Sam Baker
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2.3 million have signed up for ACA coverage

ACA sign-ups lag behind last year's pace. Photo: Andrew Harnik / AP

Roughly 2.3 million people have signed up for Affordable Care Act coverage through HealthCare.gov, the Centers for Medicare & Medicaid Services said today.

Between the lines: We're halfway through the six-week open enrollment window. Halfway through the last open enrollment window, which was twice as long, more than 4 million people had signed up for coverage.

The bottom line: It's hard to draw an apples-to-apples comparison because of differences in deadlines and the overall length of the enrollment period, but enrollment does seem likely to drop this year, in part due to the Trump administration's decision to eliminate almost all promotion and outreach.

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Vitals

Good morning … Vitals will be off the rest of this week. Console yourselves with some stuffing and mashed potatoes, and I'll see you again Monday. Happy Thanksgiving.

Higher premiums would cancel out some people's tax cuts

Data: The Commonwealth Fund; Chart: Lazaro Gamio / Axios

The Senate's proposed tax overhaul would repeal the Affordable Care Act's individual mandate permanently, and provide individual tax cuts temporarily.

Once those tax cuts expire, just about everyone on the individual insurance market will face higher health insurance costs without a tax cut to help pay for it. And even in the short term, some people's tax cuts would effectively be erased by the higher premiums they'd face without the individual mandate.

Threat level: As my colleague Caitlin Owens reports this morning, based on an analysis from the Commonwealth Fund, the biggest burden here would fall on people who buy insurance on their own, but don't get subsidies to help cover their premiums.

  • Those subsidies help insulate low-income consumers from premium hikes, but the people who don't get them will be on the hook for all of the added costs that come with repealing the individual mandate — and that would eat up a lot of the extra money they'd be keeping because of the bill's tax cuts.

​Many families can't afford even moderate deductibles

Reproduced from Kaiser Family Foundation analysis of the 2016 Survey of Consumer Finance; Note: Liquid assets include the sum of checking and saving accounts, money market accounts, certificates of deposit, savings bonds, non-retirement mutual funds, stocks and bonds; Chart: Axios Visuals

A lot of low-income families can't afford even a moderate deductible, yet deductibles continue to rise in almost all forms of insurance, Kaiser Family Foundation president Drew Altman writes in his latest Axios column.

  • Roughly 40% of all non-elderly households don't have enough liquid assets to cover a high deductible ($3,000 for an individual or $6,000 for a family).
  • Among families whose income makes them eligible for the ACA's premium subsidies, 60% don't have enough liquid assets to cover a high deductible and 44% couldn't cover the deductible for a mid-range plan ($1,500 for an individual or $3,000 for a family).

Why it matters: High deductibles are everywhere, and they're only getting higher. Many ACA plans have relatively big deductibles and Republicans' alternatives would push them higher. They've been getting bigger and bigger in employer plans, too.

  • "For many families, even if they have insurance, any significant illness could wipe out all their savings, making impossible to fix a broken car to get to work, or pay for school, or make a rent or mortgage payment," Altman says.

​Medicaid and CHIP now cover almost 75 million people

Enrollment in Medicaid and the Children's Health Insurance Program is up nearly 30% under the ACA, according to new data from the Centers for Medicare & Medicaid Services. The two programs now cover almost 75 million people — about 16 million more than they covered in 2013, before the ACA's coverage expansion took effect.

Between the lines: The ACA's Medicaid expansion is part of the equation here, but not the whole story.

  • Total enrollment has risen by 38% in expansion states and 12% in non-expansion states.
  • That's largely due to Medicaid's "woodworking" effect: All the attention in prior years surrounding open enrollment and Medicaid expansion has prompted people who were already eligible for the program, but had never signed up, to explore their options.

Quick take: This is a big part of the reason repeal-and-replace is so difficult politically. Republicans' proposals not only would have ended the Medicaid expansion, but made deep cuts to the underlying program. That's always going to end up costing a lot of people their health care coverage — and that's always going to make at least some lawmakers nervous.

​Mulvaney's face time with the health care industry

Mick Mulvaney, the director of the Office of Management and Budget, holds a lot of power when it comes to federal regulations. And the health care industry certainly has his ear, based on meeting records obtained by ProPublica and the transparency advocacy group Property of the People.

Here are just some of the health care executives Mulvaney has met with since he started earlier this year:

  • Blue Cross Blue Shield Association CEO Scott Serota (several times)
  • UnitedHealth Group CEO Stephen Hemsley
  • CVS Health CEO Larry Merlo
  • Mylan CEO Heather Bresch
  • NantHealth CEO Patrick Soon-Shiong
  • Independence Blue Cross CEO Dan Hilferty
  • PhRMA's board of directors

Go deeper: Mulvaney met with two CEOs of large home health companies the week before Medicare released a favorable rule for the home health industry.

Be smart: There's nothing inherently scandalous about regulatory officials meeting with the industries their regulations affect. But that's why the Obama administration had made these visitor records public: to give the public at least some sense of who had a seat at the table.

​1 Thanksgiving thing: Turkey doesn't make you sleepy

Everyone loves a smartypants at Thanksgiving, so when your relatives claim they're tired from all that turkey — it's the tryptophan! — let them know that they are WRONG.

It wouldn't be Thanksgiving without re-upping health economist Aaron Carroll's definitive tryptophan takedown. The gist:

  • Turkey doesn't have that much tryptophan.
  • Tryptophan is hard to absorb on a full stomach.
  • If you're tired after Thanksgiving dinner, it's probably because of you just ate an enormous quantity of food, and/or drank a lot of wine (and/or physically exhausted yourself trying to change the subject away from politics).

Antagonize your friends and family: Make them watch Carroll's explainer on your tiny smartphone screen when all they want to do is take a nap.

Happy Thanksgiving! Let me know what you'll be watching next week: baker@axios.com.

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Tobacco companies will start running anti-tobacco ads

After a protracted legal battle, tobacco companies will begin running court-ordered ads next week about the health risks of smoking. The campaign of "corrective statements," mandated by a federal judge in 2006, includes a year of TV spots and roughly four months of full-page ads in 50 newspapers.

Why now? These ads have been the subject of litigation for nearly 20 years. They're the product of a lawsuit the Justice Department filed in 1999, which was decided in 2006, then appealed, before the ads themselves were finalized earlier this year. And though the spots will run widely, both TV and newspaper advertising have lost a lot of their reach since this all began.

The details: The "corrective statements" tobacco companies must make cover five topics:

  • The U.S. death toll of cigarettes and the diseases they cause
  • The addictiveness of nicotine
  • The fact that "light" and "low tar" cigarettes are not safer
  • That cigarettes are designed to be addictive
  • The adverse health effects of secondhand smoke

Beginning next week, print ads will run in the Sunday editions of 50 daily newspapers. The television spots must run for 52 weeks, in prime time, on the major networks.


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Vitals

Good morning … This has nothing to do with health care, but if you need a brief respite from the world's myriad horrors, do yourself a favor and turn on the sound while you watch this video of a TV crew trying to set up its live shot for the implosion of the Georgia Dome yesterday. Amazing.

​The ACA is the ultimate survivor

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The Affordable Care Act has survived more assassination attempts than Fidel Castro — and it's still kicking. The Kaiser Family Foundation's Larry Levitt has a piece in the JAMA Forum laying out the argument that the ACA "continues to escape death."

  • Levitt's piece is mostly focused on the Senate's repeal-and-replace efforts and the Trump administration's implementation decisions — cutting off payments for cost-sharing subsidies and dramatically scaling back enrollment outreach.
  • "If these efforts were intended to make the marketplace implode, they may, in fact, be backfiring," Levitt says, citing the weird abundance of plans with $0 monthly premiums and enrollment totals that are beating some experts' expectations.

This is just the latest chapter. The ACA has been a fixture of public debate since 2009, and it has never veered far from death's door. In that time, it has survived:

  • Any number of make-or-break moments during the legislative debate
  • Two potentially disastrous Supreme Court challenges
  • The Republican waves of 2010 and 2014, and the countless repeal votes that followed
  • A slew of self-inflicted wounds, from provisions that proved unworkable to the hot mess that was the HealthCare.gov launch.

Between the lines: The ACA has definitely taken some hits — it's not as strong its drafters might have hoped on the day it passed. But congressional Republicans' failure to repeal it, and President Trump backing into a massive increase in its subsidies, are just the latest signs of the law's surprising durability.

Until Congress repeals the individual mandate, anyway…

​Stopgap CHIP funds top $600 million so far

The federal government has paid out more than $600 million to 14 states and territories to make up for funding shortfalls in the Children's Health Insurance Program, according to the latest data from the Centers for Medicare & Medicaid Services. Federal CHIP funding expired at the end of September, and Congress isn't likely to get the money flowing again until the end of the year.

Why you'll hear about this again: Most states have enough leftover CHIP money to make it through the end of the year, and CMS is able to tap leftover funds from previous years to help states bridge the gap if they need it. But the number of states that need it is growing. CMS had shelled out just shy of $240 million in October. An additional $368 million in November brought the total to nearly $607 million so far.

  • The agency said in a recent memo to states that it had about $3 billion available for stopgap funding, including the payments it has already made.

What's next: Nevada, which isn't included in the totals here, has requested $11 million to keep its CHIP program afloat.

​Medicare takes a hatchet to lab payments

Axios' Bob Herman reported in September that Medicare was ready to slash payments to clinical labs by $670 million next year. Well, Medicare officially is moving ahead with the cuts, despite an outcry from the lab industry.

The details: Medicare basically is keeping the same payment reductions it proposed in September. The rates for 23 of the top 25 lab services by spending — including urine tests — will decrease by 10% next year, Bob reports.

What they're saying: Lab companies will continue to try to get lawmakers to delay the cuts, perhaps through the year-end spending bill. But Spencer Perlman of Veda Partners doesn't think that's a "slam dunk" because "Congress is so distracted by taxes and other issues, and because there is a cost to delaying implementation of [lab cuts] that requires offsets."

Why ambulances are so expensive

Yes, people really do take Uber to the emergency room. This is why: Taking an ambulance can leave you with thousands of dollars in unanticipated medical bills, as Kaiser Health News and the Washington Post explain:

  • Once upon a time, ambulances were part of the local fire department. Now, they're increasingly controlled by private-equity firms, and some charge by the mile.
  • Ambulances are often out of network, even if they take you to an in-network hospital.
  • Ambulance operators often don't join insurers' networks because the two parties don't agree on how much an ambulance ride is worth, according to KHN. If you use one, your insurer will often cover some part of the bill, then the ambulance company will send you a bill for the balance.

The last iron lungs

Gizmodo has a fascinating look at three patients who still use iron lungs — a technology that, admittedly, I did not realize was still around. They're all polio survivors, and all live in fear of their iron lungs breaking or needing repairs that no one will be able to perform quickly enough.

  • According to Gizmodo, Respironics, the company that ended up with responsibility for iron lungs through mergers with other companies, has been trying to switch patients to other devices.
  • The company told patients in 2004 that they could switch to newer products; stick with their iron lungs but acknowledge that repairs might be impossible; or take full ownership of their iron lungs.
  • "The 'yellow submarine' is my necessary, trusted, mechanical friend," one patient said. "I approach it with relief in store at night and thankfully leave it with relief in the morning."

The big picture: One thing the polio survivors had in common, per Gizmodo: "a desire for the next generations to know about them so we'll realize how fortunate we are to have vaccines."

What's on your radar? Let me know: baker@axios.com.

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Vitals

Good morning ... Hope you had a restful weekend. We'll be with you for the first part of this week, before taking a short break for Thanksgiving.

​White House officials aren't insisting on mandate repeal

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The Trump administration isn't necessarily married to the idea of repealing the individual mandate in tax reform, senior officials indicated as they made the rounds on the Sunday shows yesterday.

  • "If we can repeal part of Obamacare as part of a tax bill, and have a tax bill that is still a good tax bill that can pass, that's great," White House budget director Mick Mulvaney said on CNN. "If it becomes an impediment to getting the best tax bill we can, then we're OK with taking it out."
  • Treasury secretary Steve Mnuchin sounded a similar note on "Fox News Sunday," saying: "I think right now our objective is to keep it in. It provides a big tax cut for the middle class. It gets rid of the penalty. But we're going to work with the Senate as we go through this."
  • "The White House is very comfortable with the House bill, because the House bill focuses on our three priorities: simplifying the tax code, reducing the corporate rate to bring jobs back, and focus on middle income families. As you know, it does not have the individual mandate in it," White House legislative affairs director Marc Short said on ABC's "This Week."

Yes, but: It was President Trump's tweets, in part, that helped revive this idea in the first place.

​How well does the mandate work, anyway?

My colleague Caitlin Owens asked a bunch of policy experts that question, and came up with some significantly different answers. Pretty much no one can credibly argue that simply repealing the coverage requirement in the Affordable Care Act, without a replacement, would be good for insurance markets. But that's not the same thing as saying the mandate has worked as well as intended.

So, has it?

  • "The mandate wasn't very strictly enforced, the penalty is pretty low by most people's standards, and it comes a year after dropping coverage, if it comes," Joe Antos of the American Enterprise Institute told Caitlin.
  • On the other hand, the uninsured rate among people who are too wealthy to receive the ACA's premium subsidies fell by around one-third as the ACA took effect. "That trend is very hard to explain unless the mandate has had a significant effect on insurance coverage decisions since these individuals are not eligible for subsidies or Medicaid expansion," Brookings' Matt Fiedler said.

Lawsuit on drug pricing ensnares a third company

Health insurer Anthem and pharmacy benefit manager Express Scripts are embroiled in lawsuits, each accusing the other side of being a bad business partner. And now court documents show Optum, a health care company owned by UnitedHealth Group, is getting dragged into the mix.

The details: My colleague Bob Herman has the rundown on this wild chain of events:

  • Anthem originally sued Express Scripts in March 2016 for $15 billion, alleging Express Scripts was reaping "an obscene profit windfall" from negotiations with drugmakers and was not passing enough savings back to Anthem.
  • Express Scripts countersued and said Anthem was not acting in good faith.
  • After Anthem sued Express Scripts, Anthem reached out to Optum — UnitedHealth's pharmacy benefit manager and a competitor to Express Scripts.
  • Anthem wanted Optum to provide a "pricing proposal" of drug savings in case Anthem decided to end its contract with Express Scripts, according to Optum, which obliged with the request.
  • But Express Scripts said Anthem and Optum created the proposal solely as a way to justify the alleged $15 billion worth of damages.

Why it matters: This is more than just a corporate brouhaha in a far-off courtroom. Three massive health care companies are spending consumers' premium dollars on legal teams to fight over prescription drug rebates — an issue that continues to pinch people's wallets when they pick up their medicine.

Pro-ACA group launches tax ads

Screenshot from Save My Care's digital ad on YouTube

Save My Care, a pro-ACA advocacy group, is launching digital ads today targeting 14 House Republicans who voted for their chamber's tax overhaul.

Between the lines: Liberal activists have been looking for a way to get their base as energized over taxes as it was on health care. Playing up the intersection between the two seems to be the best bet.

Threat level: The ads target Reps. Dave Brat, Mike Coffman, Barbara Comstock, Ryan Costello, Jeff Denham, Will Hurd, David Joyce, John Katko, Bruce Poliquin, Ileana Ros-Lehtinen, Peter Roskam, Ed Royce, David Valadao and Mimi Walters.

​While you were weekending …

  • Asked why she could support repealing the individual mandate now, GOP Sen. Susan Collins said on CNN: "I think we need to distinguish between taking away insurance from people who already have it, which is what the health care bills that we considered earlier this year would have done, versus removing a fine on people who choose not to have insurance."
  • But, Collins said, she doesn't want that provision in the bill, and thinks the Senate should strike it. Or – barring that – pass both Alexander-Murray's ACA stabilization bill and a bill she introduced with Democratic Sen. Bill Nelson to establish high-risk pools.
  • "I hope, next year, that we return to health care," Sen. Tom Cotton said on CBS' "Face the Nation."
  • The health care crisis in Puerto Rico continues to mount, The Hill reports.

What's on your mind? I'd love to hear your feedback, tips and questions: baker@axios.com.

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Poll: Independents say it's Trump's fault if ACA enrollment numbers are bad

The latest tracking poll from the Kaiser Family Foundation finds that answers to blame if enrollment in Affordable Care Act coverage drops this year, like everything in health care/politics/life, comes down to partisanship. The overwhelming majority of Democrats would blame President Trump for weakening the ACA; the overwhelming majority of Republicans would blame Democrats for writing a flawed law.

Reality check: Enrollment and competition began to decline last year, before Trump was even elected. But the steps Trump has taken since then have made those problems substantially worse.

Reproduced from the Nov. 2017 Kaiser Health Tracking Poll; Chart: Axios Visuals

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Vitals

Good morning .... That was a long week, but Congress is now out for its Thanksgiving recess, so we can take a little bit of a breather.

Voters will blame the other guy if ACA enrollment falls

Reproduced from the Nov. 2017 Kaiser Health Tracking Poll; Chart: Axios Visuals

Who would you blame if enrollment in Affordable Care Act coverage drops this year? Probably whoever you blame for everything else.

The latest tracking poll from the Kaiser Family Foundation finds that answers to that question, like everything in health care/politics/life, comes down to partisanship. The overwhelming majority of Democrats would blame President Trump for weakening the ACA; the overwhelming majority of Republicans would blame Democrats for writing a flawed law.

Reality check: Enrollment and competition began to decline last year, before Trump was even elected. But the steps Trump has taken since then have made those problems substantially worse.

Why repealing the individual mandate looks like a tax hike

Data: The Joint Committee on Taxation; Note: Nov. 9 proposal didn't include a repeal of the individual mandate. Chart: Andrew Witherspoon / Axios

Repealing the ACA's individual mandate might be making the GOP tax bill look like it raises taxes on poor people more than it actually would, my colleague Caitlin Owens reports this morning.

The details: The ACA's premium subsidies are administered as tax credits. So, if repealing the individual mandate causes fewer people to get insurance, and therefore fewer people collect those subsidies, they are, technically, no longer receiving a tax credit they receive now.

The assumption that fewer people will receive premium subsidies is reflected in official estimates of the GOP tax bill, and shows up as a greater tax burden on the poor. But conservative economist Douglas Holtz-Eakin argues that's a little misleading. People who get premium subsidies today could still get them even after the mandate was repealed.

  • "This is all negative taxes disappearing. It's not like they have to write a check to the government in any way," he told Caitlin.

New math: S&P Global Ratings says it believes repealing the individual mandate would only save the federal government about $60 billion over the next decade, and would leave 3 to 5 million more Americans uninsured.

  • That's a far cry from the Congressional Budget Office's estimates of $340 billion in savings and 13 million newly uninsured, though CBO itself has said those numbers are likely too high.
  • S&P didn't say how much it expects repealing the mandate would cause premiums to rise. CBO has projected about a 10% increase, borne most heavily by people who don't receive subsidies. Insurers could also leave the market altogether.

​CMS makes changes to Medicare Advantage and Part D

CMS unveiled a new proposal late Thursday that would make some rather large changes to Medicare Advantage and the Part D drug program in 2019. My colleague Bob Herman started sifting through it and found two nuggets worth highlighting:

Part D: Health insurers and pharmacy benefit managers "rarely" pass along to consumers the discounts they extract from drugmakers, CMS said. Now, the agency is asking for help to design a policy that would require Medicare drug plans to pass some of those savings onto consumers when they are actually buying their medicine.

  • Why it matters: This would potentially lower what people pay at the pharmacy counter, but it wouldn't change how drugs are priced in the first place.

Medicare Advantage: By law, Medicare Advantage insurers have to spend at least 85% of premiums on health care. Money they spend trying to combat fraud is not counted toward that 85%. CMS' proposal would change that.

  • Why it matters: It's a big win for insurers. They've wanted this for a long time, and it could boost their profits because an administrative expense could be lumped into what they have to spend on health care services.

​Azar nomination gets rolling

Alex Azar, President Trump's nominee to lead the Health and Human Services Department, was on Capitol Hill yesterday meeting with senators, and the HELP Committee announced it will hold a hearing on his nomination on Nov. 29.

What's next: The Finance Committee will formally approve his nomination, but HELP traditionally gets to hold a hearing, as well, because the two panels share health care jurisdiction. Finance hasn't set a hearing date yet. They're a little busy rewriting the tax code right now.

​Paul Singer targets another health care company

The stock of the physician staffing firm Mednax soared by roughly 12% Thursday after billionaire hedge fund manager Paul Singer disclosed he bought a hostile stake in it, Bob reports. Singer's fund, Elliott Management, said it will "engage in a constructive dialogue" with Mednax executives about "strategic options."

Translation: Mednax could go up for sale and/or make large cuts. Bob reports that it's possible Elliott could push Mednax to turn to a private-equity buyout — nearly every large physician outsourcing company (including TeamHealth and Envision Healthcare) is or used to be owned by private equity.

The big picture: Mednax, which staffs hospitals and clinics with pediatric doctors and anesthesiologists, is now the second health care company in Singer's crosshairs following Athenahealth.

  • What do both companies have in common? Underwhelming finances and founder CEOs who have been around a long time. But it's not clear Mednax's business will improve in the short term, given the low national birth rate and declining patient admissions at hospitals.

​"Gold" plans surge in California

More people are signing up for more generous "gold" plans this year through California's state-run Affordable Care Act exchange. In the first two weeks of enrollment, 12% of new customers have picked "gold" plans — up from 4% in 2016. The number of people buying more middle-of-the-road "silver" plans, meanwhile, has dropped from 56% to 45%.

Why it matters: An earlier snapshot of enrollment through HealthCare.gov showed a similar trend — slightly away from silver plans and slightly toward more generous gold plans. The more generous coverage is now more heavily subsidized, for many consumers, than it has been before.

The shifts in coverage levels this year indicate that some — but not a ton — of consumers are taking advantage of those surprising deals.

Say hello: I'd love to know what health care stories you're following (or wish you were following): baker@axios.com.

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ACA enrollment isn't as strong as you might think

ACA enrollment is trailing last year's pace. Photo: AP/file

You've probably seen a lot of headlines saying Affordable Care Act enrollment is going well. But after the most recent update, released yesterday, we should probably all recalibrate our math. And when we do, enrollment won't look so hot.

What they're saying:

  • We're two weeks into the ACA's fifth open enrollment period, and 1.5 million people have picked plans through HealthCare.gov.
  • Two weeks into the last open enrollment period, just over 1 million people had picked plans through HealthCare.gov.
  • That's the comparison folks have been making, and it does make enrollment seem stronger than last year.

Here's why the math is incomplete: Last year's open enrollment season was three months long. This one is half that, at six weeks. So, we're already a third of the way through this enrollment period.

  • A third of the way through last year's enrollment season, more than 2.1 million people had signed up for coverage.
  • The 1.5 million who have signed up so far this year doesn't look quite as good when you compare it that way — but that's the more accurate comparison, Avalere's Caroline Pearson says.
  • By that measure, enrollment definitely isn't moving faster than last year — in fact, it's about 25% weaker.
  • Twice as many people need to sign up each week to end up with the same totals when all is said and done. And that's not happening.

Yes, but: As Pearson notes, it's hard to make a direct comparison because there tends to be a surge at the end of the enrollment period. So it's hard to map out a clean trend line.

Still, given that the pace of sign-ups is already slipping, this year's last-minute surge would have to be enormous to close the gap. And it's hard to have an enormous surge without any official marketing or outreach encouraging people to sign up.

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Vitals

Good morning ... And welcome to day four of the Senate's tax/health care markup.

​ACA enrollment isn't as strong as you might think

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You've probably seen a lot of headlines saying Affordable Care Act enrollment is going well. (In fact, I've written some of them.) But after yesterday's update, we should probably all recalibrate our math. And when we do, enrollment won't look so hot.

  • We're two weeks into the ACA's fifth open enrollment period, and 1.5 million people have picked plans through HealthCare.gov.
  • Two weeks into the last open enrollment period, just over 1 million people had picked plans through HealthCare.gov.
  • That's the comparison folks have been making, and it does make enrollment seem stronger than last year.

Here's why that math is incomplete: Last year's open enrollment season was three months long. This one is half that, at six weeks. So, we're already a third of the way through this enrollment period.

  • A third of the way through last year's enrollment season, more than 2.1 million people had signed up for coverage.
  • The 1.5 million who have signed up so far this year doesn't look quite as good when you compare it that way — but that's the more accurate comparison, Avalere's Caroline Pearson says.
  • By that measure, enrollment definitely isn't moving faster than last year — in fact, it's about 25% weaker.
  • Twice as many people need to sign up each week to end up with the same totals when all is said and done. And that's not happening.

Yes, but: As Pearson notes, it's hard to make a direct comparison because there tends to be a surge at the end of the enrollment period. So it's hard to map out a clean trend line.

Still, given that the pace of sign-ups is already slipping, this year's last-minute surge would have to be enormous to close the gap. And it's hard to have an enormous surge without any official marketing or outreach encouraging people to sign up.

​Taxes are going great, ACA repeal is going great, it's all going great

Republicans didn't argue among themselves too much when they decided to try to repeal the ACA's individual mandate through their tax overhaul. But that decision is nevertheless causing some issues for the broader tax effort.

  • Sen. Susan Collins has said plainly she believes combining the two was a mistake. At a caucus lunch yesterday, she presented her GOP colleagues with an analysis that said repealing the mandate would counteract tax cuts for middle-class families.
  • "My concern is what it might do to insurance premiums ... I've got a little bit of homework to do in understanding where that is, because I think that's key to this," Sen. Lisa Murkowski told my colleague Caitlin Owens.
  • Sen. Ron Johnson became the first Republican to say he opposes the current bill (not because of the individual mandate). Reminder: If no Democrats get on board, three Republican defections would be enough to sink the bill.
  • Bringing the ACA back into the mix has made it harder to pad that margin with even vulnerable moderate Democrats who might have otherwise been inclined to reach a deal on tax cuts.

Alexander-Murray probably won't be enough. Republican senators who support the tax overhaul all offered a similar refrain when I spoke to them yesterday: Whatever disruption is caused by repealing the individual mandate will be addressed by passing the ACA stabilization bill from Sens. Lamar Alexander and Patty Murray.

  • "I think you have to do both. If you don't do both, people are going to get whacked really hard," Sen. Lindsey Graham said.
  • Quick take: This is giving Alexander-Murray too much credit. Yes, it would stabilize insurance markets relative to where they are now. But it would do so by restoring the status quo that existed before last month. And before last month, repealing the individual mandate was still seen as an existential threat to the health of the ACA's exchanges.

​Goldman Sachs sounds alarm on Community Health Systems

Goldman Sachs sold more than half of its Community Health Systems stock in the last quarter, and the banking giant issued a dire report this week that basically suggested investors jump ship, Axios' Bob Herman reports.

What Goldman said: "We believe short-term fixes…may not help [CHS] solve longer-term problems." CHS is still saddled with $14 billion of debt, which Goldman thinks could lead to accounting audits or bankruptcy by next year. Goldman suggested CHS debt holders sell their 2020 bonds because more hospital sales will not "yield enough proceeds" to cover CHS' debt that is coming due.

Go deeper: Read more about the hospital chain's struggles here and here.

​The human cost of narrow networks

The Washington Post has a moving story this morning about a Northern Virginia family whose four-year-old daughter receives spinal tap and chemo treatments at Inova Fairfax Hospital.

Yes, but: Their old insurance carrier, Anthem, decided not to sell individual policies next year in their part of the state. Only Cigna is participating there — and Cigna's provider network doesn't include Inova Fairfax Hospital. It's the only local hospital with a dedicated pediatric cancer unit, according to the Post.

Reality check: The policy and political worlds often talk about "bare counties" and "market stability" in abstract terms. This is why they matter.

What we're watching today: The same handful of senators we were watching all summer, because nothing ever changes.

Send me your tips. Or whatever else you've got. baker@axios.com.

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Nearly 1.5 million have signed up for ACA coverage in 2 weeks

ACA enrollment is strong. Photo: Alex Brandon/AP

Nearly 1.5 million people have signed up for coverage through HealthCare.gov in the first two weeks of this year's open enrollment period — up from just over 1 million at the same point in the last enrollment window. Those results are stronger than many experts anticipated, in light of the Trump administration's cuts to enrollment outreach.

Between the lines: Most of those consumers — about 77% — are renewing their coverage, not signing up for new plans.

That's about the same proportion as last year, but new sign-ups are where Trump's outreach cuts would make the biggest difference. So it's too early to tell how much Trump's actions are affecting enrollment.

Standard disclaimers apply:

  • These figures only include the 39 states that use HealthCare.gov as their enrollment platform, so they're missing a couple of state-run marketplaces — including some big ones, like California.
  • Some people who sign up for coverage do not go on to pay their premiums, so the number of people actually covered will be slightly lower than the number of people signing up for plans. This is normal and happens every year.