THE PROGNOSIS

The Affordable Care Act turns a decade old this year. But the Democrats who passed it are spending more time talking about what the law didn’t fix than what it did.

They point out that 27 million Americans still lack coverage. And for those with insurance, they repeatedly bemoan the various costs associated with their plans that are on a rapidly ascending escalator.

There’s no denying the sweeping 2010 health-care law resulted in palpable changes to the U.S. health-care system, despite some major stumbles and roadblocks along the way. It nearly halved the country’s now-8.5 percent uninsured rate. It guaranteed coverage for the 50 million Americans with preexisting conditions. It mandated more generous coverage for millions more. 

And the law’s insurance marketplaces appear more stable than ever before, with enrollment remaining relatively steady between 2019 and 2020. About 8.3 million people signed up in the 38 states that rely on Healthcare.gov, the Centers for Medicare and Medicaid Services announced last month — a dip of less than 2 percent compared with last year.

“The law was never meant as the final step to giving Americans quality, affordable coverage, but it’s taken us a long way,” said Leslie Dach, chairman of the Democratic-aligned group Protect Our Care and a former Health and Human Services adviser on the ACA. “The law was a dramatic and historic step forward when it was passed, and it is incredibly strong.”

There will undoubtedly be some applause and toasts in March, the anniversary of when Congress passed the ACA and President Barack Obama signed it. Democrats have been particularly eager to highlight the law’s preexisting-condition protections, which are threatened by a Trump administration-backed lawsuit, which a federal judge is taking a second look at.

(On Friday, the Democrat-led states who are defending the ACA in that lawsuit asked the Supreme Court to consider the case during its current term, hoping to get a final ruling on the law this year.)

But it’s also easy to forget that the health-care overhaul was Obama’s biggest domestic accomplishment. The Democratic presidential candidates are devoting much of their airtime these days to discussing Americans’ persistent struggles with costs a troubling problem the ACA didn’t solve. And they're looking to go beyond the ACA by adopting a Medicare-for-all system in which the government would become the single largest payer in the system.

“If you’re part of a typical American household, your family spent almost $12,000 on health care last year,” Sen. Elizabeth Warren (D-Mass.) said in New Year’s Eve address. “About one in five of you — including people with insurance — didn’t fill a prescription because you couldn’t afford it.”
 
“So now, imagine an America where Medicare-for-all ensures health care is a basic human right,” she continued. “Imagine an America where you could get your prescriptions filled, without worrying about the cost.”

It’s typical for political candidates to spend more time talking about what’s wrong with the country rather than what’s right. After all, they need to motivate voters to turn out at the polls. But in taking that approach with health care, the Democratic candidates have inadvertently highlighted the ACA’s glaring shortcoming: It didn’t lower the fundamental cost of medical services and health insurance.

Christopher Robertson, a health law expert at the University of Arizona, told me he’d give the ACA “a solid B” because of its coverage expansions. But it didn’t tackle health-care costs, and those have been growing unabated ever since the law’s inception, he noted.

“The quality of the coverage has gotten worse and worse,” Robertson said. “We’re seeing a hollowing-out of insurance, even by the people who have it.”

The cost growth has been particularly marked among employer-sponsored plans, which cover about half of all Americans. 

Average family premiums for workplace plans increased 22 percent over the past five years and 54 percent of the past decade, according to research by the Kaiser Family Foundation. It’s a similar story for annual deductibles, which have increased 36 percent over the past five years and 100 percent in the last 10.

So easing health-care costs has become a top Democratic promise, one the candidates will continue to focus on in 2020. During debates and on the campaign trail, they’ve rarely brought up the ACA, instead preferring to discuss ways of expanding affordable coverage either via Medicare-for-all or by adding a government-sponsored “public option” plan to the marketplaces.

The only candidate who regularly goes out of his way to applaud the ACA’s progress has been Joe Biden, who served as vice president when it was passed and once famously told Obama it was “a big, f---ing deal.” 

Biden has become increasingly critical of Sens. Elizabeth Warren (Mass.) and Bernie Sanders (Vt.) for saying Obamacare should be replaced with Medicare-for-all.

“I’m for Barack. I think the Obamacare worked,” Biden said at the September presidential debate.

In contrast, Warren and Sanders who both voted for the ACA in the Senate continually castigate the country’s system of private coverage, which the ACA expanded dramatically. Though Warren seems to have paid a price in the polls for her aggressive advocacy of Medicare-for-all, and release of dramatic cost estimates to pay for it.

“At a time when we're spending twice as much per capita on health care as any other nation, when 87 million people are uninsured or underinsured, when 30,000 people are dying each year because they don't get to a doctor when they should, and when a half a million people are going bankrupt because of the dysfunctional and cruel system that we currently have, you know what?” Sanders said at the December presidential debate.

“I think we will pass a Medicare-for-all single-payer system, and I will introduce that legislation in my first week in office,” he said.

AHH, OOF and OUCH

AHH: A Food and Drug Administration official says the administration would consider restricting the sale of menthol-flavored vaping products if its recently announced ban on most e-cigarette pods leads kids to start using menthol products. The ban, which targets disposable pods popular with young people, won’t apply to menthol or tobacco flavors. 

Mitch Zeller, director of the FDA’s Center for Tobacco Products, told CNBC the administration aimed to go after “the flavors that are most popular with kids” but the agency will “revisit” its policies if young people start to increasingly use menthol products. 

“What we said in our announcement yesterday is we have the ability to monitor and surveil what’s going on and what the patterns of use are and we’ve made it clear that if kids migrate to menthol then we will have to revisit this,” he said.  

As it announced its much-anticipated vaping policy Thursday, the administration ordered companies to stop manufacturing, distributing and selling most cartridge-based e-cigarette flavors — including mint and fruity flavors — after 30 days, as our colleague Laurie McGinley wrote.

— Anti-tobacco advocates pushed members of the D.C. Council during a five-hour hearing last week to add menthol cigarettes to its list of barred products.

During a hearing on bills meant to curb youth vaping, advocates “revived a decades-old fight over menthol cigarettes, a minty flavor disproportionately marketed to and used by African Americans,” our Post colleague Fenit Nirappil writes. “…While electronic cigarettes have captured more attention as a new product, some African American civic leaders and anti-tobacco advocates say menthol must also be targeted.”  

“The most-discussed bill in the District would prohibit the sale of any flavored e-cigarette product, a policy adopted in other major urban hubs including New York City, San Francisco and Minneapolis. Advocates say banning flavors such as cotton candy and strawberry milk can dissuade young people from forming a nicotine habit,” he adds. 

— In an op-ed in The Post, former FDA commissioner Scott Gottlieb said the Trump administration took “significant” action but that the “need for additional measures is urgent.” 

“The FDA rightly observed that young people prefer these cheap, cartridge-based e-cigarettes that deliver a jolt of nicotine because the devices look appealing — many resemble a USB drive — and are easily concealed,” Gottlieb writes. “But policymakers struggle to keep up with the rapidly changing preferences of young people, and the new rules appear to have overlooked different devices that are gaining popularity with kids.” 

He writes that the FDA should accelerate its process for reviewing manufacturers’ e-cigarette applications. He also argues that the agency should implement and enforce the newly passed minimum-age increase for tobacco product purchases and that it should “update regulations governing the sale of tobacco products to account for the higher age restriction.”

OOF: Sanders appeared to call for the end of the vaping industry in answering a question at a town hall over the weekend, Politico’s David Siders and Sarah Owermohl report

“The answer is, I think we shut down the industry if they’re causing addiction and if the evidence is that people are getting sick as a result or inhaling a lot of bad stuff,” Sanders said in a response to a question about the youth vaping crisis. 

But his campaign team quickly walked back the remarks. “Jeff Weaver, Sanders’ longtime political adviser, told POLITICO following the town hall that Sanders was ‘certainly not talking about shutting down the industry tomorrow.’ He said Sanders wants more study and regulation of the industry to ensure that it is safe and that ‘the federal government needs to act strongly in those areas,’ ” David and Sarah write. 

OUCH: Novartis, Merck and Allergan were among the drug manufacturers that have announced price increases. The three companies raised prices Friday on more than 100 prescription drugs for the new year, Reuters’s Michael Erman reports.

Reuters previously reported Pfizer, Bristol-Myers Squibb and AbbVie were among companies upping costs on more than 330 drugs for 2020. 

In total, companies have raised costs on 445 drugs at the start of the new year. 

“That is above the average of 404 drug price increases in the first three days of January over the past five years. Nearly all of the price increases are below 10%, with the median price increase around 5%, according to [health-care research firm 3 Axis Advisors],” Michael writes. “…Under pressure from politicians and patients, many makers of branded drugs have pledged to keep annual U.S. price increases below 10% a year.”

INDUSTRY RX

— U-Haul announced it will stop hiring smokers or nicotine users in 21 states at the beginning of next month. The policy, which is part of an effort to develop a “culture of wellness,” will take effect in states that don’t already have protections for smokers’ rights, our Post colleague Lateshia Beachum writes. 

Uhaul’s chief of staff Jessica Lopez told the Arizona Republic that the nicotine-free policy, which will also cover e-cigarette and vaping products, is part of “continued efforts to enhance our wellness program and decrease health care costs.” 

The moving-equipment and storage-unit rental company with 30,000 employees will grandfather in current employees who might be smokers but will offer nicotine-cessation assistance for workers. 

— And here are a few more good reads: 

Pharmaceutical companies started 2020 by raising the prices of hundreds of drugs, according to a new analysis, though the average increase of 5.8 percent was lower than a year earlier amid growing scrutiny from patients, lawmakers and health plans.
Wall Street Journal
The lawsuit claims the company targeted minority women and children despite being aware of the risk of asbestos in talc.
New York Times
Is CBD legal? New class-action lawsuits that could decimate the industry highlight just how complicated that question is. 
Stat

AGENCY ALERT

Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, sat down for a rare interview with KHN senior correspondent Sarah Varney. They discuss her views on President Do…
Kaiser Health News

STATE SCAN

D.C. Politics
City officials are investigating whether shelter water was the source of the infection.
Peter Jamison

MEDICAL MISSIVES

Health
Texas Attorney General Ken Paxton (R) said Friday that a Forth Worth appeals court had granted Lewis emergency relief while the legal issue plays out.
Marisa Iati

REPRODUCTIVE WARS

Politics
The lawmakers signed on to an amicus brief supporting a 2014 Louisiana law requiring doctors at abortion clinics to have admitting privileges at nearby hospitals.
Felicia Sonmez

DAYBOOK

Coming Up

  • The House Energy and Commerce subcommittee on health holds a hearing on legislation to improve American’s health-care coverage and outcomes on Wednesday.
  • The Bipartisan Policy Center hosts 20/20 Health Care Series: A Snapshot of Early Primary Voters on Wednesday.
  • The House Veterans' Affairs subcommittee on economic opportunity holds a hearing on resources to address veteran hunger on Thursday.

SUGAR RUSH