Axios Vitals

Hey, remember back around 2010, when critics warned that the Affordable Care Act would spell the end of private insurance? The reality has been very much the opposite: Health care stocks have been on a tear since the ACA’s passage, my colleague Bob Herman reports.

The big picture: The S&P 500 health care index, which tracks the stocks of 63 major companies, has soared by 192% since the ACA became law. By comparison, the S&P 500 and Dow Jones increased by 141% and 138%, respectively, according to FactSet.

Winners: Health insurers. The stock price of Centene, a major Medicaid and ACA marketplace insurer, has multiplied by 12 times or 1,100%. Shares of UnitedHealth Group have jumped by more than 700%.

• More winners: Hospitals have faced sizable Medicare payment cuts from the ACA, but those reductions were largely offset by the law's Medicaid expansion and other forms of new coverage.
• Also winners: The ACA did not meaningfully touch the pharmaceutical industry's business or patent practices, and those companies have reaped record profits.
• So many winners! Medical device companies hate the ACA's device tax, but Congress has already deferred that fee a few times. The device tax hasn't hampered earnings and hasn't led to widespread job losses.

Go deeper.

A serious illness will often wipe out your life savings even if you have health insurance. That's the sobering conclusion from a new national survey of people who have had to rely on the health care system intensively.

By the numbers, via the New York Times, which helped analyze the survey:

• 36% of seriously ill patients with insurance said they had used up all or most of their savings to pay for their care; 29% had a bill referred to a collection agency; and 21% said they had been unable to pay for basic necessities.
• Among seriously ill patients without insurance, 57% said they had spent through their savings, and 51% reported being unable to afford things like food and housing.

“You’re kind of at a disadvantage as a consumer going against these big complicated systems that don’t always have your best interest at heart,” University of Michigan professor Sarah Miller told NYT. “And I think that’s why there’s so much financial burden, even among people with private insurance.”

Making matters worse, 53% said their illness had kept them from working, at least temporarily. That may not be a direct health care cost — it's not money that goes into the health care system — but it's a big part of the toll that the system takes on the people who need it.

Texas' lawsuit over the ACA could roll back protections for pre-existing conditions even among people who don't get their coverage through those marketplaces, my colleague Caitlin Owens notes this morning.

How it works: Before the ACA, the federal privacy law known as HIPAA prevented employer-based insurance plans from denying employees coverage because of a pre-existing conditions or from charging those employees a higher premium.

• The ACA extended similar protections to people who buy insurance on their own.

But there's a chance some of the HIPAA protections could go away if Texas' lawsuit succeeds, because of the way the ACA incorporated them, Kaiser Health News reported.

• "The ACA certainly changed up the HIPAA provisions and it is not clear they would just reemerge," said Gary Claxton of the Kaiser Family Foundation.

Get ready for a busy fall season of regulations from the federal government. The White House yesterday released its fall regulatory agenda, teasing several significant health care rules.

Bob flags some highlights:

• A potentially major rule on Medicaid managed care that will “relieve regulatory burdens” and “promote transparency, flexibility, and innovation in the delivery of care,” according to an abstract of the regulation.
• Policies that could open the door for state Medicaid programs to tinker more with charging premiums and copays to low-income enrollees.
• A long-awaited rule targeting dialysis chains and charities that help patients get private insurance over lower-paying Medicare or Medicaid. The Obama administration originally issued a regulation on this issue in 2016, but a court struck it down because it didn’t go through a more formal process.
• A proposal that appears to allow more flexibility for grandfathered health plans under the ACA, and to expand the use of health reimbursement accounts (which we previewed back in February).
• More “policy and technical changes” to Medicare Advantage and Medicare prescription drug plans, building on last year’s efforts.
• A vague plan to “require drug pricing transparency” in Medicare and Medicaid, according to an outline of the rule.

The big picture: The Trump administration is stepping on the gas to implement conservative health care policies from the executive branch.

A new report released by Sen. Claire McCaskill reveals how Insys, a pharmaceutical company, aggressively pushed its fentanyl product, Subsys, to increase the number and strength of prescriptions written for it.

Details, via Caitlin:

• The model Insys used following the drug's approval in 2012 is strikingly similar to the one Purdue Pharma used, beginning in the 1990s, to market OxyContin.
• It featured speaker programs in which doctors, paid by Insys, spoke with colleagues about the drug.
• Sales representatives had large financial incentives to sell as much of the drug as possible via prescriptions, and higher dosages of the drug led to higher bonuses.

Between the lines: One illuminating email included in the report summarizes what appears to have been the mindset: “What drives us all? COMPENSATION," the national director of sales wrote to district sales managers in 2013.

• The strategy was effective: Subsys prescribers tended to write more scripts and generate more revenue than other fentanyl prescribers.

Why it matters: While the new Insys CEO has called the company's previous actions "unacceptable," there's clearly been a pattern when it comes to marketing opioids.

• "Just as Insys adopted and expanded methods Purdue pioneered, the next pharmaceutical company moving rapidly to establish market share in a crowded field may look to Insys as a model," the report says.