Daily on Healthcare: Obamacare’s individual mandate at death’s door

There is both a math and political rationale pushing Republicans toward backing repeal. The simple math is that the Congressional Budget Office has estimated repeal would save the government $338 billion over a decade, providing more money for the tax bill. Also, zeroing out the mandate penalties allows Republicans to claim that they at least repealed some aspect of Obamacare, after their catastrophic failure to pass a healthcare bill this year.

Now, the question is whether eliminating the penalties will have much of an effect. The rule was designed as a way of compelling younger and healthier individuals to sign up for insurance to help offset the cost of covering older and sicker enrollees. Without the mandate, the fear is that healthy individuals would drop out of the market, knowing that insurers would have to provide them with coverage when they get sick. However, though the Congressional Budget Office has projected that 13 million fewer individuals would be insured without the mandate, others have questioned whether the real world impact of the mandate is that important, especially given that Obamacare’s subsidies for people to purchase insurance and funding for the Medicaid expansion would still remain on the books. Support or oppose the move, it should provide a rare real life experiment for healthcare academics to study, as they’ll be able to look at the market before and after the mandate.

Welcome to Philip Klein’s Daily on Healthcare, compiled by Washington Examiner Managing Editor Philip Klein (@philipaklein), Senior Healthcare Writer Kimberly Leonard (@LeonardKL) and Healthcare Reporter Robert King (@rking_19).  Email [email protected] for tips, suggestions, calendar items and anything else. If a friend sent this to you and you’d like to sign up, click here. If signing up doesn’t work, shoot us an email and we’ll add you to our list.

House short-term spending bill includes children’s health insurance funding. House Republicans proposed a new spending bill Wednesday to fund the government for roughly a month and plan to include a five-year reauthorization of the Children’s Health Insurance Program. However, the reauthorization package, which mirrors a bill the House passed last month, is likely to be strongly objected to by Democrats because of funding offsets. The House Appropriations Committee released a new bill to renew spending until Jan. 19. It includes a bill that passed the House last month that would renew CHIP for five years and fund community health centers for two years. While the bill received some Democratic support when it passed last month, it got through the House thanks to Republican backing. House Democrats have condemned funding offsets that include raising Medicare premiums for seniors making more than $500,000 a year and raiding a disease prevention fund created under Obamacare.

Missing from the spending bill? Alexander-Murray. The new spending bill does not include either Obamacare stabilization bill that Sen. Susan Collins, R-Maine, asked for in return for her vote on tax legislation. Collins wanted both bills to be signed into law before the end of the year, a tall order for Congress as the end-of-the-year spending vehicle looked like the best chance to get that done. One bill sponsored by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would make payments to Obamacare insurers for two years in exchange for states having more flexibility to waive the law’s insurer regulations. A second bill from Collins and Sen. Bill Nelson, D-Fla., would give states $10 billion over two years to set up reinsurance programs to cover the sickest claims from Obamacare insurers and thus lower premiums for everyone else. Even though the Senate GOP and Trump support the bills, House GOP leadership has not gotten on board. House Republicans remain skeptical about propping up a law they deem a failure. To be sure, it doesn’t appear like this continuing resolution could be the final product. The deal would fund the government until Jan. 19 but includes a defense spending continuing resolution for the full year. Senate Democrats are sure to object to the plan to separate defense spending from discretionary spending.

Democrats skeptical of shutdown over CHIP. Several top Democrats said they are committed to fighting for CHIP but declined to say they would not support the Dec. 22 resolution if it doesn’t include long-term funding. “We are in the process of negotiating right now and it is not going to be helpful at this point to set bright lines in the sand,” said Sen. Debbie Stabenow, D-Mich. She is among Democrats in talks with Republicans over a new spending deal and said that long-term funding for CHIP is a topic of those talks. A source familiar with the matter previously told the Washington Examiner it appeared likely that a short-term measure for CHIP would be included instead of a multi-year reauthorization. Other Democrats were skeptical of issuing a shutdown ultimatum if the Dec. 22 CR doesn’t include long-term funding. “I think it is a little too vague to start drawing ultimatums now,” said Sen. Sheldon Whitehouse, D-R.I. “I would like CHIP funded as soon as possible.”

Doug Jones throttles GOP plans to bring back Obamacare repeal in 2018. The loss of one of Alabama’s Senate seats to a Democrat adds another snag to the long-sought goal to overhaul Obamacare for Republicans, who already were falling short of the support they needed. Even if a win had gone to Roy Moore, the failed Republican candidate, rather than to Doug Jones, some of the holdouts who doomed the prior efforts in the Senate said they wanted to move on to more bipartisan initiatives.“I think we need to just take a break and get through tax reform and try to find some issues or initiatives that we can come together on,” Sen. Lisa Murkowski, R-Alaska, told the Washington Examiner before Jones’ victory when asked about the prospects for repeal next year. Sen. Susan Collins, R-Maine, said Wednesday that Jones is likely to be a more centrist Democrat and that there is a “real possibility of doing some bipartisan work.” Sen. Johnny Isakson, R-Ga., pointed out that even with a majority of seats, the Senate had been unable to pass a bill that would repeal portions of Obamacare. “We had the healthcare bill we couldn’t get out even though we had 52 … the middle in the Senate has already had influence on which way we went. That’s not going to change,” he said.

The end of Graham-Cassidy? Even before Jones’ win, Sen. Bill Cassidy, R-La., was skeptical about whether the GOP would bring back his Obamacare repeal and replace bill that fell short in September. “It may be that Graham-Cassidy never comes back up because something else takes priority,” he told the Washington Examiner. “Somebody told me today that the House is gonna do welfare reform in reconciliation. That is just a rumor.” After Jones’ shocking win, Cassidy was bullish that he would support the repeal bill if it came back up because Alabama would be helped greatly by Graham-Cassidy compared to the status quo. Under the bill, states that did not expand Medicaid would see more funding than what they get now, while expansion states would see less. “Paradoxically it may help him, he’s the one guy that would say, ‘I’ve got to vote for it,’ and kind of call out others who voted no for no other reason than they were told to vote no,” Cassidy said Wednesday.

Viewers seeing more ads about insurance during open enrollment under Trump than under Obama: Study. Television viewers are seeing more commercials about health insurance this year than they did a year ago during Obamacare’s open enrollment, a new study reports. According to the Wesleyan Media Project, TV commercials about health insurance during the first 37 days of open enrollment were up 51 percent over the same window in 2016. That occurred despite the Trump administration slashing the advertising budget about open enrollment by 90 percent, to $10 million, from where it was under former President Barack Obama. Researchers noted non-governmental advertisers, in particular health insurance companies, appear to have boosted their own advertising. Most of the ads, however, did not specifically mention healthcare.gov. In one instance, the ad notifies viewers they can skip the healthcare.gov website and buy directly from an insurer. “Insurance company advertising is not a replacement for federal advertising, which in the past drove enrollees explicitly to healthcare.gov,” said Erika Franklin Fowler, co-director of the Wesleyan Media Project. “However, more ads in a shorter window make it more likely that consumers will encounter health insurance messaging on television, which may help to boost awareness and encourage enrollment generally, complimenting other efforts to spread the word.”

Democrats urge grace period for Obamacare. Democratic leaders are urging the Trump administration to allow a grace period for Obamacare enrollees who wait until the last-minute deadline on Friday to sign up for coverage. The Dec. 15 deadline is earlier than in previous years, and advocates of Obamacare have been concerned that potential customers do not know it is ahead. In the past, the website sent customers to a “waiting room” during peak periods, where a screen notified them that the site was overloaded and allowed them to begin perusing health plans as they waited. The site otherwise asked users to leave contact information so they could return to the website when it was moving faster. Under the Obama administration, people who were on the healthcare.gov site at midnight and experienced some of these delays were given a grace period so they could still obtain coverage. Democrats insisted on allowing wiggle room this year. “You have previously stated that the department is ‘committed to making this year’s enrollment as consumer-friendly as possible,” Democrats wrote in to top health officials in the Trump administration. “We hope you will carry through with that goal and commit to offering a grace period for potential enrollees still waiting to enroll at midnight on Dec. 15.”

Insurance industry, health providers raise concerns about Trump executive order. Expanding the use of short-term health insurance plans and association health plans, along with relaxing rules for employer Health Reimbursement Arrangements, would result in adverse selection, healthcare groups warned in a letter sent to state departments of insurance. “We are concerned that this could create or expand alternative, parallel markets for health coverage, which would lead to higher premiums for consumers, particularly those with pre-existing conditions,” they wrote. The letter was sent by America’s Health Insurance Plans, the Blue Cross Blue Shield Association, American Cancer Society Cancer Action Network, American Heart Association, Families USA and others. They urged states regulators to take their own actions even if the federal government writes new rules regarding what kinds of plans may be sold.

Residents of many states are better able to get and afford healthcare: Study. In nearly three-quarters of states, fewer people skipped needed healthcare because of costs in 2016 compared to 2013, according to the Commonwealth Fund report ‘States’ Progress on Health Coverage and Access to Care.” The share of low-income adults going without healthcare because of costs declined by more than 7 points, on average, in the states that expanded Medicaid, compared to 3 points in states that did not. The study also tracked uninsured rates. Overall, 47 states saw their adult uninsured rate drop by 5 percentage points or more since 2013. New Mexico’s rate dropped the most between 2013 and 2016, from 28 percent to 13 percent. A dozen other states saw double-digit drops, including Arizona, Arkansas, California, Florida, Kentucky, Louisiana, Montana, Nevada, Oregon, Rhode Island, Washington and West Virginia. Authors of the report warn that repealing the individual mandate penalty could reverse these gains because premiums would increase, making coverage unaffordable. They predicted that Alaska, Iowa, Nebraska and Wyoming would see the largest increases.

Mario Molina resigns from Molina board of directors.  Molina Healthcare announced Wednesday that Dr. J. Mario Molina has stepped down from the Molina Healthcare board of directors. “As a natural progression of his involvement in the company for more than 20 years, we understand and respect Dr. Molina’s decision, and we thank him for all of his contributions,” Chairman Dale Wolf said. Molina, who is the son of the late founder of the company, was fired as CEO earlier this year, and his brother John was fired from his role as chief financial officer. The reason cited was the insurer’s “disappointing financial performance.” Molina has been a vocal supporter of Obamacare and a critic of Trump.

Teen opioid use appears to decline despite increases in drug-related deaths among adults. Misuse of prescription opioids among 12th graders continued to decline in 2017 despite increasing rates of overdose deaths in other age groups, survey data suggests. The annual Monitoring the Future survey, published Thursday, shows that misuse of Vicodin and Oxycontin by 12th graders has reached a historic low of 4.2 percent, a 0.5 percent decrease from the year before. The totals represent half the use recorded in 2004, when 9.5 percent of high school seniors said they had misused a prescription opioid during the past 12 months. “Several years ago we became very concerned by what to my mind were remarkably high rates of prescription opioid misuse by youths all across the country,” said Dr. Wilson Compton, director of the National Institute on Drug Abuse, the agency that funded the survey. “Since then we have seen some decline,” he continued. “Over the last few years we have seen marked decline in 12th graders in particular reporting misuse of these prescription opioids. So I think that’s very good news that families and communities are finding ways to keep children safe from these potentially deadly medications.” Vicodin, the most-used opioid among teens surveyed, showed a decline in use among 12th graders from 2.9 percent in 2016 to 2 percent in 2017.

Pot reformers say statistics disprove top legalization fear. Marijuana legalization supporters say new data confirm their claim that legal adult access won’t increase teen use, a major concern among opponents of relaxed state laws. Teen marijuana use has been stable or declining since 2012, when Colorado and Washington became the first states to legalize recreational pot use for adults 21 and older, according to data released Thursday by the National Institute on Drug Abuse. The results of the national Monitoring the Future survey show eighth-, 10th-, and 12th-grade students had no statistically significant change in marijuana use rates from 2016 to 2017. Longer-term trends between 2012 to 2017 are either stable or declining. Tenth-grade students had a significant decline in past-year and lifetime use during that period and eighth-grade students reported a significant drop in daily use. “Fears of increased teen use are no longer a defensible justification for maintaining prohibition,” said Mason Tvert, a public relations consultant who co-directed Colorado’s legalization campaign. Andrew Freedman, Colorado’s first director of marijuana coordination, said “these survey results are an encouraging sign that a tax and regulate system can effectively prevent youth use if implemented correctly.”

RUNDOWN

Axios Medicare to scrutinize prescription drug plans

The Hill Obamacare expected to suffer enrollment decline as Trump cuts timeframe

Roll Call Those that shall not be named: Cost sharing reductions for Obamacare

Kaiser Health News Telemedicine for addiction treatment? The picture looks fuzzy

Los Angeles Times Obamacare is helping patients get to the doctor and pay their medical bills, new study finds

STAT News ‘Big black box’ called PBMs draws attention from lawmakers looking to solve drug prices

Wall Street Journal Study links lower birth weights to living near fracking sites

Calendar

THURSDAY | Dec. 14

MACPAC December Meeting. Details.

SATURDAY | Dec. 16

3 a.m. EST. Deadline for open enrollment on healthcare.gov.

TUESDAY | Dec. 19

Noon. Health officials to discuss hepatitis A outbreak in webinar. Details.