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Good morning ... Situational awareness: The Wall Street Journal reported yesterday that HHS Secretary Alex Azar is a contender to eventually replace Jeff Sessions as attorney general. But Azar has "no interest" in making that move, according to a person close to him.

1 big thing: How childbirth explains the health care system

Axios Visuals

The American health care system is hard to use. It's expensive. It's disjointed. It's hard to get straight answers about your care, and about your bills.

  • And while a lot of the focus on that problem lately has stemmed from emergency care, it's also true for the routine procedures that happen every day.

Axios' awesome video team dives into these frustrations through the example of childbirth — the single most common reason people are hospitalized in the U.S.

  • The average sticker price for childbirth is more than $32,000. After insurance discounts, it's more than $10,000 — still a lot more than many other industrialized countries.
  • And, like the health care system overall, we're paying more for worse results. The U.S. tops other similar countries in infant and maternal deaths.

It's not just childbirth. We wrote back in August about how hard it was for a hospital system to get to the bottom of its own prices for knee replacements — another incredibly common procedure.

  • The hospital, Gundersen Health System, eventually figured out that its list price of more than $50,000 was about five times more than the costs it actually incurred to do a knee replacement, “for reasons that weren’t always clear.”
  • Then there was the transgender woman who was charged different amounts at different times, ranging from $2,000 to $75,000, for gender confirmation surgery. Her bills were variable because the procedure was rare, so neither the hospital nor insurer knew how much to charge.

The bottom line: It doesn't matter if it's a common procedure or a rare one, a frenzied ER visit or a routine process done every day. The one constant is that it's almost impossible to know in advance what your bill will be — except that it's safe to assume it'll be high.

Watch the video.

2. Narrow networks aren’t actually that common
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Adapted from Kaiser Family Foundation; Note: The "<49 workers" category includes firms that have 3 to 49 workers; Chart: Axios Visuals

For all the time we spend talking about narrow networks in Affordable Care Act plans, they’re not really a thing outside the individual market, the Kaiser Family Foundation’s Drew Altman writes in today’s column. In the group market, where 152 million Americans get their coverage, they’re quite rare.

By the numbers:

  • Only 7% of employers that offer health benefits use narrow network plans — and only 2% kicked a hospital or health system out of the network to cut costs.
  • Compare that to the ACA exchange market, where restrictive network plans made up 73% of the market in 2018, per Avalere.
  • The big reason larger employers have not moved to narrow networks in significant numbers: It’s difficult for them to satisfy a diverse workforce with a limited network of doctors and hospitals.

The bottom line: Narrow networks still deserve attention — as long as it’s understood that they’re not a problem that most people have.

Read the column.

3. Hospitals in Hurricane Michael's wake

Devastation in Florida Panhandle. Photo: Joe Raedle/Getty Images

Hospitals and nursing homes in Florida and Georgia have been ravaged by Hurricane Michael, and some are now evacuating their patients, the New York Times reports.

Details, via NYT:

  • 4 hospitals and 11 nursing homes in Florida are closed. In Georgia, 35 hospitals or nursing homes are without power and using generators.
  • Many hospitals chose to shelter in place rather than preemptively move patients before the storm, but at least for one such facility, "soon it became evident that the hospital buildings themselves were not safe."
  • Making matters worse, 911 service is down in some areas; storms send new patients into ERs while hospitals are struggling to manage the patients they already have; and the scramble makes it harder to promptly answer family members' questions about hospitalized relatives.

"Dr. Lynn Seto was walking outside the hospital in her scrubs Thursday, and broke down in tears when asked about the state of the place," the Times reports. "'It’s devastating,' she said. 'We’re doing everything we can.'"

4. Dems in key races embrace "Medicare for All"

Illustration: Rebecca Zisser/Axios

There are 44 House seats held by Republicans but rated by the Cook Political Report as toss-ups or at least somewhat likely to flip to Democratic control in the midterms. My colleague Caitlin Owens went down the list to see how Democrats in those make-or-break districts are talking about "Medicare for All."

They're for it, or at least open to it, she reports.

Between the lines: There's still no clear agreement within the party about what "Medicare for All" means, so there's a lot of variation in how Democrats talk about it. But most of them talk about it positively.

  • Some explicitly say they support "Medicare for All." Others say they support a pathway to Medicare for All, a Medicare option for all, or a Medicare buy-in. Some simply say they support a "public option."
  • A handful of candidates have specifically said they do not support Sen. Bernie Sanders' "Medicare for All" bill, or any single-payer health care system. But most haven't drawn a hard line.

Go deeper.

5. CMS takes a victory lap on ACA premiums
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Data: CMS; Chart: Harry Stevens/Axios

“Affordable Care Act premiums are going down” is a headline no one's ever seen before, so it’s no surprise the Trump administration is trying to take credit for the change.

Driving the news: The administration announced yesterday that premiums for a "benchmark" plan will drop by an average of 1.5% next year in the federally run ACA marketplaces — the first time that’s happened since it launched.

  • The fine print: This is the average premium for a 27-year-old single nonsmoker. Actual premiums will vary based on your age and where you live.

What they're saying: Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said premiums are lower because the Trump administration has approved several state reinsurance programs — and opened the door to cheaper options like short-term plans and association health plans.

Reality check: Reinsurance has almost certainly held premiums down. But short-term plans, like the nullification of the individual mandate, aren't contributing to lower ACA premiums. State regulators have said their premiums would be lower without those policy changes.

  • Insurers also priced a lot of those expensive policies into this year's premium hikes, which averaged out to a whopping 37%. Having those increases in the bank is part of the reason premiums can go down now.
6. More kids are going without vaccines

Photo: Courtney Perry/The Washington Post via Getty Images

A growing number of children haven't received any vaccinations by the time they turn 2, the Washington Post reports.

By the numbers: The number of unvaccinated children is still small, but public health experts are still concerned by the fact that it's growing.

  • The percentage of unvaccinated children has quadrupled over the past 17 years, according to the Post. There are now an estimated 100,000 children younger than 2 who have never received any vaccinations.