THE PROGNOSIS

The holidays aren’t looking so merry for Obamacare enrollment. Three days remain to sign up for 2019 coverage in the state marketplaces — yet enrollments are down even though plan offerings are up.

Not only are fewer people re-enrolling for next year, but far fewer new customers are visiting the HealthCare.gov website and choosing a plan. Active renewals are down 8 percent compared with the same point last year, while new sign-ups are lagging by 20 percent, according to the administration’s latest figures analyzed by Get Covered America.

There’s a basket of potential reasons for why enrollment is down. We’ll get to that in a bit. But there’s a silver lining here — slightly more people who are actually visiting the federal-run marketplace are choosing a plan. And that’s not surprising, given that the marketplaces are arguably the healthiest they’ve been in their six-year lifespan.

While visits to HealthCare.gov, use of its window-shopping feature and calls to the enrollment help center are down, the number of people who actually enrolled is somewhat greater this year. About 25.5 percent of people who used those features actually enrolled in coverage last year, but that percentage has grown to 28.5 percent so far this year, according to numbers crunched by Get America Covered co-founder Josh Peck.

“If anything, the data suggest that while visits are down people are more likely to find a plan this year,” Peck wrote me.

The McKinsey Center for U.S. Health System Reform will release a report this morning that underscores the improved options on HealthCare.gov, finding that more insurers are entering the marketplaces and that consumers are seeing premiums decline across the range of plan options.

Here are some key findings in the McKinsey study, shared first with The Health 202:

— Twenty-five new insurance carriers entered the marketplaces for 2019, while just one withdrew. Compare that with 2017, when 10 carriers entered but 90 withdrew.

— The number of counties with a single marketplace plan declined in 20 states between 2018 and 2019. Next year, just five states will have a single plan in each county.

— Median premiums decreased between 1 and 2 percent for all plan levels (except the most generous platinum level) for next year. Compare that with 2017, when they increased between 22 and 32 percent, depending on the plan level.

For years, politicians have loved to blame the other party for whatever problems exist in the Obamacare marketplaces (which have certainly had their share of ups and downs — but mostly downs). Yet the marketplace premiums have a lot more to do with insurers and their struggle to figure out how to cover a segment of Americans who were previously mostly uninsured.

Many of the insurers have now hit their stride — and the ones doing best are the community-based plans that have been covering lower-income Americans all along. Per the McKinsey report, it’s the Blue Cross and the Medicaid plans (which are also selling marketplace coverage) that are offering the lowest premiums to consumers.

But lest we paint too glowing of a picture, here’s another harsh reality. The progress made under the Affordable Care Act in lowering the nation’s uninsured rate has, at best, stalled. The uninsured rate rose by nearly 700,000 to 27.4 million people in 2017, a recent Kaiser Family Foundation poll found.

Affordable Care Act advocates like to blame the Trump administration for trying to sabotage the marketplaces through undermining consumer protections and refusing to spend heavily on marketing them. That might be overstating things, as the administration could be doing a lot more to sabotage open enrollment if it so chose. It could have further shortened the sign-up period, for example, or halted a flood of recent emails reminding current customers to re-enroll for next year.

But administration officials haven’t exactly made enrollment a top priority, either. While then-President Barack Obama’s top appointees — former Health and Human Services secretary Sylvia Burwell and former Centers for Medicare and Medicaid Services administrator Andy Slavitt – spent a lot of time touting the marketplaces, their successors have devoted little time or effort to telling the American public to sign up.

HHS Secretary Alex Azar and CMS Administrator Seema Verma did make some pitches this week via Twitter:

Azar told Axios in an interview yesterday that he's not sure why the enrollment numbers are down:

Just 1 in 4 American who either buy their own insurance (not through an employer) or are uninsured knew the open enrollment deadline is Dec. 15, KFF found in another recent poll.

Of course, experts also say the low unemployment rate, Medicaid expansion in Virginia and the repeal of the penalty for lacking coverage could also factor in.

Larry Levitt, a KFF senior vice president:

Some members of Congress have been touting the enrollment deadline, trying to make up for the lack of marketing. From Sen. Bernie Sanders (I-Vt.):

AHH, OOF and OUCH

AHH: Federal funding for research into diseases such as HIV, cancer and Parkinson's using fetal tissue could  be terminated for three research projects as the administration moves forward with a wide-ranging audit.

The Department of Health and Human Services  has paused the acquisition of fetal tissue for two projects at labs at the National Eye Institute and the National Cancer Institute, our Post colleagues Lenny Bernstein, Amy Goldstein and Lena H. Sun write. A spokeswoman for the labs said cancer researchers will need more fetal tissue by the end of January, and the eye study will need more by the end of February. One other research project on HIV treatment being carried out at a National Institutes of Health lab in Montana is also affected by the crackdown.

HHS assistant secretary for health Brett Giroir insists “no decisions have been made about the use of fetal tissue and there is no timetable for action,” Lenny, Amy and Lena write. Giroir called on scientists not to “overreact.” “We’ve met with multiple groups. We are being transparent around this. The science part is being run by scientific people," he said.

But the administration's moves against fetal tissue are part of the nation's long abortion wars. “This time, however, scientists who depend on cells from aborted human fetuses face not just a cadre of determined antiabortion activists but sympathetic officials within the government itself, from Vice President Pence to key officials in the Department of Health and Human Services,” our colleagues write.

Two congressional subcommittees will hold a hearing today exploring alternatives to the use of fetal tissue in scientific research. The panels are headed by Reps. Mark Meadows (R-N.C.) and Jim Jordan (R-Ohio), who are pushing the administration to ban funding for the research. 

Democrats have chosen Sally Temple, co-founder of the Neural Stem Cell Institute in Rensselaer, N.Y. as their witness. “The feeling that the science — which is hard enough to do — that there is a war on that, that it’s not respected, it’s demoralizing,” Temple told our colleagues. 

Another witness is David Prentice, vice president and research director of the Charlotte Lozier Institute, the research arm of antiabortion group Susan B. Anthony. Prentice said his group has met with Vice President Pence to share its opposition to using aborted fetal tissue. “It’s just nice to have someone who will listen and not just close the door in your face," he said.

OOF: Incoming Republican Rep. Mark Green of Tennessee walked back comments he made at a town hall this week suggesting vaccines cause autism. Green -- a physician who last month won the seat being vacated by Rep. Marsha Blackburn -- questioned data from the Centers for Disease Control and Prevention that he called "maybe fraudulently managed." He said he wanted to “get the real data” regarding vaccinations, the Tennessean’s Natalie Allison reported.

"Let me say this about autism," Green said. "I have committed to people in my community, up in Montgomery County, to stand on the CDC’s desk and get the real data on vaccines. Because there is some concern that the rise in autism is the result of the preservatives that are in our vaccines.”

But Green later issued a statement saying his comments had been “misconstrued,” our Post colleague Felicia Sonmez reports. “I want to reiterate my wife and I vaccinated our children, and we believe, and advise others they should have their children vaccinated,” he said.

“The modern anti-vaccine movement has its roots in a 1998 study that used falsified data to claim a link between childhood vaccines and autism,” Felicia writes. “The study was later retracted, and the author’s medical license has since been revoked; even so, some figures on both the far left and the far right have embraced the widely discredited theory.”  Felicia notes that a spokesman for Green didn't respond to a request for clarification of the claim that the CDC’s data may have been ‘fraudulently managed.’ 

OUCH: The U.S. diplomats in Cuba who began reporting mysterious illnesses and unusual symptoms two years ago all experienced damage to the part of their inner ear that controls balance, according to a new report from doctors at the University of Miami.

The doctors were the first to examine individuals who reported the symptoms since the illnesses occurred, the New York Times’s Frances Robles reports. The scientific paper “confirms what these patients have said all along: Their condition is real, not the result of mass hysteria, a response to intense news media coverage or a stress reaction to being evacuated, as doctors in Cuba suggested," Frances writes. More than two dozen individuals were affected.

It's not yet clear what caused the injury or whether it is permanent. But whatever happened “resulted in ear damage and some trouble thinking,” study author Dr. Michael E. Hoffer, the director of the university’s Vestibular and Balance Program, told the Times. But identifying the inner-ear damage means the patients can seek treatment through physical therapy.

“The dizziness and cognitive problems that followed — including severe insomnia and nausea when using a computer — were so intense that at least one State Department employee went into early retirement this year,” Frances writes. “Another person who experienced the phenomenon in China went on leave. The State Department would not say how many others had returned to work.”

HEALTH ON THE HILL

 — The $867 compromise farm bill Congress passed this week dropped language to provide financial help to association health plans, a provision in the House version of the bill some patient groups had been worried would be in the final legislation.

The Health 202 wrote earlier this year that “as part of a little-noticed provision, associations of ranchers, farmers or other agribusiness owners could obtain grants or loans from the government to offer their members health coverage, with the goal of providing more insurance options for rural Americans.” The provision would have been a companion to new rules by the Trump administration making it easier for association health plans to be formed.

The American Heart Association praised the final language for scrapping any mention of AHPs. “Given the history of fraud and insolvency with AHPs, using federal funds to establish AHPs would put consumers and providers at risk of unpaid bills and taxpayers at risk of defaulted loans. In addition, establishing loan program at the USDA, which lacks expertise and experience in overseeing health plans, would have been a risky and ill-advised use of federal funds," AHA chief executive Nancy Brown said in a statement.

The House voted 386-to-47 to approve the bill on Wednesday, after the Senate passed the legislation 87-to-13 on Tuesday. Trump is expected to sign it soon, our Post colleague Jeff Stein reports.

— A dozen Republican governors sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.) and House Speaker Paul Ryan (R-Wis.), calling on the GOP leaders to repeal the ACA’s medical device tax and health insurance tax in the year-end spending bill. Medical device makers and insurers have been working hard on Capitol Hill to get the taxes delayed or even repealed.

“Congress has an opportunity to permanently repeal both taxes before the holidays and we strongly encourage you to seize this opportunity to do so,” the group wrote. The letter was signed by the governors of New Hampshire, Florida, Iowa, Kansas, Kentucky, Maine, Mississippi, Nebraska, South Carolina, Texas, Utah and Wisconsin.

INDUSTRY RX

— One of the largest grocery chains in the country, Kroger, has a new program to let people pick up discounted drugs at the pharmacies in its stores for an annual fee.

“Under the new program, which launched on Wednesday, Kroger shoppers can pay an annual fee of $36 per person or $72 per family to get discounted prices for their drugs, including 21 cheap drugs at no additional cost,” Stat’s Rebecca Robins reports. “The idea is that they can bypass insurance and pay out of pocket for drugs when it’s cheaper to do so.”

The new Kroger Rx Savings Club comes amid a nationwide debate over how to address skyrocketing prescription drug costs and, Rebecca notes, as more patients and experts are becoming aware of savings that can come from paying cash for drugs instead of a high copay through insurance.

The new program will be available in 2,000 pharmacies in 37 states where the store has pharmacies (with the exception of Washington state) and Kroger has “already been piloting the program in about 80 stores.”

OPIOID OPTICS

— Fentanyl is now the most deadly drug in the United States. New CDC data shows there were more than 18,000 overdose deaths in 2016 -- 29 percent of all overdose deaths that year. The rate of fentanyl-related overdose deaths spiked about 113 percent each year from 2013 to 2016. 

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

MEDICAL MISSIVES
Health
Some consumers also reported irritation, infections, injuries and abdominal pain among other issues, related to some U by Kotex Sleek Tampons.
Lindsey Bever
Health-care companies are making a last-minute push to delay ObamaCare taxes as part of a year-end government funding deal, but they face resistance from Democrats who want to punt the issue until next year when they control the House.
The Hill
The resolution by Rosen, then a freshman legislator in the House, would enable Congress to defend the Affordable Care Act’s requirement that insurance companies provide coverage to people wit...
Las Vegas Review-Journal
PowerPost
More than half a dozen lawmakers resigned in the past year amid allegations of sexual harassment or misconduct. In addition to secret taxpayer-funded settlements, the current process involves mandatory counseling, mediation and “cooling off” periods for accusers.
Elise Viebeck
STATE SCAN
The demand for telemedicine is renewing state and federal efforts to improve internet infrastructure.
Politico
National
In its annual report, Everytown said that 150 of the 196 candidates endorsed by its political arm in the midterm elections won seats.
Katie Zezima
It will be up to state lawmakers to decide next year if they want to pursue a course almost certain to draw fierce draw criticism.
Politico
Minnesota lawmakers are considering steps they could take to rein in the soaring cost of insulin, which one couple says has become so expensive that their diabetic son could no longer afford it and died.
Associated Press
DAYBOOK

Today

  • The House Oversight and Government Reform Subcommittees on Healthcare, Benefits and Administrative Rules and on Government Operations hold a hearing on “Exploring Alternatives to Fetal Tissue Research."

Coming Up

  • Medicaid and CHIP Payment and Access Commission holds a public meeting on Thursday and Friday.
SUGAR RUSH

— President Trump announced the establishment of the White House Opportunity and Revitalization Council to help poor communities: 

— In his farewell speech, Sen. Orrin G. Hatch (R-Utah) said a "pluralist approach" is needed to reach a compromise on LGBTQ rights and religious liberty: