With just over a week now left in the sign-up period for 2019 Obamacare plans, new figures show enrollment is down compared with last year. Overall, sign-ups through, the federal Affordable Care Act exchange, are down 11 percent through the first five weeks compared with the same time last year -- and experts say final numbers are on track to be lower overall at the end of enrollment.

It's still possible for a surge in the final days, as people wait until the last minute to choose health-care plans for 2019.

But experts who have been following ACA enrollment closely say several factors may have contributed to an overall drop, including some of the Trump administration’s policies that Democrats have warned could have a negative impact on insurance marketplaces. A combination of those efforts, including a drop in federal spending on advertising and outreach, the repeal of the individual mandate, and the move to open the door to alternative health plans, as well as factors such as less media coverage surrounding enrollment and lower unemployment rates, could all be blamed.

The Centers for Medicare and Medicaid Services announced Thursday that from Nov. 1 to Dec. 1., a total of 3,198,163 people had selected ACA exchange plans. That’s down from 3,604,440 at the fifth week of enrollment last year.

Josh Peck, who served as’s chief marketing officer under the Obama administration and is now a co-founder of Get America Covered, published an analysis predicting total enrollment on the federal exchange would fall by 800,000.

There are also fewer people enrolling for the first-time in the marketplaces.

Cynthia Cox said new consumers were down about 18 percent compared with last year, and the number of people visiting down almost 21 percent.

“You look for explanations, is it that people aren’t coming to the site? Is it that maybe they don’t know about it? Is it the repeal of the individual mandate? Is it that they just don’t want insurance?” Cox, director of the study of health reform and private insurance at the Kaiser Family Foundation, told me in an interview. “That’s one clue as to what the driver is: Are people even coming to the site or not? And there’s an even bigger drop in the number of people visiting the site and of new consumers than there is a drop of people who are signing up at all.”

Cox said the elimination of the tax penalty for people who did not sign up for health coverage, which was repealed as part of the GOP tax overhaul last year, may have had an impact on the decline. She also said with lower unemployment rates, consumers may be moving to employer-sponsored plans.

But lack of awareness of ACA enrollment may be one of the biggest factors contributing to the decline, Cox suggested:

That awareness gap could be a result of the Trump administration’s decision to dial back Obamacare advertising and to dramatically cut funding for groups, known as navigators, meant to help people obtain health insurance under the ACA.

But Joseph Antos, a health-care scholar at the conservative American Enterprise Institute, said it’s not enough to point fingers at the administration. 

He said there was also a drop in news coverage of ACA enrollment over the past year, in part due to the intense coverage of the midterm elections that “crowded out talk of health insurance.”

“I’m arguing it doesn’t matter who pays for the ads, where the news comes from,” Antos told me. “What matters is how much of it was focused on health insurance vs. everything else.”

But he said that could change going forward. “If we look again this time next year, what will we see?” he asked, arguing that as Democrats retake control of the House, "there will be a lot more talk about health insurance and a lot more reporting on it.”

Antos also suggested navigator grants, although helpful for some individuals, may not have markedly helped with enrollment overall in past years.

Here, Larry Levitt, senior vice president for health reform at KFF, breaks down some of the other factors that could be contributing to the decline, including access to leaner, cheaper plans the Trump administration made available this year:

But some experts told me it’s too soon to tell whether those alternative plans have had a major impact on enrollment. Health 202 author Paige Winfield Cunningham wrote at the beginning of the enrollment season that such plans test GOP “actions to put a more conservative stamp on the ACA.”

The lag is not just happening at the federal marketplace level. Although several states that run their own exchanges have seen an increase in enrollment thus far, some are seeing a slight drop, too.

Charles Gaba, health-care analyst at, broke down where states are up to this point:

In New Jersey, the only state that implemented its own individual mandate after it was repealed at the federal level, enrollment in the federal marketplace has still lagged compared with last year.

Democratic Gov. Phil Murphy and his administration made a big marketing push to urge residents to enroll. Still, enrollment as of the fifth week was down more than 13 percent compared with last year.

Raymond Castro, director of health policy at progressive think tank New Jersey Policy Perspective, said part of the problem may be that people aren’t aware of of the state's mandate. “Most people are reading that the national individual mandate is now gone, and they aren’t getting our news that we still have it in New Jersey.”  He said those consumers will realize the change once they are forced to pay a penalty. 

But Castro said he was optimistic about a surge in sign-ups in the final days of enrollment, as well as for future enrollment periods. “I think there will be some turnaround,” he said. “With the combination of the individual mandate and lower premiums, I don’t see why we shouldn’t.”

In California, one of the dozen state-based marketplaces, there has also been a major marketing push, but enrollment is also down slightly. Covered California noted while the number of new consumers has dropped about 11 percent to 90,500 compared with the same time last year, it’s ahead of where sign-ups were in 2016.

“On the whole we feel pretty good about the enrollment numbers. We always projected there will be a drop in enrollment because of the [individual mandate] going away,” Peter Lee, executive director of Covered California, told me. He also pointed to a delay in marketing until after the November election. But he stressed that for the state’s exchange, which allows enrollment through Jan. 15, it’s still very early.

“The next two weeks matter, and matter a lot," he added.  “I think there’s cause for very significant concern at the pulling back on federal marketing dollars  … There’s no doubt that if you cut back on marketing dollars, enrollment is going to decline.”

In Colorado, where the state exchange, Connect for Health Colorado, controls its own marketing and outreach, enrollment is so far up nearly six percent compared to the same point last year.

Luke Clarke, a spokesman for the exchange, said it’s still too early to determine if sign-ups will be up overall after enrollment in the state ends on Jan. 15. But he pointed to lower premiums, and improvements to outreach efforts, as some of the reasons for the spike.

“We control our own fate. We haven’t cut our marketing; we haven’t increased it, either, but we’ve kept it steady,” Clarke said, adding the state would continue its marketing efforts because "it's working."

President Trump announced that he will nominate William P. Barr to be attorney general. Barr held this position in the early 1990s. (The Washington Post)

AHH: William Barr, who my Post colleagues Devlin Barrett, Matt Zapotosky and Josh Dawsey report is President Trump’s leading candidate to be the next attorney general, has similar hard-line views on drug policy as his daughter, who just so happens to be the Trump administration’s point person on the opioid crisis.

My colleague Colby Itkowitz detailed this potential administration family affair in a story yesterday on Barr and his daughter Mary Daly, the Justice Department’s director of opioid enforcement and prevention efforts.

“Daly and her father seem to share a tough-on-crime philosophy on drug offenses, in line with the ‘War on Drugs’ policies of the '80s and early '90s that sent a disproportionate number of minorities to jail,” Colby writes. “Barr, who served as President George H.W. Bush’s attorney general, oversaw those policies during his time in office.”

Daly is also a former federal prosecutor who “supported rolling back the Obama administration’s policy to be more lenient with lower-level drug offenders, according to a CBS News article about her from April, and has advocated strict enforcement when it comes to addressing the nation's opioid epidemic,” Colby writes.

In effect, that means Daly and her dad are, similar to ousted attorney general Jeff Sessions, “no fan of the type of criminal justice reform that Trump and some Republicans on Capitol Hill have supported.”

“We don’t know whether Barr will actually get the job and whether Daly would stay in hers if he does,” Colby points out. “The federal government rules don’t allow the hiring or promoting of relatives, but since Daly already works there, that may not be an issue.”

OOF: National spending on health care reached $3.5 trillion last year, the Trump administration announced on Thursday, or about $10,739 per person.

But the increase in spending also slowed to a pace not seen since 2013, according to data released by the CMS's Office of the Actuary. "The 3.9 percent increase last year — down from 4.8 percent in 2016 — was the lowest since 2013," the New York Times’s Robert Pear reports

“For the first time in several years, health spending grew at about the same rate as the economy as a whole in 2017,” Robert writes. “So the share of the economy devoted to health care stabilized. By contrast, over the past few decades, health spending has generally grown faster than the economy.”

"Prior to the coverage expansions and temporary high growth in prescription drug spending during that same period, health spending was growing at historically low rates," Anne Martin, economist in the office of the actuary, said in a statement. "In 2017, health care spending growth returned to these lower rates and the health spending share of GDP stabilized for the first time since 2013."

The rate of increase in spending for medications, doctors and hospitals was also “more modest than in recent years,” Robert writes.

“Despite alarm over high drug prices, the administration reported that spending on prescription drugs at pharmacies, grocery stores and other retail outlets increased last year by just four-tenths of 1 percent, to $333 billion,” he adds. “That was the slowest growth since 2012, when many blockbuster drugs lost patent protection, driving down prices and total spending. Those figures do not include spending on drugs in hospitals, where patients receive some of the most expensive drugs.”

OUCH: A new report from the Centers for Disease Control and Prevention says 58 million Americans are still exposed to secondhand smoke, even after decades of decline in exposure rates.

In 1988, 87 percent of people in the United States were exposed to secondhand smoke, which improved by 2014 to about 25 percent. But progress in reducing exposure has stalled in recent years.

“The prevalence of secondhand smoke exposure among U.S. nonsmokers declined substantially during 1988–2014, from 87.5% to 25.2%. However, no change in exposure occurred between 2011–2012 and 2013–2014, and an estimated one in four nonsmokers, or approximately 58 million persons, were still exposed to secondhand smoke during 2013–2014,” the CDC reports.

The report points to slow implementation of smoke-free laws in certain spaced such as workplaces and public areas at the state level.

“Nonetheless, to date, 27 states and the District of Columbia have comprehensive smoke-free laws, and progress in smoke-free law adoption has occurred at the local level in more recent years,” the CDC reports.


— The Department of Health and Human Services announced it named a pharmacist and former executive from CareFirst Blue Cross Blue Shield as its top drug pricing adviser.

John O’Brien served as an adviser to HHS Secretary Alex Azar on health reform and drug pricing, the agency said in a news release. He was also previously the deputy assistant secretary for health policy for the HHS assistant secretary for planning and evaluation. Before coming to Washington, O’Brien was vice president of public policy at CareFirst Blue Cross Blue Shield and also previously worked at CMS.

“John O’Brien has already been an integral leader in HHS’s efforts to bring down the high price of prescription drugs,” Azar said in a statement.

O’Brien succeeds Dan Best, who died last month.

— HHS is defending its drug pricing proposal that would limit certain Medicare payments to what foreign countries pay for pricey prescription drugs following criticism from conservatives.

Earlier this week, Grover Norquist and Alexander Hendrie of Americans for Tax Reform panned the proposal as a “failed policy dating back to the Roman Empire and beyond.”

In a Thursday statement, newly tapped drug pricing official O'Brien said Americans for Tax Reform “could not be more wrong.” The statement was first reported by Politico’s Dan Diamond.

“Simply put: The IPI demo doesn’t just seek to end foreign free-riding, it introduces competition and negotiation to Medicare Part B drugs,” O'Brien writes in a statement. “And it provides drug companies with a valid reason to walk away from the negotiating table when other countries demand low prices subsidized by America’s seniors. The socialist systems to whom drug companies are giving better deals simply do not have monopoly power when compared to the importance of participating in the Medicare program.”

The Hill’s Peter Sullivan also points out HHS did not mention in its defense the concerns reportedly expressed by Republican lawmakers:

—  And here are a few more good reads: 


Coming Up

  • Brookings Institution holds a roundtable discussion on health care and data on Dec. 10. 
  • The House Energy and Commerce Subcommittee on Health is scheduled to hold a hearing on the 21st Century Cures Act on Dec. 11. 
  • The House Energy and Commerce Committee Subcommittee on Oversight and Investigations is scheduled to hold a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States" on Dec. 12.
  • The Heritage Foundation holds an event on "Defending the Rights and Wellbeing of Children Today" on Dec. 12.

— Time lapse: George H.W. Bush's train ride to final resting place:

Mourners gathered along the train tracks Dec. 6 as the funeral train carrying the body of former president George H.W. Bush journeyed to College Station, Tex. (Reuters)

— Ten times George H.W. Bush's humor brought laughter to his loved ones in mourning:

Amid tears, loved ones delivering eulogies at George H.W. Bush's memorial services remembered the times the former president made them laugh. (The Washington Post)