Kaiser Health Tracking Poll – August 2017: The Politics of ACA Repeal and Replace Efforts



  • The August Kaiser Health Tracking Poll finds that the majority of the public (60 percent) say it is a “good thing” that the Senate did not pass the bill that would have repealed and replaced the ACA. Since then, President Trump has suggested Congress not take on other issues, like tax reform, until it passes a replacement plan for the ACA, but six in ten Americans (62 percent) disagree with this approach, while one-third (34 percent) agree with it.
  • A majority of the public (57 percent) want to see Republicans in Congress work with Democrats to make improvements to the 2010 health care law, while smaller shares say they want to see Republicans in Congress continue working on their own plan to repeal and replace the ACA (21 percent) or move on from health care to work on other priorities (21 percent). However, about half of Republicans and Trump supporters would like to see Republicans in Congress keep working on a plan to repeal the ACA.
  • A large share of Americans (78 percent) think President Trump and his administration should do what they can to make the current health care law work while few (17 percent) say they should do what they can to make the law fail so they can replace it later. About half of Republicans and supporters of President Trump say the Trump administration should do what they can to make the law work (52 percent and 51 percent, respectively) while about four in ten say they should do what they can to make the law fail (40 percent and 39 percent, respectively). Moving forward, a majority of the public (60 percent) says President Trump and Republicans in Congress are responsible for any problems with the ACA.
  • Since Congress began debating repeal and replace legislation, there has been news about instability in the ACA marketplaces. The majority of the public are unaware that health insurance companies choosing not to sell insurance plans in certain marketplaces or health insurance companies charging higher premiums in certain marketplaces only affect those who purchase their own insurance on these marketplaces (67 percent and 80 percent, respectively). In fact, the majority of Americans think that health insurance companies charging higher premiums in certain marketplaces will have a negative impact on them and their family, while fewer (31 percent) say it will have no impact.
  • A majority of the public disapprove of stopping outreach efforts for the ACA marketplaces so fewer people sign up for insurance (80 percent) and disapprove of the Trump administration no longer enforcing the individual mandate (65 percent). While most Republicans and Trump supporters disapprove of stopping outreach efforts, a majority of Republicans (66 percent) and Trump supporters (65 percent) approve of the Trump administration no longer enforcing the individual mandate.
  • The majority of Americans (63 percent) do not think President Trump should use negotiating tactics that could disrupt insurance markets and cause people who buy their own insurance to lose health coverage, while three in ten (31 percent) support using whatever tactics necessary to encourage Democrats to start negotiating on a replacement plan. The majority of Republicans (58 percent) and President Trump supporters (59 percent) support these negotiating tactics while most Democrats, independents, and those who disapprove of President Trump do not (81 percent, 65 percent, 81 percent).
  • This month’s survey continues to find that more of the public holds a favorable view of the ACA than an unfavorable one (52 percent vs. 39 percent). This marks an overall increase in favorability of nine percentage points since the 2016 presidential election as well as an increase of favorability among Democrats, independents, and Republicans.

Trump to GOP: Get Obamacare repeal bill done


Image result for beating a dead horse

President Donald Trump renewed his call for Senate Republicans to take another crack at dismantling Obamacare, saying Thursday it’s a “disgrace” that they failed to pass a repeal bill.

“They lost by one vote,” Trump said from his Bedminster, New Jersey, golf course. “For a thing like that to happen is a disgrace.”

The president has hectored Senate Republicans for days over their collapsed health care effort, most recently singling out Majority Leader Mitch McConnell for criticism.

“I just want him to get repeal and replace done,” Trump told reporters, when asked about his multi-day string of tweets attacking the Kentucky Republican over health care. “It’s almost two years, and all I hear is repeal and replace. And I get there, and I said where’s the bill? I want to sign it.”

McConnell has suggested that the GOP should move on from health care after falling just short of the 50 votes he needed to pass a “skinny” repeal bill, and instead focus on tax reform. And earlier this week, McConnell said Trump has “excessive expectations” about how quickly Congress can pass legislation.

But Trump demanded that Republicans follow through on their agenda, suggesting further failure could cost McConnell his job atop the Senate GOP.

“If he doesn’t get repeal and replace done, and if he doesn’t get taxes done, meaning cuts and reform, and if he doesn’t get a very easy one to get done, infrastructure, he doesn’t get them done, then you can ask me that question,” Trump said.


Taxpayers Will Pay the Price for Uncertainty Over Obamacare in 2018


The health insurance industry remains in the throes of a largely unnecessary crisis of confidence, according to an analysis released by the Kaiser Family Foundation on Thursday.

With the open enrollment period approaching for Obamacare insurance plans sold through state exchanges, Kaiser Foundation experts were able to analyze the proposals for 2018 submitted by insurance companies to 20 states and the District of Columbia — the only places where enough information is made public to allow an assessment of what health care costs would look like for an average policyholder under the insurers’ requested rate structures.

“Insurers attempting to price their plans and determine which states and counties they will service next year face a great deal of uncertainty,” the authors wrote. “They must soon sign contracts locking in their premiums for the entire year of 2018, yet Congress or the Administration could make significant changes in the coming months to the law – or its implementation – that could lead to significant losses if companies have not appropriately priced for these changes. Insurers vary in the assumptions they make regarding the individual mandate and cost-sharing subsidies and the degree to which they are factoring this uncertainty into their rate requests.”

What that means for consumers is a bit of a mixed bag. Almost all insurers are seeking rate increases, with some approaching a 50 percent jump. But the actual impact on consumers varies depending on where they buy their insurance and how much money they earn. One thing is for sure, though: The federal government, and therefore taxpayers, will be on the hook for larger subsidy payments.

Because the majority of Americans obtain health insurance through an employer-sponsored plan or from federal programs like Medicare and Medicaid, the impact of the premium increases of exchange-based policies will mean little to a large element of the population.

Of those who buy insurance on the exchanges, the overwhelming majority receive tax credits meant to keep their premium payments to a specific fraction of their annual income. The remaining 16 percent, depending on their income, receive either a smaller subsidy or no subsidy at all. It is these people who, if they live in some of the regions facing large premium increases, who will be hurt the most.

The Kaiser study gathered information from the largest city in each of the 20 states plus the District of Columbia. (Benchmark levels for tax credits are based on the second-cheapest Silver Level plan available in the largest city in a state.) They estimated the change in costs for a 40-year-old non-smoker earning $30,000 a year.

In only one state was the annual premium expected to fall in 2018: Rhode Island, which anticipates a 5 percent drop. Vermont’s premiums will remain static in 2018 if the data holds. The other 19 states can all expect increases, from a modest 3 percent in Michigan to a whopping 49 percent in Delaware.

The average increase in the data collected by Kaiser is 17 percent.

However, none of those costs would be passed on to the consumer making $30,000 a year. In fact, because of adjustments to the tax credit, he could expect to see monthly costs fall by 3 percent, to $201, next year, regardless of what premium levels do where he lives.

But somebody has to pay when premiums go up, and if it isn’t the consumer, it’s the Treasury and by extension, the taxpayer.

The change in premium payments required to keep that 40-year-old’s health insurance premium at $201 per month will increase very sharply in many states, depending greatly on how far from the premium cap a silver plan was in 2017.

In Washington State, according to Kaiser, the premium tax credit would increase 239 percent, from $31 per month to $105. In New Mexico, it would jump 183 percent, from $51 to $144. In Rhode Island it would fall 13 percent, while in Vermont it would rise a modest 2 percent. On average, though, the amount of premium payment picked up by the federal government will increase by about 63 percent in the states reviewed by Kaiser.

Perversely, as Kaiser points out, that fiscal wound is largely self-inflicted. While it is impossible to gauge just how much of this year’s rate increases are attributable to insurers being nervous about whether the federal government would slash support payments in the middle of the 2018 policy year, the answer is surely non-trivial, and the dollars are coming out of the pockets of taxpayers.

Carper cast as governors’ lobbyist in health care debate


Image result for Carper cast as governors' lobbyist in health care debate

When Sen. Tom Carper was shopping for votes to block GOP health care bills, he didn’t just turn to his fellow senators. He turned to their governors.

A self-described “recovering governor,” himself, the Delaware Democrat carried out a communications blitz – calling, texting, emailing – and made contact with up to half of them. He skipped out on a Democratic campaign retreat to make a case at the National Governors Association summer meeting in Rhode Island.

His message: The legislation will hurt your states. Put your opposition in writing so the Senate can pause, work together to stabilize the insurance exchanges, and return to “regular order,” with hearings, bipartisan amendments — and input from governors, he said.

Delaware’s senators are bullish that debate over health care will turn to fixing the Affordable Care Act after the Senate early Friday morning defeated a proposal to repeal parts of the landmark law. 7/28/17 Damian Giletto/The News Journal

“He came up and spent a morning discussing the ins and outs, the details of health care changes,” Colorado Gov. John Hickenlooper, a Democrat, said on CBS’s “Face the Nation” Sunday.

Ohio Gov. John Kasich, a Republican, speaking on the same show, said, “Tom Carper from Delaware has been unbelievable in terms of his looking at trying to solve this problem.”

Carper believed that governors’ objections would be key to blocking the GOP effort to repeal and replace Obamacare, and it turned out they were. Even Sen. John McCain of Arizona, one of three Republicans who helped sink the GOP’s last-ditch effort, repeatedly highlighted his governor’s concerns.

Senate Minority Leader Charles Schumer of New York tapped Carper to lead outreach efforts to governors in early July when Carper complained that their voices weren’t being heard. In the health care drama, where there were many players, Democrats’ casting of Carper as the lead governors’ lobbyist made sense. He’s a former NGA chairman who loves the organization (and is prone to gushing about it).

“Tom Carper was really our point person with the governors, he kind of managed it,” said Sen. Tim Kaine, a former Democratic governor of Virginia. “He played a very important role in all of this. And the governors themselves, their voices were very important.”

Several days before the NGA summer meeting, Carper learned administration officials would discuss GOP health care proposals with the governors and was alarmed to discover that no one was scheduled to present the opposing view. He wangled an invitation to speak on a closed-door panel on July 15 alongside Seema Verma, administrator of the Centers for Medicare and Medicaid Services, and Secretary of Health and Human Services Tom Price.

“(Carper) was spreading this word that we should do this together, that people shouldn’t be hurt who are not in a position of being able to help themselves,” Kasich, an opponent of the GOP health care bills, said in an interview with USA TODAY. “And it was a message of slow down and let’s get this right. At no time did he ever say we should do nothing.After that, Carper kept contact information for every governor by his side, calling them during free moments between hearings and meetings. They discussed how the legislation would impact states’ Medicaid expansions, for example, or how a straight repeal of Obamacare would impact the states.

When he couldn’t reach Arizona Gov. Doug Ducey, a Republican, he said he talked several times to his Medicaid director and to his chief of staff. He said he spoke with Kasich “a dozen times or more.”

“One night he called me and it was like 10:30 at night,” Kasich said. “He was relentless in terms of what he did. And do I think he made a difference? I have no doubt that he did. Did he switch anybody? You don’t know. Did he have some people that would have not voted for this had McCain not voted ‘no,’ I just can’t tell you. But he deserves a lot of credit for being a really good public servant, keeping in mind the people that he serves.”

Carper said his outreach efforts helped him develop trust with governors “and just to let them know if they are interested in finding a path forward, they have a number of Democratic senators… who want to find common ground.”

Three days after Carper’s pitch at the NGA meeting, Kasich, Hickenlooper and nine other bipartisan governors who had been vocal about their concerns issued a statement opposing efforts to repeal the current system and replace it later. The statement, which Kasich said had been in the works for a while, called for governors to be included in the next steps.

“The best next step is for both parties to come together and do what we can all agree on: fix our unstable insurance markets,” they wrote.

They may be getting their wish, and so may Carper.

After the GOP’s three legislative failures, the Senate Health, Education, Labor and Pensions Committee announced it would begin hearings in September on ways to stabilize the individual health insurance market. The committee will hear from a wide range of stakeholders, including governors.

Moving forward, Carper said “the stage has been set” for better, more affordable health care coverage. Though he isn’t on the HELP Committee, he believes he can play a role in bipartisan discussions on health care.

“The key now is for the Senate to do its job,” Carper said.

It’s not Obamacare anymore. It’s our national health-care system.


Image result for how the obamacare repeal failed in two minutes

Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation. Larry Levitt is senior vice president of the Kaiser Foundation.

Republicans failed to repeal and replace the Affordable Care Act early Friday because of divisions within their own ranks, and because they tried not only to repeal and replace the ACA but also to cut and cap the Medicaid program, generating opposition from many red-state governors and their senators.

But most of all, they failed because they built their various plans on the false claim — busted by the Congressional Budget Office — that they could maintain the same coverage levels as the ACA and lower premiums and deductibles, while at the same time slashing about a trillion dollars from Medicaid and ACA subsidies and softening the ACA’s consumer protection regulations. Had they succeeded, they would have won a big short-term victory with their base, which strongly supports repeal, but suffered the consequences in subsequent elections as the same voters lost coverage or were hit with higher premiums and deductibles.

The challenge now is to stabilize the ACA’s insurance marketplaces. They are not in free fall or imploding, as President Trump suggests, and in most markets insurer profits have been improving. But these are fragile markets, especially in rural areas, and there are 38 “bare counties” where no insurer currently intends to participate in 2018. About 20 percent of marketplace enrollees have access to only one insurer, with the biggest problems in rural areas.

Senate Republicans failed to pass their ‘skinny bill’ that would repeal parts of the Affordable Care Act on July 28. Three republicans, including Sen. John McCain (R-Ariz.), voted against the bill. (Video: Amber Ferguson/Photo: Melina Mara/The Washington Post)

Insurers have submitted their initial rates to state regulators for 2018, and in some areas, the increases are steep. These companies are hedging their bets in the face of uncertainty emanating from Washington, and who can blame them? Now, with ambiguity over legislative action to repeal and replace the law lifted, the remaining uncertainty is whether Congress and the administration will take steps to stabilize markets or instead undermine them.

The immediate question is whether the administration will implement the law as intended or, in a sense, enact “skinny repeal” through administrative action. To stabilize the marketplaces, the administration would need to enforce the individual mandate as intended, commit to providing payments to insurers that compensate for reducing cost-sharing for low-income enrollees, and continue to provide outreach funds to support enrollment and consumer education activities.

Insurers need to finalize their 2018 rates soon and sign contracts with the federal marketplace by the end of September, so clarity on the $7 billion in cost-sharing payments to insurers is key. If they’re not made, insurers will need to raise premiums by about 19 percent, or they might just decide to exit the market entirely. These payments are subject to a lawsuit filed the House, so Congress might need to step in and assure that the payments will continue.

It is unclear whether Republicans and Democrats can work together on narrow legislation to stabilize the marketplaces without once again opening up a broader debate about the ACA. Republican bills included significant federal funds to help insurers cover the cost of high-risk patients, an idea that was also part of the ACA for its first three years of implementation. These reinsurance or risk-sharing pools would bring premiums down, especially for middle-class consumers not eligible for tax credits in the marketplaces, a primary goal for both parties.

Conservatives may be resistant to such spending, so Congress might also consider ideas they advocated in the recent debate, such as allowing premiums to be paid from health savings accounts. This, too, would provide premium relief to middle-class people buying their own insurance.

Still, only 7 percent of the American people get their insurance through the individual market. Finding consensus on the narrow issue of stabilizing this slice of the health insurance system should be possible if the larger, partisan debate about Obamacare is truly over.

It is also possible as the smoke clears on the health-care battlefield that more states will want to move forward with Medicaid expansions, now that federal funding for those expansions appears secure. Red states will likely seek a conservative stamp on their expansions, adding elements such as work requirements, drug testing, premium payments, time limits or testing private insurance models. Some of these policies will be controversial, and others may stretch what’s allowed under federal law too far. But some wrinkles will no doubt be necessary if Medicaid is to be expanded to the millions of people in the 19 holdout states.

But one thing is clear: 59 percent of the public says President Trump and the Republicans are now in control of government and are responsible for making the ACA work, and 74 percent says they should “do what they can to make the law work.”

It’s apparent what needs to be done to stabilize the marketplaces and who owns the ACA going forward. It’s no longer Obamacare; it’s now just the nation’s health insurance system.

Scripps CEO Chris Van Gorder responds to healthcare vote


Image result for chris van gorder

When Sen. John McCain, R-Ariz., cast his decisive vote Thursday night to stall GOP efforts to repeal the ACA, Chris Van Gorder, president and CEO of San Diego-based Scripps Health, took it not as a rejection of specific policies but instead a rejection of partisan politics.

In a written statement, Mr. Van Gorder emphasized that while healthcare has been subject to divisive political rhetoric during recent reform efforts, it is vital not to lose sight of the actual goal of healthcare professionals — to provide patients with quality care.

“The health care vote in Washington is important, but not as important as what we do every day and ensuring we’re able to do it,” says Mr. Van Gorder. “For now at least, the ACA will continue with its current provisions for care delivery. Despite its challenges with reduced reimbursements, this will provide us some increased stability as we plan for the future.”

Mr. Van Gorder points out that the political process is vital to deciding how care is paid for and delivered, and he encourages politicians to work across the aisle to craft legislation that provides Americans with robust coverage.

“That said, when it comes to health care legislation, representatives from both parties agree the ACA needs to be changed. But any healthcare bill passed unilaterally by one party — whether it’s the ACA in 2010 or repeal/replace in 2017 — will not stand the test of time,” said Mr. Van Gorder. “Something as complex, life changing and personal as healthcare deserves thoughtful consideration and debate and a true dialogue with those on the front lines of health care delivery.”

Republicans learn the limits of reconciliation with failed ACA repeal


Image result for Republicans learn the limits of reconciliation with failed ACA repeal

With late night drama not often seen on the Senate floor, Republicans’ latest attempts to pass a bill repealing the Affordable Care Act failed last night, thanks in part to a divide the party’s congressional leaders, especially in the Senate, could simply not bridge.

In Congress, we expect that the majority party’s choices about what to work on and how to work on it will be guided, in large part, by their desire to maintain and grow their majority in the future. As the process went on over the past several months, it became increasingly clear that, for the current GOP leadership, what they thought was best for the party’s collective fortunes was adopting something that they could credibly claim “repeals Obamacare.” After all, doing so has been one of their central campaign promises since the law was adopted in 2010—and what helped account for some of their electoral success since that time. The content of the narrow bill to which Senate Republicans retreated in an attempt to keep the process moving reflects this priority, in that it contained symbolic provisions that would be easy for voters to understand as “Obamacare repeal” should the bill have ultimately become law. Chief among these provisions was the repeal of the requirement that individuals purchase health insurance, known as the individual mandate. This provision is among the law’s best known and the change in the Senate bill would have been easy for voters to understand. Under Obamacare, they were required to do something; under the Republican bill, they would not have been.

At the end of the day, however, individual Senate Republicans concluded that even if leaders had judged that “repealing Obamacare” was in the best interests of the party collectively, they could not support the different proposals drafted to actually get there. This was perhaps most true of Senators Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), who opposed beginning debate and all three alternative proposals considered this week. There were also, however, 11 other senators who voted no on at least one of the alternatives offered this week. While some of those votes may have been strategic, as members knew that the proposal would not ultimately be enacted, they do help illustrate the persistent divides within the Republican Party about the best way to proceed on health policy. In an era of high party polarization and a well-sorted electorate, this kind of cross-pressuring, where what’s good for the party is not necessarily good for the individual member, is less common than it once was. But as the experience of the last few months suggests, those situations can still and do arise.

While the choice by Republicans to pursue their collective goal of “repealing Obamacare” through the fast-track budget reconciliation process meant that Senate Majority Leader Mitch McConnell (R-Ky.) only needed to find 50 votes, it also constrained his task in important ways. The rules of the budget process, including the Byrd Rule, place restrictions on the content of reconciliation bills and amendments to them. While it can be difficult to know exactly how these rules shape a particular piece of legislation, one consequence of them is that leadership does not necessarily have as much room to maneuver in terms of deal-making as they might have on other bills. What’s more, by turning to a process that did not require the support of any Democrats to move forward, Republicans could not rely on the opposition of the other party as a useful foil while they sought to build a winning coalition. Instead, all attention was focused on the party’s internal conflicts and inability to reach agreement—a task made harder by the presence of a same-party president without the policy expertise or interest to help broker the necessary deals. Special legislative procedures that prevent filibusters, in sum, can help majority parties get legislative wins, but only if the party agrees internally on the policy particulars of what that win should look like.

As an agenda item, health care generally and Obamacare specifically aren’t going anywhere any time soon. The Children’s Health Insurance Program, which covered about 9 million children in 2016, needs to be reauthorized by the end of September, and uncertainty about the continued payment of certain subsidies for some Obamacare enrollees on the individual marketplace remains. But with a range of other major issues needing action in the coming weeks—including spending bills and the debt ceiling—Republicans appear ready to move on from their legislative pursuit of their biggest collective goal of recent years.