Over the next three months, insurers who sell plans on Healthcare.gov and a dozen state-run marketplaces will be finalizing their rates and plan offerings for 2020. They’ve weathered plenty of uncertainty before – most notably when Republicans tried to repeal the ACA two years ago – but Trump’s renewed attacks on the ACA this week feed into what insurers hate the most: Uncertainty about who will be buying their plans and what those plans will need to cover.

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“I think you kind of settle in for a roller-coaster with this president,” said Joel Ario, who directed the insurance marketplaces in the Obama administration. “Each time you think he’s going to support it, he undercuts it. It’s the back and forth that makes the insurers little less aggressive.”

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Matt Eyles, president of the health insurers trade group America’s Health Insurance Plans, called the administration’s position “misguided and wrong.” “This harmful position puts coverage at risk for more than 100 million Americans that rely on it,” Eyles said in a statement.

It should be the golden era for the marketplaces, which have showed signs of stabilizing in recent years after an initially tough rollout under the Obama administration. Yet they’re not exactly flourishing, as they attract fewer new customers and signups on Healthcare.gov creep downward.

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There are a few bright spots, most notably that the share of enrollees under age 35 – who are healthier and thus crucial to the marketplace functioning as intended – has remained steady at around 35 percent. But consider these data points.

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In 2017 , 31 percent of the enrollees were new. But the share of new enrollees fell to 27 percent last year and for this year , just 24 percent are buying plans for the first time.

Overall enrollment has declined from 12.6 million people in 2016 to 11.4 million people this year.

There are some plausible reasons for the decline, such as an historically low unemployment rate and Virginia’s recent Medicaid expansion. But the declines also come as the country’s uninsured rate has started inching back upward – precisely the opposite effect intended by the writers of the ACA.

“You’re not getting that new blood into the risk pools,” Ario told me. “That’s not a good sign.”

Things look brighter in the states running their own marketplaces. Enrollment in state-based exchanges actually increased by 1 percent this year, even as enrollments on Healthcare.gov declined by 4 percent. New Jersey Gov. Phil Murphy announced last week his state will revert to its own marketplace as a way to protect residents from federal efforts to undermine the ACA.

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But the uneven enrollment figures could be seen as evidence that the Trump administration, while not destroying the marketplaces, could be doing more to promote them. And the president isn’t helping the situation.

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Trump tweeted this yesterday:

Trump’s quick pivots on how he talks about Obamacare are indeed head-spinning. He spent the early months of his presidency blasting the ACA. But after congressional Republicans tried and failed to repeal the law, the president focused on ways his administration could change it on the margins, promising over and over again to offer Americans “terrific” coverage at a lower cost.

Trump’s top health officials have largely adopted that line – that they’re making the best of a bad law. Seema Verma, head of the Centers for Medicare and Medicaid Services, often points to several types of newly-expanded leaner, cheaper health plans as evidence that her agency is expanding options for Americans and giving them greater flexibility in how they get covered.

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Yet Trump reverted to his old attacks on the ACA this week, turning up pressure on Republicans to try once again to repeal it, just hours after CMS released final 2019 enrollment totals on Monday. There was a clear disconnect between his rhetoric and that of Verma, who stressed that the signup season went smoothly.

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“Another year of stable enrollment through the exchanges directly reflects the strong work CMS staff put into ensuring that exchange consumers experience a seamless enrollment process free from unnecessary hurdles and IT glitches,” Verma said in a release.

Charles Gaba, who runs a website devoted to ACA analysis, reacted this way, writing: “You have the Trump Administration talking out of both sides of their mouths with a split tongue: ‘The ACA sucks and is horrible and needs to be repealed! Also, the ACA is awesome and doing great!’”

Trying again for Obamacare repeal is the last thing most Capitol Hill Republicans want to do. Top Senate Republican Mitch McConnell signaled to Trump he wants no part of it, telling Politico he looks forward "to seeing what the president is proposing and what he can work out with the speaker."

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“I am focusing on stopping the ‘Democrats’ Medicare for none’ scheme," McConnell added.

Yet the president is pouring on the pressure, yesterday naming Sens. John Barrasso (R-Wyo.), Bill Cassidy (R-La.) and Rick Scott (R-Fla.) as the point people on Capitol Hill crafting new health-care legislation, my colleague Colby Itkowitz reports.

“They are going to come up with something really spectacular,” Trump told reporters before heading to a political rally in Michigan. Trump also claimed that Republicans “will take care of preexisting conditions better than they’re taken care of now.”

New York Times's Maggie Haberman:

Vox's Aaron Rupar:

CNN's Manu Raju:

Politico's Dan Diamond:

CNBC's Christina Wilkie:

AHH, OOF and OUCH

AHH: In the administration's latest healthcare-related blow this week, a federal judge rejected its expansion of association health plans, calling them an obvious “end-run around the ACA.”

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In a 43-page ruling, U .S. District Judge John D. Bates of the District of Columbia blocked the rules overseeing the alternative plans, which allow small businesses to join forces to offer less expensive plans that don’t comply with all the ACA requirements on individual market plans, as our colleague Timothy Bella writes.

“Indeed, as the president directed, and the secretary of labor confirmed, the final rule was designed to expand access to AHPs to avoid the most stringent requirements of the ACA,” wrote Bates, an appointee of President George W. Bush.

Yet the association health plans are subject to the same requirements as the health plans provided to employers of large companies, and there's some initial evidence that Democrats' dire predictions of their effects aren't playing out. It's likely the Department of Labor, which put forward the new regulations, will appeal the decision. But if the ruling went into effect immediately, thousands of people could lose their health plans.

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"This includes self-employed farmers and employees of small businesses whose employers cannot afford health coverage in the existing small group market," insurance analyst and legal expert Chris Condeluci told me.

More context from Larry Levitt, senior vice president of the Kaiser Family Foundation

And Andy Slavitt, who headed CMS under President Obama

OOF: Arkansas Gov. Asa Hutchinson (R) said he has called on the Trump administration to appeal a federal judge’s decision to block rules in the state that require low-income people on Medicaid to work in order to quality for benefits, as our colleague Amy Goldstein writes.

Hutchinson called the ruling handed down by U.S. District Judge James Boasberg a “great disruption of the status quo” and said “no one will lose coverage from this day forward.” He vowed to push to have the state, which was the first in the nation to impose work rules, to continue the program.

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HHS spokeswoman Caitlin Oakley told The Post the Arkansas governor had spoken with department officials but said “no appeal decisions have been made yet.”

In a pair of opinions on Wednesday, Boasberg “invalidated the federal approvals and said federal health officials would need to reconsider the Arkansas and Kentucky plans, for a second and third time, respectively,” Amy writes.

“At a news conference in the state capitol in Little Rock, Hutchinson said that to comply with the judge’s ruling, Arkansas had immediately closed the online portal for people to report their work hours — and would not remove anyone else from the program, though it had been preparing to announce a new round of cut-offs within a few weeks,” she adds. “But he emphasized, ‘I remain fully committed to a work requirement, and we are in this for the long haul because we believe it is the right policy.’”

OUCH: The state of New York announced a sweeping lawsuit targeting the Purdue Pharma-owning Sackler family as well as four drug distributors. New York joins a growing list of both state and local governments seeking legal action against Purdue, the maker of the opioid OxyContin, for its role in the U.S. opioid crisis.

“The lawsuit, filed by the state attorney general Letitia James, is one of the very few in a wave of opioid litigation across the country that name the Sacklers,” the New York Times’s Roni Caryn Rabin reports. “It targets eight family members: Richard, Jonathan, Mortimer, Kathe, David, Beverly and Theresa Sackler, as well as Ilene Sackler Lefcourt.”

The suit also comes as a growing number of cultural institutions in the U.S. and around the world have said they would stop accepting donations from the family that has donated to museums for decades, as our colleague Peggy McGlone has reported. This week, after facing rejection from three major museums, the Sackler family’s philanthropic trust said it would halt donations.

A family spokesman called the allegations “a misguided attempt to place blame where it does not belong for a complex public health crisis. We strongly deny these allegations, which are inconsistent with the factual record, and will vigorously defend against them.”

MEDICAL MISSIVES

— In a medical milestone, surgeons at Johns Hopkins Hospital transplanted a kidney from a living HIV-positive donor to an HIV-positive recipient. For the first time in a year, the recipient no longer needs kidney dialysis.

The breakthrough transplant brings hope to the medical community that it could help change HIV perceptions and lead to an expanded pool of available organs, our Post colleague Lenny Bernstein reports.

“Society perceives me and people like me as people who bring death,” the 35-year-old donor Nina Martinez told Lenny in an interview before the operation. “And I can’t figure out any better way to show that people like me can bring life.”

There are more than 113,000 people on a waitlist to receive organ transplants and most of them are waiting for kidneys.

“Surgeons have transplanted 116 organs from deceased HIV-positive donors to recipients with HIV since 2016, when a new law allowing that surgery took effect,” our colleague writes. “Among people without HIV, more than 152,000 kidneys from living donors have been transplanted over the past 30 years, and a few hundred livers from live donors are implanted each year.”

“People with HIV today can’t donate blood. But now they’re able to donate a kidney,” said Dorry Segev, a Johns Hopkins University School of Medicine professor of surgery, who led the research team and removed Martinez’s left kidney. “They have a disease that 30 years ago was a death sentence. Today they’re so healthy they can give someone else life.”

AGENCY ALERT

— During a hearing before a Senate appropriations subcommittee, the outgoing Food and Drug Administration commissioner Scott Gottlieb said he wants drug manufacturers to develop pain treatments that could replace older opioids.

“Given the public health crisis we face, and that American families are still being destroyed by the opioids epidemic, I believe that the FDA should treat opioids, as a class, differently from other drugs,” Gottlieb said.

“We need to be willing to embrace actions in the setting of opioids that we must accept would be unsuitable to any other drug category,” he added. He suggested the development of abuse-deterrent properties in new drugs to make them better than traditional opioids.

The commissioner’s April 5 departure date may make this particular goal a distant one, Bloomberg’s Anna Edney reports

“Even if the FDA advances the plans, they would take a long time to become reality,” Anna writes. “Gottlieb encouraged Congress to grant opioids that are proven safer a period of additional time to sell their treatment free from competition to prod development of such drugs.

STATE SCAN

— Officials in Washington, D.C. are preparing to markedly increase the supply of the opioid overdose antidote naloxone in the city with the purchase of 66,000 naloxone kits and plans to buy 10,000 more in the coming months.

They hope to distribute the 76,000 kits by the end of the fiscal year in September, our Post colleague Peter Jamison reports. Doing so would be a significant expansion of efforts to provide naloxone in overdose-heavy neighborhoods throughout a city that has had one of the highest rates of drug deaths in the nation. By comparison, just 2,396 naloxone kits were passed out in the city during the last nine months of 2017, when overdose deaths hit a peak in D.C.

After Peter wrote in December about public health officials' failed response to the crisis, federal officials launched an audit of the city’s opioid grant spending and Mayor Muriel E. Bowser (D). announced she would buy 50,000 naloxone kits, though details weren’t announced about any distribution plans.

— And here are a few more good reads:

TRUMP TEMPERATURE

INDUSTRY RX

REPRODUCTIVE WARS

DAYBOOK

Coming Up

The Senate Health, Education, Labor and Pensions Committee holds a hearing on addressing campus sexual assault on April 2.

The House Energy and Commerce Subcommitee on Oversight and Investigations holds a hearing on rising insulin costs on April 2.

SUGAR RUSH