with Paulina Firozi

THE PROGNOSIS

There’s an ever-growing chasm between the number of Americans who receive government subsidies -- meant to offset the cost of buying health insurance on the individual marketplaces -- and those who don’t under the 2010 law known as Obamacare. 

Fresh enrollment data released Monday by the Centers for Medicare and Medicaid Services show a troubling trend that began to emerge under the Obama administration: As monthly premiums for marketplace plans rise, more unsubsidized Americans drop out of the marketplaces, because, most believe, they find the monthly costs of buying a health plan increasingly unaffordable.

The figure that caught our attention in the newly released data was just how wide that gap has grown over the past several years. In 2014, the subsidized portion of the market was 23 percent larger than the non-subsidized piece of it. In 2017, that share was 61 percent larger, according to the new CMS enrollment analysesThat means that more people with fewer financial resources are getting their health insurance through the Affordable Care Act, while others who don't qualify for such assistance are opting out -- either for private insurance, or presumably no insurance at all. It's a costly trend as it means the government is increasingly picking up the tab for the bulk of Americans insured under the ACA.

As is always the case when it comes to the Obamacare, there will be a lot of partisan finger-pointing over who is to blame.

Republicans argue Democrats created an unsustainable model that places an undue burden on middle-class Americans who earn too much to qualify for subsidies but too little to afford premiums in the marketplaces. It is true that under the Obama administration the marketplaces have been plagued by insurers raising rates on their plans -- and some insurers have even dropped out of the marketplaces altogether.

“As the Trump Administration took office, there were warning signs that we were dealing with a crisis in the individual health insurance market and Obamacare was failing its consumers," CMS Administrator Seema Verma said in a statement. “These reports show that the high price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage.”

But Democrats contend that all the Trump White House’s rhetoric, threats and actual action around dismantling the ACA have caused insurance companies to raise rates further. Most notably last year when, less than a month before open enrollment season for ACA plans began, Trump signed an executive order canceling government payments to insurers to help offset the additional discounts they were required to give some low-income Americans, known as cost-sharing reductions, or CSRs.

"Premiums reached a roughly sustainable level in 2017, so the situation for unsubsidized enrollees likely would have stabilized after 2017 if policy had remained stable," Matt Fiedler, an expert on health policy at Brookings Institution told me. "Unfortunately, policy did not remain stable, which drove big additional premium increases in 2018. And we seem to be on track for meaningful additional increases in 2019. That means we are likely to see additional—and avoidable—attrition in the unsubsidized individual market population in the years to come."

Maryland is a great case study on the burden that ensured, as I wrote last year. In late October, state regulators gave two insurance carriers permission to substantially raise monthly premiums to absorb the loss of the CSRs. Customers eligible for the discounts would continue to receive them, but the insurers would no longer get the government assist.

As is true in most states, nearly all the Marylanders who purchased individual plans in 2017 received some financial assistance, but an estimated 25,000 who didn't were expected to pay more out of pocket, regulators predicted last year. 

That smaller percentage is the pool of people, typically the self-employed, who don’t get insurance through an employer, for whom the Trump administration has pledged help. The administration recently finalized a rule that these individuals could buy “association plans,” which are not required to offer the essential benefits mandated in the ACA. 

Still, as our colleague Amy Goldstein points out, the data has a silver lining for ACA advocates. As of February, 10.6 million people paid their premiums for ACA insurance, which is about 3 percent more than the year before. As Amy writes, it's “striking because it happened even though federal health officials last year slashed ACA funding to grass-roots groups that help consumers sign up for coverage, cut advertising and other outreach activities by 90 percent, and shortened the enrollment period by half.”

Programming note: We'll be off tomorrow celebrating July 4th. We hope you are too! See you back in your inbox on Thursday.

AHH, OOF and OUCH

AHH: The administration has named top White House lawyer Uttam Dhillon as the new head of the U.S. Drug Enforcement Administration, replacing former acting administrator Robert Patterson who retired last month, Reuters reports. Dhillon takes over at a time when the DEA is putting more resources toward combating the U.S. opioid epidemic.

"The work of the Drug Enforcement Administration is critical to fighting this crisis, and President Trump and I are committed to continuing to give it the strong leadership it deserves," Attorney General Jeff Sessions said in a statement yesterday.

OOF: The nation is starting to revert to the insurance landscape of a decade ago — a hodgepodge that created the political pressures that culminated in the sweeping 2010 Affordable Care Act, The Post's Amy Goldstein reports.

This year, New Jersey Gov. Phil Murphy signed into law a requirement for most residents to carry insurance. New Jersey’s insurance mandate and a similar one that the D.C. Council adopted last week are timed to begin in January, when the ACA's federal penalty is scheduled to disappear. A requirement that Vermont just approved is supposed to take effect in 2020.

Several states are erecting barriers against rules the Trump administration is writing to promote short-term health plans, and some states, led by Democrats and Republicans alike, are trying to slow insurance rate increases through methods that Congress considered but did not pass. These changes are all part of a nascent movement with states stepping out on their own to counteract Washington’s efforts to erode the ACA, Amy writes.

The latest wave of ­state-by-state decisions is a sequel of sorts to a process that the Supreme Court unleashed in 2012, when it ruled each state could decide whether to embrace the health-care law's expansion of Medicaid. “The high court did not give states latitude on any of the law’s other elements,” Amy notes. “But action — as well as inaction — by the Trump administration and the GOP-led Congress is starting to have that effect.”

OUCH: Kentucky Gov. Matt Bevin's (R) administration announced yesterday that it is cutting Medicaid dental and vision benefits to almost half a million residents after a federal judge blocked the state's Medicaid work requirements on Friday, The Courier-Journal reports. Bevin's Kentucky HEALTH plan — which had been approved by the Trump administration — required most able-bodied adults to work or volunteer and pay monthly premiums to enroll in Medicaid. The plan also eliminated dental and vision benefits but allowed enrollees to earn points to pay for these services by completing online classes or volunteer work.

The Cabinet for Health and Family Services said Sunday in an email that about 460,000 Medicaid members had been notified that basic dental and vision benefits would end, effective July 1, Deborah Yetter writes. “When Kentucky HEALTH was struck down by the court, the 'My Rewards Account' program was invalidated, meaning there is no longer a legal mechanism in place to pay for dental and vision coverage for about 460,000 beneficiaries who have been placed in the Alternative Benefit Plan,” the email said. “As such, they no longer have access to dental and vision coverage as a result of the court’s ruling.”

In a separate email on Sunday, the Bevin administration described the cuts as “an unfortunate consequence of the judge's ruling,” per the Courier-Journal. Yesterday, it issued a statement saying it was “working through” the impacts of the judge's order and that it hopes to “quickly resolve the fallout from the court ruling.”

— Friday's decision by U.S. District Judge James E. Boasberg sent Kentucky HEALTH back to the federal Department of Health and Human Services for further review, our colleagues Lena H. Sun and Amy reported. Boasberg said that top HHS officials “never adequately considered whether [the program] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.” That “signal omission” renders the decision “arbitrary and capricious,” he concluded.

AGENCY ALERT

— Staff at the Office of Refugee Resettlement — the division in HHS that oversees the care of unaccompanied migrant children — haven't received guidance on how to move forward on reuniting children with their parents, Politico reports. A federal judge has given the Trump administration until July 10 to return children under age 5 to their parents, after they'd been separated in May and June under the administration's “zero tolerance” policy.

“Federal officials are struggling to reunite migrant children with their families despite a court deadline, and agencies do not have the resources or procedures to help thousands of children detained at the border back into the arms of their parents, according to a dozen current and former officials, advocates and experts,” Politico's Ted Hesson and Dan Diamond write.

“It’s been really difficult to start the reunification process because we just don’t have a lot of direction from leadership,” one official at the refugee office told Ted and Dan. “That’s been slowing things up, because there’s just been a lot of confusion.”

NBC White House correspondent Geoff Bennett tweeted that HHS isn't sharing how many of the children separated under the "zero tolerance" policy are still in its care:

TRUMP TEMPERATURE

— It's far from guaranteed that Trump's Supreme Court nominee to replace Justice Anthony M. Kennedy would enable the high court to overturn Roe v. Wade, but it does seem clear the president will prioritize a justice who would rule that way.

In an interview with Fox airing Sunday and Monday, Trump doubled down on his rhetoric about sending the issue of abortion to the states, which is another way of saying overturning Roe, our colleague Aaron Blake notes. Trump said he would “probably not” ask potential nominees directly about Roe — given that such litmus tests are frowned upon — but then he reiterated his view of how this issue would play out.

“Maybe someday it will be to the states,” Trump said. “You never know how that’s going to turn out. That’s a very complex question. The Roe v. Wade is probably the one that people are talking about in terms of having an effect, but we’ll see what happens. But it could very well end up with states at some point.”

— Yesterday, Trump interviewed four potential Supreme Court nominees as the White House keeps up its swift pace in the search for a successor to Kennedy, The Post's Anne Gearan and John Wagner report. “I had a very, very interesting morning,” Trump said after meeting with the candidates, describing them as “outstanding people.”

Trump said he expects to meet with two or three additional candidates, and that an announcement is planned for next Monday. White House press secretary Sarah Huckabee Sanders wouldn't provide names or other details for the candidates Trump saw Monday, but did say that each meeting lasted about 45 minutes, per Anne and John.

— GOP Sen. Susan Collins -- under intense pressure from abortion rights groups to oppose any Trump pick -- suggested yesterday that Chief Justice John Roberts could be a vote against overturning Roe regardless of who the new justice is.

"I think, for example, [Chief Justice] John Roberts given his respect for precedent and his cautious approach, despite what personal views he may hold, I would be very surprised if the chief justice would ever vote to overturn Roe v. Wade, just to give you an example," Collins told The New York Times's "The Daily" podcast.

Abortion rights activists are sending coat hangers -- a symbol of the era before abortion was legal -- to Collins's office, New York Magazine reports.

BRAIN WAVES

— A pro-Obamacare group launched a television ad to air in the states of Sen. Collins and Lisa Murkowski (R-Alaska.) -- the two Republicans who Democrats are hoping will block a conservative justice to the Supreme Court, The Hill reports. 

The 30-second commercial, paid for by the advocacy group Protect our Care, focuses on the new justice's power to further dismantle the Affordable Care Act, most notably protections for people with preexisting conditions. The Trump administration's Justice Department has already said it would not defend any part of the law in court.

The ad, titled "Emergency," warns that Trump and Senate Majority Leader Mitch McConnell want to install a nominee "who will overturn those protections, who would take us back to a time when insurance companies could deny you coverage."

HEALTH ON THE HILL

— Sen. Elizabeth Warren (D-Mass.) caught the eye of Post fact-checker Salvador Rizzo when she claimed last month that the U.S. locks up more people for “low-level” offenses on marijuana” than for all violent crimes. 

What she said: “We need criminal justice reform in this country, but we need to understand it’s not a little slice. We need reform of the whole system. And it starts on the front end with the activities we criminalize, for example, low-level drug offenses — more people locked up for low-level offenses on marijuana than for all violent crimes in this country. That makes no sense at all.” — Warren, in remarks at the We the People summit, June 13, 2018

The facts: Most crimes are prosecuted by state and local authorities, not the federal government, Salvador writes. Nearly 44,700 people at the state level were serving a sentence of one year or longer at the end of 2015 after being convicted of drug possession as their most serious offense, according to the Bureau of Justice Statistics. This includes not only marijuana but also heroin, cocaine and other illicit drugs. These 44,700 people represented 3.4 percent of the total population under the jurisdiction of state correctional authorities in 2015, while those convicted of violent crimes made up 54.5 percent of the total population.

MEDICAL MISSIVES

— A 30-year-old Alabama woman discovered the swelling in her stomach and increasing weight gain was the result of a 50-pound cyst, the size of a watermelon, growing inside her ovary. After months of discomfort, Kayla Rahn went to the emergency room complaining of abdominal pain, swelling and shortness of breath. The very next day doctors operated. 

The cyst had crowded out her other internal organs, which forced them to cram inside her abdomen, the Post's Lindsey Bever writes. Doctors estimated the cyst had been growing inside Rahn for about a year. Cysts are normally harmless, but left alone one that large could have ruptured and caused internal bleeding. 

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

INDUSTRY RX
STATE SCAN
REPRODUCTIVE WARS
SUGAR RUSH

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