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Trump’s war of attrition against Obamacare

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The administration can do plenty to undermine the law even if Republicans are unable to repeal it.

Obamacare may escape another GOP repeal effort, but surviving a hostile administration could be a much tougher challenge.

If a last-ditch repeal effort fails in Congress next week, all indications are the Trump administration will continue chipping away at the Affordable Care Act — if not torching it outright.

President Donald Trump, who regularly says Obamacare is dead, has already taken steps to undermine the law even as the legislative battle over repeal drags on. His administration has slashed crucial advertising dollars, cut the enrollment window in half, and regularly pumps out anti-Obamacare videos and graphics — actions sure to reduce the number of people who sign up.

Trump has plenty of other options to roll back a program covering roughly 20 million Americans. Those include ending enforcement of the mandate to carry insurance, imposing work restrictions and nominal premiums on low-income adults who qualify for Obamacare’s Medicaid expansion and letting states relax the law’s robust coverage rules.

The man charged with the oversight of many of these decisions, Health and Human Services Secretary Tom Price, noted in his confirmation hearing that Obamacare grants him broad authority about how to enact it — powers that in his hands could be used to the scale back the law’s reach.

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

One possible brake on the administration might be the pushback from some Republican governors and lawmakers who oppose letting insurance markets crumble on their watch — even as Trump insists voters will blame Democrats. After the Senate’s repeal effort appeared to unravel earlier this week, Sen. Lamar Alexander, chairman of a key health care committee, announced plans to hold hearings on stabilizing Obamacare’s shaky insurance marketplaces.

“The best next step is for both parties to come together and do what we can all agree on: fix our unstable insurance markets,” wrote 11 governors this week in a bipartisan letter led by John Kasich of Ohio and John Hickenlooper of Colorado.

However, there’s no sign that most Republicans in Washington are ready to drop their longtime vow to dismantle Obamacare, even with a planned Senate vote on repeal next week likely to fail.

The most devastating thing the administration could do to Obamacare is pull insurance subsidies, worth about $7 billion this year, that are paid to insurers to cover the out-of-pocket costs of low-income consumers. That could lead to an exodus of insurers from the Obamacare markets, send premiums soaring, and lead already wobbly markets in some states to collapse.

“We pay hundreds of millions of dollars a month in subsidy … and when those payments stop, it stops immediately,” Trump said in a meeting with Republican senators Wednesday. “It doesn’t take two years, three years, one year — it stops immediately.”

The Trump administration confirmed Wednesday it will make this month’s subsidy payments. However, insurers fear the administration could nix the subsidy at any time.

The other immediate concern for insurers is whether the administration will continue enforcing the individual mandate penalty for Americans who do not purchase insurance. Many saw Trump’s Day One executive order instructing agencies to weaken Obamacare as a green light for the IRS to stop enforcing the tax penalty for skipping coverage. So far, however, the mandate remains.

While the mandate has proven weaker than insurers had hoped to induce Americans — particularly the young and healthy — to purchase coverage, the industry still sees it as a key tool for keeping down costs and stabilizing the markets. Many are boosting premiums higher than planned due to fears Trump will no longer enforce it.

Signals that the mandate will no longer be enforced are sure to worry insurance companies whose participation in Obamacare’s marketplaces are key to making them function. Some major national and regional insurers have already said they will pull out of the marketplaces next year, with most citing uncertainty about the effort to roll back the law.

“If there are questions, if there are unknowns, [insurers] have to proceed conservatively,” said Ceci Connolly, CEO of the Alliance of Community Health Plans. “If they price on wishful thinking, they will come up short next year.”

Trump health officials have already shown a willingness to flex executive power to whack at the law.

Weeks after taking office, the Trump administration canceled $5 million in HealthCare.gov advertising in the final days of the previous enrollment season — a particularly crucial time for attracting young and healthy customers. On Wednesday, Trump’s HHS confirmed it will soon terminate two contracts for outreach programs designed to sign up people for insurance across the country.

“The contracts were never intended to be long term,” said Jane Norris, a spokeswoman for the Centers for Medicare & Medicaid Services, which oversees the law’s implementation.

The administration could also pare back federal funding for enrollment outreach programs. The Obama administration awarded $63 million in grants last September to help states bolster enrollment efforts, and another tranche of funding is supposed to be released by this fall. However, the administration hasn’t signaled whether it would continue this funding, and an appropriations bill advancing in the House would block dollars for the so-called navigator programs.

The next enrollment period starting Nov. 1 is looming. The Trump administration has already cut the sign-up period in half — to six weeks in the nearly 40 states using HealthCare.gov — worrying advocates that the shortened window will depress sign-up numbers.

In past enrollment seasons, the Obama administration rolled out a full-court marketing press, with top administration officials making media appearances to push enrollment. It’s hard to imagine Price and other top HHS officials making a similar effort after his department has trumpeted Obamacare’s struggles on a daily basis.

“They have to sign up millions of enrollees just to maintain the same amount of total enrollment,” said Larry Levitt of the nonpartisan Kaiser Family Foundation. “If there’s minimal outreach … there could be a big drop-off in enrollment.”

While the previous administration also took an active role in boosting insurer participation in the marketplaces, the Trump administration has taken a hands-off approach. There are no signs that HHS is looking to persuade insurers to sell coverage in the 40 counties that potentially won’t have any insurers selling Obamacare plans next year. Trump and administration officials often tout these “bare” counties as another sign of Obamacare’s flaws.

“40 counties in 3 states are currently projected by @CMSgov to have zero insurers on #Obamacare,” Price tweeted on Thursday.

HHS could also give red states much wider latitude to limit who can sign up for Medicaid. Arkansas, Arizona, Kentucky, Indiana, Maine and Wisconsin are among the states with Republican governors seeking federal permission to add work requirements or make able-bodied adult beneficiaries pay more for care. The Obama administration largely shunned similar requests because they would shrink enrollment.

At least one state is seeking the Trump administration’s permission to significantly overhaul Obamacare’s coverage rules in order to attract insurers back to its struggling marketplace. Iowa, which is at risk of having no insurer sell coverage statewide next year, wants to scrap Obamacare’s subsidies helping customers pay for premiums and medical bills and replace them with a limited tax credit. That could make lower-income and sick enrollees pay a lot more for coverage.

Iowa also wants to implement a single, standardized health insurance option instead of allowing insurers to sell a range of health plans as they now do under Obamacare. Finally, the state would create a reinsurance program meant to backstop insurers with particularly expensive customers, an idea pursued by Alaska, Minnesota, New Hampshire and other states.

At least one insurer said it would re-enter Iowa’s marketplace if the plan goes through. Though some Obamacare advocates have questioned whether Iowa can legally roll back Obamacare standards as the state has proposed, the Trump administration is expected to greenlight the plan.

Senate Leaders Press for Health Care Vote, but on Which Bill?

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Senate Republicans ended a demoralizing week on Thursday with their leaders determined to press ahead with a vote to begin debating health care next week, but with little progress on securing the votes and no agreement even on which bill to take up.

With President Trump urging them to move forward on their seven-year quest to erase the Affordable Care Act, Republican senators on Thursday still had not decided whether to revive a proposal to replace former President Barack Obama’s health care law with one of their own, or to simply repeal it and work on a replacement later.

The choice is unpalatable: The nonpartisan Congressional Budget Office said on Thursday that the latest version of the bill to repeal and replace the health law would increase the number of people without health insurance by 15 million next year and by 22 million in 2026. Those figures are the same as the estimates in the budget office’s previous analysis, despite numerous changes to the bill intended to win votes.

On the other hand, if senators opted simply to repeal the existing law, the budget office said on Wednesday, 32 million more people would be uninsured in 2026 compared with current law.

The majority leader, Senator Mitch McConnell of Kentucky, remained unswerving in his drive toward a vote next week on a procedural motion to begin debating health care. But he has not specified which version of the legislation he intends to put before the Senate. In effect, he is asking 50 senators to roll the dice and hope they land on an option they can work with.

“You can’t debate something that you don’t initiate the debate on,” said Senator John Cornyn of Texas, the No. 2 Senate Republican. “And everybody can offer endless amendments, so if anybody’s got a better idea, they can offer that and get a vote on it. And in the end, 50 people are going to decide whether we’re going to have an outcome or not.”

Asked whether senators want to know the plan before they vote, Mr. Cornyn said that was “a luxury we don’t have.” (He later wrote on Twitter that it was “hard to predict” the final legislation because of the amendment process.)

The release of the budget office’s analysis capped a tumultuous period that began with the seeming collapse of Mr. McConnell’s health care bill. Then Mr. Trump’s changing demands added to the disarray. Finally, the week turned heavy-hearted with the news that Senator John McCain, Republican of Arizona, has brain cancer.

It remained far from clear whether Republicans would be able to assemble the votes to begin debate, let alone coalesce around legislation to repeal the health law and, possibly, to replace it.

“I want us to remember that our attempt here is to lower the cost of health care; it’s not just about getting 50 votes,” said Senator Bob Corker, Republican of Tennessee. Mr. Corker said a repeal-only measure now seemed like the best course of action, and he expressed concern about the continuing negotiations for a broader bill that would replace the health law.

“I’m beginning to fear that it’s taking on some of the same characteristics that Obamacare took on when it was passed,” Mr. Corker said. “It’s beginning to feel a little bit like a bazaar, if you will, where, ‘Let’s throw $50 billion here, $100 billion there.’”

How the Number of Uninsured Would Change

The increase in the number of uninsured is virtually the same under the initial and the revised versions of the proposed Senate Republican health plans.

To start debate, Mr. McConnell can afford to lose only two Republican votes — or just one if Mr. McCain is absent. It was unclear on Thursday whether Mr. McCain would be able to travel to Washington in the near future, and Senator Susan Collins of Maine remained firmly in opposition, barring a drastic change in the direction of the Senate’s efforts. She said the Senate should hold hearings on the problems with the Affordable Care Act and try to produce bipartisan bills on the subject.

“As long as we are fundamentally changing Medicaid and taking some $700 billion out of the program, I do not see myself voting for a bill that does that,” Ms. Collins said. “And to do that without holding a single hearing on what the implications would be for some of our most vulnerable citizens, for our rural hospitals and our nursing homes, is not an approach that I can endorse.”

The budget office said the latest version of the Senate bill would cut projected federal spending on Medicaid by $756 billion in the coming decade, and in 2026, it said, 15 million fewer people would be enrolled in Medicaid, compared with current law.

Senators from states that have expanded Medicaid worry about the loss of coverage. To address those concerns, Republican leaders are considering a proposal to add $200 billion to the bill to help reduce the costs of private insurance for people who lose Medicaid.

“It sounds like a lot of money, and it is a lot of money,” said Senator Christopher S. Murphy, Democrat of Connecticut. But he said it represented just a slice of the funds that are being cut and described it as only “a temporary Band-Aid on a much bigger problem.”

The budget office has yet to take into account a provision that would allow insurers to offer low-cost, stripped-down insurance plans, an idea that has been pushed by Senator Ted Cruz, Republican of Texas, and is critical to winning his vote and that of another conservative, Mike Lee of Utah.

Mr. Cruz’s proposal was included in a version of the bill released last week, but it has been assailed by the insurance industry. The provision was omitted from the latest version of the bill that was released on Thursday, but congressional aides said that was because an assessment from the budget office was not ready yet, not because the proposal had been jettisoned.

The budget office did have good news about the latest version’s fiscal impact: It would reduce federal budget deficits by a total of $420 billion over 10 years, about $100 billion more than an earlier version of the legislation. The change resulted mainly from the decision of Senate leaders to keep two taxes on high-income people that were imposed by the Affordable Care Act, but that would have been eliminated under the earlier version.

The latest version of the Senate bill would increase average insurance premiums by about 20 percent next year for a typical “benchmark plan,” the budget office estimated, but would reduce premiums after 2019, so that in 2026 premiums for a benchmark plan would be about 25 percent lower than under current law.

But, the budget office said, the Senate bill could sharply increase deductibles, raising the amount that a person would pay out of pocket for most services before insurance made any contribution. For a single person, it said, the annual deductible could soar to $13,000 in 2026. That could push many lower-income Americans into the ranks of the uninsured.

“Because a deductible of $13,000 would be a large share of their income, many people with low income would not purchase any plan even if it had very low premiums,” the budget office said.

Moreover, the budget office said, even though average premiums for a standard benchmark plan would fall after 2019, many older people would face substantial increases in premiums.

For example, it said, the net premium, after tax credits, for a midlevel “silver plan” for a 64-year-old person with annual income of $26,500 would be $5,500 a year in 2026, more than three times the amount projected under current law.

Trump Plan Might Cut Expenses For Some Insured Patients With Chronic Needs

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Erin Corbelli takes three medications to treat high blood pressure, depression and an anxiety disorder. Her health plan covers her drugs and specialist visits, but Corbelli and her family must pay a $3,000 annual deductible before the plan starts picking up any of that tab.

Corbelli’s insurance is linked to a health savings account so that she and her husband can put aside money tax-free to help cover their family’s drug and medical expenses. But there’s a hitch: Plans like theirs can’t cover any care for chronic conditions until the deductible is satisfied.

Those out-of-pocket expenses could shrink under a Trump administration draft executive order that would change Internal Revenue Service rules about what care can be covered before the deductible is met in plans linked to health savings accounts, or HSAs.

“It would save us a lot of money,” said Corbelli, 41, who lives in Orlando with her husband and their two children, ages 3 and 5.

Health plans with deductibles of thousands of dollars have become increasingly commonplace. Plans often cover services like generic drugs or doctor visits before consumers have satisfied their deductibles, typically requiring a copayment or coinsurance rather than demanding that consumers pony up the entire amount.

But plans that link to health savings accounts have more restrictions than other high-deductible plans. In addition to minimum deductibles and maximum HSA contribution limits, the plans can’t pay for anything but preventive care before consumers meet a deductible. Under current IRS rules, such preventive care is limited to services such as cancer screenings and immunizations that prevent a disease or condition, called “primary prevention.” With HSA-eligible plans, medical services or medications that prevent an existing chronic condition from getting worse or prevent complications from occurring — called “secondary prevention” — can’t be covered before the deductible is paid.

The Trump administration’s draft executive order, which was first obtained last month by The New York Times and has yet to be issued, would allow such secondary preventive services to be covered.

Under the Affordable Care Act, most health plans, including HSA-eligible plans, are required to cover services recommended by the U.S. Preventive Services Task Force without charging consumers anything for them. That requirement is generally limited to primary prevention.

“We know health savings accounts are here to stay and we’d like to make them better,” said Dr. A. Mark Fendrick, an internist who is director of the University of Michigan’s Center for Value-Based Insurance Design and who has advocated for the change.

If people have diabetes, for example, they need regular eye and foot exams to prevent complications such as blindness and amputations down the road. But HSA plans can’t pay anything toward that care until people satisfy their deductible. “The executive order gives plans the flexibility to do that,” he said.

Similarly, it’s critical to remove obstacles to treatment for people like Corbelli with high blood pressure or heart disease, said Sue Nelson, vice president for federal advocacy at the American Heart Association.

“For people with cardiovascular disease, affordability is their No. 1 concern,” Nelson said.

The draft executive order is short on details, and administration officials would have to determine which new preventive services should be covered pre-deductible. Guidelines from medical specialty boards and quality metrics that many physicians are already being measured against could be used, said Roy Ramthun, president and founder of HSA Consulting Services who led the Treasury Department’s implementation of the HSA program in the early 2000s.

Back then, they took a conservative approach. “We said we can be more flexible later, but we can’t put the genie back in the bottle,” said Ramthun, who supports expanding preventive services coverage.

Many more employers would offer HSA-eligible plans if the list of services that could be covered pre-deductible were expanded, said Tracy Watts, a senior partner at human resources consultant Mercer. Fifty-three percent of employers with 500 or more workers offer HSA-eligible plans, according to Mercer survey data. Three-quarters of employers put money into their employees’ HSA accounts, she said.

Erin Corbelli’s husband’s employer contributes up to $1,500 every year to their health savings account, which can help cover their pre-deductible costs.

Not everyone is so fortunate. “You’re kind of at the mercy of what your employer can offer and what your disposable income is,” she said.

Republicans have long advocated for the expanded use of health savings accounts as a tax-advantaged way for consumers to get more financial “skin in the game.”

Consumer advocates have been much less enthusiastic, noting that the accounts typically benefit higher-income consumers who have cash to spare.

Still, given the reality of the growing prevalence of high-deductible plans, with or without health savings accounts, it’s a sensible proposal, many say.

“This is not a silver bullet or a solution to the problems that high-deductible plans can pose,” said Lydia Mitts, associate director of affordability initiatives at Families USA, an advocacy group. “But this is a good step in thinking about how we offer access to treatment people need in a timely and affordable way.”

As repeal and replace falters, more say GOP should abandon repeal plan

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A new CNN poll conducted by SSRS finds a growing share of Americans want to see the GOP abandon its effort to repeal and replace the 2010 health care law known as Obamacare, as majorities across party lines want congressional Republicans to aim for a bill with bipartisan support.

Overall, 35% in the poll say they’d like President Donald Trump and the Republicans in Congress to give up their plans for repealing and replacing Obamacare, up from 23% who said the same in a March survey.
A majority still favor some form of repeal (34% would prefer repeal with replacement at the same time, and 18% favor repeal regardless of whether the law is replaced at the same time). The share in favor of repeal without replacement has held roughly steady since March; it remains the least popular option.
But public preferences are shifting away from repealing the law and enacting replacements concurrently (down from 59% in March), and more now say they’re unsure how they want Republican leaders to proceed (13% say so in the new poll).
Trump to GOP senators: ‘Inaction is not an option’
Increases in support for abandoning repeal have come largely among groups that aren’t central to the GOP’s base: Younger adults, non-whites and those with lower incomes have become notably more supportive of leaving the ACA as is.
On the growing uncertainty, the percentage of respondents in a poll who say they don’t know how they feel about an issue is often related more to the methodology and administration of the survey than to real uncertainty about an issue, however, given the real-life uncertainty about the Senate’s plan to replace the ACA while the poll was in the field, in this case, it’s possible there’s been a meaningful increase in unknown feelings about the law itself.
The poll also finds that with several failed efforts at repealing and replacing the bill in the rear view mirror, about half think it’s likely the President and Republicans in Congress will ultimately be able to reach a deal to repeal and replace Obamacare. That’s down from 58% who felt it was likely in an April CNN/ORC survey, but remains above the share who say it’s unlikely the ACA will be repealed and replaced (41%).
Republicans themselves remain optimistic that their party’s leaders in the White House and Congress will be able to come together to achieve this long-standing goal, 78% say it’s very or somewhat likely to happen, but less than half of independents or Democrats agree.
Overall, almost eight in 10 in the new poll say they’d like Republicans in Congress to try to work with Democrats to pass a health care bill that has bipartisan support (77% say so). Just 12% favor continuing to try to pass a bill that only has GOP backing. Even among Republicans, only about a quarter favor an approach that only has the backing of Republican lawmakers.
Interviewing for the CNN poll conducted by SSRS was completed July 14-18 among a random national sample of 1,019 adults. The survey included 405 respondents reached on landline telephones and 614 reached on cellphones. The margin of sampling error for the full sample is plus or minus 3.7 percentage points.

 

Podcast: On the failed health care bill

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Molly Reynolds, a fellow in Governance Studies, describes why it has been so difficult for Senate Republicans to even begin writing legislation to repeal and replace Obamacare and outlines the uncertainties in the future of national health care policy.

 

 

AHCA savings, $487 billion in Medicare cuts remain in House budget proposal

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The House Budget Committee on Wednesday agreed to bake in hundreds of billions in Medicaid cuts from its ACA repeal bill to the budget resolution, plus an additional $114 billion in cuts over 10 years.

The committee’s Republicans’ unanimously approved the decision with no Democrats on board. The budget resolution, which is the foundation for passing tax reform in the Senate without Democratic votes, also assumes Medicare will reduce spending by $487 million from 2018 to 2027.

Some of the additional savings would come from imposing a work requirement on Medicaid adult beneficiaries who are younger than 65 and are not on Social Security disability as a condition of eligibility.

The Medicare savings are built on an idea long-favored by Republicans — using vouchers to buy insurance, though Republicans say future beneficiaries will have the option to buy traditional Medicare too. Democrats during Wednesday’s hearing complained that traditional Medicare would cost 25% more than it does now if vouchers come into play.

The Republicans also included savings that would stem from raising the Medicare eligibility age for future beneficiaries who are 51 or younger. Under the proposal, those individuals would not become eligible for full Social Security benefits or Medicare until the age of 67. The Congressional Budget Office has estimated that would reduce Medicare spending by 2% once everyone in the program is covered by the later eligibility age.

The proposal includes a requirement that affluent seniors pay higher premiums, and that people with incomes of $1 million or more pay the full cost of Medicare premiums without any federal subsidy.

Rep. Matt Gaetz, R-Fla., said during the hearing that the proposed changes are based on math rather than Tea Party politics, as some have alleged.

The Republican spending outline also assumes the government will do better at recouping or avoiding improper payments. The proposal said that there was $59.7 billion in improper Medicare payments in in the last fiscal year, and $36.3 billion in improper Medicaid payments. The outline assumes future improper payments will be 50% lower than today’s levels.

Rep. Debbie Wasserman-Schultz, D-Fla., introduced an amendment that would have changed the resolution so that it no longer assumed American Health Care Act changes would be future law, citing the Senate bill’s collapse this week.

But every Republican present on the committee voted against the amendment. “This is the official position of the House on repeal and reform efforts,” said Rep. Bill Johnson, R-Ohio.

The budget resolution also includes a reduction in health spending of $43.9 billion over 10 years, the CBO estimate of how much the malpractice reform bill that passed the House would save.

Ranking Member John Yarmuth, D-Ky., called the budget disgraceful and others called the cuts to Medicare, Medicaid and food stamps draconian, several Republicans worried what it envisions might not come to pass.

“We might fail to achieve savings in mandatory spending,” which includes Medicaid and Medicare, Johnson said, noting that the budget resolution might make it harder to pass tax reform in the Senate.

The first hurdle, however, is for the resolution to pass the entire House of Representatives.