with Paulina Firozi


Obamacare’s health insurance marketplaces haven’t failed, as some Republicans still insist. Yet the Obama appointee who set them up gives them only a passing grade.

Kathleen Sebelius – the former Health and Human Services secretary who played a crucial roll in implementing the Affordable Care Act – said she’d give the marketplaces “maybe a ‘B’ or ‘C-plus.’”

“It isn’t that the marketplaces are failing in their own,” Sebelius said in a recent interview with Health 202. “The framework in which they operate is – I would say – more constrained than could be helpful.”

As I wrote in this weekend piece, the Affordable Care Act is more enmeshed than ever before in the country’s health-care system, even as President Trump recently renewed calls for Congress to repeal and replace it. Thirty-six states and the District of Columbia have expanded Medicaid — including more than a dozen run by Republicans — and 25 million more Americans are insured, with millions more enjoying coverage that is more comprehensive because of the law.

In a broad sense, the ACA accomplished what lawmakers set out to do: Dramatically reduce the U.S. uninsured rate and make comprehensive coverage available to people no matter what their health condition. Yet its marketplaces, a central component of the law, are seeing enrollments gradually diminish and its plans remains unaffordable for many consumers who don’t get federal subsidies.

Few have more experience with marketplace challenges than Sebelius, who presided over the initially disastrous launch of Healthcare.gov in 2013 and resigned from her position shortly thereafter. To her, the possibilities for improvements in the marketplaces are most evident in comparing states that have embraced the ACA and those that haven’t.

“You have a mix and match in these marketplaces,” she told me. “The states that are engaged and all in…and the states where they’ve sat back.”

At this point, only 11 states and the District run their own marketplaces rather than relying on the federal Healthcare.gov website. But these states appear to have achieved more stable enrollments and insurer participation, partly because their leaders have played a more active role in promoting the marketplaces and tailoring their own enrollment portals.

For example, nine of the dozen states chose to lengthen their signup periods beyond the federal deadline. And leaders in these states tend to take a more proactive role in trying to improve the marketplaces. California Gov. Gavin Newsom (D) has suggested expanding subsidies to people earning more than 400 percent of the federal poverty level and reinstating a mandate to buy coverage after Congress repealed the national penalty for lacking coverage. Minnesota Gov. Tim Walz (D) has proposed funding additional premium subsidies by reallocating some of the state’s reinsurance dollars.

The efforts appear to have paid off. Enrollment in the state-run marketplaces held steady – at around 3 million people – while enrollments in the federal-run marketplaces declined from 8.7 million last year to 8.4 million this year, according to the latest enrollment figures from the Centers for Medicare and Medicaid Services.

Of course, there’s plenty Congress and the administration could do to improve the marketplaces, but Republican uniformly opposed a recent slate of such measures from House Energy and Commerce Democrats. Sebelius said enhancing subsidies for monthly premiums and funding targeted outreach could go a long way – even as she acknowledged the chance for bipartisan agreement on the matter is slim.

“There has never been a piece of legislation that is as massive and complicated as the Affordable Care Act where there was an absolute refusal of the U.S. Congress to ever try and make it work – to even provide technical assistance to clarify issues that might not be clear,” Sebelius said.

Yet individual Republicans appear increasingly willing to acknowledge the successes of the ACA, even as they remain unwilling to try to improve it. Ten years ago, Sen. Chuck Grassley (R-Iowa) was at the forefront of GOP opposition to the law, ominously pushing the debunked claim that it would allow the government to “pull the plug on grandma” by creating “death panels.”

Today, Grassley is chairman of the Senate Finance Committee, the panel that would be responsible for drafting a new health-care law, and he has shown little enthusiasm for Trump’s call for congressional Republicans to produce a replacement for the ACA.

Republicans from states that embraced the law’s Medicaid expansion also concede that it has benefited large portions of the low-income population, many of whom were previously uninsured.

“For the people who are in that tranche of expanded Medicaid, I think it has been very helpful,” said Sen. Shelley Moore Capito (R-W.Va.). Nearly one-third of West Virginians are on Medicaid, and the percentage of uninsured has dropped by about 56 percent since 2013.


AHH: The Centers for Disease Control and Prevention said 90 more people were sickened by measles in the second week of April, bringing U.S. outbreak to 555. It’s the third week in a row that health officials have reported an increase in measles cases, our Post colleague Lena H. Sun reports, and they warn the 2019 outbreaks could hit a record two years after the highly contagious virus was “eliminated” in the United States.

New York City has experienced a major part of the spread of the contagious, potentially deadly disease, with 329 cases that are largely concentrated in Brooklyn. Of those 329, 273 cases have been reported this year.

So far, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas and Washington have all reported cases to the CDC. And six current outbreaks in the states of California, New Jersey, New York and Washington are linked to travelers who brought the disease back from other countries, including Israel, Ukraine and the Philippines.

OOF: A traveler who drove from New York to Michigan, unaware of his measles diagnosis, became Michigan’s Patient Zero, and spread the virus to 39 people, Lena reports.

The man, who had traveled from Israel to Brooklyn last November, was raising money for charity in Brooklyn’s ultra-Orthodox Jewish community. He then traveled to the Detroit area in early March. When he felt ill, he saw a doctor there, who misdiagnosed him with bronchitis. Michigan health officials are not identifying the man, who continued to stay in people’s homes and attend daily synagogue services, offering a “cautionary tale about how easily one of the most infectious pathogens on the planet spreads within close-knit communities — especially those whose members live, work and socialize outside the mainstream,” Lena writes.

— The effort to address the measles outbreak in New York has created some tension with the city’s ultra-Orthodox Jewish community, and put the spotlight on New York Mayor Bill de Blasio’s ties to that community and how it may have impacted his response, the New York Times’s Jeffrey C. Mays reports.

“Some critics accused the mayor of acting too slowly because the outbreak, affecting now close to 300 people, first began in the fall,” Jeffrey writes. “Yet some members of the ultra-Orthodox community accused Mr. de Blasio of having overstepped his authority by issuing the vaccination declaration.”

In Brooklyn, a group of parents have filed a lawsuit against the New York City Department of Health in an effort to block a mandatory measles vaccination order from taking effect.

“The parents who are suing argued ‘there is insufficient evidence of a measles epidemic or dangerous outbreak to justify’ forced vaccinations and they accused the city of failing to take the least restrictive measures to end the outbreak,” ABC News’s Aaron Katersky and Meghan Keneally write.

OUCH: Obesity is poised to become the No. 1 preventable cause of cancer, overtaking smoking, which has been the leading preventable cause of cancer for decades.

It could take the top spot in the next five to 10 years, our Post colleague Laurie McGinley reports, as the increase in obesity rates threatens to disrupt what’s been a steady decline in cancer death rates since the early 1990s.

Obesity and being overweight is related to about 8 percent of all cancers in the country, and it has been linked with an increased risk of 13 types of cancer, Laurie writes, including stomach, pancreatic, colorectal and liver malignancies and postmenopausal breast cancer.

Not all Americans are aware of the relationship between excess weight and cancer and even still, researchers have not been able to answer to why there’s such a link or whether losing weight may help prevent cancer or a recurrence of cancer.

A 2015 JAMA Internal Medicine article found about 7 in 10 Americans are overweight or obese. "The proportion of adults who are overweight has remained relatively stable in the past several decades, but the obesity rate has soared," Laurie writes.


— During a town hall with Democratic presidential contender Sen. Bernie Sanders (I-Vt.) hosted by Fox News, the audience signaled it was largely supportive of a Medicare for all plan (granted, the audience just may have been packed with supporters of the 2020 candidated but it still made for an interesting visual). Sanders recently unveiled an updated version of his Medicare-for-all bill that goes beyond what he intially proposed in September 2017.

In a notable moment, when co-host and network anchor Bret Baier asked the audience how many of them would support a switch to Medicare for all, most of the audience raised their hands. That was after most of the audience, including Baier and Sanders himself, raised their hands when asked if they now receive coverage through private employer-sponsored plans.

The town hall, as Politico's Holly Otterbein writes, "took place in a cultural center in the shadows of a former steel mill here, in a county in Pennsylvania that voted for Trump after twice supporting Barack Obama." She also adds it was "packed with Sanders supporters." 

During questions about how Sanders would fund his health-care proposal, he was upfront about the increased taxes Americans would pay, but said the "overwhelming majority" of Americans would eventually save money without deductibles or out-of-pocket costs, Holly writes. 


— In 2016, more than 20 percent of all arrests in many areas of the country were related to pot possession, according to new county-level arrest data from the National Archive of Criminal Justice Data. And in a handful of counties, marijuana possession accounted for more than 40 percent of all arrests.

The data does not specify whether there are repeat offenders, nor does it include marijuana-sale or production-related arrests, but our Post colleague Christopher Ingraham writes it illustrates “how marijuana enforcement continues to make up a big part of many police agencies’ caseloads.”

“The findings reflect, in part, a few simple realities: The federal government incentivizes aggressive drug enforcement via funding for drug task forces and generous forfeiture rules that allow agencies to keep cash and other valuables they find in the course of a drug bust,” he writes. “But given that recreational marijuana is legal throughout the West, and that two-thirds of the public supports legalization, critics view such aggressive enforcement tactics as wasteful, ineffective and even racially biased.”


— With all the focus on the fate of the ACA, the president and chief executive of the Kaiser Family Foundation Drew Altman argues there’s not enough concentration on the problems for individuals who get their coverage outside of the ACA marketplaces.

In this new piece in Axios, Altman points to data that suggests for low-income people, health coverage through employer-sponsored insurance plans is markedly less affordable than for their counterparts who are covered through ACA plans.

“A low-income family with a marketplace plan pays 8.4% of their income on premiums and out-of-pocket costs, compared to 14% for a lower-wage family with employer coverage (those with incomes below twice the poverty level),” he writes. “For low-income families with marketplace plans, the out-of-pocket costs are 4.7% of their income, while the premiums are just 3.7% of their income. For those with coverage through work, the out-of-pocket costs are 5% of their income, roughly the same as the families with marketplace plans."

Drew argues individuals with ACA plans better afford their plans because there are financial protections for lower-income people, while there are no such income-based subsidies for those who are under employer-based plans.

— And here are a few more good reads: 


Coming Up

  • The Heritage Foundation hosts an event with the Institute for Behavior and Health and Smart Approaches to Marijuana, “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence,” on Thursday.
  • The Kaiser Family Foundation holds a forum on the Trump administration’s HIV initiative on April 22.

How the devastating fire at Notre Dame Cathedral unfolded

French President Emmanuel Macron spoke as crews battled the catastrophic blaze: "We will rebuild Notre Dame":