Tucked into the massive House farm bill are millions of dollars for health plans structured similarly to the nonprofit plans that failed so dramatically under Obamacare.

As part of a little-noticed provision, associations of ranchers, farmers or other agribusiness owners could obtain grants or loans from the government to offer their members health coverage, with the goal of providing more insurance options for rural Americans. A total of $65 million would be provided over four years, to be awarded by the agriculture secretary.

The initiative is part of Congress’s sweeping 2018 farm measure, which funds the bulk of the country’s agricultural and nutrition programs but has been caught up in partisan controversy over strengthening work requirements for food stamps. House leadership says it’s aiming to bring the bill to the floor this month.

The work requirements are controversial enough without adding the money for association-style health plans. But Republicans appear to be be complementing President Trump’s move to allow the expansion of insurance coverage with fewer rules as the administration inches away from regulations laid out under the Affordable Care Act.

At least in structure, these agriculture plans seem eerily similar to two dozen cooperative plans created under the ACA that almost all collapsed over the past few years under heavy financial losses. The dramatic and undeniable failure of the co-op plans — which had been added to the ACA to spur competition in the marketplaces — were, for a while at least, a top GOP critique of the health-care law.

“Hundreds of thousands of Americans have lost or will lose their health insurance, and taxpayers are still on the hook,” Sen. Orrin Hatch (R-Utah) said at a Senate Finance hearing on the co-ops in January 2016. “In some ways, the co-ops were doomed to fail from the outset … they were limited to less profitable markets, had no historical claims data and no brand recognition or trust.”

Even the ACA’s most devoted supporters have been forced to acknowledge that part of the law was a bust. Four years since the marketplaces opened for business, just four of 23 original co-ops are still operating: Maine Community Health Options, Montana Health Cooperative, Wisconsin’s Common Ground Healthcare Cooperative and New Mexico Health Connections.

The commercial group business of a fourth co-op in New Mexico has been acquired by health-plan manager Evolent Health, although that co-op continues to sell individual plans. And the group organized in 2010 to support the co-ops — the National Alliance of State Health Co-ops — has shuttered.

Like the agriculture association health plans being funded in the House farm bill, these co-ops were also seeded with federal money and operated as nonprofit organizations. The federal government lent them $2.4 billion to get up and running, and got very little of that back as they folded one by one.

The co-ops had a few initial bright moments, in some cases offering monthly premiums significantly lower than those of commercial insurers. But their problems quickly mounted. Some increased enrollment too quickly and couldn’t keep up with the rising costs. Others failed to gain enough members.

“The lesson of the co-ops is that insurance is a tricky business,” said Dan Mendelson, chief executive of Avalere Health. “Just like you wouldn’t ask your cousin to do brain surgery on you, you probably wouldn’t ask your cousin to underwrite your health risk.”

Bill Pierce, senior director at APCO Worldwide, said lawmakers should learn lessons from the failures of the co-ops as they pursue new spending for association health plans. “One of the biggest takeaways from the co-op debacle was that they lacked experience running a health plan," he said. “The same risk exists for [association health plans], whether agricultural or not."

Of course, there are also some differences between the co-ops and how these agriculture association plans might operate, which could indicate a more promising future for the association plans.

For one thing, the co-ops had to accept any marketplace customers, meaning they had less control over the makeup of their risk pool. If sicker, more expensive consumers bought in, too bad for the co-ops. Association health plans can limit their enrollment to association members — farmers and ranchers in this case – so it could be easier for them to anticipate the costs of coverage.

Co-ops were also required to cover a certain set of benefits laid out by the ACA, whereas association plans will be subject to a varying set of requirements depending on the state in which they operate. And association plans typically use a third party to administer the coverage, whereas co-ops tried to do this internally – and failed miserably.

Association health plans — including those in the agriculture space — have a mixed record. Some, such as Western Growers Insurance Services in California, are thriving and even expanding. Others haven’t managed to survive, like Citrus cooperative Sunkist Growers, which was forced to close its self-insured plan in 2002.

However, rural communities have long lacked enough health insurance options. Although it’s too early to say how well agriculture association plans might work, they could present a viable option under the right circumstances, Mendelson said.

“In agricultural communities, there have been issues with health access and issues with having products really responsive to their needs,” he said.


AHH: Melania Trump has said she'll announce her initiatives as first lady today in the Rose Garden. The focus will be on the overall well-being of children, encompassing a range of issues children face growing up instead of a single topic, the AP reports.

"Mrs. Trump has a 12-year-old son, Barron, and has expressed her interest in children through numerous visits to hospitals and schools," the AP writes. "She recently turned the Blue Room at the White House into a mock classroom and invited middle school students to share their hopes and dreams with her."

(More on Melania and Donald Trump's relationship in a piece by my colleagues Mary Jordan, Emily Heil and Josh Dawsey, which details how the couple live "remarkably separate" lives)

The first lady tweeted this yesterday:

OOF: The original manuscript of the Alcoholics Anonymous book — lost for decades and containing handwritten notes by its primary writer Bill Wilson and his friends — has been sold at auction for $2.4 million to billionaire Indianapolis Colts owner Jim Irsay, who attended his first AA meeting 25 years ago, The Post's Gillian Brockell writes.

“First published in 1939, the Alcoholics Anonymous book has stats most authors only dream of: more than 30 million copies sold,” Gillian notes. “Translated into 67 languages. In 2012, the Library of Congress ranked it No. 10 in its top 25 'Books That Shaped America.' " The sale on Saturday came after a year of legal wrangling, as AA's publishing wing tried unsuccessfully to halt the auction.

Irsay told the Associated Press he will display the manuscript publicly for several months a year at AA's New York headquarters. “I’ve held it. I’ve looked through it. It is absolutely mind-blowing,” he said. “It was just a miracle to see this thing live.”

OUCH: The Drug Enforcement Administration has cut off opioid sales by a wholesaler for the first time in six years, The Post's Lenny Bernstein and Sari Horwitz report. The agency announced Friday it had immediately suspended opioid sales by Shreveport, La.-based Morris & Dickson, accusing the company of failing to “properly identify large suspicious orders for controlled substances sold to independent pharmacies,” in some cases sending out six times a drugstore’s normal order without notifying federal drug officials as required by law.

The 177-year-old company denied the charges, saying it could have shown the DEA it had done nothing wrong but was denied the chance. The company also said it has “voluntarily” rejected 142 pharmacies in recent years to avoid “improper distribution of opioids” — a number that amounted to an 8 percent reduction of Morris & Dickson’s customer base.

“Large, frequent or unusual drug orders can be signs that legitimate painkillers are being diverted to the black market by rogue drugstores,” Lenny and Sari report. “Federal law and DEA policy require that distributors — the middlemen in the drug distribution chain — notify the agency and hold back the drugs ... An immediate suspension order is the DEA’s most potent weapon, reserved for the most egregious cases.”


— The vice president’s lead doctor, Jennifer Peña, resigned Friday from her post, the latest in the fallout from White House doctor Ronny Jackson's withdrawal from his nomination to lead VA. Peña had raised concerns about Jackson and repeatedly clashed with him, our colleague Josh Dawsey reports.

“The Vice President’s Office was informed today by the White House Medical Unit of the resignation,” Alyssa Farah, the vice president’s spokeswoman, said in a statement. “Physicians assigned to the Vice President report to the White House Medical Unit and thus any resignation would go entirely through the medical unit, not the vice president’s office.”

Peña was the unnamed doctor in a CNN report who raised concerns inside the White House that Jackson may have violated patient privacy protections for [Mike] Pence’s wife and then sought to intimidate the doctor during confrontations over the episode, Josh reports. "Peña clashed repeatedly with Jackson, whose nomination to run VA was abandoned amid allegations of liberally prescribing drugs, drinking on the job and creating a hostile workforce, according to a senior White House official," he writes.


— This week and next, the full House Energy and Commerce Committee will hold two markups of more than 50 bills aiming to address the opioid crisis. According to a schedule released Friday, the hearings will be held May 9 and May 17 and will center on 57 bills advanced by a subcommittee late last month (The Health 202 covered those measures here). Chairman Greg Walden (R-Ore.) has said his goal is to get opioids legislation to the House floor by the Memorial Day holiday.

The dozens of bills passed in Energy and Commerce's health subcommittee in April make small — but significant — changes to the ways federal agencies regulate, oversee and enforce rules on opioid painkillers; how states and localities try to mitigate abuse; and how Medicaid handles patients struggling with addiction.


— Cigna and CareFirst BlueCross BlueShield, two Obamacare insurers in Virginia, have proposed major premium hikes for 2019. In filings on Friday, the companies cited policies by the Trump administration and Congress's decision to repeal Obamacare’s individual mandate as some of the reasons for the hikes, The Hill’s Nathaniel Weixel reports.

Cigna is calling for an average premium increase of 15 percent for the company’s 103,264 customers in the state, raising prices 6.4 to 40 percent depending on the plan. CareFirst proposed an average 64 percent increase for its 4,500 customers in the state. The rates aren't final, and both companies could decide to ease back if they feel enough pressure from regulators.

— Four major insurers -- Cigna, Centene, Molina Healthcare and Anthem – all reported improved profits in the first quarter of 2018, but theor outlooks don’t include moves to offer short-term health policies proposed by the Trump administration, Forbes’s Bruce Japsen reports. Instead, some of these insurers are considering returning to the Obamacare marketplaces in 2019 after departing them this year.

“The Trump administration has said Americans need more choices than Obamacare, saying the cost of individual coverage offered on public exchanges under the Affordable Care Act is too expensive for an increasing number of people,” Bruce writes. “But Trump’s short-term health plan ideas have yet to gain much interest in health plans' public disclosures and statements to Wall Street analysts.”


— On Friday, Iowa’s Republican Gov. Kim Reynolds signed into a law a ban on most abortions once a fetal heartbeat can be detected. The "heartbeat bill," which prohibits abortions as early as six weeks, is one of the country's earliest-in-pregnancy bans on abortions and sets up for a legal showdown. “This is bigger than just a law, this is about life, and I’m not going to back down,” Reynolds said about the law on Friday, acknowledging it would likely face litigation, the AP’s Barbara Rodriguez reports.

“The bill signing came shortly after the Iowa affiliates of Planned Parenthood and the American Civil Liberties Union warned that they would sue the governor if she signed the bill, which the Republican-controlled Legislature quickly approved in after-hours votes earlier in the week,” Barbara writes.

“Backers of the so-called heartbeat bill — which didn’t get a single Democratic vote in the Legislature during final passage — expressed hope it could challenge Roe vs. Wade, the landmark 1973 U.S. Supreme Court ruling that established women have a right to terminate pregnancies until a fetus is viable," she continues. "Conservatives say an influx of right-leaning judicial appointments under President Donald Trump could make it a possibility.”

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

President Trump will lay out a plan this month to make good on his promise to lower prescription prices. Drug companies are ready to resist.
New York Times
The president has gone after Sen. Jon Tester after he derailed the VA nominee, but it’s unclear whether voters will respond.
Sean Sullivan
D.C. health officials said the shop failed to comply with rules tied to real-time sales reporting.
Susan Svrluga
Los Angeles Mayor Eric Garcetti called it “the greatest moral and humanitarian crisis of our time.”
Scott Wilson
Health & Science
E-visits have been expanding, but there are lots of restrictions on what is covered.
Steven Findlay


  • The American Hospital Association’s annual membership meeting continues.

Coming Up

  • The House Energy and Commerce Oversight and Investigations Subcommittee holds a hearing about the opioid epidemic on Tuesday.
  • The House Judiciary Committee holds a hearing on the opioid crisis on Tuesday.
  • The House Ways and Means Committee holds a hearing on the Medicare Advantage Program on Tuesday.
  • The House Veterans’ Affairs Subcommittee on Oversight and Investigation holds a hearing on VA logistics modernization on Tuesday.
  • The House Energy and Commerce Health Subcommittee holds a hearing on substance use disorder treatment on Tuesday.
  • The Bipartisan Policy Center holds an event on federal science funding on Tuesday.
  • The Coalition for Life Sciences holds an event on medical marijuana on Tuesday.
  • The House Oversight Subcommittees on Healthcare, Benefits, and on Administrative Rules holds a hearing on “Program Integrity for the Supplemental Nutrition Assistance Program” on Wednesday.
  • The Kaiser Family Foundation holds a forum on healthcare prices on Wednesday.
  • The Heritage Foundation holds an event on mental illness on Friday.
  • The Alliance or Health Policy holds an event on state opportunities to address prescription drug costs in Medicaid on Friday.
  • Senate Health, Education, Labor and Pensions Committee holds a hearing on “Examining Oversight Reports on the 340B Drug Pricing Program” on May 15.
  • The American Enterprise Institute holds an event on “Reshaping the veteran narrative with the Department of Veterans Affairs” on May 15. 
  • The American Enterprise Institute holds an event on “Fixing health care: Driving value through smart purchasing and policy” on May 16.

Watch SNL’s Stormy Daniel’s cold open, annotated:

President Trump says the world never appreciated America:

From the Fact Checker: Unraveling President Trump's top 5 claims: