If the Trump administration was trying to sabotage Obamacare enrollment this year, it failed miserably. But if it was trying to maximize enrollment on the cheap, it did a pretty darn outstanding job.

There was across-the-board amazement yesterday at the enrollment totals released by the Centers for Medicare and Medicaid Services, showing that 8.8 million Americans — a whopping 96 percent of last year's total — signed up for health coverage on, the federal website for subsidized individual market plans. It's a terrifically high number that few had predicted, considering the 2018 sign-up season was just half the length of last year's and CMS dramatically reduced spending on outreach and advertising.

CMS Administrator Seema Verma initially tweeted the 8.8 million figure yesterday afternoon, before the agency emailed out a more complete snapshot a few hours later:

Verma noted that CMS spent far less than the Obama administration on promoting the law. Under her lead, it cut the advertising budget to 10 percent and dramatically slashed grant dollars for navigator groups.

The grand total  — which isn't final because it doesn't include enrollments from the 11 states plus the District, which run their own marketplaces -- isn't the only impressive figure here.

What's also astounding is there were more new enrollments this year compared to last year in every single week of the sign-up season. Last week, 1 million customers picked health plans, crushing the previous record of just under 900,000 in the final week of enrollment two years ago, my colleague Amy Goldstein notes.

Even though premiums mostly went up for 2018, in some areas by a lot, many people eligible to buy coverage on the marketplaces received even more generous subsidies than last year because of a complicated side effect of the Trump administration cutting off payments for extra cost-sharing subsidies; I explained it in this edition of Health 202. Analysts have found that in nearly all U.S. counties with marketplaces operated by the federal government, certain bronze plans are available free to people earning 150 percent of the federal poverty level.

And when people find something they want (health insurance) at an affordable price (with the help of federal subsidies), they tend to buy it, regardless of how much outside forces are prodding them to do so.

“The demand for affordable coverage speaks volumes — proving yet again the staying power of the marketplaces,” said Lori Lodes, co-founder of Get America Covered.

It was a victorious moment for Democrats, who have been chafing over the past few weeks at the GOP's repeal of the Affordable Care Act's individual mandate in its tax overhaul. The vigorous pace of signups suggests that ACA plans are worth buying to many Americans, they said, while also expressing regret at the enrollment numbers that might have been had the Trump administration more enthusiastically promoted the law this year.

“Today’s enrollment numbers make clear that the American people want access to high-quality, affordable health insurance coverage, and they want Congress and the administration to stop playing games with our health-care system," said Rep. Frank Pallone Jr. (N.J.), the ranking Democrat on the House Energy and Commerce Committee.

House Minority Whip Steny Hoyer (D-Md.) said he has “no doubt” that even more Americans would have enrolled “had it not been for the Trump administration’s efforts to deter them, which were shameful.”

Topher Spiro, vice president for health policy at the left-leaning Center for American Progress:

Health wonks and advocates also cheered the beefy numbers, mostly crediting consumer demand for health coverage and a website that worked smoothly throughout the enrollment season, unlike in its initial years.

The enrollment total “makes it crystal clear that Americans demand and support the quality, affordable health insurance and consumer protections the ACA offers,” said Robert Restuccia, executive director of Community Catalyst, a large grass roots health-care advocacy group.

Senior VP at the Kaiser Family Foundation:

Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities:

Kaiser Health News reporter Phil Galewitz:

And the final tally could be even higher. The 8.8 million figure doesn't include people signing up in states that run their own marketplaces or several others using in which enrollment seasons were extended until late December because they were affected by hurricanes and other major fall storms.

Charles Gaba, health-care analyst at

-- Programming note: The Health 202 will be taking a holiday hiatus all next week and New Year's Day. We'll see you back here Jan. 2, hopefully well rested and ready to take on 2018 (or just go hide under a rock somewhere). Have a very Merry Christmas and Happy Holidays!


--It's official: There won't be a government shutdown in 2017. (As a side note: If my own life success was measured by keeping my home's water and power on, I'd like to note I pretty much crushed it this year.)

Yesterday, Congress passed a stopgap spending bill, averting a partial government shutdown at midnight Friday but pushing into January showdowns on spending, immigration, health care and national security, The Post's Mike DeBonis and Erica Werner report. The measure extends federal funding through Jan. 19 and provides temporary extensions of the Children’s Health Insurance Program through the end of March, a move that somewhat helps states facing enrollment freezes but doesn't give them the long-term funding certainty they're seeking.

House lawmakers also included in the stopgap a measure waiving mandatory cuts to entitlement programs, including Medicare, forced by the passage of the tax bill. Because the tax overhaul added to the federal deficit, it triggered the so-called "Paygo" law that makes automatic spending cuts to Medicare and other programs unless Congress waives it.

"Democrats opposed the GOP tax bill in part because they said it was fiscally irresponsible, and some said they would not help Republicans by passing the waiver — particularly as many Republicans have vowed to target deep spending cuts to social welfare programs next year," Mike and Erica report. "But Democrats — who are typically fiercely opposed to any reductions in Medicare, which would see roughly $25 billion in cuts per year — did not object Thursday."

But in the Senate, Rand Paul (R-Ky.), accused his fellow Republicans of reneging on calls to slash spending and forced a separate vote on the waiver, which still ultimately passed 91 to 8.

“We have a spending problem,” Paul said on the Senate floor, urging colleagues to vote it down. “We have rules to keep spending in check, and we disobey our own rules.”

--Senate Majority Leader Mitch McConnell (R-Ky.) has finally told NPR exactly what Republicans have been whispering since last week: The effort to repeal the ACA probably died when Alabama elected Democrat Doug Jones to the Senate.

“We obviously were unable to completely repeal and replace with a 52-to-48 Senate,” McConnell said in an interview. “We’ll have to take a look at what that looks like with a 51-to-49 Senate. But I think we’ll probably move on to other issues.”

Jones, who on the campaign trail firmly opposed efforts to repeal the ACA, is expected to join the Senate when it returns in January.  “Repeal and replace is a political slogan,” Jones said this month. “It’s not something that’s workable.”

"Jones’s arrival will allow just two Republicans in the Senate to block any repeal bill," my colleague Dave Weigel reports. "Throughout 2017, Republicans lost at least three votes from their side on every version of repeal. By their last attempt, in September, key Republicans such as Sens. John McCain (Ariz.) and Susan Collins (Maine) warned that the repeal bills were not workable and needed to go through regular order."

Former CMS administrator under Obama, Andy Slavitt:

--But Sen. Lindsey Graham, who co-sponsored the last repeal-and-replace bill the Senate seriously considered, pushed back, issuing a statement insisting the campaign is not over.

“I’m fully committed to repealing and replacing Obamacare in 2018 by block-granting the money back to the states and away from Washington bureaucrats who are completely unaccountable to the patients of America,” Graham said. “To be successful we will need presidential leadership with the same passion to replace Obamacare as President Obama demonstrated in passing Obamacare.”

--Tensions are emerging among Republicans over what part of their agenda to tackle next, now that taxes are done. For weeks, House Speaker Paul Ryan (R-Wis.) and other conservatives have been trying to build momentum for reining in spending on Medicare, Medicaid and other safety-net programs. But McConnell threw cold water on those ambitions, telling my colleagues he would rather focus on an issue with potential for bipartisan appeal: an infrastructure initiative that spurs new spending on the nation’s ailing roads, bridges, airports and waterways.

“I don’t think, as a practical matter in the Senate, we can do entitlement reform without bipartisan agreement,” McConnell told John Wagner, Ed O'Keefe and Paul Kane. “And you can fill in the blanks. I mean, it applies to entitlements in general — Medicare, Social Security, welfare — they’re so doubled down on that, I’m not going to devote floor time to something that has no Democratic support.”


AHH: A group of Senate Democrats and more than 300 public-health organizations yesterday called on top Trump administration officials to lift any restrictions on how Health and Human Services employees communicate in official documents, The Post's Juliet Eilperin and Lena H. Sun report.

The two letters come in the wake of a report by The Post that budget writers at the Centers for Disease Control and Prevention and other HHS agencies were instructed to avoid using “diversity,” “vulnerable” and “entitlement” in the narratives they were preparing for the fiscal 2019 budget process, based on a “style guide” that was part of a lengthy budget guidance document. 

Ten Democrats wrote that if “these allegations are indeed true, we respectfully request that you immediately reverse these policies. Additionally, we request that you follow up with a written response to Congress regarding your plans to mitigate the adverse effects from these reports on HHS’s commitment to science.”

Separately, representatives of 315 public-health groups wrote acting HHS Seretary Eric Hargan to warn that limiting the use of any words could undermine CDC's role as “a leader” in coordinating responses to public-health crises at home and abroad.“ "As the nation's premier public-health agency, the CDC cannot carry out its mission of improving the health and safety of all Americans when its staff are urged to avoid using basic phrases that are so intrinsic to public health,” the coalition wrote.

OOF: A second federal court has blocked the Trump administration from enforcing new rules to exempt more employers from the "contraception mandate" under the ACA, Reuters reports. HHS wants to exempt any employer that cites a religious objection from covering no-cost birth control for workers, a rule established by the Obama administration.

U.S. District Judge Haywood Gilliam Jr. temporarily suspended the new rules, ruling in a lawsuit brought by Democratic attorneys general in California, Delaware, Maryland, New York and Virginia. Writing that the federal government probably didn't follow proper administrative procedures in establishing them, Gilliam said a preliminary injunction was necessary given the “dire public health and fiscal consequences” that could occur as a result of the administration adopting the rules without proper public input.

“If the court ultimately finds in favor of plaintiffs on the merits, any harm caused in the interim by rescinded contraceptive coverage would not be susceptible to remedy,” Gilliam wrote.

Justice Department spokeswoman Lauren Ehrsam said the agency disagrees with the ruling and is contemplating its next action. “This administration is committed to defending the religious liberty of all Americans and we look forward to doing so in court,” Ehrsam said in a statement provided to Reuters.

Under the new rules HHS rolled out in October, businesses can be excused from providing workers with no-cost birth control coverage by simply citing religious or moral objections. Conservatives are concerned about religious freedom for business owners, while backers of the mandate are worried about female employees having access to a range of contraceptives.

OUCH: The Washington Post's Terrence McCoy tells the story of Kentucky residents Roger and Melinda Ray in their struggle to move past the use of painkillers after Roger's knee injury, trying to get their lives back on track. It's a story that reflects the experience of all too many Americans, as disability in the United States has surged.

"As the number of people receiving federal disability benefits surged, before tapering off in 2015, the share with circulatory disorders such as heart disease, once the plurality, shrank significantly amid medical advances," Terrence writes. "Meanwhile, the percentage of workers awarded Social Security Disability Insurance for musculoskeletal disorders — disabilities frequently treated with opioids — began to rise sharply. By 2012, nearly half of the beneficiaries were using opioids, and more than one-fifth chronically."

To get a glimpse of this shift, just visit Kentucky.

"It’s here where the counties with the highest rates of opioid use are also the counties with the highest participation rates in federal disability programs, clustered in the hills and hallows of Appalachia," Terence writes. "Between 2000 and 2015, annual opioid use among adult recipients of Supplemental Security Income for the disabled poor more than tripled in Kentucky ... from 48 pills per capita to 147. Among Kentucky’s general population, over approximately the same period it rose from 30 pills to 72."

--A few more good reads from The Post and beyond:

As President Donald Trump completes his first year in office, Americans are increasingly concerned about health care, and their faith that government can fix it has fallen.
Associated Press
Public Safety
The undocumented teen was part of a legal challenge to the administration’s policy of refusing to “facilitate” abortions for minors in U.S. custody.
Ann E. Marimow
The crisis accelerated in 2016, new numbers show.
Christopher Ingraham
Fentanyl and its analogs are appearing across America, making the US’s deadliest drug overdose crisis ever even worse.
A Health and Human Services hackathon produced smart ideas for the fight against opioid addiction—but can only do so much in the face of a collapsing health care system.
The Fix
Republicans managed to slash Obamacare just enough to spike premiums and lower choices. And then Trump just owned it.
Amber Phillips
The organization said that the law would effectively ban medication abortion in the state.
Washington Examiner

Coming Up

  • The American Enterprise Institute holds an event on “New thinking about poverty and economic mobility” on Jan. 18. 

Sen. Dick Durbin (D-Ill.) says millions of Americans will lose health care protection because of the GOP tax bill:

How did Rudolph get his famous red nose? A biologist explains:

How did Scrooge travel in time? A physicist attempts to explain:

Seth Meyers takes a closer look at President Trump's claim he repealed Obamacare: