The Health 202: Obamacare marketplaces survived Trump’s term better than expected

“The overall impact of the Trump administration’s policies towards the marketplaces have probably been more muted than most expected — at least so far,” said Adam Gaffney, a professor at Harvard Medical School and president of Physicians for a National Health Program.

Enrollment in and the state-based marketplaces is open through Dec. 15.

People can shop for private plans, and qualify for federal subsidies if their income is between 133 percent and 400 percent of the federal poverty level.

To the concern of health-care advocates, enrollment has ticked down over the past four years, contributing to the nation’s worsening uninsured rate amid the coronavirus pandemic and fueling a growing sense among Democrats that further health restructuring is needed.

Yet by some measures, the marketplaces look healthier than ever.

Individual insurance premiums and choices have steadily improved over the past four years, despite Democrats’ insistence that the administration’s policies would destroy the marketplaces. That trend will continue in the 2021 enrollment season.

“One thing the marketplaces proved is how resilient they actually are,” said Andy Slavitt, former administrator of the Centers for Medicare and Medicaid Services under President Barack Obama.

Still, there’s a clear difference in how a Joe Biden administration would approach the ACA.

It certainly would invest more in boosting marketplace enrollment, advisers say. The Democratic nominee, if he wins tomorrow’s election, is expected to restore funds Trump scrapped to advertise the law and may push Congress to pass legislation increasing the income-based subsidies available to people. 

A Democrat-led administration may also reverse some of the changes President Trump made to the marketplaces — although Trump’s record on them is more nuanced than either party claims.

“The truth is somewhere in middle between what Republicans say and what Democrats say,” said Larry Levitt, a vice president for the Kaiser Family Foundation.

The average Obamacare customer can choose from plans offered by four to five issuers.

That’s up from an average of three to four issuers in 2020, according to data from the Centers for Medicare and Medicaid Services. Four percent of enrollees will have access to plans from just one issuer, up from 12 percent of enrollees this year.

And premiums are declining for the third straight year. The average premiums for the second-lowest-cost “silver”-level plan will be 2 percent lower next year. Average premiums for these “benchmark” plans have declined 8 percent since 2018.

“Despite the uncertainty of the pandemic and concerns about the future of the ACA, the marketplaces are strong and healthy, and premiums for high-quality, comprehensive coverage remain very affordable,” said Joshua Peck, co-founder of Get America Covered — a nonpartisan group that has worked to spread the word about the marketplaces even as the administration has cut advertising for it.

It’s a distinct shift from how things looked during the Obama administration. The first few years of the marketplaces were marked by double-digit premium increases and a steady stream of exits by insurers, as they struggled with how to price and sell insurance plans on an entirely new forum.

The marketplaces were starting to stabilize by the time Trump took office, and actuaries and economists say the subsequent improvements probably reflect that natural adjustment by insurers to the demands of the marketplace — and less so the specific changes the new administration made.

Trump’s administration has allowed some significant changes in the marketplaces.

CMS yesterday approved Georgia’s request to let its eligible residents bypass and buy coverage directly through Web brokers or insurance companies. The state also received permission to set up a reinsurance program, which could help lower individual market premiums.

Previous changes made by the administration have also been themed around lifting or lightening Obamacare requirements, which Republicans frequently characterize as onerous. 

In fall 2017 Trump ended extra payments for insurers, which had helped them discount cost-sharing for the lowest-income enrollees.

A few months later, the president signed a bill repealing the law’s penalty for lacking health insurance, letting people opt out of the marketplaces or other types of coverage without being fined.

And in 2018, his administration rolled out rules expanding two types of insurance plans — short-term plans and association health plans — which aren’t required to cover the full range of benefits required for marketplace plans. 

But the disastrous consequences Democrats warned about didn’t exactly transpire.

Scrapping the cost-sharing payments had an unexpected effect: It prompted insurers to raise premiums for silver-level plans. It’s on these plans that the government bases its subsidy payments. So Trump’s move, while intended to undermine the law, instead had the effect of raising subsidies for many marketplace enrollees.

That may be the single biggest contributing factor to the current stability of the marketplaces, Levitt said. A growing majority of enrollees are people who qualify for subsidies — and now those subsidies are more generous.

“The president was very public that his intention was to cause the ACA to collapse, but if anything it’s had exactly the opposite effect,” he told me.

Trump’s other changes didn’t affect the marketplaces as much as expected.

The insured rate certainly has declined since the mandate penalty was ditched — but not by as much as experts had predicted. The Congress Budget Office estimated that repealing the mandate would increase the number of uninsured people by 4 million in 2019. The actual figure was about half that.

And expanding the ACA-exempt health insurance plans didn’t attract enough people away from the marketplaces to make much of an impact, experts say.

“I don’t think it had a big impact either way in terms of taking people away from ACA,” said Maryam Saeedi, professor of economics at Carnegie Mellon University.

Ahh, oof and ouch

AHH: After weeks of rising infections and hospitalizations, coronavirus deaths are also increasing.

“The nation passed another milestone Friday with 9 million confirmed cases since the start of the pandemic, including more than 98,000 new cases, a daily record. More than 1,000 deaths in the United States from the novel coronavirus were reported each day Wednesday and Thursday, according to health data analyzed by The Washington Post, continuing an upward trend that began two weeks ago,” The Post’s Joel Achenbach, Brittany Shammas and Jacqueline Dupree report. 

Deaths generally lag infections by many weeks. The massive surge in infections across the country probably will drive up the death toll for weeks, if not longer. Meanwhile, colder weather and more indoor gatherings may further drive the spread of the virus.

“But the mortality numbers have become political fodder on the campaign trail. Depending on whom you listen to, the coronavirus just isn’t that deadly anymore. Or it’s killing people in droves,” Achenbach, Shammas and Dupree write. “The truth is that mortality rates have improved, but the accelerating spread of the virus is driving up the absolute numbers of deaths.”

There’s a spot of good news: Improved techniques for treating patients and new therapeutics have led to better outcomes for hospitalized patients. A recent study of more than 5,000 patients from researchers at NYU Langone Health found the death rate dropped from 25.6 percent in March to 7.6 percent in August. Nationally, the daily death toll remains below that seen in the initial spring wave of the pandemic, when more than 2,200 people were dying each day on average. 

But the trend is grim. A mashup of models being used by the Centers for Disease Control forecasts 248,796 total deaths by the end of the month, with more than 6,000 deaths a week until then. Anthony Fauci, the nation’s top infectious-disease expert, has expressed skepticism about the possibility of accurately predicting the death toll, but he said that he expects to see an increase in deaths over the fall and winter.

Doctors slammed Trump for pushing a conspiracy theory claiming inflated covid-19 death counts. 

“You know, our doctors get more money if somebody dies from covid. You know that, right?” Trump told a rally in Waterford Township, Mich., on Friday. “I mean, our doctors are very smart people … so what they do is they say, ‘I’m sorry, but, you know, everybody dies of covid.’ ”

“Medical groups, including the American Medical Association, denounced Trump’s assertion that doctors inflate the number of deaths. AMA President Susan Bailey called Trump’s claim ‘malicious, outrageous and completely misguided’,” USA Today’s John Fritze reports.

According to Johns Hopkins University, 230,000 people have died in the United States of covid-19. Data on excess deaths show even more striking numbers: Nearly 300,000 more people have died during the coronavirus pandemic than would be expected in a typical year. 

“To imply that emergency physicians would inflate the number of deaths from this pandemic to gain financially is offensive, especially as many are actually under unprecedented financial strain as they continue to bear the brunt of covid-19,” the American College of Emergency Physicians said on Friday.

“Doctors and nurses go to work every day to save lives. They do their jobs. Donald Trump should stop attacking them and do his job,” Biden told a drive-in rally in Minnesota on Friday.

Ashish K. Jha, dean of the Brown University School of Public Health:

Emergency room physician Cleavon Gilman:

OUCH: Rallygoers told Trump to fire Fauci, and Trump suggested he might.

Speaking at a late-night campaign rally in Florida in the early hours of Monday morning, Trump suggested he could fire Fauci, the director of the National Institute of Allergy and Infectious Diseases.

A crowd at the Miami Opa-Locka airport broke out in a chant of “Fire Fauci.” In response, Trump said: “Don’t tell anybody, but let me wait until a little bit after the election.”

Polling shows that Americans generally place a high level of trust in Fauci, although Republicans have lost some confidence in the doctor in recent months as Trump has lashed out at him.

Indeed, the White House is considering a major second-term Cabinet haul if Trump wins, including the removal of top health officials.

“The shift would amount to a purge of any Cabinet member who has crossed the president, refused to mount investigations he has demanded, or urged him to take a different, more strict tack on the coronavirus response,” Politico’s Nancy Cook reports. “Already, the White House and administration officials have started to vet names of health care experts who could take over the agencies running many elements of the government’s pandemic response and overseeing the country’s health insurance system, according to two Republicans close to the White House.”

While a major overhaul of top health leaders could disrupt the nation’s pandemic response, the Trump White House has repeatedly clashed with officials at the Centers for Disease Control, Health and Human Services and the Food and Drug Administration. 

“On the health side, the administration could see the departures of figures like HHS Secretary Alex Azar, Centers for Disease Control and Prevention head Robert Redfield, National Institutes of Health head Francis Collins and Centers for Medicare and Medicaid Services head Seema Verma. Some, like Verma, may leave on their own terms to return to their home states, while others, like Collins, may retire,” Cook writes.

Aides say that the president, however, has not been overly focused on personnel changes or his second-term agenda, preferring to turn his attention to his rallies and effort to win reelection. White House and agency officials, however, have suggested that if the president wins, he will do more to tackle surprise medical bills and prescription drug costs.

More in coronavirus

The Trump administration is funding a plasma company based in its owner’s condo.

“When the Trump administration gave a well-connected Republican donor seed money to test a possible COVID-19-fighting blood plasma technology, it noted the company’s ‘manufacturing facilities’ in Charleston, South Carolina,” the Associated Press’s Richard Lardner and Jason Dearen report. “Plasma Technologies LLC is indeed based in the stately waterfront city. But there are no manufacturing facilities. Instead, the company exists within the luxury condo of its majority owner, Eugene Zurlo.”

Robert Kadlec, a senior Trump appointee at the Department of the Health and Human Services, pushed the deal with Plasma Technologies despite reservations from scientists on his staff. Few plasma industry experts contacted by the Associated Press had heard of the company, which claims former Republican senator Rick Santorum of Pennsylvania as a part owner.

“It’s also another in a series of contracts awarded to people with close political ties to key officials despite concerns voiced by government scientists. Among the others: an ill-conceived $21 million study of Pepcid as a COVID therapy and more than a half billion dollars to ApiJect Systems America, a startup with an unapproved medicine injection technology and no factory to manufacture the devices,” Lardner and Dearen write.

State officials are frustrated by a lack of federal funds to distribute coronavirus vaccines.

The CDC has told states to be prepared to distribute the first doses of by Nov. 15, even though it is unlikely that a vaccine will be approved until later this year. State health officials, however, say that they don’t have enough money for the complicated preparations, which include recruiting thousands of people to staff vaccine clinics, developing vaccine-related communications campaigns and ramping up data systems to track vaccine inventory and administration, The Post’s Lena H. Sun reports.

“State officials have been planning in earnest in recent weeks to get shots into arms even though no one knows which vaccine will be authorized by the Food and Drug Administration, what special storage and handling may be required and how many doses each state will receive,” Sun writes.

Despite uncertainties, the CDC has asked states to prepare to “preposition” doses of a coronavirus vaccine in key locations across the country to move as quickly as possible should a candidate get emergency authorization.

“As part of that effort, the CDC is asking states to provide by Tuesday critical information, including a list of each jurisdiction’s top five sites capable of receiving and administering a vaccine that must be stored at ultracold temperatures of minus-70 Celsius (minus-94 Fahrenheit). The letter refers to the vaccine only as Vaccine A, but industry and health officials have identified it as Pfizer’s candidate,” Sun reports.

The Department of Health and Human Services, the CDC’s parent agency, told The Post that the CDC has sent $340 million to states to support flu and coronavirus vaccine planning and distribution. Some state health officials say it’s not enough.

“It is absolutely ridiculous that the administration, after spending $10 billion for a Warp Speed effort to develop a vaccine, has no interest in a similar investment in a Warp Speed campaign to get the vaccine to every American as quickly as possible after it is approved,” said Michael Fraser, executive director of the Association of State and Territorial Health Officials. Operation Warp Speed is the federal initiative to develop vaccines and other coronavirus countermeasures as quickly as possible.

Elsewhere in health care

  • More U.S. patients will be able to gain easy access electronic copies of doctors’ notes under a new federal transparency requirement. While patients have had long had legal access to their medical records, obtaining them has often entailed records requests and fees, the Associated Press’s Carla K. Johnson reports.
  • A powerful gene-editing tool known as CRISPR can cause serious side effects in the cells of human embryos, according to a study published in the journal Cell on Thursday. Bioethicists and scientists say that the findings underscore that it is too soon to ethically use the technology in reproductive genetics, the New York Times’s Katherine J. Wu reports.
  • The Trump administration finalized a new transparency rule for health insurers, requiring them to share cost-sharing estimates with enrollees and to publicly release negotiated rates for in-network providers. HHS has said that the changes will help health-care consumers predict costs of coverage and comparison shop, Health Affairs’s Katie Keith reports.
  • Nearly 1 in 3 Americans is unfamiliar with all five signs of a stroke, which include sudden numbness or weakness, especially on one side; trouble speaking or confusion; sudden trouble with eyesight; sudden trouble with walking or dizziness; and a sudden, severe headache with no known cause. The finding, based on data from the 2017 National Health Interview Survey, is concerning because the rate of strokes among young adults has risen sharply in recent decades, The Post’s Erin Blakemore reports.

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