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How GOP Will Still Carve Up Medicare

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https://www.forbes.com/sites/johnwasik/2017/07/19/how-gop-will-still-carve-up-medicare/#48a9aa5943f1

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Now that the GOP’s plan for repealing and replacing Obamacare seems to be in a coma, the party has turned its attention to the 2018 federal budget.

Although specific spending details in the House committee mark-ups are still being hammered out, the GOP is back to its old script.

The GOP has a working blueprint to cut billions out of federal programs and balance the budget without tax increases. And, among other items, it still wants to privatize Medicare.

Speaker of the House Paul Ryan (R-WI). (Photo by Win McNamee/Getty Images)

Medicare covers more than 55 million Americans. Most of them are 65 or older and millions are permanently disabled. It’s the nation’s second-largest government-managed single-payer plan after Medicaid, which covers some 70 million.

 

While Medicare provides coverage for doctors and hospitals, it also covers prescription drugs if you pay an additional premium. You also have the option to buy into private policies through Medicare Advantage — if you don’t want the fee-for-service part of basic Medicare.

The rehashed House GOP budget blueprint wants to reshape Medicare into more of a Medicare Advantage model, which now covers some 19 million Americans.

What does that mean? Funding for the guaranteed part of Medicare would be shifted into the privatized scheme. You’d receive a fixed stipend or “premium support” to buy a private policy on an exchange.

Buying private plans on an exchange? Where have we heard that before? Oh yes, that was the model for the Affordable Care Act, or Obamacare, which the GOP has spent the last seven yearstrying to repeal. It’s been a staple of House Speaker Paul Ryan’s policy platform for years.

According to the House Budget Committee blueprint:

“The Medicare improvements envisioned in this budget resolution would adopt the popular simplified coverage structure of Medicare Advantage, and allow seniors greater plan choices while reducing costs.

It would resemble the private insurance market, in which the majority of Americans select a single health care plan to cover all their medical needs.”

In theory, having private insurers compete with the government to provide more coverage at a lower cost sounds like a good idea. But is it possible, given the government’s massive economies of scale?

Without generous subsidies, the prospect of insurers offering a better Medicare deal is like the corner grocer trying to compete with Wal-Mart. Moreover, using Medicare Advantage as a model is a horrible idea.

Medicare Advantage insurers have been embroiled in numerous billing scams, according to the non-partisan Center for Public Integrity. The Center, an independent watchdog, has published more than two dozen pieces on this ongoing morass. Here’s a summary of their findings:

“Congress created private Medicare Advantage health plans 11 years ago to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.”

The formula is supposed to pay health plans more for sicker patients and less for healthy people, but often it pays too much. The government has for years missed opportunities to corral tens of billions of dollars in overcharges and other billing errors tied to abuse of risk scores.

Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program.”

Back to the main story: What House Speaker Paul Ryan and GOP congressional leaders are proposing is to tear down and remold basic Medicare into the troubled Medicare Advantage program, which would be like throwing kerosene on a house fire.

There’s even more of a muddle on how the GOP would calculate how much to give seniors for their yearly stipend to cover private premiums. What if policy costs go up double digits and the stipend doesn’t keep pace with the private market?

Would private insurers offer lower rates to healthier seniors and price less-healthy Americans out of the market? Although basic Medicare would still be available, wouldn’t the money diverted to premium support undermine funding for the traditional Medicare Hospital Trust Fund, which may be insolvent by 2029?

I think there’s a reason why there’s a billboard in Kenosha, Wisconsin — in the heart of Ryan’s Congressional District — that shows Ryan in a robber’s mask. There’s an attempted theft in progress, but older Americans and the disabled will be the victims.

State-by-State Estimates of Reductions in Federal Medicaid Funding

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Better Care Reconciliation Act (BCRA): State-by-State Estimates of Reductions in Federal Medicaid Funding – Issue Brief

Medicaid Changes under the BCRA and Possible State Responses

Our analysis examines the changes in the BCRA that would phase out the enhanced matching rate for the ACA Medicaid expansion and limit federal Medicaid spending to a capped amount per enrollee for five eligibility groups (expansion adults, other adults, children, the elderly and people with disabilities). First, under the BCRA, for states that adopted the expansion as of March 1, 2017, the enhanced federal match would phase out from 90% in 2020 to 85% in 2021, 80% in 2022, 75% in 2023 and then to the regular state match rate in 2024 and beyond. This phase out lowers federal Medicaid spending relative to current law, under which federal financing for the expansion population would remain at 90% in 2020 and in subsequent years.

Second, under the BCRA, federal Medicaid spending for most enrollees would be limited to a set amount per enrollee. To establish these limits, states would use data from FY 2014-2016 to develop base year per enrollee spending that would be inflated to 2019 based on the medical component of the consumer price index (CPI-M). Beginning in 2020, federal spending would be limited to the federal share of spending based on per enrollee amounts calculated by inflating the base year spending by CPI-M for children and adults and CPI-M plus one percentage point for the elderly and disabled. Beginning in 2025, all per enrollee limits would be increased by general inflation (CPI-U). Certain spending and populations would be excluded from the per enrollee caps, including enrollees who do not receive the full scope of Medicaid benefits.

States could respond to these changes in federal policy in several ways. We examine changes in federal Medicaid spending under two possible scenarios of state responses: (1) All states, both expansion states and non-expansion states, fill gaps in the loss of federal funding and maintain coverage, including the ACA Medicaid expansion coverage, and (2) states that expanded Medicaid under the ACA fully drop their expansions but maintain spending and coverage for other groups, resulting in declines in both federal and state spending. In the second scenario, we model the loss of federal dollars that the state would have received had it fully maintained its expansion.

Building a ‘nimble’ multi-state health system: 5 questions with Ascension CEO Dr. Anthony Tersigni

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http://www.beckershospitalreview.com/hospital-management-administration/building-a-nimble-multi-state-health-system-5-questions-with-ascension-ceo-dr-anthony-tersigni.html

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With 2,500 sites of care — including 141 hospitals and 30 senior living facilities that sprawl across 23 states and Washington, D.C. — St. Louis-based Ascension may not seem well-suited to make sudden business changes. But Ascension President and CEO Anthony Tersigni, EdD, aims to make the nation’s largest nonprofit health system into one of America’s most agile hospital networks.

Here, Dr. Tersigni discusses the system’s recent national rebrand, how he instills a spirit of risk-taking and innovation and the issues he is focusing on over the next five years, despite uncertainty on Capitol Hill.

Question: What prompted the decision to rebrand Ascension’s healthcare facilities? What effect has the rebranding had within the organization and outside in the communities it serves since being implemented in 2016?

Dr. Anthony Tersigni: In 1999 we decided not to brand Ascension because the brand equity was in the local entities. But since then, we believe we’ve made enough inroads in safety, quality and high-reliability that we felt Ascension has developed a reputation of its own. How do we combine the national reputation with the local reputation? Since co-branding the Ascension name with the names of our hospitals in our communities in advertising and on the web, the results have been outstanding. It’s about making it easier for the people we serve to navigate our system within a particular community because they now understand we’re all connected. We’re going to roll this out throughout the country, but we’re doing it in a sequential way because it’s very costly. But we believe now is the time to position ourselves as the national system that we are.

Q: What are your primary goals for the organization for the next five years?

AT: We want to continue to grow our primary care, expand access and continue to move toward value-based care. We want to be able to take on risk in a way where we can move into first-dollar coverage so we can move the patient through the continuum of care. We promise healthcare that works, that is safe and that leaves no one behind — for life. For us to do that, we need to be able to put patients in the right setting for the right care at the right time. If we can take on risk and walk with our patients and their families through our clinically integrated systems of care, we believe we can keep them well.

When it comes to population health management, the mindset is we need to change the way we look at our current business. We are moving from fee-for-service, where we get paid for doing things, to fee-for-value, or how to keep people well. We’ve been so successful as a hospital company under fee-for-service, and now we have to change the mindset and culture of all of these stakeholders. We have to go in a different direction. It’s like changing a flat tire on a car while it’s moving. No one has figured out yet how to do it, but you’re going to have to figure it out.

Another priority is mental and behavioral health. That’s very important to us. It’s a core part of our mission, and we want to be partners with whoever else sees that as a key component.

Q: What are the most important management practices when leading such a vast system with thousands of employees?

AT: In the 18 years since we created Ascension, we’ve been trying to have a culture that’s transparent, candid and nonpunitive. That’s a dramatic departure from the healthcare industry of old. I like to think I surround myself with really bright individuals and subject matter experts, and I try to empower everyone to do what’s in the best interest of those we serve. That’s what this is really all about. I like to think I hire people who are brighter than I am and give them the resources to do their jobs. Then I get out of the way.

That’s one of the principles we try to instill in our Leadership Academy — a program where we take high-potential employees for two to three years and help them develop. They focus on spiritual health to better understand their inner self. The second thing is leadership development. Everyone comes to us with certain gifts. We want them to hone those gifts and develop other skills. And the other piece, which people don’t talk about often, is personal health and vitality management. We expect our executives to work eight, 10 or 12 hours per day at optimal performance level. That’s virtually impossible unless you understand the physiology of your body.

Q: How would people describe you personally as a boss?

AT: My job is to allow leaders across the country to do what they are capable of doing. I like to think I am the supporting cast to what they do, and therefore I want to give them as much leeway and support as possible, and I want them to take risks. I am a risk-taker. As long as you don’t hurt people, that’s how we learn — through making mistakes. So take that risk.

Q: How do you plan for the future amid the current uncertainty surrounding healthcare policy?

AT: We need to be the highest-quality, lowest-cost, best-outcome provider in every market that we’re in. Then regardless of what happens in Washington D.C., we are going to be there for our patients and they’re going to want to seek us out.

We are working to do our part to reduce costs and cut waste in healthcare. But at the other end of what we do are human beings whose lives can either be helped or ruined by our actions or inactions. We are constantly advocating as a voice for the voiceless because many of those folks don’t get a chance to have this kind of conversation. I feel compelled to represent them because we are at ground zero in terms of healthcare. We see the pain and suffering that’s happening in society. They are in our clinics; they’re in our emergency rooms; they’re in our hospitals; they’re in our nursing homes.

I spent a couple weeks on Capitol Hill meeting with every senator I could meet and say, “Look, we want to be a resource. If you have a policy idea, let us know what that is and we will tell you the practical implications of that policy on the people we serve.”

We will continue to advocate for the poor and vulnerable. Last year we provided $1.8 billion of community care, community benefit and charity care. Given where this is going, I believe that number is going to go up next year. Because we are a faith-based, Catholic organization, we are going to continue to serve those people. If it ends up being over $2 billion, we’re going to figure out a way to serve them. We have to do so until we find a national solution here.

Wondering Which Health Bill the Senate Will Vote On? Here’s Your Scorecard

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https://www.thefiscaltimes.com/2017/07/21/Wondering-Which-Health-Bill-Senate-Will-Vote-Here-s-Your-Scorecard

 

There hImage result for health bill scorecardave been times when congressional leaders decided to roll the dice and send major legislation to the floor with no certainty of the outcome because the odds of passage were a toss-up. Former House Speaker John Boehner (R-OH) did that more than once in trying to break a deadlock between far-right Freedom Caucus members and more moderate members of his party.

But rarely has a leader from either party asked his members to vote on a controversial bill – one with huge political implications for them — with no advanced warning of what was in the legislation.

Senate Majority Leader Mitch McConnell, a 32-year veteran lawmaker who some consider a “Master of the Senate” because of his wily ability to overcome legislative log-jams, is about to do just that next Tuesday, when he seeks to bring up health care reform legislation that for now remains a mystery to most of his own members, let alone the Democrats and the public.

McConnell spent months in secret backroom negotiations with a select group of Republican senators and Trump administration officials devising an alternative to a House-passed version of the legislation. But when the emerging plan was met with hostility from senators who thought it didn’t go far enough in gutting Obamacare or went too far in cutting Medicaid funding, McConnell engaged in an intense round of deal making to try to buy off opponents. But that didn’t work either.

Now, seemingly baffled by how to proceed, McConnell appears determined to seek closure on his party’s seven-year crusade to repeal and replace the Affordable Care Act. Unable to muster a minimum 50-vote Republican majority around any of a half-dozen competing plans to scrap and replace Obamacare, McConnell is considering a smorgasbord of choices next week to see which – if any—can win approval on the Senate floor in a wide-open showdown.

The options would range from an outright repeal of the ACA while delaying the effective date for two years to give Congress more time to devise a replacement, to simultaneously repealing and replacing Obamacare, to essentially punting on the issue by allowing states to decide for themselves whether to stick with the increasingly popular Obamacare program.

McConnell’s tactic is nearly unprecedented and would mark an extraordinary abdication of leadership responsibility in the drafting of historic health care reform legislation affecting one sixth of the economy, the health and well-being of 20 to 30 million Americans, and the long-term debt.

President Trump vowed throughout the 2016 presidential campaign that he and Republican lawmakers would repeal and replace the national health insurance program practically overnight once he took office. But for months, Trump was largely AWOL from the early talks and lobbying efforts that led to the narrow passage of a plan in the House in early May to the current deadlock in the Senate. Now Trump is making eleventh-hour demands that the Senate stay in town and pass some version of a GOP health bill, leaving McConnell caught between a rock and a hard place.

Steve Bell, a senior official at the Bipartisan Policy Center who spent 32 years on Capitol Hill as a Republican budget and economic adviser, said in an interview Friday, “I have never seen anything like this on an issue of this magnitude.”

Bell, who took part in past congressional deliberations over Social Security reform, deficit reduction deals and nuclear disarmament, added that “In all my years I’ve never seen a major issue that has been as mishandled as this.”

When Senate Majority Whip John Cornyn (R-TX) was asked by reporters whether senators would know in advance precisely what they would be voting on next week, he replied: “That’s a luxury we don’t have.”

There are several possible scenarios for how this political melodrama will play out on Tuesday, provided McConnell can persuade the majority to even proceed with a debate, which is far from a given. Here are the likely choices:

Repeal and Delay

Called the Obamacare Repeal and Reconciliation Act, this version of the bill is perhaps the simplest, if only because it does the least. Over the course of two years, the ORRA would eliminate many elements of the ACA entirely. The mandates would disappear, as would the tax increases, the new regulations regarding what insurance policies must cover, the subsidy payments to keep insurance affordable, and much more. What ORRA would not do is replace the ACA with a different structure meant to prevent the insurance markets from imploding.

The idea behind the ORRA is that, by giving lawmakers two years before the full impact of the law will be felt, there will be ample opportunity to craft a replacement. And because the alternative is so terrible, the argument goes, it follows that lawmakers will do just that.

This is not, to be clear, a sure thing at all. Congressional leaders used the same logic in 2011, putting the prospect of budget sequestration in place to force themselves to craft an alternative. They failed, and the country has been dealing with a policy that even its authors believed was terrible ever since.

CBO reviewed the ORRA earlier this week and determined that it would reduce federal deficits by $473 billion over a decade. But that reduction would come at the cost of 32 million fewer Americans with health care and premium costs for those who remain increasing 100 percent.

Repeal and Replace (I)

The Better Care Reconciliation Act is a sort of half-measure when it comes to doing away with the ACA. It would eliminate much of the law, including the hated individual mandate and many of the related taxes and regulations. However, it would leave much of the law’s structure in place, including subsidies paid to low- and -middle-income Americans. It would also leave many of the requirements related to what insurance policies must cover in place.

Those subsidies, however, would be smaller, and the policies they would buy would generally be worse in terms of coverage. The law changes the benchmark insurance policy from one that covers 70 percent of the expected costs of an individual’s average health care expenses to one that covers about 58 percent. While premiums would come down, the law would also cause deductibles to increase, in some cases by very large amounts. The CBO on Thursday found that the bill would result in Americans living near the poverty line being obligated to spend nearly their entire annual income in deductibles before full coverage kicked in.

CBO found that this version of the GOP repeal effort would save the Treasury $20 billion over a decade. That would come at the cost of about 22 million more Americans without insurance than would have it under current law.

Repeal and Replace (II)

This is an alternative version of the BCRA, restructured to make conservatives who felt the first draft of the bill left too much of the ACA intact. Championed by Texas Sen. Ted Cruz, it contains a provision that would allow insurance companies to offer policies that do not comply with the ACA coverage mandates. This would be conditional on them also offering plans that do comply, at the same time.

The CBO has not scored the BCRA with the Cruz amendment yet, and it is unclear that it will be able to do so before Senate leadership tries to reach an endgame on the health care reform process next week. But while there is no official tallying of the impact, experts have weighed in to warn that the Cruz amendment would have a serious negative effect on people with pre-existing medical conditions.

By allowing young and healthy people to choose bare-bones insurance policies, it will drain the risk pool for more substantial policies, leaving only older and sicker people covered under them. Because this means the insurers will face considerably more risk, they will, in turn, raise premiums and create a vicious cycle that could eventually price many Americans out of the market entirely.

Punt to the States

Some members of the Senate appear to have had their fill of attempting to restructure the health insurance industry in the US and are ready just to hand off the task to the states. Last week, on the same day that McConnell introduced the latest version of the BCRA, South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy announced that they would be offering their own alternative bill devolving much of the responsibility for structuring health care markets to the states.

“There’s about $500 billion in money; rather than trying to run health care from Washington, we’re going to block grant it to the states,” Graham said on CNN last week. “And here’s what will happen. If you like Obamacare, you can reimpose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced. It will be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

The bill has not been scored by CBO and has received relatively little attention from the media. However, it offers senators two things that many of them would like very much. First is the ability to say that they brought the health care debate to a conclusion that included the demise of the ACA. Second is that it gives the opportunity to claim that they had a role in funneling billions of dollars back into their states’ economies. While it’s unlikely to come up for a vote next week, given the confused state of play in the GOP conference, it would be unwise to rule it out completely.

GOP wrestles with soaring deductibles in healthcare bill

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GOP wrestles with soaring deductibles in healthcare bill

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Senate Republicans have run into another problem in passing their ObamaCare replacement bill: It could increase deductibles by thousands of dollars, potentially alienating moderates who are already skeptical of the bill.

An analysis released Thursday by the nonpartisan Congressional Budget Office (CBO) concluded that a single policyholder purchasing a standard benchmark plan under the GOP bill could face a deductible of $13,000 in 2026.

Under current law, an individual making $56,800 would have a deductible of $5,000, while someone making $26,500 would have an $800 deductible.

A higher deductible is the tradeoff Republicans made when they decided that lowering premiums would be a top priority for their legislation; plans with lower premiums generally have higher deductibles.

“The way we come together, the way we bring together senators all across the ideological spectrum, is focusing on lowering premiums,” Sen. Ted Cruz (R-Texas) said on Fox News on Friday.

“If we’re lowering premiums, that’s a win for everyone.”

Deductibles could become so high under the GOP plan, the CBO said, that many low-income people might decide not to purchase a health insurance plan, even if the premiums were low.

That could be an issue for moderates who have worried about coverage losses, especially for those who gained coverage through ObamaCare’s Medicaid expansion.

The Republican legislation ends the expansion by 2023, and those people will be eligible for tax credits to buy insurance under the GOP plan.

Under the Senate bill, the tax credits for purchasing coverage are tied to ObamaCare’s less generous “bronze” plans that have lower premiums and higher deductibles.

Another factor driving the higher deductibles under the Republican proposal, according to the CBO, is the elimination of ObamaCare insurer payments known as cost sharing reduction subsidies. These payments reimburse insurers for giving discounted deductibles to low-income people.

In an attempt to address the issue, the White House is trying to win over moderates by proposing to allow states to use some Medicaid funding to help low-income people pay for their deductibles.

Higher deductibles for low-income people are a concern, said Sen. Bill Cassidy (R-La.), but he hopes the new White House proposal will fix that.

Senate Republican leaders are also considering offering $200 billion to states that expanded Medicaid, which would be funded by leaving in two of ObamaCare’s taxes on high earners.

That money would come in addition to $132 billion the revised bill already sets aside for a long-term state innovation fund and $45 billion to treat opioid addiction.

“If there’s enough to make it real that someone who is lower-income can get the assistance they need to afford insurance, then that matters,” Cassidy told reporters Thursday.

Sen. Mike Rounds (R-S.D.) said the purpose of leaving those taxes in was to “redistribute” that money to people facing higher costs under the bill.

“What we’re trying to do is allow more local control in some areas so individual states can do some things to help people based on what their needs are,” he said.

“That’s why we kept some of that tax revenue in place. So we can redistribute some of that money to help them because they have no place else to go.”

But some lawmakers question whether the additional funding would make a difference.

While the proposal would add $200 billion in funding, the legislation would cut $756 billion from Medicaid over the next decade, which includes the rollback of the expansion.

“As long as we are fundamentally changing Medicaid and taking some $700 billion out of the program, I do not see myself supporting a bill that does that,” Sen. Susan Collins (R-Maine) told reporters Thursday.

The CBO noted in its score that funding provided to states for stabilization would likely be used to reduce premiums, not deductibles, though the analysis did not include the additional $200 billion.

“The CBO expects that most of these funds would be used to lower premiums. There’s not a lot of money left over for cost-sharing,” said Cynthia Cox, an insurance expert with the Kaiser Family Foundation.

What Trump can do to cripple ObamaCare

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What Trump can do to cripple ObamaCare

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If Congress isn’t able to repeal ObamaCare, it’s likely that the Trump administration will follow through on the president’s vow to let the law fail.

President Trump regularly asserts that ObamaCare is dead or dying, and the administration has already taken steps to undermine the law while congressional Republicans struggle to enact healthcare legislation.

The administration has broad authority over the implementation of ObamaCare, giving officials the power to limit the law’s effectiveness even without congressional involvement.

Here are four ways Trump could cripple the law.

Stop the cost-sharing subsidies.

The biggest thing the Trump administration can do to hurt ObamaCare would be to stop making key subsidy payments to insurers, known as cost-sharing reductions (CSR).

Should the subsidies stop, the insurance markets would likely be thrown into chaos, which could bolster claims from Senate Republicans and the White House that ObamaCare is failing.

Trump has publicly waffled on whether he will continue the payments. At times he’s threatened to withhold them, let the ObamaCare markets collapse and then blame Democrats. At other times, he’s acknowledged the political risks and said the payments would continue.

“We pay hundreds of millions of dollars a month in subsidy that the courts don’t even want us to pay,” Trump said during a lunch with Republican senators Wednesday. “And when those payments stop, it stops immediately. It doesn’t take two years, three years, one year — it stops immediately.”

The White House made the payments for July, but has not made a commitment beyond this month. Insurers have called the payments critical, saying that without them, they would have to massively increase premiums for 2018 or exit the individual market.

Many insurers blamed uncertainty surrounding the payments for proposed double-digit rate increases for 2018.

Stop enforcing the individual mandate.

ObamaCare requires everyone in the country to have health insurance, or pay a penalty. Trump can’t unilaterally abolish the mandate, but he can instruct the IRS to stop enforcing it.

Trump hinted at such a move on the first day he took office, issuing a vaguely worded executive order instructing federal agencies to waive or defer any part of ObamaCare that imposed a “fiscal burden” on states.

But despite the threats, the mandate is still the law and people are still supposed to pay a penalty for lacking coverage.

Insurers are worried that if the Trump administration eases up on the mandate or creates more exemptions to it, it would create a “death spiral” in the ObamaCare markets.

The mandate helps bring in healthy enrollees to balance out the sick ones, with the goal of preventing premiums from spiking. If the healthy people don’t buy insurance, only the sickest will, and premiums will skyrocket.

The mixed signals from the administration about the mandate are spooking insurers. They don’t know what to plan for, and that’s showing in their filings.

“With open enrollment for 2018 only three months away, our members and all Americans need the certainty and security of knowing coverage will be available and affordable for them,” the BlueCross BlueShield Association said in a statement.

Pennsylvania’s five insurers, for example, filed premium increase requests averaging nearly 9 percent. But that increase could be hiked up to 36 percent without the individual mandate and the cost-sharing reduction payments.

Stop advertising and outreach.

The Obama administration used each open enrollment period to heavily promote exchange signups. Administration officials would appear in ads online and on TV.

The Trump administration has taken the opposite approach.

Shortly after Trump took office, the Department of Health and Human Services said it withdrew about $5 million of advertising that was intended to encourage people to sign up for insurance through ObamaCare.

HHS has also shortened the annual open enrollment period from three months to six weeks, and the agency churns out anti-ObamaCare charts, studies and graphics on a regular basis.

HHS Secretary Tom Price has also been producing swaths of ads showcasing “victims” of ObamaCare to promote the law’s repeal.

According to an AP report, the administration recently cancelled contracts with two companies that helped facilitate ObamaCare signups in 18 cities.

Advocates worry that without outreach from the government, Americans who need insurance won’t know they can sign up. Lower signups generally mean higher prices, which has been one of the most consistent Republican critiques of the law.

There’s also no indication that the administration is doing anything to convince insurers to stay in any of the “bare” counties across the country without an ObamaCare plan to buy.

The Centers for Medicare and Medicaid Services under Obama played an active role in enticing insurers back into the markets, but the Trump administration has taken a more hands-off approach.

Use administrative flexibility.

HHS Secretary Tom Price has enormous flexibility within the law to redefine some of its parameters. The powers given to the HHS secretary were meant to help implement ObamaCare, but Price has indicated he’ll use them to dismantle the law.

“Fourteen hundred and forty-two times the ACA said ‘the secretary shall’ or ‘the secretary may,’ ” Price said during his confirmation hearing in March.

Congressional Republicans have urged Price to use every regulatory lever possible.

“There are a lot of things that can be done with regulations, that people don’t see happening on a daily basis,” Sen. John Barrasso (R-Wyo.) told The Hill recently.

For example, Price could change the rules requiring how much insurers would have to cover under the category of essential benefits. While the administration can’t repeal the requirement completely, they can change the definition.

Many congressional Republicans would like to either eliminate the essential health benefit requirement, or at the very least, let states and insurers opt out, so long as they also offer plans that comply with the rules.

If ObamaCare repeal fails in Congress, Republicans will be looking for Price to do the next best thing.