The Washington PostDemocracy Dies in Darkness

The Health 202: Trump is trying to gut Obamacare. But it hasn't worked.

with Paulina Firozi


President Trump's health-care actions could have ripple effects throughout the Affordable Care Act's marketplaces. (Video: Jenny Starrs/The Washington Post, Photo: Jabin Botsford/The Washington Post)

The Affordable Care Act is surviving. Advocates say it could be thriving. 

Since President Trump took office, the law has been under attack by the White House and the Republican Congress, both rhetorically and practically. Just Thursday night at a campaign rally in Pennsylvania, Trump boasted about gutting the ACA. Short of repealing the entire law, his administration has done a lot to contribute to its failure.

And yet, despite their best efforts, enrollment in President Obama's signature domestic program remained steady this year, proposed premium increases for 2019 in many markets are in the single digits and insurers that had previously left some marketplaces are reentering the individual exchanges. 

But advocates of the ACA, as well as health policy experts who follow the law closely, still say it would be doing better were it not for the administration's systematic attempts to gut it.

"Some people have been surprised that the increases are generally modest, given the steps the Trump administration and Congress have taken to undermine the ACA," Larry Levitt, senior vice president for health reform of the independent Kaiser Family Foundation, told me in an email. "What that misses is that insurers are quite profitable in the individual insurance market right now, so they don’t need premium increases in spite of repeal of the individual mandate penalty and expansion in loosely-regulated short-term plans. If not for those policy changes, we’d be seeing a lot of premium decreases right now."

That's an argument Brookings Institute's Matt Fiedler makes in a new analysis of what the individual market would look like next year in a world where Republicans largely left the ACA intact.

Fiedler has crunched some numbers for this hypothetical situation, which take into account his own estimates that insurers will see a considerable profit increase in 2019. In a "stable policy environment," he calculates average nationwide premiums would fall 4.3 percent next year. That is, if Congress hadn't eliminated the individual mandate penalty and the Trump administration hadn't extended the length of "short-term" plans that are cheaper but skimp on some benefits. Both actions are expected to spark fear in the market that healthier consumers won't buy insurance, driving up costs.

Still, even with those policy changes, the individual market is chugging along. 

"This is exactly why I wrote this piece," Fiedler told me. "Because the experience would be so good this year if policy was stable, the difference between a 4.3 percent decline and what actually happens in 2019 ... we might end up in the single digits, but [premiums] are much higher than they could have been."

Helping to keep alive the ACA are government subsidies ensuring coverage is affordable  for most of the people buying insurance on the exchanges. As long as those stay in place, the law has a better chance of surviving. States have also been taking matters into their own hands by creating their own reinsurance programs that help them shoulder the higher costs of sicker patients, a subject I wrote about earlier this week. 

All is not rosy, however.

Premium rates for 2019 will raise the cost of insurance for the tens of millions of people who purchase insurance from the individual markets but earn too much to get any government assistance. These people tend to be entrepreneurs or small-business owners. And research shows they've been dropping out of the marketplaces as insurance has become more costly -- and that even more are expected to flee now that the individual mandate is gone. 

Just taking into account the White House's decision this week to extend short-term plans, Linda Blumberg, a health-policy fellow at the Urban Institute, says her research shows that decision will cause 2.2 million fewer people to enroll in ACA-compliant plans in 2019.

"I think [Republicans] are being quite successful. The ACA still stands and the subsidies still hold a lot of the subsidized people in place and that’s really helpful. But the people hit the hardest are the people who have to pay the full cost [of insurance] themselves and the evidence so far is there has been significant decrease in [the] number of people buying without subsidies," Blumberg told me.

She worries that short-term plans will be marketed like any other health coverage without full transparency that they offer much less.

Even Health and Human Services Secretary Alex Azar, who has been extolling the virtues of allowing people to buy these cheaper plans, tweeted a warning that these plans are not for everyone:

Blumberg warned that individuals may choose their plans based on their health status: healthy people could leave the marketplaces in favor of cheaper insurance, but return to an ACA plan if they get sick in the future.

"These efforts are playing with fire on the long-term stability of the pools, which people with health problems really need," she said. 

It's with these considerations in mind that, as we mentioned briefly in yesterday's Health 202, four cities, Columbus, Baltimore, Cincinnati and Chicago, and residents from Charlottesville, Va. (Read this story I wrote last fall to understand why the latter) are suing the Trump administration for its actions to weaken the ACA.

They are asking the court to force the White House to restore funding for ACA advertising and the "navigator" programs that help promote enrollment, extend the 2019 enrollment period, and promote ACA-compliant plans over ones with less benefits.

“The ACA has been more resilient than the administration would have hoped, but their efforts are taking a toll,” Adam Grogg, senior counsel on the case, said. “When the ACA was faithfully implemented, it was functioning as Congress intended: to broaden access to affordable, comprehensive health insurance. The Trump Administration is trying to grind that progress to a halt.”


AHH: The Trump administration said in a new court filing yesterday that it wants help from the American Civil Liberties Union and nonprofit groups to help find parents who were deported without their children.

Lawyers for the Justice Department said it has contacted foreign governments in an effort to find the adults, but called on the ACLU to use its “considerable resources” to help locate the parents.

The report was requested by Judge Dana M. Sabraw, who has been overseeing the family reunification process, in order for the Trump administration to explain its plans for reunifying the remainingmigrant families. But the report “gives a sense of the complex challenges ahead for both U.S. officials and immigration lawyers in locating the parents who are no longer in the U.S.,” our Post colleague Samantha Schmidt writes.

The ACLU fired back that the government still must bear the most responsibility in these efforts. “Not only was it the government’s unconstitutional separation practice that led to this crisis, but the United States Government has far more resources than any group of NGOs,” ACLU lawyers wrote in the court filing, according to Samantha. “Plaintiffs therefore hope that the Government will take significant and prompt steps to find the parents on their own.”

HHS reports that as of Wednesday, for 410 children, the associated parent or adult is no longer in the United States.

The ACLU warned tracking these parents down will not be an easy task, as about 120 of the deported parents don’t have a “potentially viable” address or location in the government’s database.

OOF: There have been four positive tests for Ebola in and around the town of Mangina in the Democratic Republic of Congo, confirmation of the latest outbreak of the virus.

But a small silver-lining: The version of Ebola has been confirmed as the Zaire strain, the same one that was previously protected by the experimental Merck-developed vaccine that was critical for treating the last outbreak, according to Reuters.

“Still, this outbreak poses new challenges. Eastern Congo is a tinderbox of conflicts over land and ethnicity stoked by decades of on-off war and this could hamper efforts to contain the virus,” per the report.

The World Health Organization said the death and unsafe burial of a woman in Mangina was a “trigger event,” according to Reuters that “set alarm bells ringing in the latest Ebola outbreak.” “WHO’s emergency response chief Peter Salama said seven of the woman’s immediate family later also died from Ebola-like symptoms, and potential cases were now being traced in 10 localities,” per the report.

OUCH: Hundreds of people have sued drugmakers Bristol-Myers Squibb and Otsuka over claims that taking aripiprazole, an antipsychotic drug under the name Abilify has caused compulsive behavior, which for some included gambling, eating, or compulsively having sex.

“Scientists haven’t figured out how, exactly, a drug might trigger compulsive behavior. Psychiatrists say that even if Abilify does have a role, it’s probably just part of the explanation, since millions of people take the drug without experiencing such problems,” Stat’s Megan Thielking reports. But reports caused enough concern for the Food and Drug Administration that it issued a safety warning in 2016 that such compulsive urges, including gambling, binge eating, shopping and having sex had been reported with the drug.

“Experts say the more critical question — and the bigger mystery — is why impulse-control problems might show up in just a small slice of the millions of patients who take Abilify each year,” Megan writes.

It’s worth reading Megan’s entire fascinating story about the lawsuits, and the story of one mother of four who describes the shame she felt as she took money out of savings to gamble, rode her bike 35 miles to a casino, went to the casino in the middle of a workday, and more than once left to go to the casino in the middle of her oldest son’s high school basketball game.

Senior White House adviser Ivanka Trump said on Aug. 2 she was “vehemently against” President Trump’s family separation policy and that it was a “low point." (Video: C-SPAN)

— Ivanka Trump distanced herself from the administration on two critical issues during an event on Thursday, including the administration's "zero tolerance" policy, saying that she was “vehemently against” the separation of migrant families at the border.

During the event hosted by Axios, Mike Allen asked the first daughter to share a high and low point of her time in the White House, suggesting the family separation was a particular low point for “a number your colleagues.”

“Yes, that was a low point for me, as well,” Ivanka Trump said. “I feel very strongly about that. I am very vehemently against family separation and the separation of parents and children.”

“I think immigration is incredibly complex as a topic, illegal immigration is incredibly complicated," she added. “I am a daughter of an immigrant. My mother grew up in Communist Czech Republic, but we are a country of laws… These are not easy issues. These are incredibly difficult issues. I experience them in a very emotional way.”

“Her comments at a public event underscored the difficult balance Trump has sought as she provides private counsel to a president and father with whom she does not always see eye to eye, while enduring criticism for not being more outspoken about their differences,” The Post’s John Wagner and Felicia Sommez report.

— Here’s how drug companies are beating the president at his own game: Announce buzzy, headline-grabbing moves to roll back or temporarily halt drug prices without having to make major changes.

“The gestures turned out to be largely symbolic,” Politico’s Sarah Karlin-Smith, Sarah Owermohle and Andrew Restuccia report. “Of the few companies that actually cut prices, for instance, most targeted old products that no longer produce much revenue — such as Merck’s 60 percent discount to a hepatitis C medicine that had no U.S. revenues in the first quarter.”

One lobbyist told Politico it was a “calculated risk” and “nothing-burger steps,” while another said it was “meaningless to satisfy Trump.”

And drug prices remain top of mind for Trump. He speaks three times a week with HHS Secretary Azar, and brings up the issue every time, Sarah, Sarah and Andrew write.

“Drug prices are a fixation for Trump, who rants about them in conversations with aides and advisers, according to people close to the president,” they add. “He sees the issue as a political winner, especially among his conservative — and largely older — base, which relies heavily on prescription drugs. And after facing huge hurdles moving his legislative priorities through Congress, he sees this as something he can win on by using his executive authority.”


—  Azar touted the administration’s short-term health plans during a "Fox News" interview yesterday, saying they delivers on a pledge from Trump to provide affordable health insurance.

“What we are doing is bringing cheap and more affordable options to individuals who are trapped under the [ACA] with insurance that is actually not affordable or not available or doesn’t deliver them hospitals and doctors that they need,” Azar said in the interview. He said the plans could be “attractive” for individuals who are in a transition period or who live in one of the nation's counties that have just one Obamacare exchange.  

“They may not be right for everybody and everyone needs to go in with their eyes open but its another option the president is delivering to provide affordable insurance for people,” Azar said.


— Senate Democrats will try to force a vote to block the Trump administration’s recently announced rule to allow these short-term plans.

Sen. Tammy Baldwin (D-Wis.) is leading the effort, the Associated Press’s Alan Fram reports, noting that while it has a chance of advancing in the Senate, such legislation is unlikely to pass in the House, nor would it be signed by the president. It’s yet another example demonstrating how Democrats have prioritized health care ahead of the midterm elections, seeing it has a key issue for voters.

"This is an issue the American people should know where everyone stands," Senate Minority Leader Charles E. Schumer (D-N.Y.) told reporters, adding Republicans should “instead of saying they're for it, actually do something to preserve preexisting conditions."

— Trump called on senators yesterday to adopt a proposal from House lawmakers to tighten food-stamp work requirements.

“The House work requirement proposal, part of the 2018 farm bill, narrowly passed on strict party lines in June,” our Post colleague Caitlin Dewey reports. “But the Senate version of the farm bill made only technical tweaks to food stamps, officially known as the Supplemental Nutrition Assistance Program.”

Negotiators are hoping to meet to reconcile differences between the versions in September. Republicans support such a proposal because they believe it provides people with incentive to move off government assistance, while Democrats warn many could go hungry.

— Sen. Marco Rubio (R-Fla.) introduced legislation yesterday to provide paid family leave by allowing parents to draw early from Social Security payments. Parents would then delay the date they receive their retirement benefits to offset the amount withdrawn during the leave, our Post colleague Erica Werner reports.

“This is important legislation. It is also unique,” Rubio said at a news conference unveiling his bill. “This is a dramatic readjustment of the way we deal with economic insecurity in the modern era.”

Ivanka Trump, who has made family leave a signature issue, applauded the bill, but said it’s unlikely to move forward in an election year. “Really at this point we’re curating ideas with the hope of being able to build consensus, but it will take time,” she said at an event yesterday. “I’m cautiously optimistic that it can happen next year.”


— If one company falters, another can gain: That’s the approach competitors to Purdue Pharma seemed to take when criticism was escalating over that company's risks connected to OxyContin, Kaiser Health News’s Fred Schulte reports.

Several years of Purdue’s marketing plans for the opioid drug reveal that the company and its biggest rivals fought for the market share of such drugs, Fred reports. “Some of those drug makers’ sales promotions downplayed or ignored the risks of taking opioids, or made false claims about their safety, federal regulators have asserted in warning letters to the companies,” he writes. “Purdue has become the most high-profile drug maker linked to the surging opioid crisis. But other opioid manufacturers didn’t sit by idly as sales of OxyContin skyrocketed, topping $1 billion in 2000, despite reports of overdose deaths and addiction.”

“Purdue’s marketing reports indicate the company was worried about losing business to fentanyl-laced patches called Duragesic, as well as morphine pills and, to a lesser degree, methadon,” Fred continues. “In its 1999 marketing report, Purdue noted that Janssen Pharmaceuticals, an arm of drug giant Johnson & Johnson, was making ‘slow but steady’ progress in promoting its Duragesic patches…. In September 2004, the FDA told Janssen to ‘immediately cease’ making ‘false or misleading’ claims, including saying that Duragesic was ‘less abused than other opioid drugs.’"

— A new Gallup survey found a 30 percent jump in the number of Americans who cite drug abuse as causing family troubles. That’s up from the last Gallup survey on this issue in 2005, when it found 22 percent of respondents said the same.

Broken down by region, 38 percent of people in the West reported that their family has been affected by drug abuse, much more likely than 27 percent of people in the Midwest, 28 percent of people in the East or 26 percent of people in the South.

The report also found 33 percent of women cited drug abuse as a source of family issues, compared with 26 percent of men.

Gallup notes that while it did not ask participants “about the effects of drug abuse on families between 2005 and 2018, the latest figure, a historical high, tracks with the overall increase in deaths from opioids over that period.”

The survey also concluded that alcohol is a source of family trouble, with 37 percent of Americans reporting that drinking has caused problems in their family. Gallup reports that’s a “historical high” that ties with the 37 percent response rate in 2004.

— According to newly obtained documents, the FDA had data revealing a widespread off-label prescribing of a dangerous class of fentanyl drug, but agency officials did not do much to step in, the New York Times’s Emily Baumgaertner reports.

More non-cancer patients are being prescribed the fast-acting fentanyl only meant for certain kinds of back pain and migraines, a practice that could put them at a higher risk of overdose and death, Emily reports, citing thousands of documents obtained by Johns Hopkins University researchers via the Freedom of Information Act.

For their part, agency officials said it was difficult to determine the extent of the risk to patients from the data that they had. “The information we have isn’t very good, but it seems to indicate people who aren’t cancer patients are getting this and people who aren’t opioid tolerant are getting this,” Janet Woodcock, the director of the FDA’s Center for Drug Evaluation and Research told the Times. “There has been a tremendous back-and-forth with companies on how to get better information.”


— Maryland’s House Speaker Michael E. Busch wants abortion rights protected under the state constitution, and plans to introduce and push for legislation that would have people vote on a constitutional amendment perhaps during the next presidential election year, The Post’s Erin Cox reports.

Busch’s plan is the latest in a growing effort by states looking to address abortion rights before, they fear, the Supreme Court has as chance to overturn abortion protections.

“If [voters] decide that this becomes part of the constitution, a woman’s right to choose will never be debated, it will never be a bargaining chip," Busch said Wednesday.

“The influential Maryland Catholic Conference is likely to be the most powerful opponent of any constitutional amendment effort, though the group’s new executive director, Jennifer L. Briemann, declined to specify how the group would work to defeat it,” Erin writes. “Briemann said that given the state’s other needs — including more education funding, helping immigrant families and stemming violence in Baltimore — ‘this effort seems misdirected at best.’”

— The Trump administration said yesterday it would continue to fund Planned Parenthood for the 2018 fiscal year, the Washington Examiner’s Robert King and Kimberly Leonard report. The group was part of list of 96 organizations that HHS said will continue to receive family-planning grants under the Title X program even as the Trump administration considers potential new regulations to slash future funding to clinics that provide abortion services.

Planned Parenthood makes up 11 of the 96 providers that will get the grants, Robert and Kimberly report. The administration has not yet released the dollar amount it will provide the recipients.


— Juul Labs Inc. has fired back after the Food and Drug Administration said it would review the use of flavored tobacco, saying a move to prohibit the electronic nicotine delivery systems known as ENDS would deprive “millions of adult smokers of tools that may help them quit smoking.”

“FDA should fully understand whether flavored ENDS actually pose risks to youth that cannot be mitigated with other regulatory alternatives,” the company wrote to the FDA, according to Bloomberg News’s Janine Wolf and Olivia Zaleski. The company also warned a restriction of flavors in the products would lead to a “gray market" of illegal sales. 

“Our focus has been providing flavors that are helpful for adults to switch and to stay switched,” Juul’s Chief Administrative Officer Ashley Gould told Bloomberg.

The FDA has found itself in a difficult position as it considers regulating flavors in e-cigarettes, given their potential to help adult smokers move away from combustible tobacco products while also appealing to young consumers who find ways to get access to the nicotine pods,” Janine and Olivia write. “This spring, the agency sent a slew of warning letters to companies selling e-liquids about misleading kids with products resembling food and candy.”

— And here are a few more good reads: 

Allergan sues Pfizer over costs of opioid litigation (Reuters)

With scant record, Supreme Court nominee elusive on abortion (Associated Press)

Is There Room to Be Anti-Abortion in Today’s Democratic Party? (Politico)


Worker Charged With Sexually Molesting Eight Children at Immigrant Shelter (ProPublica)

She Got Her Baby Back From Immigration Foster Care. Now What? (ProPublica)

A 12-year-old had one-sixth of his brain removed. He feels ‘perfectly normal.’ (Lindsey Bever)


‘It Can Happen Even to Guys’: Ohio State Wrestlers Detail Abuse, Saying #UsToo (The New York Times)

Can you change how criminals think? Chicago hopes behavioral therapy can cut gun violence (USA Today)



  • 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."  

From the Fact Checker: Who supports this $800 billion plan to slash Medicare?:

An ad from the Congressional Leadership Fund misleads viewers about funding for Medicare. (Video: Meg Kelly/The Washington Post)

Another fact check: Has Trump cut 22 regulations for every new one?

President Trump has taken on the regulatory state, but his team overstates his success with fishy numbers. (Video: Meg Kelly/The Washington Post)