THE PROGNOSIS

For all the Obamacare political battles over the past decade, a harsh reality remains: Health insurance is still unaffordable for many Americans. And it’s unclear whether a soon-to-be-divided Congress will do much about it.

I wrote in Monday’s Health 202 that the Affordable Care Act’s marketplaces are looking more stable than ever before, given that average premiums dipped for the first time and plan offerings increased rather than diminished. That’s broadly true — but it’s also true that consumers in some U.S. counties are still seeing big price hikes. In fact, several of you wrote me to say your premiums are still rising by double digits.

— Fairfax, Va., resident Susan wrote that the monthly premium for a Kaiser plan for herself and her child is increasing 30 percent from last year and that she isn’t eligible for any subsidies to pad the extra expense.

“This is the second year in a row of 30 percent premium increases!” Susan wrote. “I currently have Kaiser’s cheapest silver plan, but their bronze offering isn’t going to be the ‘answer’ — it is only about $60 per month cheaper. And premiums aren’t much lower if I switched to Cigna (and started over with all new doctors).”

— Another reader, named Fern, said she enrolled in Oregon’s marketplace because she wants to support the ACA. But the premiums for her "Providence Bronze-level plan" went up 33 percent. “Not sure where premiums were lower, but I want to move there,” she wrote to me.

The big picture here is that despite the recent good news, premiums are still 75 percent higher on average than when the marketplaces opened in 2014. And that’s not the only way consumers are feeling pinched on health-care costs. Out-of-pocket spending — the extra costs associated with a plan such as deductibles and coinsurance — has accelerated for the past three years across all types of health insurance, including for employer-sponsored coverage.

American families paid an average of $625 in out-of-pocket costs in 2017, up 8.5 percent from the year prior, according to a health-care spending report by the JPMorgan Chase Institute. Out-of-pocket spending as a percentage of income also ticked up slightly.

Particularly hard-hit by the increases are low-income families, who are seeing larger cost increases relative to their income. Thirty percent of Americans say health-care costs make it hard for them to pay for basic necessities, and nearly 1 in 4 non-elderly adults say they forgo necessary medical care because of cost.

“Health coverage still is too expensive, and I think everyone recognizes that,” Shawn Gremminger, senior director of federal relations at Families USA, told me.

But he also acknowledged that other health-care issues — such as protecting people with preexisting conditions and expanding Medicare — have been getting a lot more attention lately on Capitol Hill. “On the other hand … I haven’t heard as much screaming on the Hill about it as we have [heard] on preexisting conditions and Medicare,” Gremminger said.

Drug costs are also top of list for lawmakers in both parties and, come January, could be the most likely issue to prompt a bipartisan response from the Republican-led Senate and the Democratic-led House. But the cost of health insurance is a big, outstanding problem that some lawmakers haven’t forgotten, even though a bipartisan effort toward that end failed spectacularly earlier this year.

This morning, Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, is holding a fifth hearing on health-care costs. He previously forged an agreement with the committee’s top Democrat, Sen. Patty Murray (Wash.), to stabilize the marketplaces. But that effort collapsed when Republicans repealed the ACA’s penalty for being uninsured and added in antiabortion language, enraging Democrats, who then backed away.

Murray plans to push at the hearing for a return to the bipartisan effort, in remarks shared in advance with The Health 202.

“Mr. Chairman, I’m hopeful we can revive those discussions in the new Congress, and find a way past the ideological standoffs of the past,” Murray said, according to the prepared remarks.

A Senate Democratic aide told me “there’s cause to believe there is momentum” on the Alexander-Murray effort. Yet it’s unclear whether the two senators have even resumed conversations about a stabilization package. And Democrats and Republicans often have widely differing views on the range of medical benefits health plans should be required to cover — which, of course, has a huge impact on plans’ cost.

Many Democrats and liberals would like to expand the availability of insurance subsidies, ensuring that middle-class Americans can get more government assistance in affording their coverage. That’s a no-go for most Republicans, however, who didn’t like Obamacare’s subsidy system to begin with. They’d rather expand health savings accounts, although that’s an approach Democrats say doesn’t go nearly far enough.

In any case, Democrats clearly feel they have the upper hand on health care after their victories in the midterm elections, in which they pummeled Republicans over protecting people with preexisting conditions.

“Voters’ anger about Republicans’ health-care sabotage just handed the GOP its biggest electoral defeat in generations,” said Henry Connelly, a spokesman for likely new House Speaker Nancy Pelosi (D-Calif.). “Republicans should recognize they need to reverse course and start working constructively with Democrats to lower premiums and out-of-pocket costs for all Americans.”

Of course, the Trump administration argues it is already doing things to lower insurance costs. It has issued new regulations allowing the expansion of short-term health plans and other kinds of leaner, cheaper insurance. On Thursday, it will outline specific ways states can back away from Obamacare insurance regulations through receiving what are known as “1332 waivers.”

Despite President Trump's claims that these moves have given Americans more affordable insurance options, actual implementation has been much slower. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, told reporters Tuesday she’s unsure how many short-term plans are even for sale because the regulation wasn’t finalized until well into this year.

“It’s not clear how many plans are being offered,” Verma said. “I think you will see more movement, probably, in the following year.”

Sign Up! Our newest 202 newsletter is launching Tuesday, Dec. 4: The Technology 202 by Cat Zakrzewski. Cat worked at The Wall Street Journal covering venture capital in Silicon Valley before joining The Washington Post to launch this new venture. She’ll be covering the dynamic and evolving relationship between Washington and technology companies, delving into everything from proposed privacy regulations to artificial intelligence and quantum computing. Get your copy here.

AHH, OOF and OUCH

AHH: In its first tracking poll since the midterm elections, the Kaiser Family Foundation finds a majority of Americans want Democrats to use their new House majority to work with Republicans to address heath care.

Health care came in second for the issue respondents wanted to see Congress act on in 2019. When asked to detail in their own words the issue that Congress should work on in the next session, 21 percent said immigration or border security, while 20 percent said health care. Gun control came in third, with 8 percent of respondents' support.

Specifically asked which health-care issues they would like to see Congress tackle, 19 percent of those surveyed said health-care cost and affordability issues, while 10 percent mentioned the ACA and 6 percent said Medicare.

But  respondents weren't confident lawmakers would actually act. Thirty-four percent of those surveyed said they were “not very confident” and 35 percent said they were “not at all confident” that Congress can come up with bipartisan solutions on health care. Just 6 percent said they were “very confident” that both parties would be able to work together on bipartisan legislation.

OOF: The Food and Drug Administration three months ago touted its approval of a generic version of the EpiPen that it said would produce a “lower-cost option” for those in need of the allergy relief device.

But the generic version that Teva Pharmaceutical launched has the same wholesale price of $300 for its generic version as Mylan charges for its generic version of the emergency allergy shot.

“The pricing appears to undercut a notion promoted by FDA officials that approving more generics can help relieve the pocketbook pressure many Americans feel over the cost of their medicines,” Stat’s Ed Silverman reports. “In announcing the approval last August, FDA Commissioner Scott Gottlieb noted that such moves were part of an ‘overarching effort to remove barriers’ to access to ‘critically important’ drugs.”

“Of course, consumers may very well pay less than $300,” Silverman adds. “In fact, several large retailers sell EpiPen for $150 when including a coupon, according to GoodRx. But the opaque pharmaceutical pricing and supply chain may well lower the price of the Teva product.”

Linda Cahn, a consultant who advises health plans and employers on pharmacy benefit contracts, told Stat the “list prices of most generic drugs, they are actually different from actual sales price, so we don’t know yet what the consumer might pay until you see what price the company charges wholesalers and markups that are taken.”

OUCH: The search for the victims of California’s deadliest fire is slowing, with rescue teams finding fewer and fewer human remains each day. As of Monday, there were 203 people still missing, the Los Angeles Times’s Rong-Gong Lin II reports.

And authorities are “coming to terms with the possibility that the search for victims of the Camp fire might never be complete and that some human remains won’t ever be recovered,” Lin writes.

DNA analysis is being  used to identify the victims. “Investigators have had an extraordinarily difficult time sifting through ashes to find remains,” Lin reports. “The heat of the fire left remains so charred that only bones, or even bone fragments, have been recovered. Without intact skulls being found, investigators can’t use dental records to make identifications, and instead have had to resort to the extraordinary use of extracting DNA samples from the victims and attempting to match them to genetic material of families using rapid DNA analysis.”

AGENCY ALERT

— CMS administrator Verma said the agency is examining the reasons behind the loss of coverage for thousands of Medicaid beneficiaries in Arkansas since the state’s new work requirements were put into place. But she reiterated strongly support for the new policy even if there might be some hitches in how it's initially carried out.

“We are looking closely at the people that have left the program to understand the reasons why they have left the program,” Verma told reporters at a breakfast roundtable at the American Enterprise Institute, adding that it’s “not clear” why people had dropped from the program. More than 12,000 people have been removed from the state's Medicaid program for failing to meet the state’s new requirements. 

Verma said the administration wants “to do more than just hand out Medicaid cards." “We know that work is something that contributes to positive health outcomes, so when you’re administering the Medicaid program that’s an important objective — to improve people’s health and health outcomes, we know work has an impact on that, and that’s why there’s the tie-in," she said. 

— Verma also said in response to a reporter question that there is a backup plan in case a judge strikes down the ACA's protections for people with preexisting conditions in the Texas-led lawsuit against the health-care law. A ruling is expected any day now.

“Yes, we do have contingency plans,” Verma said. “We want to make sure people with preexisting conditions have protections, and we want to make sure people have access to affordable coverage.”

TRUMP TEMPERATURE

— The Trump administration’s proposed “public charge” regulation could cost the Medicaid coverage of hundreds of thousands of community health center patients nationwide, according to a new analysis from George Washington University School of Public Health. It also found the proposal would result in 6,000 lost jobs and up to $624 million in losses to community health center revenue.

The administrations' proposed change would make it harder for immigrants to come to or stay in the United States if they need to use public assistance programs such as Medicaid, food stamps or public-housing programs. Enrollment in such programs would become a factor weighed heavilyin deciding whether an immigrant deserves legal status, as The Health 202 has explained.

“Because the communities in which health centers operate also tend to have sizable immigrant populations, policies that either directly or indirectly implicate their Medicaid enrollment are likely to produce significant spillover effects,” the analysis reads. “While the public charge rule does not treat health centers as a type of public benefit that counts toward a determination of public charge status, this analysis underscores that its indirect effect could be considerable if large numbers of patients affected by the rule begin to disenroll.”

INDUSTRY RX

— Chinese researcher He Jiankui defended his work during his first public appearance since he claimed to have successfully helped produce the world’s first genetically edited babies.

“[T]he Stanford-trained bioengineering professor said he felt ‘proud’ of his work and its implications for public health in the face of nearly universal condemnation,” our Post colleagues Gerry Shih and Carolyn Y. Johnson report.

He also apologized for the “leaking” of news of his report before it passed peer review, adding it had been submitted to a journal.

“We should, for millions of families with inherited disease, show compassion,” the scientist told an audience at the Second International Summit on Human Genome Editing in Hong Kong. “If we have this technology, we can make it available earlier. We can help earlier those people in need.”

During his talk, He explained his research, including that eight couples with fathers with well-controlled HIV and noninfected mothers were involved in a clinical trial, and that one dropped out. “There were 31 embryos created through in vitro fertilization, and 70 percent were successfully edited,” Shih and Johnson write. “He showed data indicating that he had not detected unintended genetic changes caused by CRISPR/Cas-9, the gene-editing tool that he used — although it remains to be seen whether outside scientists will find the evidence convincing.”

“The disclosure this week of He’s research — carried out in southern China mostly under a shroud of secrecy — has sparked urgent debate about the ethics of gene-editing and raised the prospect of a future in which parents produce ‘designer babies’ with selectively improved traits like intelligence or strength,” they add.

OPIOID OPTICS

— Dozens of employers in New Hampshire are taking part in a new approach to job opportunities for people who are recovering from drug and alcohol addiction, billing themselves are “recovery friendly” workplaces.

“These workplaces are willing to overlook employment gaps and some brushes with police that accompany drug use,” our Post colleague Lenny Bernstein reports. “They encourage open discussion of addiction in the workplace to reduce stigma. Perhaps most significantly, they treat substance abuse and relapse as medical issues like surgery or maternity — a time for the company to support, not abandon, the employee.”

And it’s happening in a state where about 60,000 people are in recovery and in 2016, had the nation’s third-highest rate of drug overdose deaths, our colleague reports. But he also adds New Hampshire’s 2.7 percent unemployment rate is even lower than the national rate.

“One of the most important things that people in recovery talk about is how it feels, with their self-worth and identity, getting employed again,” David Mara, New Hampshire’s drug czar, told Bernstein.

“There is no good data on whether former substance abusers make more reliable workers or perform better at their jobs than other employees, according to the Recovery Research Institute,” Bernstein reports. “But employers, researchers and government officials suggested that successfully helping an employee with a substance abuse problem breeds allegiance to the company… That doesn’t mean the approach always works.”

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

MEDICAL MISSIVES
A vaccine and new treatments are on hand, but the outbreak is in an area rife with unpredictable gunfire, bandits and suspicion of outsiders.
The New York Times
During the previous flu season, 329 Californians under 65 died from flu-related complications, but state officials acknowledge that is just a fraction of the actual death toll. Why? The state’s pub…
California Healthline
Public Safety
The facility’s gates had been closed after an initial report Tuesday of a possible shooter prompted a police response.
Peter Hermann and Dan Morse
Unilever is in talks to acquire GlaxoSmithKline’s nutrition business, people familiar with the matter said, a deal that would hand the consumer-goods giant one of India’s best-known brands.
Wall Street Journal
The U.S. Food and Drug Administration said on Tuesday it had found high levels of heavy metals such as lead and nickel in some kratom products, following field investigations.
Reuters
When Polly Varnado's 9-year-old daughter was diagnosed with Type 1 diabetes, it didn't take long for the family to hear about insulin pumps.
Associated Press
The quality of the data is low, and there's too little of it, to draw any firm conclusions about what He's team accomplished, experts told STAT.
Stat
HEALTH ON THE HILL
The senator said he was taking the temperature around the country to see whether he would be the strongest candidate to take down Trump.
Politico
STATE SCAN
The autopsy raised questions about how Roxsana Hernandez Rodriguez, 33, a transgender woman from Honduras, was treated in custody before she died from illness.
The New York Times
DAYBOOK

Today

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

Coming Up

  • 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.
SUGAR RUSH

Here's alook at holiday decorations at the White House over the years: