THE PROGNOSIS

Half of Americans think the Obamacare marketplaces are falling apart. But they’re not — even though Republicans have pulled out some legs from under them.

Fifty-three percent of people believe the individual marketplaces — where those without workplace coverage can get subsidized health-care plans — are “collapsing,” according to a Kaiser Family Foundation poll released this morning. And while 64 percent of Republicans believe this narrative, nearly half of all Democrats buy into it, too.

Such public sentiment is perhaps not surprising, given the marketplaces’ turbulent year under the GOP’s congressional and executive branch rule. Democrats are responsible for the structure of the marketplaces — and new health benefit mandates that pushed premiums higher. But Republicans have not solved the existing problems and perhaps even made them worse.

Recall late last month, when it became clear lawmakers weren’t going to fund extra payments to help insurers lower premiums in the omnibus spending bill — or perhaps ever. Before that, President Trump took steps to exempt more plans from Affordable Care Act requirements by expanding short-term and association health plans, which could lower premiums for healthy folks but make them more expensive for the sick.

Congressional Republicans did try and dramatically fail to replace the much-maligned ACA with a system offering cheaper health insurance. And they’ve been bragging since December about how they repealed its penalty for lacking coverage, which could further inflate premiums if enough healthy people drop coverage as a result.

Add all these actions together and it certainly means the marketplaces aren’t headed for the kind of dramatic revitalization they needed, where the 10 million people covered under them suddenly find a wide selection of affordable plans instead of double-digit rate hikes and insurer exits.

Over the next few months, insurers will be filing their 2019 rates with the Centers for Medicare and Medicaid Services. Stakeholders are closely watching the trajectory for premiums and level of competition in the marketplaces. There remains the possibility that some counties may lack insurers, a problem the administration narrowly circumvented last year.

But Republicans’ actions, while perhaps maladroit, aren’t exactly a death knell to the marketplaces, either. The insurers have had five years to adjust premiums to make them sustainable, and those unable to survive have mostly exited. Enrollment for 2018 came in higher than most people expected, and a strong demand remains for health coverage among people who don’t get it from their employer.

“I do think [enrollment] is headed down rather than up if there’s not a solution. But it won’t happen overnight,” Joel Ario, who headed up the marketplaces during the Obama administration, told me.

Ario said the repeal of the law’s individual mandate will negatively affect the marketplaces because it could cause younger, healthier people to drop out of them, pushing up premiums for everyone left. But the Kaiser poll offers evidence that at least among current enrollees, most intend to continue their coverage even without a requirement by the federal government to do so.

Nine in 10 respondents to the Kaiser survey said they will continue buying their own insurance even when the penalty for being uninsured is no longer in effect. Respondents indicated they’re more driven to buy coverage to avoid hefty medical bills and for peace of mind, rather than simply because it's required by the government.

Seventy-five percent said a major reason for being covered was to “protect against high medical bills in the case of severe illness or accident” and 66 percent cited “peace of mind” as another major reason. Just 34 percent said the mandate was a major reason they’d decided to buy a plan.

And there’s evidence that marketplace insurers are beginning to regain profitability, if you look at how much insurers pay out in benefits versus how much they collect in premiums. Medical loss ratios began to decline in 2016 and showed even more improvement last year, according to a January report by KFF researchers Cynthia Cox, Ashley Semanskee and Larry Levitt.

As time ticks down to the next enrollment period, which will again run from Nov. 1 to Dec. 15, the question is whether increased stabilization among insurers is enough to counter the negative effects of repealing the individual mandate. When all is said and done, the two effects might end up roughly canceling each other out.

“The carriers have now gotten their rates to a point where their balance sheets are pretty good,” Ario told me. “What would have been fairly stable rates will be up some, but not hugely.” 

AHH, OOF and OUCH

AHH: Here's how Iowa is trying to create cheaper health plans: by contending that not all health plans are health insurance. Yesterday, Gov. Kim Reynolds (R) signed a bill allowing the century-old Iowa Farm Bureau to collaborate with the state’s dominant insurer to sell “health benefit plans,” which are expected to cost customers less than ACA coverage because they will not have to comply with federal requirements, The Post's Amy Goldstein reports.

The law says such plans “sponsored by a nonprofit agricultural organization . . . shall be deemed not to be insurance.” That means they will be allowed to avoid both federal and state insurance regulations, sparking debate over whether the strategy is a creative path to offer some residents an alternative to spiking prices in the state's ACA marketplace — or a path to substandard coverage that will divide the healthy from the sick.

Iowa's Farm Bureau plan is the state’s second attempt to bypass parts of the ACA. “Iowa Insurance Commissioner Doug Ommen said that he is officially undecided about the new Farm Bureau law but that he sympathizes with the need for more-affordable coverage,” Amy writes. “As consumers have been 'hammered' by the ACA rates, he said, enrollment in Iowa’s marketplace has tumbled from nearly 75,000 in 2016 to about 61,000 last fall to 46,000 last month.”

OOF: Persistent water and sewage leaks in and around the operating rooms of Washington’s largest hospital are at the center of a lawsuit seeking millions in damages for the infection-related death of a patient early last year, The Post's Ann E. Marimow, Peter Jamison and Peter Hermann report. D.C. health inspectors found MedStar Washington Hospital Center had not ensured a safe, sterile environment for patients, reporting at least seven sewage leaks during an 11-month period.

During a tour last summer they described a “black, grainy, foul smelling substance” on the floor between two operating rooms. Sewage leaks, including from clogged toilets, were common enough that hospital employees referred to the problem as “black water,” according to an August 2017 report from the D.C. Department of Health. A hospital spokeswoman said yesterday there have been no new leaks since the report and that the medical center is in “full compliance” with a follow-up plan accepted by the health department.

OUCH: Questions are swirling about how seriously the gay hookup app Grindr takes its users' privacy. BuzzFeed News reports the app, which has more than 3.6 million users, has been providing information about its users’ HIV status to two other companies. The two companies — Apptimize and Localytics, which help optimize apps — receive some of the information Grindr users choose to include in their profiles, including their HIV status and “last tested date," reporter Azeen Ghorayshi writes.

"Grindr was founded in 2009 and has been increasingly branding itself as the go-to app for healthy hookups and gay cultural content," Azeen writes. "In December, the company launched an online magazine dedicated to cultural issues in the queer community. The app offers free ads for HIV-testing sites, and last week, it debuted an optional feature that would remind users to get tested for HIV every three to six months."

The Norwegian nonprofit SINTEF first identified the issue. "SINTEF’s analysis also showed that Grindr was sharing its users’ precise GPS position, 'tribe' (meaning what gay subculture they identify with), sexuality, relationship status, ethnicity, and phone ID to other third-party advertising companies," Azeen writes. "And this information, unlike the HIV data, was sometimes shared via 'plain text,' which can be easily hacked."

....But the new analysis, confirmed by cybersecurity experts...calls into question how seriously the company takes its users’ privacy."

OPIOID OPTICS

—The Drug Enforcement Administration has arrested 28 pharmacists and drug prescribers and revoked the license of 147 people who handle controlled substances as part of a nationwide crackdown on opioid use and distribution, our colleague Lenny Bernstein reports.

“Over the last 45 days, the DEA has surged resources and personnel to prevent the diversion of opioids, arresting dozens of people and taking away drug dispensing authority from nearly 150 medical professionals,” Attorney General Jeff Sessions said yesterday in a news release about the efforts.

The enforcement surge followed a review of 80 million drug transactions that revealed dispensers who sold disproportionately large amounts of drugs -- particularly opioid painkillers -- and sparked 188 investigations. “In the recent drug crackdown, authorities said the DEA issued 283 administrative actions,” Lenny writes. “Those included forcing providers to surrender their controlled substance licenses… orders that immediately prohibit the dispensing of narcotics and orders that require recipients to show at a hearing why they should not be barred from providing the drugs.”

—Making medical and recreational marijuana available may be one way to help fight the opioid epidemic. Two new studies published yesterday found availability of marijuana is linked with lower rates of opioid prescription rates, our colleague Christopher Ingraham reports.

  • The first study found the passage of medical and recreational marijuana laws led to reductions in Medicaid opiate prescription rates of 5.88 percent and 6.38 percent, respectively.
  • The second study found that at the state level, medical marijuana laws were connected to an 8.5 percent drop in the number of daily opioid doses filled under Medicare Part D, a 14.4 percent reduction for states with medical marijuana dispensaries and a 6.9 percent drop in states that allowed pot cultivation at home. That’s compared with states that don’t have medical marijuana laws. 

“The studies are the latest in a long line of research showing that marijuana availability is associated with reductions in opiate use and misuse,” Christopher writes. The first study, by Hefei Wen of the University of Kentucky and Jason Hockenberry of Emory University, is significant for finding a link between recreational marijuana and opiate use, as most previous research has focused on medical marijuana.

"There is widespread agreement among doctors and public-health experts that marijuana is effective at treating chronic pain," Christopher writes. "Doctors often treat that condition with opiate medication, despite little evidence that opiates are effective for it."

“Marijuana is one of the potential alternative drugs that can provide relief from pain at a relatively lower risk of addiction and virtually no risk of overdose,” Wen and Hockenberry wrote. “These findings suggest that medical and adult-use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose.”

AGENCY ALERT

—The confusion continues over whether former Veterans Affairs Secretary David Shulkin resigned or was fired. But our colleague Aaron Blake points out that if Shulkin decided to step down from his role, as the White House says, they should be able to prove it by producing a resignation letter. “If it exists, the White House has yet to produce it,” Aaron writes. “Unless, of course, the White House never obtained one, which would seem to be a pretty bad oversight from an HR perspective.” 

Why does it matter? “This may seem like inside baseball, and after so much dishonesty over the past 14 months, it's easy to gloss over this as a semantic dispute,” Aaron adds. “But the White House claimed this weekend — repeatedly and unequivocally — that Shulkin had resigned, and Shulkin is basically calling that a lie. It's worth figuring out who is telling the truth… And whoever isn't being honest here should be judged accordingly.”

— Health and Human Services Secretary Alex Azar is making sure he has good eyes and ears at the agency's major operating divisions. At the CDC, new director Robert Redfield has tapped as his chief of staff someone who worked at HHS, Kyle McGowan, as director of external affairs, my colleague Lena H. Sun has learned.

According to an email Redfield sent to agency staff yesterday afternoon, McGowan “worked in the Immediate Office of the Secretary and across HHS operating divisions to coordinate with external groups, and this included working closely with the secretary’s public affairs team to amplify messages about HHS priorities.” The email said McGowan worked directly on “many of the department’s priority issues, including the opioid epidemic, drug pricing and health reform.”

McGowan joined HHS a year ago. Before that, he had worked for then-Rep. Tom Price (R-Ga.) for nearly six years, including as deputy chief of staff. Redfield’s email said McGowan would be starting “soon,” but gave no specifics, according to Lena.

McGowan was also political director for Karen Handel’s unsuccessful run for the Republican nomination for governor of Georgia in 2010, according to his LinkedIn page. Handel defeated Democrat Jon Ossoff in a special congressional election last year to fill the seat vacated by Price in Georgia’s 6th congressional district. 

—The federal government is lagging behind the private sector when it comes to addressing sexual harassment concerns among its employees, The Post's Lisa Rein details in a new report. A new study found one in five women at large federal agencies say they’ve experienced some form of inappropriate behavior by a co-worker or supervisor and almost 9 percent of male employees report similar concerns, Lisa writes. 

Veterans Affairs, along with the Navy, Homeland Security and Agriculture, has among the highest rates of harassment, according to the Merit Systems Protection Board. VA is also one of the four departments that provided full or partial responses to The Post about data on settlements and discipline for alleged sexual harassers since the beginning of 2014. That agency paid $5.4 million to settle all forms of complaints with the Equal Employment Opportunity Commission in 2017, Lisa reports.

—A few more good reads from the Post and beyond:

"This will NOT happen again,” an NIH official promised an alcohol industry lobbyist in an email, referring to a study linking marketing to underage drinking.
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DAYBOOK

Today

  • The National Academies of Sciences Engineering Medicine holds a workshop.
  • The Economic Club of Washington, D.C.'s 2018 Medical Panel.

Coming Up

  • The Bipartisan Policy Center holds an event on “Advancing Innovation, Competition, and Access for Biologics Through Patent Policy” on Wednesday.
  • MedPAC holds a public meeting on Thursday and Friday.
  • The Advisory Committee to the Director of the National Institutes of Health will host a meeting on an opioid report on Friday.
  • Harvard School of Public Health holds an event on the gun violence epidemic on Friday.
SUGAR RUSH

Rep. Elizabeth Esty (D-Conn.) said she won’t seek reelection after she took months to remove a top aide accused of threatening to kill a colleague:

Here's what you need to know about Bill Cosby's retrial: 

Watch the president and first lady kick off the annual Easter Egg Roll: