THE PROGNOSIS

Obamacare enrollment for 2020 begins today in insurance marketplaces that have recently taken a turn for the better. But that doesn’t mean all is rosy for Americans buying health coverage on their own – far from it.

The effects of several turbulent years for Healthcare.gov and the state-run marketplaces linger, even as next year’s average monthly premiums decline somewhat. Compared to four years ago, average premiums in most states are still much higher, fewer plans are available to consumers and those ineligible for government assistance have fled the marketplaces in large numbers.

“This administration has made no secret about it: We believe the Affordable Care Act simply doesn’t work,” Health and Human Services Secretary Alex Azar told reporters last week. “It is still unaffordable for far too many.”

The longstanding political battles over Obamacare through two administrations have led to dire predictions about the 2020 Obamacare marketplaces, which are now open for enrollment until Dec. 15. They certainly aren’t imploding as both Democrats and President Trump had ominously predicted. Congressional Democrats blamed Trump administration policies would be ruinous to the sweeping legislation passed under President Barack Obama, while Trump insisted the law was rotten at the core.

Recent improvements in the markeplaces are only incremental -- and it’s not clear the Trump administration deserves much credit for them, either. The administration did make some tweaks to the marketplaces last year, including shortening the open enrollment period and giving states more flexibility in how they defined essential health benefits plans must cover.

But many outside factors were in play. Insurers were able to reach profitability by hiking rates dramatically in 2017 and 2018, so their need to raise prices lessened in 2019 and 2020. And, under a provision in the ACA, they are forced to rebate consumers if they collect more in premiums than they’re allowed relative to their overhead costs.

Those are the biggest reasons why the marketplaces are looking better next year. Average premiums for mid-level ‘silver’ plans -- which offer moderate coverage and moderate out-of-pocket costs for medical care -- will decrease 4 percent, while the number of plans available will swell 13 percent. Nearly 7 in 10 people will have access to at least three marketplace plans, up from six in 10 last year (the figures don't include the 11 states running their own marketplaces instead of relying on Healthcare.gov.).

But consider what the marketplaces looked like four years ago. Here are some ways the marketplaces have worsened since 2016, according to figures from the Centers for Medicare and Medicaid Services:

—Average “silver” level monthly premium for a 27-year-old: $240 in 2016; $388 in 2020

—Average “silver” level monthly premium for a family of four: $873 in 2016; $1,520 in 2020

—Average number of plans available in a state: 5 in 2016, 3.5 in 2020

—Percentage of enrollees with just one insurer option: 2 percent in 2016; 12 percent in 2020

“The individual market has been defined by its instability,” the Robert Wood Johnson Foundation’s Kathy Hempstead wrote in an analysis, noting “mass carrier exits in 2017 and 2018, leaving many counties with only one insurer by 2018.”

And while the marketplaces have improved in some states, that’s not the case everywhere, Hempstead notes. For example, Georgia’s Barrow County dropped from nine insurance carriers in 2015 to two in 2018 and will still have just two next year. Chicago’s Cook County had eight insurance carriers in 2016 but that dropped to just three the following year and hasn’t changed since.

In West Virginia, which had initial major improvements in its uninsured rate, people have been losing coverage and enrollment in the marketplace has declined sharply since 2017. Kelly Allen, director of policy engagement for the West Virginia Center on Budget & Policy, argues that's because the state is one of just three states banning insurers from a practice called "silver-loading," which came about when the Trump administration blocked insurers from getting extra subsidies to help the lowest-income enrollees afford their plans' co-pays and deductibles.

Here are the basics of how silver-loading works. Because insurers were no longer receiving these "cost-sharing reductions," they made up for the losses by raising premiums for only the "silver" mid-level plans in the marketplaces. Obamacare subsidies are based on the price of these silver plans. So the result was that consumers could get larger subsidies but purchase other plans like gold, bronze or platinum that hadn't experienced the premiums increases of the silver plans.

"Marketplace plans cost thousands of West Virginia residents more than they should," Allen wrote. "For 2020 health plans, affected West Virginia consumers across the state could have saved thousands of dollars if the state had allowed insurers to utilize silver loading."

AHH, OOF and OUCH

AHH: There was a time when there weren’t many adult patients with cystic fibrosis because patients often didn’t live that long. Now, a long-anticipated cystic fibrosis treatment could make it a manageable condition, our Post colleague Carolyn Johnson reports. The new therapy shows signs of targeting the genetic root of the disease, markedly improving lung function rather than just alleviating symptoms.

Cystic fibrosis is an illness that affects about 30,000 people in the United States. The current life expectancy for patients is on average 44 years.

“The data, being unveiled Thursday at a national conference in Tennessee and simultaneously published in two leading medical journals, was so persuasive that the Food and Drug Administration last week approved the three-drug combination, called Trikafta — five months ahead of the agency’s deadline,” Carolyn writes. “The drug could benefit 90 percent of patients with the disease, a major advance over previous drugs that worked in a tiny fraction of the people with the disease or had more modest effects.”

“We’ve finally reached the time that an improvement is possible,” 38-year-old Jenny McGlincy told Carolyn. “To think of my lung function improving or my digestion increasing, or even adding a few years to my life that I could spend with my daughter. … Now that it’s available, I’m a little like, ‘Is this really happening?’ ”

But the drug will cost $311,000 a year, which could be a major barrier to accessing the treatment. “While that is a tremendous amount, orphan drugs for small patient populations typically carry very large price tags, and physicians are optimistic that insurers will cover the drug,” Carolyn adds.

OOF: Indiana announced it would postpone its plans to require Medicaid beneficiaries to work or prepare for a job in order to keep their coverage. It’s the second state in two weeks – after Arizona – to do so.

Both states pointed to federal lawsuits that have questioned so-called “community engagement” rules that critics say violate the purpose of the federal program, our Post colleague Amy Goldstein reports.

“Indiana and Arizona — both with Republican governors — are the first states to do voluntarily what a federal judge in Washington has achieved through court orders in three others,” she writes. “…Critics of the policy filed a lawsuit in Indiana in late September. There is no such litigation in Arizona, but in notifying federal health officials in mid-October that it was postponing its work rules ‘until further notice,’ the Medicaid director there cited “the evolving national landscape” concerning such requirements and ‘ongoing litigation.’”

OUCH: Measles is much more harmful that scientists once thought: The virus can make your body forget how to fight other diseases.

Beyond just making you sick, the measles infection can destroy up to half of the antibodies that protect people against other viruses and bacteria, our Post colleague Lena H. Sun reports.

“That means people, especially children, who get measles become much more vulnerable to other germs that cause diseases such as pneumonia and influenza that they had previously been protected against,” Lena writes. “The discoveries have enormous and immediate public health implications, researchers and clinicians said, and underscore more than ever the importance of measles vaccination. In recent years, anti-vaccine misinformation has been one reason vaccination rates have plummeted and global measles cases have surged. This year, the United States has had 1,250 cases of measles, the most since 1992.”

AGENCY ALERT

— Georgia Gov. Brian Kemp (R) announced a much-anticipated plan to request a waiver from the federal government to alter the state’s individual insurance market to offer cheaper plans not compliant with the ACA’s requirements.

The move makes Kemp’s state the first to request such a waiver after the Trump administration said last year it would allow states to apply for waivers to seek relief from the ACA requirements. The Health 202 wrote this week about how Democrats have sought to capitalize politically on the push from the administration, although until now, no states had jumped at the offer.

“No one has done this yet,” Katie Keith, a professor of health law at Georgetown University told the Atlanta Journal-Constitution’s Ariel Hart and Greg Blustein. “This is exactly what the Trump administration encouraged states to do, and no one yet has taken them up on it. So this is going to be a really big deal.”

“One part would set aside more than $300 million in public money for reinsurance — money that the government could pay insurance companies to cover high-cost claims that are meant to lower premium prices,” Ariel and Greg write. “A separate and more contentious effort would take on the structure of the ACA exchange market by moving it from federal to state control — bringing with it the $2.7 billion in federal subsidies that lower costs for lower-income policyholders.

— In a Halloween-themed blog post, the Centers for Medicare and Medicaid Services compared the debate around a single-payer health-care system to the “cinematic formula to our favorite horror movies.”

“The best horror films tend to have common themes that unsettle viewers and include the element of fear—characters often find themselves powerless and trapped.  Unfortunately, major debates around our health care systems seem to follow a similar cinematic formula,” CMS administrator Seema Verma wrote.

She said that despite the warnings that the Medicare Trust Fund will deplete by 2026 and that there are triple the number of Medicare beneficiaries compared to when the program was signed into law, “here are people calling for Medicare for All -, a proposal that would strip 180 million[1] people of their private health insurance and cost taxpayers $32 trillion[2]. A looming cost crisis will destroy the U.S. economy. You can almost hear the scary escalating music.”

— And here are a few more good reads: 

Much of the recent focus on Warren and Medicare has been about how she will pay for the plan, which would replace the private health insurance that currently covers two-thirds of Americans. It is by far the most expensive proposal in Warren’s long list of plans, but she has been silent on how she will fund it. As she rose in the polls not having a plan became a major liability.

TRUMP TEMPERATURE

Millions of people buying coverage during the enrollment period starting Friday will find that average premiums have dropped across the country. When consumers go to HealthCare.gov, they’ll be paying 4 percent less on average for the most popular health plans — with six states reporting a double-digit decline.
Politico

INDUSTRY RX

The Federal Trade Commission is scrutinizing Marlboro maker Altria's role in the resignation and replacement last month of the CEO of embattled e-cigarette maker Juul, the tobacco giant said Thursday in a regulatory filing.
CNBC

MEDICAL MISSIVES

She spent five days in the hospital undergoing psychiatric care. The bill she got is about the same price as a new Honda Civic.
Kaiser Health News
A crucial difference between a single-payer plan and more moderate Democratic proposals is how much spending would shift to the federal budget.
New York Times

HEALTH ON THE HILL

A bipartisan group of senators on Wednesday introduced a bill designed to expand telemedicine services through Medicare benefits.
Modern Healthcare

DAYBOOK

Coming Up

  • The Senate Special Committee on Aging holds a hearing to examine "veteran scams, focusing on protecting those who protected us" on Nov. 6. 
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the response to lung illnesses and youth e-cigarette use on Nov. 13. 

SUGAR RUSH