As we mentioned in yesterday's Health 202, Republican Gov. Scott Walker (Wis.) received approval Sunday from the Trump administration to create a "reinsurance program" to help stabilize the Affordable Care Act's individual markets. Then Monday, the Centers for Medicare and Medicaid Services cleared Maine to do the same. 

Reinsurance programs are the unicorn of health care. While most things ACA-related incite partisan rancor, these programs are supported by Republicans and Democrats alike because they're a relatively simple fix to a complex problem. 

Here's how they work: The federal government pays insurers for patients' priciest medical bill claims. Because the government is absorbing the most expensive costs, insurers can then offer lower premiums. With premiums lower, the government pays less in ACA subsidies to consumers buying on the individual market who are eligible for financial assistance. Under this model, the government and insurance companies don't lose money and consumers get a better deal.

"In some ways it's amazing more states haven’t moved to do them," said Larry Levitt,  senior vice president for health reform at the Kaiser Family Foundation. "These reinsurance program waivers are like magic money trees."

Alaska was the first state to apply for permission to create a reinsurance program at the end of the Obama administration. Its program is credited with saving the state's individual marketplace, where all but one insurer had pulled out and rates were increasing by more than 40 percent annually. The program was originally a state-funded operation, and in its first year rates increased by just single digits. In April 2017, Vox published an article titled, "How Alaska fixed Obamacare." 

Then Alaska filed an application in late 2016 with CMS reasoning that the federal government should pay the insurers' highest claim costs with the money it was saving on premium subsidies thanks to the state's program.  The Trump administration approved that request in July 2017. CMS Administrator Seema Verma called Alaska a "trailblazer."

Other states have in fact followed Alaska's lead. Minnesota and Oregon were also approved to create reinsurance programs last year; Wisconsin and Maine this week; and New Jersey and Maryland have applications pending. 

The three states where the programs are currently in effect are expecting to see insurance rate decreases or significantly lower increases than they otherwise would have seen next year. In Minnesota, for example, the state's Commerce Department announced in June that individual market rates are projected to fall between 7 percent and 12 percent in 2019.

Members of both parties blame the other side for the rise in insurance premiums every year. Democrats say it's because the GOP has created so much uncertainty around the law's future that insurers are forced to prepare for worst-case scenarios. Republicans counter that it's simply evidence the ACA doesn't work, particularly for individuals without government subsidies who tend to be small-business owners and entrepreneurs. 

But reinsurance programs have bipartisan appeal because for Democrats they serve as a way to stabilize Obamacare, and for Republicans they give more power to states and don't increase spending. They "uniquely work here because everyone is winning under them," said Heather Howard, a lecturer at Princeton who also works with states on health changes. 

Of course nothing can be completely apolitical. If you read through the states' waiver requests, it's not hard to spot where each governor's political allegiances lie. 

For example, in Wisconsin's application, the state took the opportunity to sideswipe the ACA, whereas in Oregon, the state praised the ACA, writing it needs the program to shore up the marketplace so people can continue to have affordable care and options:

"Prior to the ACA, Wisconsin had a thriving market. However, the Wisconsin health insurance market is now fragile due to a number fo unique variables that arose from implementation of the ACA."

"Oregon has seen significant improvements under the Affordable Care Act (ACA). The state's uninsured rate has been reduced from 17 percent to just 5 percent, and more individuals are able to purchase affordable coverage." 

If there's any criticism of the reinsurance plans it's that they're not a long-term solution to the problems ailing the ACA.

"It’s not a fix to overall health-care costs, but those fixes are what are so hard politically," Howard told me. "This one is easier because it’s patching a system and at least it’s helping consumers and it’s all winners. Efforts to go deeper at the problem have been elusive."

So for now, states are stepping up to govern when Washington is not. 


AHH: New data from the first quarter of this year shows enrollment in the individual market fell by 12 percent compared to 2017, according to a Kaiser Family Foundation analysis. The decline came from people either buying off the ACA exchanges or those who are not eligible for government subsidies. Enrollment in the ACA exchanges increased slightly, but mostly through people who receive subsidies.

Of the 10.6 million Americans who buy insurance from the ACA marketplaces, 9.2 million receive federal aid to offset the cost. "I think the overall message here is that with high premiums, coverage is becoming increasingly unaffordable for middle-class people," said Levitt, vice president of health reform for Kaiser, in an interview. "There's a bipartisan consensus that middle-class is struggling, but far from consensus about what to do about it."

OOF: A nationwide class-action lawsuit claims that Juul Labs, the San Francisco-based company behind the trendy e-cigarette, deceptively marketed the product as safe and pushed the USB-sized e-cigarette to young people.

“The 10 named plaintiffs, who range from 14 years old to adult users living in several states, allege that Juul caused nicotine addiction in consumers,” our Post colleague Deanna Paul reports. “According to court documents, the Juul device is ‘more potent than a cigarette,’ allowing high levels of nicotine to enter the bloodstream at a faster speed than cigarettes.”

“How much nicotine is the Juul actually delivering into the bloodstream of an average person?” asks Esfand Nafisi, a lawyer who is representing two of three lawsuits that were filed against Juul Labs last month. “If it’s far more than a cigarette, we believe that’s information that ought to have been disclosed but was not.”

In a statement to The Post, Juul Labs spokeswoman Victoria Davis said the company’s officials “do not believe the cases have merit and will be defending them vigorously.”

OUCH: The Food and Drug Administration yesterday said it would crack down on “vaginal rejuvenation” devices, which claim to treat menopause symptoms, problems with sexual function as well as urinary incontinence, our Post colleague Laurie McGinley reports.

The agency warns it is “deeply concerned” about potential harm to women, and said the products are not supported by any scientific evidence and can cause vaginal burns, scarring and chronic pain.

The statement refers to the “energy-based devices” that use sources like lasers to reshape vaginal tissue. The devices themselves have been previously approved or cleared by the FDA for other uses, such as to kill precancerous tissue or genital warts, but have not been reviewed for so-called “vaginal rejuvenation,” Laurie explains.

“The treatment of these symptoms or conditions by applying energy-based therapies to the vagina may lead to serious adverse events, including vaginal burns, scarring, pain during sexual intercourse, and recurring/chronic pain,” the FDA warns in its safety alert.

“The agency recently notified seven device manufacturers expressing concern about ‘inappropriate marketing’ and requested that they respond within 30 days,” Laurie writes. If the FDA's concerns go unaddressed, the agency may consider enforcement actions.


—With several red states likely to expand Medicaid through ballot initiatives, some governors have sought permission from the federal government to only partially expand the program for low-income Americans. Those states are seeking to deflect political pressure without adding as many people to the program as the ACA allows. 

But the New York Time's Robert Pear writes that President Trump shut down the debate until after the midterm elections. According to a confidential memo Pear obtained, top government health officials warned the White House there "is significant risk that Utah will vote to expand fully with a November ballot initiative. H.H.S. believes allowing partial expansion would result in significant savings over the 10-year budget window compared to full Medicaid expansion by all."

Trump's rejection of the proposal was political, as he did not want to be seen as supporting any form of ACA expansion, Pear writes. 


— Robert Wilkie was sworn-in yesterday as the next Veterans Affairs secretary. During a ceremony in the Oval Office, Wilkie vowed to work to “protect those who protect us,” the Associated Press reports.


— Sen. Joe Manchin (D-W.Va.) became the first Democrat to meet with the president’s nominee for the Supreme Court, sitting down with Brett Kavanaugh for two hours yesterday. Manchin did not say following the meeting how he may vote, but said the meeting was “very productive,” the New York Times’s Sheryl Gay Stolberg and Michael D. Shear report.

In a statement following the session, Manchin said he spoke with Kavanaugh on a variety of issues including health care, which is a “central issue for the senator, who has said he is concerned that the Supreme Court will roll back protections for people with pre-existing medical conditions.”

“Senate Democrats have been avoiding the standard meet-and-greet courtesy visits with the judge as they clash with Republicans over access to emails from his time as staff secretary to former President George W. Bush,” Sheryl and Michael write. “But Democrats appear to be losing that battle; on Friday, Republicans asked the National Archives for certain documents related to Judge Kavanaugh, but they left the Bush White House emails out of the request.”

Manchin is one of three Democrats, including Indiana Sen. Joe Donnelly and North Dakota Sen. Heidi Heitkamp, who voted to confirm Trump’s first Supreme Court nominee.

— A new study from a libertarian policy center found that the “Medicare for all” plan touted by Sen. Bernie Sanders (I-Vt.) would increase federal health spending by $32.6 trillion over 10 years.

The study looked at estimated costs of such a program from 2022 to 2031. The report was authored by Charles Blahous at the Mercatus Center at George Mason University in Virginia, which receives funding from GOP megadonors Charles and David Koch.

But the report also indicates that total national health spending would decrease by billions.

Slate’s Jordan Weissman points out a tweet from economist Ernie Tedeschi about the reports findings on total health-care spending in the United States. “Blahous’ report also shows that total U.S. health care spending would fall by about $2.05 trillion during that time period, even as all Americans would finally have insurance, because the plan would reduce payments to doctors and hospitals to Medicare rates (which are lower than what private insurance pays) while saving on prescription drug costs and administrative expenses,” Jordan writes.

Sanders tweeted pointing out this finding as well:

Sen. Kirstein Gillibrand (D-N.Y.) yesterday unveiled a bill that would block pharmaceutical companies from hiking prescription drug prices without a reason. “We must solve this crisis, and one of the most effective ways we can do that is by finally holding drug companies accountable with tough penalties when they spike the price of prescription drugs that New Yorkers need to treat their illnesses," Gillibrand said at a senior living community in New York as she announced the "Stop Price Gouging Act," local ABC affiliate WHAM reports.

The bill would “require pharmaceutical corporations to report any price increases and the justification for the increases and impose a financial penalty proportional to the price increase for any excessive or unjustified price increase,” according to WHAM.


— New York City last week announced a plan to spend $12.8 million on an initiative to collect information on maternal deaths, increase public awareness and fund implicit bias training in an effort to reduce maternal deaths and injuries among women of color, ProPublica’s Annie Waldman reports.  

The effort was announced following a report from ProPublica and NPR about such racial disparities among hospitals.

The new initiative, to be carried out over the next three years, will target “nearly two dozen public and private hospitals over four years, focusing on neighborhoods with the highest complication rates, including the South Bronx, North and Central Brooklyn, and East and Central Harlem,” Annie reports. “Hospital officials will study data from cases that led to bad outcomes, and staff will participate in drills aimed at helping them recognize and treat those complications.”

The city’s health department will also in 2019 launch a campaign with grass roots organizations to boost public knowledge about maternal health and safety.

“In New York City, the racial disparity in maternal outcomes is among the largest in the nation, and it’s growing,” Annie writes. “According to a recent report from New York City’s Department of Health and Mental Hygiene, even as the overall maternal mortality rate across the city has decreased, the gap between black and white mothers has widened.”

— New York Gov. Andrew Cuomo (D) said state regulators will reject the request for insurers to hike Obamacare plan premium rates by an average of 24 percent. Insurers asked to increase the premiums to offset the loss of the individual mandate penalty from consumers who don’t obtain health insurance.

"If we allow that rate increase to go through, it would be hundreds of millions of dollars as a bonanza to the insurance companies," Cuomo said at an event yesterday, the Democrat & Chronicle’s Joseph Spector reports. “It would increase the cost to normal, hard-working families. We’re not going to let it happen."


— And here are a few more good reads: 

Sierra Leone has announced that a new species of Ebola has been discovered there in bats. It has been called, provisionally, the Bombali virus.
Two years after federal authorities said they would consider licensing new suppliers of marijuana for scientific purposes, none has been approved.
To Your Health
Most differences between male and female voices are not biologically determined but learned from a young age, which means they can also be relearned.
Amy Ellis Nutt
It’s often too complicated. And even when it isn’t, almost no one does it.
The New York Times
J.P. Morgan Chase's CEO Jamie Dimon said Monday that his partnership with Jeff Bezos and Warren Buffett to improve health care for employees will likely start small, akin to Amazon's small-scale operation during its first few years.


  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on health care costs on Tuesday.

Coming Up

  • The Senate Veterans Committee holds a legislative hearing on Wednesday.
  • The U.S. Food and Drug administration holds a joint meeting of the “Drug Safety and Risk Management Advisory Committee and the Anesthetic and Analgesic Drug Products Advisory Committee” on Friday.  



Why Sacha Baron Cohen’s ‘Who is America?’ has people divided: