Majority Leader Mitch McConnell wants to hold a vote on a bill that would repeal major parts of Obamacare and give Republicans two years to pass a replacement. A new CBO report finds that repealing Obamacare without a replacement would result in 32 million more Americans losing health insurance over a decade — far deeper coverage losses than any of the health plans Republicans have proposed. Further, 75 percent of Americans would live in areas without any insurers selling coverage in the individual market by 2026.
The latest GOP health plan would strike:
Individual mandate
Insurance subsidies
Medicaid expansion
Planned Parenthood funding
The bill would effectively kill Obamacare’s individual and employer coverage mandates, strike health insurance subsidies, roll back Medicaid expansion and defund Planned Parenthood.
Repealing Obamacare would more than double the number of Americans without health insurance.
Under Obamacare, 10 percentof Americans would lack health insurance.
But if Republicans repeal Obamacare, the number could grow to 21 percent by 2026.
The uninsured rate plunged under the ACA, but would now skyrocket
ACARepeal ACA0510152025%1997201020172026Before the ACAACA passed10%21%
In the first year alone, nearly 17 million more people would no longer have insurance — or (16 percent) of Americans. That includes 10 million fewer buying plans on the individual market, 4 million fewer people covered through Medicaid, and 2 million fewer with job-based coverage.
But once Medicaid expansion and subsidies were repealed (roughly two years after enactment), the number of uninsured Americans would increase by 27 million in 2020. By 2026, about 59 million people or 21 percent of Americans would be uninsured.
California’s Obamacare exchange scrubbed its annual rate announcement this week, the latest sign of how the ongoing political drama over the Affordable Care Act is roiling insurance markets nationwide.
The exchange, Covered California, might not wrap up negotiations with insurers and announce 2018 premiums for its 1.4 million customers until mid-August — about a month later than usual. Similar scenarios are playing out across the country as state officials and insurers demand clarity on health care rules and funding, with deadlines fast approaching for the start of open enrollment this fall.
“It’s insane,” said John Baackes, CEO of L.A. Care Health Plan, which has about 26,000 customers on the California exchange. “Here we are in the middle of July and we don’t even know what rules we will be operating under for open enrollment. It is not how you want to run a business.”
Consumers could face sharply higher premiums and fewer choices if more health insurers leave the insurance marketplaces due to lingering uncertainty. State and industry officials around the United States are concerned that the federal government could stop funding so-called cost-sharing subsidies that reduce out-of-pocket costs for low-income consumers. And they worry the Trump administration won’t enforce the individual mandate that requires people to purchase health coverage or pay a penalty.
Amid those concerns, there was a sense of relief Tuesday among many exchange officials and insurers after the U.S. Senate’s latest attempt to replace the Affordable Care Act failed.
Two large insurer trade groups bluntly warned last week that parts of the Senate plan were “unworkable” and could plunge the market into chaos. In a letter to the Senate, America’s Health Insurance Plans and the Blue Cross Blue Shield Association particularly objected to an amendment by Sen. Ted Cruz (R-Texas) that would have allowed insurers to sell bare-bones health plans to people who wanted cheaper premiums. That provision, the insurers said, would split the market between the healthy and the sick, driving up costs for people with pre-existing conditions.
However, the Republicans’ failure to pass that ACA replacement plan did not resolve questions swirling around the current health law.
Tuesday, President Donald Trump expressed disappointment at the outcome in the Senate, telling reporters, “We’ll let Obamacare fail and then the Democrats are going to come to us and they’re going to say, ‘How do we fix it?’”
Some Senate Republicans struck a more conciliatory tone, suggesting that lawmakers should work on a bipartisan measure that would help stabilize the individual insurance markets.
Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pensions, said he plans to hold hearings in the coming weeks on ways to shore up the individual insurance market. Lawmakers may look at creating a new stabilization fund that helps compensate insurers for higher-cost patients. Such a fund would be similar to one that existed during the first three years of the ACA exchanges.
Some insurance industry executives welcomed the talk of bipartisanship, but they said action must be taken quickly to resolve key issues affecting consumers.
“We are running out of time and we need a resolution on what we are charging for 2018,” said Gary Cohen, vice president of public affairs at Blue Shield of California in San Francisco, the largest Covered California insurer by enrollment.
Cohen, who helped launch the exchanges in 2014 as an official in the Obama administration, noted that the Republican bills in both the House and Senate included money for reinsurance that can help lower premiums industry wide. Those provisions are among the “immediate steps Congress and the Trump administration need to take in order for markets to provide coverage that is affordable.”
A federal reinsurance program helps compensate insurers for the high costs incurred by the sickest patients. That, in turn, allows health plans to keep their overall premiums lower and attract healthier customers into the insurance pool.
Lawmakers could also appropriate federal funds for the cost-sharing subsidies, which have a price tag of about $7 billion a year. Those payments, made directly to insurers, help reduce deductibles and other out-of-pocket costs for policyholders who earn up to 250 percent of the federal poverty level. This year, that’s up to about $29,000 for an individual or around $61,000 for a family of four. More than half of the people enrolled on exchanges nationwide qualify for this financial assistance.
Without it, many consumers would face annual deductibles of $2,000 or more when visiting the doctor or undergoing medical tests. That would make people far less likely to sign up with participating insurers.
Conservatives generally oppose the subsidies, calling them a bailout of the insurance industry and arguing that the Obama administration didn’t have the authority to pay them. Trump has repeatedly threatened to cut off those cost-sharing subsidies as well.
With their future up in the air, some states, including California and Pennsylvania, allowed insurers to submit two sets of proposed premiums. One filing reflects continued federal funding of those subsidies, and a separate one assumes they are eliminated and their cost is included in health plan premiums.
In Pennsylvania, premiums next year without the subsidies would increase by an average of 20 percent, compared with 9 percent if they remained intact.
Pennsylvania Insurance Commissioner Teresa Miller said the market in her state would be in good shape without the uncertainty over federal policy. “The only thing right now keeping everyone on edge is what’s going to happen in Washington, D.C.,” Miller said. “If things calm down in D.C. and if we don’t see further changes, then Pennsylvania’s market really is stabilizing.”
On Tuesday, Covered California said the two different rate filings its health plans submitted will be released Aug. 1. The exchange may announce that same day what the final premiums are, or it could postpone the decision for several more weeks if Congress has begun to pursue fixes to the ACA.
“This decision is based on the ongoing federal uncertainty around the repeal and replacement attempts of the Affordable Care Act and the dramatic potential impacts such uncertainty has on the rates and on California consumers,” the exchange said in a statement.
A recent analysis commissioned by Covered California estimated that premiums for silver-tier plans would jump by 16.6 percent if the federal government stopped paying for the cost-sharing subsidies. That would be in addition to normal increases meant to cover rising medical costs. An exchange spokeswoman declined to comment further Tuesday, citing the ongoing developments in Washington.
In the Florida exchange market, health insurers have sought an average rate increase of nearly 18 percent. But Florida Blue, the state’s largest health insurer, said those rates would go even higher if the cost-sharing reduction payments disappeared.
Robert Laszewski, an industry consultant in Virginia and a frequent ACA critic, said the exchange markets aren’t imploding, despite what the Trump administration has often said. But their premiums will continue to rise unless more young and healthy people are persuaded to buy coverage, he said.
“I think most insurance companies will at least break even, or even make a profit, in 2018,” Laszewski said. “Coverage will be ‘stable,’ but it will stabilize at a horrific premium rate level.”
Sen. John McCain (R-Ariz.) has been diagnosed with brain cancer, the Mayo Clinic Hospital in Phoenix said Wednesday.
The tumor was discovered after the senior Arizona senator underwent a minor procedure last week to remove a blood clot from above his left eye.
“Subsequent tissue pathology revealed that a primary brain tumor known as a glioblastoma was associated with the blood clot,” the hospital said in a statement.
“The Senator and his family are reviewing further treatment options with his Mayo Clinic care team. Treatment options may include a combination of chemotherapy and radiation.”
McCain’s latest diagnosis is not his first battle with cancer. He underwent a procedure in 2000 to remove a type of skin cancer called melanoma from the left side of his face.
McCain, 80, also had a melanoma removed from his left arm in 2000 and another removed from his nose in 2002. Both were determined to be the least dangerous types of melanoma.
McCain’s office said in a statement that the Arizona Republican remained in good spirits Wednesday and is confident that any treatments will be effective.
“He is in good spirits as he continues to recover at home with his family in Arizona,” his office said.
“He is grateful to the doctors and staff at Mayo Clinic for their outstanding care, and is confident that any future treatment will be effective.”
His office said further consultations with his doctors will determine when he will return to the Senate.
Sen. Lindsey Graham (R-S.C.), a close friend of McCain and one of his most ardent allies on Capitol Hill, spoke with the Arizona senator on Wednesday. He said they talked only briefly about McCain’s diagnosis before shifting to a conversation about the Senate’s healthcare reform efforts and the National Defense Authorization, the federal defense spending bill.
“Literally, it went five minutes until we turned away from what I think most people have a hard time absorbing and focused on what he loves the best,” Graham told reporters after speaking with McCain.
The news of McCain’s diagnosis prompted an immediate outpouring of support from fellow lawmakers.
“God knows how this ends, not me,” Graham said. “But what I do know is this disease has never had a more worthy opponent.”
Senate Majority Leader Mitch McConnell (R-Ky.) characterized McCain as a fighter, saying in a statement that “he will face this challenge with the same extraordinary courage that has characterized his life.”
“John McCain is a hero to our Conference and a hero to our country. He has never shied away from a fight and I know he will face this challenge with the same extraordinary courage that has characterized his life,” McConnell said in a statement. “The entire Senate family’s prayers are with John, Cindy and his family, his staff, and the people of Arizona he represents so well.”
Sen. John Cornyn (Texas), the No. 2 Senate Republican, echoed McConnell’s characterization of McCain, and said the diagnosis was “just the latest challenge” for Arizona Republican.
McCain’s eldest daughter Meghan, a Fox News host, said in a statement that her father appeared to be the calmest family member upon receiving the diagnosis.
“It won’t surprise you to learn that in all of this, the one of us who is the most confident and calm is my father,” she said. “He is the toughest person I know.”
President Trump issued a statement shortly after news of McCain’s diagnosis broke, calling him a fighter and sending his family well wishes from the White House.
“Senator John McCain has always been a fighter,” Trump said. “[First lady] Melania and I send our thoughts and prayers to Senator McCain, Cindy, and their entire family. Get well soon.”
Former President Barack Obama, whom McCain ran against in the 2008 presidential election, called his former opponent “one of the bravest fighters” he has ever known, saying that “cancer doesn’t know what it’s up against.”
McCain was first elected to the House in 1982, and won a bid for the Senate just four years later.
Before entering Congress, McCain served in the U.S. Navy as a pilot. While fighting in the Vietnam War, he spent five-and-a-half years as a prisoner of war in North Vietnam.
Senate Republican leaders are desperately searching for the 50 votes they need to open a debate on ObamaCare repeal-and-replace legislation after a Wednesday scolding at the White House from President Trump.
Leaders have reopened negotiations on their previous bill, reversing course from their plans to move to a vote on a straight repeal of ObamaCare.
But it’s not clear if they will have any more luck this time in corralling enough centrist and conservative Republicans to move the bill forward.
Senate Majority Leader Mitch McConnell (R-Ky.) needs to win 50 votes to proceed and has faced opposition from conservatives, who believe the previous bill kept too much of ObamaCare, and centrists, who think it would leave too many people without affordable insurance.
GOP leaders haven’t closed the door on bringing a straight repeal of ObamaCare, with a two-year delay, to the floor.
But Trump, who has given mixed messages on whether he wants to just repeal or simultaneously repeal and replace ObamaCare, on Wednesday told Republican senators at a White House lunch that repealing ObamaCare without a replacement was not an option.
“We can repeal it, but we should repeal it and replace, and we shouldn’t leave town until this is complete, until this bill is on my desk,” Trump said.
McConnell appears to believe that if he can get the Senate to agree to open debate on an ObamaCare measure, he’ll have an opportunity to clear legislation by grinding away at his members. As the pressure intensifies, he clearly hopes that opposition will fall away.
But he first must get past the motion to proceed.
“Next week, we’ll be voting on the motion to proceed, and I have every expectation that we’ll be able to get on the bill,” McConnell told reporters Wednesday at the White House.
McConnell has failed three times so far to win the support that he needs.
A mix of conservative and centrist senators said they would oppose a procedural motion to begin work on an initial repeal-and-replace bill.
That led to a new round of negotiations and a second repeal-and-replace measure largely similar to the first bill.
On Monday, it became clear that the new bill also lacked the support to advance in the Senate.
McConnell then signaled he’d abandon repeal-and-replace, saying the Senate would seek to advance legislation repealing ObamaCare — with no guarantee on any replacement.
Centrists then came out against that plan, too.
After the Trump meeting, GOP leaders changed course and signaled a third effort to win support for a repeal-and-replace bill.
Senate Majority Whip John Cornyn (R-Texas) told reporters after the lunch that while the repeal-only bill might come to the floor, he preferred to negotiate a version of the repeal-and-replace bill, known as the Better Care Reconciliation Act (BCRA).
“If we can get an agreement here, my preference would be to start with the BCRA, agree to language — and I think we’re getting closer,” he said.
Senators were expected to meet Wednesday evening in Sen. John Barrasso’s (R-Wyo.) office with Vice President Pence, Health and Human Services Secretary Tom Price and Seema Verma, administrator for the Centers for Medicare and Medicaid Services, to discuss the bill. At press time it was not clear which senators would attend the meeting.
“There are going to be some meetings tonight up here with people who still have outstanding issues, and I think the question will be, yeah, can we find a way to get to yes?” said Sen. John Thune (S.D.), the Senate’s No. 3 Republican.
Leaders face the same problem that has bedeviled them since the beginning. If the bill is moved to the right, moderate senators are lost. If the bill moves to the center, conservative senators defect.
The bill’s treatment of Medicaid is a major sticking point for moderates.
The latest attempt to win over members is being called a “Medicaid wraparound.”
This would allow states to take money allocated to them through Medicaid and use the money to cover healthcare expenses for people who no longer qualify for Medicaid because the program’s expansion ended.
The idea is to make up for the reduction of federal funding for ObamaCare’s Medicaid expansion, which would be curtailed by the Senate bill. Under the previous bill, states are given federal tax credits to help people who would no longer quality for Medicaid, but senators have expressed fears that this will not be a big enough pool — particularly considering the nation’s opioid epidemic.
But the plan would actually involve taking more money away from Medicaid, which would already see its federal funding reduced under the Senate bill.
Verma discussed the proposal at the White House lunch.
“She explained very briefly, very, very briefly some of the parameters of what they’re calling this wraparound for Medicaid,” said Sen. Lisa Murkowksi (R-Alaska), one of the moderates who has threatened to vote against a motion to proceed to the bill.
Despite all the problems they’ve had with their ObamaCare effort, a number of Senate Republicans said they believe they are close to getting enough votes on a repeal-and-replace bill.
McConnell’s move to bring a repeal-only bill to the floor “brought it to a head, and he offered one way forward,” Sen. Mike Rounds (R-S.D.) told The Hill after the lunch at the White House. “A lot of us went back in and talked with leadership and said, ‘Look, we’re close enough on this, we put a lot of work into this, we don’t want to go that route.’ ”
They are also facing increasing pressure from groups warning of political repercussions if they fail.
The conservative group FreedomWorks said they will hand out “traitor” awards to Republicans who oppose a healthcare procedural vote next week.
And the conservative Club for Growth said it will track the motion to proceed leading to a vote on a repeal-only bill as a “key vote,” warning that voting against it would be “tantamount to supporting ObamaCare.”
Repealing ObamaCare without a replacement would result in 32 million people losing their insurance in the next 10 years, according to the Congressional Budget Office.
The bill, much of which would take effect in 2020, would also massively increase insurance premiums. According to the CBO, average premiums would increase by about 25 percent in 2018 alone. The increase would reach about 50 percent in 2020, and premiums would increase nearly 100 percent by 2026, CBO said.
Senate Republicans said this week they would consider voting on repeal only, after it appeared their replacement legislation had failed. However, negotiations attempting to revive repeal and replace continue and senators are scheduled to huddle Wednesday night to discuss if there’s a path forward.
The unfavorable score of the repeal-only bill could help jumpstart discussions about returning to the repeal-and-replace legislation.
A previous CBO score of the Senate’s repeal-and-replace bill estimated that 22 million people would lose insurance over the next decade.
The CBO hasn’t released a score on the most recent revision, which includes a controversial amendment from Sen. Ted Cruz (R-Texas).
The Senate will vote next week on a motion to proceed, though it’s not clear which bill Majority Leader Mitch McConnell (R-Ky.) wants to move to — a straight repeal or the repeal-and-replace legislation that seemed dead just days ago.
Both the House and Senate passed the “repeal-only” bill in 2015 that was vetoed by President Obama. Among other provisions, the “repeal only” bill would eliminate: ObamaCare’s individual and employer mandates, the Medicaid expansion, and subsidies for low-income individuals.
It would retain the requirements that protect people with pre-existing conditions from discrimination and would continue to require insurers to offer specific benefits.
According to the CBO “eliminating the penalty associated with the individual mandate and the subsidies for insurance while retaining the market regulations would destabilize the nongroup market, and the effect would worsen over time.”
Republicans have argued that they need to repeal and replace ObamaCare to “rescue” the growing number of people who live in counties with no insurers on the healthcare exchanges. But according to the CBO, repeal-only would make the problem worse.
The repeal-only bill would cause insurers to begin dropping out of the marketplace as soon as next year, the CBO said. It would also leave about half of the nation’s population without any ObamaCare insurers by 2020, a figure that would increase to about three-quarters of the population by 2026.
A fully privatized system can never adequately provision the nation.
The Republicans have big plans for health care in this country: to eliminate coverage for millions of Americans while delivering a big tax cut to the rich.
As someone who stands to benefit from that tax cut, let me just say: I don’t need it, and I don’t want it. No tax cut is worth excluding millions of Americans from the health services they need.
Any new health care legislation should be focused on providing the best available health services for all Americans, not deliberately putting them out of reach. And yet, this is exactly what the twin monstrosities that came out of the House and Senate would have done.
According to the Congressional Budget Office, the House bill would’ve left 23 million Americans uncovered by 2026. The Senate version was only a shade better, leaving 22 million people out. Those bills were nonstarters with the public — the party was forced to pull them, along with any immediate plans to repeal the Affordable Care Act (aka Obamacare).
This Republican-majority Congress has shown their cards: They favor less coverage for workers and the elderly and lower taxes for the wealthy.
Republicans in both chambers claim they’re doing this to support “freedom” and “choice” for the American people. They say the “free market” is the only way to provide Americans with access to affordable health care. They claim deregulation will help drive down health costs.
Well, for starters, so-called “free markets” are unicorns — fanciful creatures with magical powers that don’t exist in the real world. All markets are designed; they don’t emerge spontaneously from nature. We form, structure, regulate, and enforce markets through policy and institutions which reflect private and public interests.
When it comes to health care, we’re talking about something closer to a “natural monopoly” like electricity, not an industry like autos or breakfast cereals. Everyone needs basic medical services on a regular basis, and we need to make sure the same quality is available to everyone — even in hard to reach or low-income areas.
This will always require some form of direct government funding of services, especially with respect to primary care. Failing to do so means we’re not serious about the goal of quality care for all Americans.
This doesn’t necessarily mean an entirely government-run system — there’s plenty of room for private medical practices and businesses to provide the spectrum of services we need. But it does mean some degree of public funding is essential.
A fully privatized system can never adequately provision the nation. Rural communities don’t have adequate medical facilities and staff. Underdeveloped urban communities suffer from the same lack of basic resources, and their residents often don’t have the ability or time to travel to other locations.
Republican leaders claim they want affordable access to quality health care for all Americans, but all of their proposals have focused on lowering taxes on businesses and the rich, regardless of the very real cost in terms of human life.
It’s a false choice, and the effects will be cruel.
A healthy nation is a prosperous nation. This is primarily a challenge of real resources and the distribution of those resources, not of money. Congress can and should authorize any necessary funding to achieve the stated public goal simply by appropriating the funds.
This includes designing a system that will ensure there are enough facilities, doctors, nurses, specialists, transportation systems, and all the other elements of quality care in close proximity to all who need it — at any level of need and ability to pay.
Members of the House and Senate were put there by the voters and have an obligation to fight for and protect all of their constituents, not just the ones wealthy enough to bankroll their campaigns.
Amir Rubin, executive vice president and CEO of UnitedHealth’s Optum division, is leaving to take on the CEO role at One Medical, according to a CNBC report.
One Medical is a concierge primary care group with 60 locations across the country. It also offers a virtual medical team and mobile applications. Members pay an annual fee and can get access to same-day appointments, scheduled electronically.
Companies can also offer One Medical’s services as a benefit. The group has gained more than $180 million in investor funding since its inception a decade ago, according to the report.
Mr. Rubin led Optum since January 2016, prior to which he served as president and CEO of Palo Alto, Calif.-based Stanford Health Care. His previous leadership roles include serving as COO for the UCLA Health System in Los Angeles and COO at Stony Brook University Hospital in New York City.
Mr. Rubin succeeds One Medical founder Tom X. Lee, who will stay on as executive chairman of the group.
The healthcare industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare is off the table for Congress. Here’s what to watch.
The bulk of the Affordable Care Act (ACA) has survived the latest Republican efforts to repeal it, as Senate leaders were forced to admit Tuesday their best chance to fulfill years of campaign promises to gut the law has floundered.
The Senate plan to replace the ACA sank Tuesday night when the total number of Republicans opposing the bill rose to four. Republican Senate Leader Mitch McConnell immediately pivoted to an effort to repeal the ACAwithout a replacement plan. Only hours later, however, that plan also became unrealistic, as moderate Republicans said such a move would be too risky and they would not vote for it.
Industry groups were happy with the news. Scores of policy experts and healthcare professionals had railed against both the Senate and House bills to replace the ACA. Congressional Budget Office estimates found they would take away health insurance coverage for more than 20 million people. Both proposals also drastically cut Medicaid and eliminated protections for people with pre-existing conditions.
Millions more uninsured would have caused a hefty increase in uncompensated care costs for hospitals. The Commonwealth Fund estimated both replacement bills would have meant nearly a million healthcare jobs lost by 2026.
The industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare will be off the table in Congress. Here’s what to watch.
Stabilizing the individual market
The most immediate concern for payers with ACA repeal out of the picture is cost-sharing reduction (CSR) payments and the stabilization of the individual market. McConnell has said legislation to help shore up the market would be needed if the Senate’s Better Care and Reconciliation Act (BCRA) failed. But at least one lawmaker — Senate Majority Whip John Cornyn — said Tuesday he would “not be part of any bailout of insurance companies.”
President Donald Trump said Tuesday that Republicans should “let Obamacare fail” and pin the blame on Democrats. This would likely mean withholding CSRs, a position Trump has repeatedly advocated.
CSRs are meant to help insurers pay for beneficiaries with more care needs and therefore higher costs. They help payers keep a balanced risk pool. Congress and the White House have so far refused to commit to the payments for next year, and insurance companies pulling out of the ACA exchange markets have cited that inaction as a major reason for withdrawal.
The Trump administration still has to decide whether to continue defending a lawsuit against the White House from House Republicans claiming the Obama administration was paying the CSRs without proper appropriation. Payers are hoping Republicans agree to commit to future CSRs with a clearly above-board fund.
Republicans who balk at the CSRs may try to push their own ideas for how to stabilize the market. They have previously proposed changing the age band to allow insurers to charge older people more and tightening requirements for special enrollment periods. The BCRA included $112 billion to help payers stabilize the market, but that funding lasted only two years and assumed the other numerous changes the BCRA called for would go into effect.
Payers would much prefer a commitment to funding CSRs with a clearly above-board fund. That would certainly help steady the ACA marketplaces, but Republican rhetoric about the markets’ “death spiral” is overblown. The CBO has said the individual market would remain stable in most areas under current law, and a Kaiser Family Foundation report showed that payers are regaining profitability in the market while stability is increasing.
Executive actions
The White House will likely be making its own plans in case efforts in Congress fall through.
Trump has said very little about healthcare policy during his time in office. Other than a few tweets, Trump didn’t participate in vote-wrangling for the ACA replacement bills and didn’t make much use of his bully pulpit.
He held a celebratory press conference in the Rose Garden when the House passed its ACA replacement bill and also supported the BCRA. When the Senate bill failed, he immediately called for a repeal without replacement, but the administration didn’t elaborate on when a replacement might come or what it would look like.
Trump has already issued one major executive order on healthcare. Immediately after taking office, he told federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement that of the Act that would impose a fiscal burden on any state or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, purchasers of health insurance, or makers of medical devices, products, or medication.”
The IRS under Trump is still technically enforcing the individual mandate, although it also accepted tax returns that don’t indicate whether the filer has health insurance. With the failure to replace the ACA in Congress, Trump could push for complete abandonment of the requirement. Without the mandate, healthy people who don’t need much care would be less likely to get coverage and risk pools would become more unstable.
HHS has already indicated it will allow more state waivers under the ACA, letting states dictate what benefits are required and how people qualify for Medicaid. Conservative states have started planning waiver applications with aspects like a requirement that Medicaid beneficiaries have a job.
The administration could also weaken the ACA by refusing to publicize it. Immediately after Trump took office, the government scaled back advertising for the ACA open enrollment period. This led to fewer signups in the typically busy final days of enrollment. Without a push for young and healthy people to enroll, risk pools could again get off balance.
It hasn’t meant much yet, but with repeal off the table for now, the administration could push for more use of the order. Executive action could be tricky, however, as HHS remains understaffed.
Bipartisan options
Although Republicans and Democrats are far apart on nearly every aspect of healthcare reform, they could find that working together is their only chance of getting anything passed.
One jumping off point could be the bill put forward earlier this year by two of the more moderate Senate Republicans. It would repeal the individual and federal mandates as well as essential health benefits, but keep some aspects of the ACA, like a ban on coverage caps. It would also allow states to implement their own alternative plans, possibly with federal assistance.
Giving more control to state governments — a tactic embraced by HHS Secretary Tom Price — appeals to the left in some ways, but Democrats and patient advocates will oppose any weakening of protections for people with pre-existing and chronic conditions. Republican plans that throw out coverage mandates cannot guarantee such protections because they can easily create unbalanced risk pools.
One initiative that has nearly universal support is MACRA, as well as the movement toward value-based care in general. As providers deal with implementing MACRA payment model changes, Congress may be asked to make some tweaks or delays.
It’s unlikely any major healthcare changes in the near future will be bipartisan, but lawmakers willing to reach across the aisle could try to tackle some smaller issues.
CHIP reauthorization
Another chance to pass healthcare legislation will come at the end of September when the Children’s Health Insurance Program (CHIP) is set to expire. Lawmakers want to ensure the program continues, but may also see it as a possible vehicle for other bills. Republicans have already delayed hearings on renewing CHIP as they’ve debated how to move forward on healthcare changes.
This could be the route for a bill to stabilize the individual market. Republicans and Democrats may try to use this opportunity to push through other changes, but any delay that threatens the continuation of CHIP will be heavily criticized.
The Senate GOP’s revised Better Care Reconciliation Act stalled indefinitely Monday evening after two more Republican senators defected from the bill. With the bill dead, Senate Majority Leader Mitch McConnell, R-Ky., has proposed a full ACA repeal strategy that involves repealing the ACA and initiating a two-year delay.
Here are six reactions from healthcare industry leaders, provided via emailed statements.
American Medical Association President David Barbe, MD, stressed that the debate over healthcare reform is ongoing, and said a collaborative process must commence among lawmakers “that produces a bipartisan approach to improve healthcare in our country.”
“The status quo is unacceptable. Near-term action is needed to stabilize the individual/nongroup health insurance marketplace. In the long term, stakeholders and policymakers need to address the unsustainable trends in health care costs while achieving meaningful, affordable coverage for all Americans. The American Medical Association is ready to work on short- and long-term solutions.”
American Hospital Association President and CEO Rick Pollack called for “protect[ing] care for patients.”
“This [consistent call from the organization] is grounded in the belief that coverage must be preserved for all who currently have it. Repeal without any effort to replace would leave millions of patients at risk during their most vulnerable times. We have urged Congress to consider advancing solutions aimed at making our healthcare system stronger, protecting access and coverage, and exploring new delivery system reforms that have the potential to make care both more affordable and safer. Our hope is that the Senate will use this opportunity to regroup and work in a bipartisan manner to make the much-needed repairs and refinements, creating a healthcare system that can stand the test of time. We ask Congress to extend the Children’s Health Insurance Program and vital rural health programs and stabilize the health insurance marketplaces by funding the cost-sharing reduction payments.”
American Association of Medical Colleges President and CEO Darrell Kirch, MD, said his organization has maintained that an ACA repeal “must be accompanied by a simultaneous replacement that provides at least comparable healthcare coverage.”
“Patients — particularly those with complex conditions — require stability and continuity in their care. Without access to affordable meaningful coverage, many would forego or delay necessary medical care. This puts millions of Americans, including the most vulnerable patients, at risk. Any healthcare reform legislation must put patients first by maintaining or improving current levels of coverage.”
America‘s Essential Hospitals President and CEO Bruce Siegel, MD, said his organization welcomes the BCRA failure.
“We hope lawmakers seize on this opportunity to bring all stakeholders to the table and develop a plan to protect coverage for everyone — especially those in greatest need. The newly surfaced plan to repeal the ACA’s core provisions with a two-year delay is not the way to protect coverage and almost certainly would jeopardize care for people who face financial hardships.”
He added, “The repeal-and-delay strategy would leave millions of lives in limbo and create uncertainty that would destabilize insurance markets and paralyze hospitals and other providers. Needed improvements and expansion of services would stall without a clear path forward, threatening access in communities across the country. Insurers might abandon the ACA marketplace, further degrading access.”
Physicians for Reproductive Health Board Chair Willie Parker, MD, hopes congressional leaders realize ” it is time to cease efforts to destroy what is a literal lifeline for millions of Americans.”
“It’s time to stop inventing ways to deny people the right to affordable, comprehensive health care. It’s time to stop targeting women’s healthcare via making it more expensive and finding new ways to restrict care. It’s time to start treating abortion care as what is it is: a part of comprehensive healthcare that should be covered by all forms of insurance, including public insurance. It’s time to listen to evidence: birth control without extra copays has helped patients be healthier and thrive, access to preventive care saves lives, and comprehensive sex education and resources work. It’s time for healthcare equity for all. It’s time to stop attacking Medicaid, one of the most successful health care programs in our country’s history. It’s time to close the gap between Americans who have healthcare and those who don’t. In short, repeal of the ACA is an idea whose time will never come.”
Catholic Health Association of the United States President and CEO Sister Carol Keehan penned a letter to senators.
“On behalf of the Catholic Health Association of the United States, the national leadership organization of more than 2,000 Catholic healthcare systems, hospitals, long-term care facilities, sponsors, and related organizations, I strongly urge you to start anew in an open dialogue and bipartisan effort to improve healthcare coverage in our country. We believe that this moment calls for statesmanship on the part of both political parties to work together to make the improvements in our healthcare system that will stabilize the individual insurance market, improve affordability, and strengthen and expand the coverage gains already achieved.”
HENRY KOTULA 