writes. "Now, as the youngest of the Briggs’s nine children battles cancer, her parents are in a desperate fight of their own ...The only insurance option for Christopher Briggs, who is a self-employed communications consultant for nonprofit groups, is Cigna. But Cigna does not cover Fairfax Hospital, the only local hospital with a dedicated pediatric cancer unit and where Colette has been a patient for more than two years."

“We have spent the last two months on the ceiling trying to figure out where the insurance is going to come from,” Briggs said one recent afternoon. “And I have to solve this problem for myself.”

--Still, some Virginia consumers did receive welcome news this week when Cigna announced it had reached an agreement with Virginia Commonwealth University Medical Center to bring the Richmond-based hospital system in-network.

Among them is Cindy Jones, who serves as Virginia's Medicaid director. Jones's adult son, Daniel Bowling, was diagnosed two years ago with leukemia. He moved home so his mother could care for him and he could receive cancer treatments at VCU. Now too old to go on Jones's employer plan, he bought highly subsidized Anthem insurance--for roughly $30-a-month, his mother said -- on the individual marketplace.

Jones said the experience has made her a better Medicaid director because she is more empathetic when people call in angst about their coverage.

“The navigation of the health care system is almost as bad as the disease,” she said. “We talk about the number of people who might have lost their care, but behind each of those numbers is a family under severe distress wondering how we’re going to handle this next. It doesn’t matter who you are, when you have a sick child it’s devastating.”

A few more good reads from The Post and beyond:


Coming Up

  • The Center for American Progress holds an event on "Women of Color and Mental Health" on Friday

Fact Check: Would the GOP bill 'kick' millions off health insurance?:

Lawmakers speak out about sexual assault in Congress:

President Trump once criticized Sen. Marco Rubio (R-Fla.) for awkwardly sipping from a water bottle in 2013 – but the president just had a water bottle moment of his own:

Samantha Bee says "each community has to kick out their own creeps:"