THE PROGNOSIS

The first Affordable Care Act enrollment season opens today in which GOP-led changes to Obamacare are fully in place. The changes may not be as disastrous to the insurance marketplaces as Democrats would have you believe.

To be sure, the Trump administration has adopted a sharply different approach than the Obama administration to the insurance marketplaces where about 11 million people get their health coverage. It has opened the door to cheaper, leaner plans. It has slashed spending on advertising and outreach. It has applauded Congress for repealing the penalty for being uninsured.

In response, Democrats seeking to gain seats in next Tuesday’s midterm election have kept up a drumbeat of criticism slamming the administration for trying to sabotage Obamacare:

Sen. Patty Murray (Wash.), top Democrat on the Health, Education, Labor and Pensions Committee:

Senate Minority Leader Charles E. Schumer (D-N.Y.):

The basic conditions, however, that drove Americans to seek insurance in the marketplaces created by the 2010 ACA remain the same. That includes subsidies, which help about four in five lower-income marketplace shoppers afford plans, and a requirement that plans accept people with preexisting conditions and cover a full range of health services. Republicans still say they want to repeal and replace the ACA --  but in order to try again, the GOP would have to hold its House majority, plus gain some additional Senate seats.

There are some signs insurers have finally found their sweet spot in the marketplaces. After several years of spiking premiums and insurer exits, the marketplaces appear much more stable at the start of the 2019 enrollment season, which runs Nov. 1 through Dec. 15.

Recall the widespread surprise last year when marketplace enrollment dropped by only 400,000, despite frequent predictions the Trump administration’s attempt to "sabotage" them would result in a million or more people dropping out of the marketplaces.

The final enrollment figure for 2018 — 11.8 million — is the benchmark number to keep in mind when the administration releases 2019 signup totals. It will be interesting to see whether enrollment holds steady, decreases or even increases, considering that some marketplace plans actually became cheaper for to buy for next year.

Top health officials, including Health and Human Services Secretary Alex Azar and Centers for Medicare and Medicaid Services administrator Seema Verma, still regularly criticize Obamacare. 

Azar and Verma are not terribly eager to talk about Obamacare -- spokespeople for both officials said they have no public events scheduled today as open enrollment launches. And when they do refer to the ACA, they argue they’re making the best of what they view as a bad situation and law.

And you could view this enrollment period as a test of their actions to put a more conservative stamp on the ACA, as my colleague Amy Goldstein notes in this story.

“In fostering such new policies, the administration’s senior health officials have been walking a balance beam in the lead-up to the open enrollment: They are claiming credit for causing the marketplaces to be less turbulent than in the past few years, while continuing to argue for an end to the sweeping 2010 health-care law that was President Barack Obama’s prime domestic achievement,” Amy writes.

We’ll know a lot more about how these changes affected enrollment once the six-week signup period is over. But there’s reason to believe the administration's actions won’t have a huge effect on coverage for the vast majority of customers — at least not yet.

For one thing, the individual mandate, eliminated in the GOP tax cut overhaul, was less effective in practice than in theory. That's because the fine for people who didn't buy insurance was less than many people might pay in annual premiums. The executive branch also lacked sufficient enforcement mechanisms all along. There are estimates that repealing the penalty caused higher premiums than if it had been left in place, but premiums also haven't skyrocketed as Democrats had predicted.

And there’s something else: The leaner, cheaper policies being encouraged by the Trump administration — those “junk” plans Democrats keep referring to — aren’t yet widely available.

Over the summer, the administration finalized two new policies expanding two alternative types of health coverage — short-term health plans and association health plans — that generally cost less but are also exempt from ACA requirements to cover a full slate of services and accept people with preexisting conditions.

In theory, these plans could put upward pressure on premiums because they would draw healthy people away from the marketplaces, leaving sicker people behind. Plus, some activists and experts fear people might lured into buying these cheaper plans without realizing they might not cover needed benefits.

The new regulations didn’t go into effect until this fall, so insurance carriers are still working on developing plans that fit these new categories, insurance experts say.

Sean Malia Sr., director of carrier relations for the web broker eHealth, told me there's interest among insurers in offering expanded short-term plans. But he said they won’t be ready to roll out these plans until early next year and it's uncertain how widely available they’ll be in the end anyway. Plus, Malia noted, 20 states have placed stricter limits on short-term plans than allowed by new federal rules.

Malia said he’s also hearing some interest from insurers in offering association health plans (referred to by health wonks as AHPs). But he said carriers are still figuring out exactly how such plans would work under the new rules and considering whether it’s worth selling them.

“The challenge is not a lot of carriers haven’t bought into AHPs as of yet, so they’re not widely available right now,” Malia said. “A lot of it is still very fluid. As more carriers start to get involved, things will start to get more concrete.”

AHH, OOF and OUCH

AHH: The Centers for Medicare and Medicaid Services yesterday approved a plan to allow Wisconsin to become the fourth state to implement work requirements for people who receive Medicaid benefits.

The state will require Medicaid beneficiaries to complete 80 hours a month of work in order to maintain enrollment. Individuals in the program will be locked out of it for six months if they fail to comply with the requirements for 48 months. That appears to be far more lenient than the requirement in Arkansas, which says people will lose insurance if they fail to comply for three months in a year.

“Four other states have won such permission this year, including Arkansas, which has cut off several thousand people from benefits for failing to meet its ‘community engagement’ requirement,” our colleague Amy Goldstein reports. “A federal judge has blocked the work requirement in Kentucky, the first state to attain permission last winter; Wisconsin becomes the administration’s first new approval since the court ruling early this summer.”

Verma acknowledged “there are people who disagree with this approach.” “Some believe that our sole purpose is to finance public benefits, even if that means lost opportunity and a life tethered to government dependence,” she said in a statement yesterday. “We will not retreat from this position.”

Amy also notes that Wisconsin will be the first state to “compel certain poor residents to disclose behavior such as drinking and exercise to qualify for Medicaid — and to charge more to people whose behavior the state judges as risky.”

From Verma: 

Wisconsin Gov. Scott Walker (R) touted the announcement: 

OOF: Former Vice President Joe Biden pulled no punches when he dismissed claims from Trump and the Republicans who say the party wants to protect people with preexisting conditions.

"They’re either not telling the truth or they’re really stupid," Biden said during a rally to support Lauren Underwood, an Illinois Democrat running for Congress, Politico’s Matthew Choi reports. "Because there's no way you can afford to cover preexisting conditions without everybody being in on the deal."

The president has repeatedly said that Republicans would defend these protections, again making the claim in a tweet yesterday.

OUCH: Verma took a jab at “Medicare-for-all” in a tweet yesterday, using a Halloween-themed post to reiterate her opposition to the idea of a universal, government-run health-care program. The idea has gained momentum among Democrats and has been the subject of attack from Republicans and by the president.

“Ideas like, ‘Medicare for All’ would only serve to hurt and divert focus from seniors,” Verma said in July during remarks at the Commonwealth Club of California. “In essence, Medicare for All would become Medicare for None. By choosing a socialized system, you are giving the government complete control over the decisions pertaining to your care, or whether you receive care at all.  It would be the furthest thing from patient-centric care.”

In October, she called it a “bad idea.” Verma followed up with a tweet later in the day saying “Medicare for All isn’t a joke”:

HEALTH ON THE HILL

— One of Democrats’ top priorities if they recapture the House majority would be tackling the increasing costs of prescription drugs, the New York Times’s Nicholas Fandos reports. It’s one of a number of agenda items, including campaign and ethics changes and infrastructure investment, that top Democrats told the Times is part of their agenda.

In an interview with the Times, House Minority Leader Nancy Pelosi (D-Calif.) also said Democrats would work to improve Obamacare instead of looking to immediately replace it with a single-payer system.

Pelosi predicted a Democratic victory and said it would be a “bitter pill for them all to swallow when they see the election results, if they turn out as we expect.” “I don’t think he himself knows what he is going to do,” she said about the president’s willingness to cooperate if Democrats are successful in the House.

“Democrats have also prepared detailed, more liberal approaches for a $1 trillion infrastructure package and how to slow the increases in prescription drug costs, but indicated that they would steer proposals through the regular committee process in an effort to try to build a consensus with Republicans first,” Nicholas writes.

Meanwhile, Pelosi has been declaring victory for Democrats both in public and private, Politico’s John Bresnahan and Caitlin Oprysko report.

“Pelosi's spiking of the ball — even if her supporters wouldn't call it that — could be risky. House Republicans have spent millions of dollars this cycle trying to tie Democratic candidates and incumbents to the California Democrat, the same tactic they used successfully in 2010,” John and Caitlin write. “Pelosi has been extremely careful to avoid making herself an issue in battleground races, focusing all her attention on President Donald Trump and the Republican legislative record on health care and taxes.”

“Yet Pelosi — like other party leaders — has taken a hard look at the most recent polling and turnout data, and she feels confident about her call.”

TRUMP TEMPERATURE

—Trump’s State Department is considering a plan that would ban U.S. diplomats from using the terms “sexual and reproductive health” and “comprehensive sexuality education,” Politico’s Nahal Toosi and Dan Diamond report.

The proposal would be for officials to instead use phrases like “reproduction and the related health services.” The proposal from Secretary of State Mike Pompeo is “being pushed by a handful of conservative political appointees at the State Department and other agencies, including Mari Stull, an adviser at State whose alleged mistreatment of career government staffers has already sparked multiple federal investigations,” Nahal and Dan write.

It’s not clear how such a change would impact policy, if at all.

“But changing the terms could lead to more contentious negotiations at the United Nations and other forums over language used for resolutions and agreements,” Nahal and Dan write. “At the very least, abandoning the use of the word ‘sex’ would be a symbolic move that aligns with other Trump administration efforts to reduce funding for and focus on women’s reproductive issues — especially anything related to abortion.”

STATE SCAN

— Abortion took the stage in Indianapolis this week in the debate between Democratic Sen. Joe Donnelly and his Republican challenger Mike Braun in their competitive matchup. For his part, Donnelly tried to force the issue and coax a response from Braun, the Associated Press’s Brian Slodysko reports.

Both candidates have said they are opposed to abortion, although Donnelly says he supports exceptions being made in the cases of rape, incest or when there’s a risk to the mother’s health.

“If your daughter happens to be raped, Mike thinks the government has a role in the middle of that — I don’t,” Donnelly said.

But Braun seemed to avoid the same gaffe-filled fate of Donnelly’s 2012 opponent, who during a debate said that women who get pregnant after being raped are carrying a “gift from God," Brian writes. “The senator tries to have it both ways. When it comes to the sanctity of life, you cannot say you are pro-life and have your voting record,” Braun said of Donnelly. He added he would “never demonize anyone who disagrees with my point of view.”

"The politics of abortion are complicated in Indiana, a state so dominated by Republicans that policy fights over the issue are typically waged by differing factions within the party," Brian reports. "In an election that could hinge on support from independents and moderate Republican women, it could also prove to be a volatile electoral issue."

MEDICAL MISSIVES

— Yet another mass shooting has restarted an ongoing national conversation about American’s gun laws, and this time just days before the midterm elections.

Our Post colleague Eugene Scott writes that’s in part driven by the president’s own comments about guns on the same day a shooting left 11 people at Tree of Life synagogue in Pittsburgh. Police say the shooter was armed with multiple handguns and an assault rifle. While Trump suggested that an armed guard inside the synagogue could have stopped the shooter, he also said that gun laws have “little to do with it.”

“Gun laws are among the most politically polarizing issues, but heading into the midterm elections there had not been much talk about them,” Eugene writes. “A week before the shooting, the Pew Research Center published data showing that there are some specific policy proposals that both Republicans and Democrats support broadly. Most Americans say gun laws should be more strict — and the number who say so has increased over the past year. Nearly six in 10 — 57 percent — of Americans think gun laws should be stricter. That number was 52 percent last year.”

“After mass shootings, it is common to hear questions and concerns about the suspect’s mental health. Perhaps in light of that, overwhelming majorities (89 percent) of Republicans, Democrats and independents who lean toward one of the parties say people who are mentally ill should be barred from buying guns.”

Trump and Republicans have previously campaigned on protecting gun ownership, but passing any legislation to address limitations on purchasing guns “hasn’t really hinged on public onion in the past, and it’s not likely to anytime soon,” Eugene reports.

“The gun lobby, including highly influential groups such as the National Rifle Association, holds sway with large swaths of Congress, and voters in the Republican base still generally oppose stricter gun laws. In the Pew survey, Republicans were four times (76 percent) more likely than Democrats (19 percent) to say that gun rights are more important than gun control.”

— And here are a few more good reads: 

World
A massive wave of migrants is transmitting once-rare diseases to other parts of Latin America
Anthony Faiola, Marina Lopes, Rachelle Krygier, Gui Christ, Joanne Lee and Chloe Coleman
Rep. Michael Burgess, R-Texas, isn’t shying away from the Obamacare repeal bill that the House passed last year, a stark contrast from some of his colleagues facing tough re-election races this fall.
Washington Examiner
The National Rifle Association — long seen as a kingmaker in Republican politics — is taking a lower profile in this year’s high-stakes midterm campaign, a sign of the shifting dynamics of the gun debate as the GOP fights to maintain its grip on Congress
Associated Press
Voters in 37 states will decide 155 ballot measures this midterm. In many states ballot measures echo larger national trends.
Kate Rabinowitz
A group of Senate Democratic appropriators have asked their Republican colleagues to hold a hearing regarding how the Trump administration has been funding the detention of unaccompanied migrant children.
The Hill
INDUSTRY RX
Fact Checker
Under attack from Democrats for health-care votes, some Republicans have begun borrowing language from the 2008 Obama campaign
Glenn Kessler
Express Scripts revenue surged in the three months through September, even as speculation mounted that the Trump administration will try to revamp a key piece of its business model.
Washington Examiner
People can livestream their every move on Facebook and chatter endlessly in group chats. But in most parts of the U.S., they still can’t reach 911 by texting — an especially important service during mass shootings and other catastrophes when a phone call could place someone in danger.
Compared to open surgery for cervical cancer, the less invasive approach was more likely to result in cancer recurrence and death, new studies found.
New York Times
DAYBOOK

Coming Up

  • HHS Advisory Committee on Heritable Disorders in Newborns and Children holds a meeting on Thursday and Friday.
  • The FDA holds a joint meeting of the Psychopharmacologic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee on Friday.
SUGAR RUSH

GOP hopefuls say they fight insurance companies, just like Obama: