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The Health 202: Obamacare enrollment is lagging, despite cheaper options

with Paulina Firozi


More Americans can get Obamacare plans for free next year. But enrollment in the health-care marketplaces still appears to be lagging halfway through the Affordable Care Act's sixth sign-up season.

Total sign-ups this year are down by about 300,000 people compared to the same time last year — a roughly 11 percent decline. Enrollment could certainly pick up as the Dec. 15 deadline nears — that's been the pattern in previous years. But the initial figures don’t look so great for the Trump administration, which has been frequently accused of trying to sabotage the ACA.

If final enrollment figures are less than 11.8 million — the number of people who signed up for 2018 marketplace coverage — that would be surprising considering the 2019 plan options look better for more people. Obamacare had several rough years, as insurers spiked premiums by double digits and dropped out of the marketplaces altogether. But if the health-care law ever had a banner moment, it would be now.

For one thing, it’s the first year marketplace premiums are dropping instead of rising. And that’s true  across the spectrum for the leanest health plans to the most comprehensive. The average monthly premium is 0.3 percent lower for the lowest-cost “bronze” plan, 1 percent lower for the lowest-cost “silver” plan and 2 percent lower for the lowest-cost “gold” plan, according to a new analysis from the Kaiser Family Foundation.

Not only are premiums lower, but government subsidies for low-income Americans who want health insurance continue to be more generous than in years past. That’s because insurers are still engaging in what’s become known as “silver-loading.” We explained this practice here in detail, but it basically means insurers are hiking silver-plan premiums to make up for cost-sharing subsidy payments the Trump administration severed last year. As a result, subsidies are larger because they’re based on the cost of more expensive silver plans.

This means more low-income, subsidy-eligible Americans can find a monthly premium cheap enough to be entirely covered by their subsidy. Consider a few examples:

—A 40-year-old earning $25,000. Kaiser estimates such an individual would be able to find a no-cost bronze plan in 2,014 counties next year, compared to 1,679 counties this year (there are about 3,100 counties in the United States). In 411 counties, they could even find a no-cost gold plan.

—Say that 40-year-old earns $35,000. They’ll be able to find a no-cost bronze plan in 417 counties next year, compared to 169 counties this year, per Kaiser’s analysis.

And insurers are returning to some counties that had previously lost nearly all of their plans. Kaiser Health News’s Jordan Rau reports on how the marketplaces have improved for residents of Memphis and Phoenix, who are now paying less and choosing among more options.

That isn’t to say premiums are suddenly affordable for everyone. They’re still far more expensive than some Americans can afford to pay, especially those who earn too much for subsidies available only to those between 100 and 400 percent of the federal poverty level. Average silver premiums for 2019 are 75 percent higher than they were in 2014, the marketplaces’ first year, according to Kaiser data.

For the first time next year, those who find coverage unaffordable — or just don’t want to buy it for one reason or another — can opt out without being subject to a penalty. Recall that Congress zeroed out the penalty for lacking coverage in its tax overhaul.

The absence of this penalty is among several things ACA advocates are citing as reasons that enrollment might come in under last year’s levels. It’s possible more people have coverage through their job, given the unemployment rate is 0.5 percent lower than last year. Some leaner, cheaper plans have become available and could be drawing a small number of consumers away from the marketplaces.

“The year-over-year decline we’re seeing is almost certainly the result of a combination of a lot of factors,” wrote Lori Lordes, co-founder of the group Get America Covered.

The Centers for Medicare and Medicaid Services also has significantly dialed back its advertising of — although that was also the case last year and enrollment came in higher than most observers expected. The agency has notably been emailing sign-up reminders to those with existing accounts on (I’ve received a dozen such emails in the past month), which is a cost-effective way of making sure customers return but doesn’t necessarily help add new enrollees.

CMS Administrator Seema Verma has been spending more time touting enrollment in Medicare, which covers four times the number of Americans as the marketplaces, but she hasn’t completely ignored ACA enrollment either. Verma tweeted this last week:


AHH: The Trump administration has called on the health-care industry to make recommendations for a change to the rule that bans kickbacks and payments made to influence care for Medicare and Medicaid beneficiaries.

“With its request for advice, the administration has touched off a lobbying frenzy,” the New York Times’s Robert Pear reports. “Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.”

In the past few weeks, health-care executives and lobbyists have sent letters to the administration regarding a potential change. “The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries,” Pear reports. “The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.”

He notes the move has “astonished some experts.” “The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” lawyer James J. Pepper told the Times. Meanwhile, James L. Madara, chief executive of the American Medical Association, said the laws “impose undue burdens on physicians and serve as obstacles to coordinated care.”

OOF: A nursing home chain exposed about 25,000 patients to increased health risks while under the ownership of The Carlyle Group, one of the richest private-equity firms in the world.

Our Post colleagues Peter Whoriskey and Dan Keating detail in this deeply reported piece “devastating consequences” that existed as a result of the inadequate care in HCR Manor-Care nursing homes. “One man had been dosed with so many opioids that he had to be rushed to a hospital, according to the inspection reports,” they write in the piece worth reading in full. “During an undersupervised bus trip to church — one staff member was escorting six patients who could not walk without help — a resident flipped backward on a wheelchair ramp and suffered a brain hemorrhage. When a nurse’s aide who should have had a helper was trying to lift a paraplegic woman, the woman fell and fractured her hip, her head landing on the floor beneath her roommate’s bed.”

The chain also violated health codes. Each year, the number of violations increased 26 percent between 2013 and 2017, according to an analysis of 230 of the chain’s homes. Under Carlyle’s ownership, the chain also had financial setbacks, filing for bankruptcy in March.

“The rise in health-code violations at the chain began after Carlyle and investors completed a 2011 financial deal that extracted $1.3 billion from the company for investors but also saddled the chain with what proved to be untenable financial obligations,” Whoriskey and Keating write. “Taking the money out of ManorCare constrained company finances. Shortly after the maneuver, the company announced hundreds of layoffs. In a little over a year, some nursing homes were not making enough to pay rent. Over the next several years, cost-cutting programs followed.”

Meanwhile, representatives from Carlyle and HCR ManorCare told our colleagues that care at the homes were not compromised by any financial circumstances.

OUCH: An E. coli outbreak that sickened dozens across various states and led to a CDC food safety alert to completely avoid romaine lettuce is likely connected to romaine lettuce in California.

Food and Drug Administration commissioner Scott Gottlieb tweeted the update on Friday and said the likely link is based on an assessment of “growing and harvesting patterns.” He also said the FDA is looking to establish a labeling standard to determine where lettuce comes from and when it was harvested.

“States affected by the outbreak include California (which had the highest number of cases — 10), Michigan, Connecticut, Illinois, Massachusetts, Maryland, New Hampshire, New Jersey, New York, Ohio and Wisconsin,” USA Today’s Ashley May reports.


— An Axios-SurveyMonkey poll found a majority of Americans are either “very worried” or “somewhat” worried about the impact of a Texas lawsuit that seeks to undermine the ACA and how it will affect protections for people with preexisting conditions. A federal judge is expected to make a ruling on the lawsuit soon.

It found 74 percent of respondents are at least somewhat worried about themselves or a family member having to pay more if such protections are overturned, Axios’s Sam Baker reports. Broken down by party, the poll found 54 percent of Republicans were at least somewhat worried about the impact of the lawsuit, as were 81 percent of independents and 90 percent of Democrats.


— There were fewer abortions in the United States in 2015 than at any point since the landmark Roe v. Wade Supreme Court ruling, according to a report released last week from the Centers for Disease Control and Prevention.

In 2015, there were 638,169 abortions reported across the country. The abortion rate was 11.8 abortions per 1,000 women ages 15 to 44. That’s down from 12.1 in 2014 and 15.9 in 2006. And the number of abortions in 2015 was down 2 percent from the 652,639 abortions in 2014.

“In the years immediately after abortion was legalized nationwide in 1973, the number of legal abortions rose dramatically, reaching its peak in the 1980s, The Washington Post's Ariana Eunjung Cha reports. “Abortions then began dropping at a slow rate until around 2006 to 2008, when they increased slightly, followed by even greater decreases in recent years.”

The CDC’s report comes as the Trump administration looks to introduce policies to limit abortion funding to providers. “While the CDC paper did not delve into the reasons for the decline, analysts have cited improved access to birth control, which has led to a decrease in unintended pregnancies, especially among teens, as well as the state laws regarding parental consent, waiting periods and other conditions that make it more difficult for women to get abortions,” our colleague writes.


— While people were sleeping, a machine that helps millions with sleep apnea was also collecting information. The CPAP breaching machines were tracking when the machines were being used and sending that data to the device maker, the medical supply company and health insurers, ProPublica’s Marshall Allen reports.

That information helped insurers determine whether to cover the machines at all. “In fact, faced with the popularity of CPAPs, which can cost $400 to $800, and their need for replacement filters, face masks and hoses, health insurers have deployed a host of tactics that can make the therapy more expensive or even price it out of reach,” Allen writes. “… Experts who study health care costs say insurers’ CPAP strategies are part of the industry’s playbook of shifting the costs of widely used therapies, devices and tests to unsuspecting patients.”

Now, such practices have led to lawsuits and have sparked concerns by doctors who say limiting coverage for machines can have serious consequences for patients. Allen reports that 22 million Americans have sleep apnea, according to the American Sleep Apnea Association, though he adds it's often not diagnosed.

“Sleep apnea specialists and health care cost experts say insurers have countered the deluge by forcing patients to prove they’re using the treatment,” Allen writes. He adds, “a Blue Cross Blue Shield spokesperson said that it’s standard practice for insurers to monitor sleep apnea patients and deny payment if they aren’t using the machine. And privacy experts said that sharing the data with insurance companies is allowed under federal privacy laws.”


— A judge in Maine ordered Republican Gov. Paul LePage to implement the expansion of the state’s Medicaid program, but the outgoing governor has said he plans to appeal the order.

LePage has repeatedly avoided expanding Medicaid, which voters approved via a ballot initiative last year. 

“Although the governor may believe implementation to be unwise and disagree with the (expansion law) as a matter of policy, he may not ignore the will of the people and refuse to take any action toward accomplishing the policy objectives of the (law),” Kennebec County Superior Court Justice Michaela Murphy wrote in an order issued last week, the Portland Press Herald’s Scott Thistle reports.

The judge called on LePage to comply with the order by Dec. 5. Democratic governor-elect Janet Mills has said she will implement expansion on her first day in office. “Murphy’s order, retroactive to July 2, requires the DHHS to file an amendment to paperwork already submitted to the federal government,” Thistle writes. “The amendment must state that there are no legal or constitutional grounds for delaying the expansion.”

— And here are a few more good reads from The Post and beyond: 


After a Wildfire, Rebuilding Life Can Be Hardest for the Oldest (The New York Times)

Fertility fraud: People conceived through errors, misdeeds in the industry are pressing for justice (Ariana Eunjung Cha)

Former CIA director Michael Hayden hospitalized after suffering a stroke (Deanna Paul)

The maternity homes where ‘mind control’ was used on teen moms to give up their babies (Diane Bernard and Maria Bogen-Oskwarek)

Public doesn't trust Trump, GOP to bring down drug prices (Axios)

Can House Democrats really protect Obamacare? (Politico)

How many kids have autism? US government measures 3 ways (Associated Press )


This City’s Overdose Deaths Have Plunged. Can Others Learn From It? (The New York Times)


Coming Up

  • The American Enterprise Institute holds an event with CMS Administrator Seema Verma on "The new Medicare physician payment regulation" on Tuesday.
  • The Heritage Foundation holds a discussion about fetal tissue research on Tuesday.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on reducing health-care costs on Wednesday.
  • The Senate Armed Services Committee holds a hearing on the nomination of Thomas McCaffery to be assistant secretary of defense for health affairs on Thursday.

From deadly wildfires to debilitating hurricanes: White House releases major climate report:

The Trump administration released on Nov. 23 a long-awaited report outlining that climate change impacts "are intensifying across the country." (Video: Luis Velarde/The Washington Post)