House Republicans left for spring break last week, without reaching a deal to repeal and replace the Affordable Care Act. Their bill to overhaul the health care system collapsed on the House floor last month, amid divisions in the caucus.
Even without Congress, however, President Trump has the authority to modify important provisions of the health law, including many that House Republicans sought to change or repeal. Here are some examples of actions he could take (or has already taken):
Premiums, insurer choice, and overall stability of 2018 Affordable Care Act (ACA) marketplaces could be affected by decisions from Congress and the Trump Administration on the health law’s cost-sharing reduction provision. With a legal appeal pending on a lawsuit from the U.S. House, the federal government and Congress are in a position to choose whether to continue reimbursing insurers for the subsidies, which were established as part of the ACA to reduce out-of-pocket costs for lower-income people buying plans through the marketplaces. Failure to continue the payments would not only disrupt the marketplaces, but it also might signal a more obstructionist approach to the ACA, following House Republicans’ failed attempt at repeal. Continuing the payments could help to avoid further exits and premium increases by insurers.
On Thursday, April 6, the Kaiser Family Foundation hosted a web briefing for the media to explain how the cost-sharing reduction program works, where it stands now, and how consumers could be affected by either choice from the federal government. Panelists presented new analysis on the magnitude of the cost-sharing payments and how much premiums would have to rise in different states to compensate for insurers’ loss of federal funding.
Panelists included Gary Claxton and Larry Levitt, co-executive directors of the Foundation’s Study of Health Reform and Private Insurance. Rakesh Singh, the Foundation’s vice president of communications, moderated the discussion.
https://www.axios.com/a-warning-from-the-polls-about-letting-obamacare-explode-2347777457.html
President Trump has said the Democrats will take the fall politically if and when Obamacare “explodes.” But new polling shows that the public will hold Trump and the GOP accountable for failing to address problems in the marketplaces, not the Democrats. That means they’ll have to think twice about some of the moves they might make that could make the Affordable Care Act’s problems worse.
What’s on the line: The polling has direct implications for some of the specific actions Republicans could take, or not take, in the months ahead:
These steps would cause insurers to exit the non-group market, cause premiums to spike, and could leave millions without affordable coverage.
As the chart from our latest tracking poll shows, 62% of the public say Trump and the Republicans in Congress are in charge of the government and are responsible for problems with the ACA from now on; just 31% say President Obama and the Democrats are responsible. As is always the case with the ACA, there are party differences; 81% of Democrats and 65% of Independents said Trump and the Republicans “own it”, but just 35% of Republicans feel that way.
Trump has also said that the collapse of the ACA would bring Democrats to the table to forge a new “deal” with him on health care. That’s not impossible, but it seems unlikely: it’s hard to think of a single major element of health reform where the Democrats agree with the president and the Republicans.
As we saw when the Freedom Caucus refused to support the American Health Care Act because it wasn’t conservative enough for them, the substance and the details matter to policymakers far more than they appear to the President. He has suggested that he mostly wants a deal on health care.
Basic rules of politics seem to be holding up pretty well in the fights over the ACA. One rule, that benefits once conferred on the American people cannot be taken away, was a primary reason for the collapse of the GOP health care plan. The other: If severe problems develop in the marketplaces, or are caused by actions the administration takes to undermine the law, the party in charge gets the blame.
For years, Republicans vowed that if they ever got control of the White House and both houses of Congress, the Affordable Care Act would quickly end up in the trash heap. As of January 20, those pieces were firmly in place.
Yet nearly 3 months later, the GOP appears no closer to enacting a repeal-and-replace bill than they were when Barack Obama was sitting in the Oval Office.
House Republican leaders have been unable to forge a consensus among its conservative and moderate wings as to what should come after the ACA. One bill had to be pulled from a floor vote when it became clear that neither the GOP’s Freedom Caucus nor Democrats would support it. And, earlier this week, a push led by top administration officials to appease the Republican conservatives — by making certain ACA elements retained in the GOP plan optional for states — was quickly declared dead on arrival.
MedPage Today asked physicians and policy experts why President Obama’s signature legislation is so hard to kill and whether Republicans might give up trying.
“Advocacy against the AHCA [American Health Care Act, the GOP’s initial repeal-and-replace bill] was broad and intense, with health care and public health organizations repeatedly raising concerns about health insurance coverage, access, and costs, including proposed dramatic changes to Medicaid funding that would preferentially hurt low-income people (including children), and risks of coverage gaps for those with chronic and pre-existing conditions,” wrote Jan Carney, MD, MPH, associate dean for public health and professor of medicine at the University of Vermont in Burlington, Vt., in an email.
Carney underscored the importance of the Congressional Budget Office’s report projecting a dramatic increase in the number of uninsured Americans — 14 million more in 2018 and 24 million more in 2026.
She also highlighted an April 4 Kaiser Family Foundation poll, which found 75% of Americans felt that Congress should work on fixing the ACA instead of repealing it.
https://www.nytimes.com/aponline/2017/04/10/us/politics/ap-us-health-overhaul-shifting-focus.html
Move over, “Obamacare.” The health care debate has shifted to ideas from President Donald Trump and GOP lawmakers in Congress, and most people don’t like what they see.
With Republicans in command, their health care proposals as currently formulated have generated far more concern than enthusiasm.
Even among rank-and-file Republicans, there’s opposition to changes that would let insurers charge higher premiums to older adults, and many disapprove of cuts to Medicaid for low-income people, according to a recent poll by The Associated Press-NORC Center for Public Affairs Research. It also found more than half of Republicans at least somewhat worried about leaving more people uninsured, as the House plan is projected to do.
March polls by Fox News and Quinnipiac University showed overall margins of opposition to the GOP bill nearing or even exceeding those of the Obama-era Affordable Care Act, or ACA, at its lowest points — such as when the HealthCare.gov website went live in 2013 and promptly crashed.
“Republicans are taking ownership of the health care issue, and all the pleasure and pain of health reform,” said Drew Altman, president of the nonpartisan Kaiser Family Foundation, which tracks the health care system. “There has been a shift in focus from the ACA itself to the Republican plans, and who might lose benefits as a result.”
Highlighting the stakes, the uninsured rate among U.S. adults rose slightly in the first three months of this year, according to Monday’s update of a major ongoing survey. The Gallup-Healthways Well-Being Index found that 11.3 percent of adults were uninsured, an increase from 10.9 percent in the last two calendar quarters of 2016.
“Only time will tell” if the uptick means the U.S. is again losing ground on health insurance, said survey director Dan Witters.
“A lot of uncertainty has been introduced into the marketplace through efforts to repeal,” Witters added. “That will scare people off who have real reason to believe that the ACA won’t even exist in a year. Plus premiums are now realizing a big jump for the first time in the ACA era, so some folks may be priced out of the market even with income-based subsidies.”
Trump came into office with big, bold promises. In a Washington Post interview shortly before his inauguration he declared his goal was “insurance for everybody,” hand-in-hand with affordable coverage, “lower numbers, much lower deductibles.” Although Trump said he’d soon release a plan, none appeared.
Instead, after weeks of laboring behind closed doors, House Republican leaders rolled out a proposal March 6 that the president enthusiastically embraced. But all the efforts of the White House and congressional leadership haven’t convinced GOP lawmakers to pass it. Congress is on a two-week break with the bill in limbo.
Frustrated, Trump is seeing his promise slip away to quickly repeal “Obamacare” and replace it with something better. Instead he could get left as the caretaker of the ACA, a law he’s repeatedly called a “disaster” on account of rising premiums and insurer exits that diminish consumer choice in many communities.
Trump’s personal image has taken a blow, with the AP-NORC poll finding that he gets his worst rating on health care. About 6 in 10 people disapprove of how the president has handled the issue.
“It is a major failure that a high priority of President Trump and the congressional Republican leadership leads to no bill, and the bill as proposed becomes unpopular even among their own voters,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health, who follows opinion trends on health care. “It’s a real leadership crisis issue.”
Amid disapproval of the House GOP plan, some polls have shown improved ratings for the ACA. Gallup, for example, found “Obamacare” gained majority approval for the first time. But Republican voters remain overwhelmingly opposed to former President Barack Obama’s signature law and want it repealed.
Nonetheless, there’s recent evidence that Republicans differ among themselves about what “repeal” may mean.
A Quinnipiac poll last month found that 55 percent of Republicans said Trump and the Republican-led Congress should repeal “parts” of the ACA, while 42 percent said “all” of it should go. Only 2 percent of Republicans said the law should not be repealed.
Republican views compare with 50 percent of the general public who say parts of the ACA should be repealed, 20 percent who say all of it should be repealed, and 27 percent who say it should remain.
The divisions among rank-and-file Republicans appear to mirror those in the House, where disagreements among hardliners and moderates are keeping Speaker Paul Ryan, R-Wis., from taking the bill to the floor.
Tim Malloy, assistant director of the Quinnipiac poll, said, “You have to figure a lot of people who voted for Trump are on Obamacare.”
In contrast to the dire pronouncements from President Trump and other Republicans, the demise of the individual insurance market seems greatly exaggerated, according to a new financial analysis released Friday.
The analysis, by Standard & Poor’s, looked at the performance of many Blue Cross plans in nearly three dozen states since President Barack Obama’s health care law took effect three years ago. It shows the insurers significantly reduced their losses last year, are likely to break even this year and that most could profit — albeit some in the single-digits — in 2018. The insurers cover more than five million people in the individual market.
After years in which many insurers lost money, then lost even more in 2015, “we are seeing the first signs in 2016 that this market could be manageable for most health insurers,” the Standard & Poor’s analysts said. The “market is not in a ‘death spiral,’ ” they said.
It is the latest evidence that the existing law has not crippled the market where individuals can buy health coverage, although several insurers have pulled out of some markets, including two in Iowa just this week. They and other industry specialists have cited the uncertainty surrounding the Congressional debate over the law, and the failed effort two weeks ago by House Republicans to bring a bill to the floor for a vote.
The House G.O.P. leadership went home for a two-week recess on Thursday, unable to reach a compromise between conservative and moderate members over the extent of coverage that should be required for the very sick.
If the markets were to falter without a resolution in Congress, the risk of eroding public opinion before the midterm elections next year is bound to increase. The latest monthly Kaiser Health Tracking Poll by the Kaiser Family Foundation showed that more than half of Americans now believe that the president and Republicans own the health care issue and may shoulder the blame for any failings. The survey reported that more than half now support the Obama health care law.
The S.&P. report also buttresses the analysis of the Republican bill by the Congressional Budget Office, which said the markets were relatively stable under the current law, contradicting some Republican assessments of volatility.
“Things are getting better,” Gary Claxton, a vice president at the Kaiser Family Foundation, said of the insurance markets. The foundation has been closely tracking the insurers’ progress.
Although it took longer than expected, the insurers appear to be starting to understand how the new individual market works, said Deep Banerjee, an S.&P. credit analyst who helped write the report. The companies have aggressively increased their prices, so they are now largely covering their medical costs, Mr. Banerjee said. They have also significantly narrowed their networks to include fewer doctors and hospitals as a way to lower those costs.
Death By 1,000 Cuts: How Republicans Can Still Alter Your Coverage
The Affordable Care Act’s worst enemies are now in charge of the vast range of health coverage it created. They’re also discussing changes that could affect a wider net of employment-based policies and Medicare coverage for seniors.
Republicans failed last month in their first attempt to repeal and replace the ACA. But President Donald Trump vows the effort will continue. Even if Congress does nothing, Trump has suggested he might sit by and “let Obamacare explode.”
In California, which has extended coverage to more than 5 million residents under the ACA, fear of losing those gains is a big part of the reason why many of the state’s political leaders, consumer advocates and labor unions are pushing plans for universal health care.
Nationwide, health insurance for the 20 million people who benefited from the ACA’s expanded coverage is especially at risk. But they’re not the only ones potentially affected. Here’s how what’s going on in Washington might touch you.
A 3-year-old lawsuit threatens many plans.
A suit by the Republican-led House challenges some subsidies supporting private plans sold to individuals and families through the ACA’s online marketplaces, also called exchanges. It has already gained one court victory. By many accounts, it would wreck the market if successful, stranding up to 12 million without coverage.
“It’s the single-biggest problem facing the exchanges,” said Rachel Sachs, a health law professor at Washington University in St. Louis. “That would make insurers not only exit tomorrow but also not want to offer plans in 2018.”
The litigation involves lesser-known ACA subsidies that reduce out-of-pocket costs such as copayments and deductibles for lower-income consumers. These are different from the law’s income-linked tax credits, which help pay for premiums.
Filed in 2014, when Barack Obama was president, the suit could backfire by politically harming the Republicans now in charge. House leaders have delayed the litigation and said they won’t drop the lawsuit but will continue the subsidies while it gets considered. The administration has not said how it plans to handle the lawsuit.
Policy confusion undermines coverage.
Even if Congress doesn’t repeal the ACA, the continuing battle makes insurance companies think twice about offering marketplace policies for next year. The less clarity carriers have about subsidies and whether the administration will promote 2018 enrollment, the likelier they are to bail or jack up premiums to cover themselves.
Preserving the subsidies, which limit out-of-pocket costs for lower-income consumers, “is essential,” said Kevin Lewis, CEO of Community Health Options, a nonprofit Maine insurer. “Markets don’t like uncertainty. The ‘sword of Damocles’ hanging over our collective heads is unsettling, to say the least.”
Democrats say Republicans are sabotaging Obamacare.
Shortly after taking power, Trump officials yanked advertising designed to maximize enrollment in marketplace plans just before a Jan. 31 deadline. It was partly restored after an outcry.
Then the administration said it would scrap an Obama-regime plan of rejecting tax returnsfrom individuals who decline to say whether they had health insurance — weakening the requirement to be covered.
Trump aide Kellyanne Conway suggested in January the administration might entirely stop enforcing that requirement — the part of the law most hated by Republicans. If officials persist with that message, plans could attract even fewer of the young and healthy members whose premiums are needed to support the ill. That would cause more rising premiums and insurer exits.
The House’s debate over repealing ObamaCare has had an unintended effect: Republicans are now defending key elements of President Obama’s health law.
Many House Republicans are now defending ObamaCare’s protections for people with pre-existing conditions, in the face of an effort by the conservative House Freedom Caucus to repeal them.
Some Republican lawmakers are also speaking out in favor of ObamaCare’s expansion of Medicaid and its mandates that insurance plans cover services such as mental health and prescription drugs.
Rep. Patrick McHenry (R-N.C.), the GOP’s chief deputy whip, said Wednesday that the Freedom Caucus’s calls for states to be able to apply for waivers to repeal pre-existing condition protections are “a bridge too far for our members.”
Those ObamaCare protections include what is known as community rating, which prevents insurers from charging higher premiums to people with pre-existing conditions, and guaranteed issue, which prevents insurers from outright denying coverage to them.
McHenry spoke in personal terms about the importance of keeping in place those Affordable Care Act (ACA) provisions, contained in Title I of the law.
“If you look at the key provisions of Title I, it affects a cross section of our conference based off of their experience and the stories they know from their constituents and their understanding of policy,” McHenry said.
“My family history is really bad, and so my understanding of the impact of insurance regs are real, and I believe I’m a conservative, so I look at this, understand the impact of regulation, but also the impact of really bad practices in the insurance marketplace prior to the ACA passing,” he continued. “There are a lot of provisions that I’ve campaigned on for four election cycles that are part of the law now that I want to preserve.”
McHenry’s defense of those ObamaCare pre-existing condition protections is striking because just last year, House Republicans touted a healthcare plan, called A Better Way, that would have repealed the protections and replaced them with a different system.
Rather than ObamaCare’s protections, the Better Way plan would have protected people with pre-existing conditions only if they maintained “continuous coverage,” meaning they had no gaps in coverage. Unlike under ObamaCare, the plan would not extend the protections to people who were uninsured and trying to enroll in coverage. For those people, Republicans proposed subsidizing coverage through separate high-risk pools.
During a town hall at Georgetown University last year, Speaker Paul Ryan(R-Wis.) called for repealing ObamaCare’s community rating protection and allowing insurers to return to the days of “underwriting,” when they could charge people with pre-existing conditions more. Instead, sick people could get coverage subsidized through high-risk pools, he said.
“Open up underwriting, have more insurance companies, have more competition, and just pay for the person with the pre-existing condition to make sure that they can get affordable coverage when that moment happens and make it much more competitive for everybody else,” Ryan said then. “I think it’s a smarter way to do it economically and it gives people more freedom, more choices.”
Now, though, many House Republicans are defending the ObamaCare protections.
Block grant funding of public health insurance: the Canadian example
Speaker Paul Ryan wants to reform Medicaid by “block granting” the program, that is,
by capping federal funding and turning control of the program over to states. The aim of such reforms is to reduce federal funding over the long term, while preserving a safety net for needy, low-income Americans. An additional valuable aim of this effort has been to advance federalism by reducing the federal government’s role and giving states and governors more freedom and flexibility in managing their Medicaid programs and helping people in their states.
What are the likely consequences of block granting? Benjamin Sommers and David Naylor write in JAMA about how Canada’s joint federal/provincial funding of health care provides lessons about the likely consequences of block granting.
Canada is a single payer health care system. However, there isn’t a Canadian single payer. Rather, there is a single payer for each province: I am covered by the Ontario Health Insurance Plan (OHIP). These plans are primarily funded by provincial taxes. However, provinces also receive a health transfer from the Canadian federal government, i. e., a block grant. The provincial health insurance plans are run by provincial health ministers, not the federal minister in Ottawa.
So, does provincial autonomy facilitate experimentation and tailoring by the provinces? Sommers and Naylor think not.
there is little evidence that the alleged advantages of block grants have materialized in Canada. Advocates argue that with greater flexibility and proper incentives, states can reduce costs by improving the efficiency of care. In Canada, however, the provinces’ primary means of coping with budget pressures under block grants has been to reduce funding to hospitals and bargain harder with provincial medical associations. Ironically, then, if this scenario plays out in the United States, it would exacerbate one of the chief Republican criticisms of Medicaid — that it pays clinicians such low rates that they have reduced incentives to care for low-income patients.
Indeed, physician refusal to take Medicaid patients is one of Speaker Ryan’s central criticisms of Medicaid.
What about the effects of a block grant system on federal funding of health care?
Once block funding was initiated in 1977, health care funding became a line item in the federal budget that could be arbitrarily cut or capped for fiscal or political reasons, as opposed to a level of spending pegged to the needs and health care use of the population. Importantly, these cuts occurred under both conservative and liberal federal governments.
When the Canadian health transfer began, the federal government paid 50% of provincial costs. However, the transfer has steadily declined, until it is now about 20%. Sommers and Naylor predict that US federal block grants would also decline, and this is clearly one of Speaker Ryan’s goals.
However, Canadian health care spending per capita has not declined.
As the cost of providing care has risen, but the federal health transfer has stayed fixed or declined, the provinces have taxed more and the federal government has taxed less. The provincial governments hate this, because they would rather have the federal government make the unpopular choice to raise taxes. But it’s not clear whether block granting has made a big difference in the health care received by Canadians.
American states could similarly increase taxes in response to a declining federal Medicaid block grant, but would they? The key difference between Canadian public health insurance and Medicaid is that the former is universal, while the latter is means-tested. Ontarians prefer lower taxes, but if Ontario decreases funding for OHIP, every Ontarian will experience longer waits for care. But American states can cut Medicaid — and reduce taxes — without affecting the health care of better off and able-bodied citizens.
The affluent and able-bodied are also the citizens most likely to vote. American states determine their own voting procedures. Block granting gives states an incentive to manage voting so as to reduce the participation of the marginalized communities who are most in need of public health insurance. Block granting is likely to undermine the health care for the poor and disabled, and it could reinforce the post-Shelby County v. Holder efforts to restrict voting.
In their latest amendment to the American Health Care Act, House Republicans have created something called an “invisible risk sharing program.” The amendment is befuddling. The invisible program is a minor tweak that won’t improve the AHCA’s dismal coverage numbers. It’s not even really a program. If there’s any prospect at all of salvaging Republican-style repeal and replace, this newest amendment isn’t it.
The statutory text is spare. It appropriates $15 billion over nine years—or $1.67 billion each year—and tells the Secretary of Health and Human Services to use the money “to provide payments to health insurers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market.” The Secretary can supplement that funding with any money from the AHCA’s high-risk pools that states don’t find a way to use.
Beyond that, however, the statute tells us next to nothing about how the program is supposed to work. Hilariously, a section of the statute titled “Details of Program” contains no details. It says, for example, that the program should include “[a] definition for eligible individuals,” but leaves the defining up to HHS. So too with “[t]he identification of health conditions” that, if an eligible person has them, would qualify her insurer for extra payments.
Oh, and the program is supposed to be in place in time for the 2018 plan year.
Read generously, this newest amendment tells HHS to create a kind of reinsurance program for insurers who enroll high-cost individuals. The statute doesn’t use the word “reinsurance,” maybe because Republicans have spent years railing against the risk corridor and reinsurance programs as insurer bailouts. But if those were bailouts, then this is too.
Judging from the title, the program is supposed to look something like the proposal pioneered by Maine and described in this Health Affairs post. But Republicans are delusional to think that the Secretary can establish and implement a complex reinsurance-style program in time for the 2018 plan year. Insurers that want to participate on the exchanges have to submit bids to HHS by June 21. Even if the AHCA passed tomorrow—which it won’t—there’s no chance that Secretary Price could ramp it up in time.
Nor does the amendment explain how the new program is supposed to interact with the ACA’s risk adjustment program, which the AHCA leaves in place. The point of risk adjustment is to equalize risk across insurers: those with healthier-than-average enrollees have to pay into a central kitty, and those with sicker-than-average enrollees get some of that money. But if insurers get “invisible” risk sharing money for high-cost individuals, should they get less in risk adjustment money? The amendment doesn’t say.
In any event, the money is too insubstantial to make much of a difference. Sure, $1.67 billion per year sounds like a lot of money. But $1.67 billion is chump change compared to the subsidy reductions that are contemplated under the AHCA. It’s like using a band-aid to treat a gunshot wound.
HENRY KOTULA 