Tag Archives: Bipartisanship

Why ACA market upheaval still looms large despite failure to repeal the law

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http://www.healthcaredive.com/news/why-aca-market-upheaval-still-looms-large-despite-failure-to-repeal-the-law/449117/

Whether lawmakers are done with efforts to repeal the ACA or not, some important changes for healthcare could be on the horizon.

At least one part of the healthcare industry is still looking to Washington D.C. after the flurry of activity last month, if only for one action. In addition to the highly public failure to pass major healthcare legislation before leaving town for a month, Congress and President Donald Trump also left the Affordable Care Act (ACA) exchange markets in a dangerous flux by not taking action on the cost-sharing reduction (CSR) payments for insurers.

It’s not clear whether Congress will continue to take up Republican healthcare legislation to repeal the ACA when it returns. Even within the party, senators are singing different tunes, while President Donald Trump continues to pressure lawmakers to get an ACA repeal bill on his desk. A bipartisan group with members from both chambers has a few ideas, but the majority of lawmakers appear ready to move on. Regardless, they will still have to take up reauthorization of the Children’s Health Insurance Program (CHIP) in September, potential reigniting some debates around the ACA.

If GOP leaders do declare ACA repeal off the table for this year, its opponents will look to the executive branch for efforts to weaken the law and its effects. Here’s what to look out for.

Cost-sharing reduction payments

Payers have been begging for assurance that CSRs will continue to be paid, but the White House and Congress have so far refused. The result has been many payers pulling out of the exchange markets or reducing their footprints, as well as premium hikes of 30% or more. Just last week, Anthem announced it is pulling out of the Nevada and Virginia exchange markets and reducing its participation in Georgia.

Not paying the CSRs would increase federal spending, because the higher premiums will require higher premium subsidies for the 84% in the exchanges who qualify for help. That’s not to mention the 30,000 or more who would have no insurance options.

Trump hasn’t been shy about his plan to halt any efforts that stabilize the exchange markets (like CSRs) in an effort to sabotage the ACA and force unwilling Democrats to cooperate on a repeal bill. Others in the GOP, however, have been reluctant to hurt constituents with such an overtly political play.

America’s Health Insurance Plans has said it is imperative the CSRs are funded. “These benefits are essential to making coverage and care affordable for American families who receive them,” the organization said. “Clarity and commitment to this funding is needed to eliminate confusion and anxiety for consumers.”

It may soon be too late for CSR payments to matter for next year. Payers must sign their contracts with HealthCare.gov by Sept. 21. The CMS and some states have tried to give insurers more flexibility because of the uncertainty by pushing back rate filing deadlines. Connecticut said it will allow payers to refile their rates if the CSR payments are eliminated, and California allowed them to file two sets of rates, one of which assumes no CSRs.

Weakening the ACA

Trump’s threat to “let Obamacare implode” may go beyond refusing to shore up the exchange markets. His administration has already pulled advertising and promotion of the exchanges, and is being investigated by the Government Accountability Office for pushing the GOP healthcare bills in official HHS communication channels. Immediately after his inauguration, Trump signed a wide-ranging executive order instructing federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement” of the ACA that imposes a fiscal or regulatory burden.

No major changes have resulted from the order so far, but it could be used to roll back benefit requirements for preventive care, contraception and mental health services.

HHS Secretary Tom Price could also make changes that weaken the ACA’s individual mandate. Repealing the mandate would mean 15 million fewer Americans would have coverage by 2026 and result in premium increases of about 20%, according to the Congressional Budget Office. Watering down the requirement instead of ditching it completely would have less drastic results, but there would still be an impact.

Price could create more exemptions for the mandate or attempt to force the Internal Revenue Service to stop enforcing it. Either of these actions would add turmoil to the exchanges markets and undermine the efforts of the ACA.

Reauthorizing CHIP

Those watching health legislation in Congress are eyeing CHIP reauthorization as a possible vehicle for changes to the ACA. Lawmakers will be hesitant, though, as CHIP is a successful program with bipartisan support.

The program, which turned 20 years old this past weekend, covered nearly 9 million children in fiscal 2016. CHIP coverage is more affordable than employer-sponsored or marketplace coverage, while children covered under CHIP are more likely to have a usual source of care and regularly attend well-child visits, according to the Medicaid and CHIP Payment and Access Commission, which recommends Congress extend CHIP funding through 2022.

The commission estimates more than a million children would lose coverage if CHIP loses funding.

Bipartisan legislation and state waivers

A bipartisan group of about 40 members of the House is proposing some relatively small changes to the ACA that have received support from both sides of the aisle in the past. The plan is to put them in a bill that would also immediately fund the CSRs.

Their suggestions include exempting smaller businesses from the employer mandate, a fund states can go to for help covering people with high care costs and more flexibility and guidance for states looking to apply for ACA waivers. Another possible measure is repeal of the medical device tax.

Their proposal is to change the employer mandate by having it apply only to businesses with 500 or more employees, instead of the current requirement for businesses with 50 or more workers. Analysis from the Urban Instituteand Rand Corporation has shown the employer mandate has little effect on the number of people who have coverage, partly because nearly all businesses with at least 50 employees offered coverage even before the mandate went into effect.

The ACA has always given states the option of applying for a waiver that allows them to eschew essential health benefits and other requirements — as long as they can prove their plans will cover the same number of people with coverage that is just as comprehensive and affordable. HHS under President Barack Obama was careful in ensuring that state proposals met those guidelines, but current HHS Secretary Tom Price has said he wants to encourage more waivers and will be less strict with approvals of those waivers and Medicaid demonstration waivers.

With this in mind, some recent proposals have included aspects that would have previously been rejected. Last week, Maine applied for a Medicaid demonstration waiver that includes work requirements and asset testing. Those measures are likely to restrict access to coverage for people with low incomes.

Many of the options available for Congress and the executive branch could roil the industry, but some bipartisan options could provide much needed clarity. Summer is usually pretty quiet in Washington D.C., but this year has not been business as usual. Healthcare leaders would be wise to be ready for new developments with the ACA and beyond.

CBO to release analysis of ending key ObamaCare insurer payments

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CBO to release analysis of ending key ObamaCare insurer payments

CBO to release analysis of ending key ObamaCare insurer payments

The nonpartisan Congressional Budget Office (CBO) will release an analysis next week detailing the effects of ending key ObamaCare insurer payments.

The CBO announced Friday the score would be released next week.

President Trump has threatened to cancel the payments, known as cost-sharing reductions, which reimburse insurers for giving discounted deductibles and copays to low-income people.

The administration has made the payments on a month-to-month basis but insurers have pleaded for long-term certainty.

The reimbursements total $7 billion for fiscal 2017, and regardless of whether the administration pays them, insurers would still be on the hook to offer these discounts to enrollees — they just wouldn’t be reimbursed for doing so.

Uncertainty over the future of the payments has contributed to insurers exiting the healthcare exchanges and proposed premium increases for 2018. More insurers might leave or increase premiums if the payments aren’t continued.

The Senate Health Committee will hold bipartisan hearings in September on ways to stabilize and strengthen the individual market.

The goal is to craft a bipartisan, short-term proposal by mid-September, which could include funding the payments.

Bipartisanship is Back: Congressional Cooperation Suggests Momentum is Growing for Aging Reforms

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http://altarum.org/health-policy-blog/bipartisanship-is-back

In a much-discussed early-morning vote on July 28, the U.S. Senate voted decisively to move in a different direction on health care, sending a clear signal that future reform efforts will likely have to be bipartisan. Affirmation came on August 1, when Sens. Lamar Alexander of Tennessee and Patty Murray of Washington, the Senate Health Committee’s top ranking Republican and Democrat, announced bipartisan hearings will begin this fall on possible policy solutions for American consumers and insurers participating in state exchanges.

Yet, beyond the fights over “repeal and replace,” a larger issue is looming: Our health care system is not prepared to care for the age wave—which will come with a surge in need for ongoing, daily assistance. Congressional representatives from both sides of the aisle must work together to plan for burgeoning numbers of  elders and individuals with disabilities, recognizing that there are diminishing numbers of family caregivers, and that the health services and delivery system as currently configured is poorly designed to meet  long-term care needs.

Combining Forces for Better Policy

Fortunately there are stirrings of interest and activity: Rep. Ileana Ros-Lehitnen of Florida, the most senior Republican woman in the House of Representatives, joined Rep. Michelle Lujan-Grisham, a Democrat who served as Aging Secretary in New Mexico before her election to Congress, to introduce the Care Corps Demonstration Act. HR 3494 is a thoughtful measure that is designed to galvanize communities by helping them train and deploy volunteers of all ages, whose mission would be to help aging neighbors, friends, colleagues, and family members thrive in their own homes. Rep. Ros-Lehitnen’s predecessor from the 27th District of Florida was one of Congress’ best-known champions of older adults, Rep. Claude Pepper. Rep. Ros-Lehitnen announced on April 30 that she would not be running for re-election, while Rep. Lujan-Grisham has said she will run for Governor of New Mexico in 2018. Before Reps. Ros-Lehitnen and Lujan-Grisham leave Congress, they are trying to recruit supporters from across the aisle and around the country for the Act, so that it can either find its way into a “must pass” bill, or attract widespread acceptance as a standalone measure.

Here’s what the Care Corps Demonstration Act would do:

  • Invite groups to apply for Care Corps grants and administer the program locally;
  • Train volunteers to support the achievement and maintenance of the highest level of independent living (but not provide professional medical services, administrative support services, or institutional care) and deploy them to communities in need; and
  • Award Corps members living allowances and benefits, including health insurance coverage, during their volunteer period, and offer tuition assistance or loan repayment after completion of their assignment.

“It’s clear that seniors want to remain in their homes and they want control over their own health care,” Rep. Lujan-Grisham noted on introduction. “Most of all, they want to remain as independent as they can, for as long as they can. The same is true for individuals with disabilities. Care Corps will allow them to keep that independence. Unfortunately,” she added, “we’re facing high costs, along with a shortage of direct-care workers, which results in the lack of access to these important services, especially for middle class families. A national Care Corps will help build the workforce, while building intergenerational relationships that allow seniors and young people to learn from each other.”

Addressing the looming shortage of direct care workers is exactly what Rep. Bobby Scott of Virginia’s third congressional district is setting out to do. Next month, the Virginia lawmaker will introduce the Direct Creation, Advancement, and Retention of Employment (CARE) Opportunity Act (or Direct CARE Opportunity Act), which will propose to give the Department of Labor funds to establish advanced care training and mentoring programs and establish career ladders and better job opportunities, for direct care workers in up to 15 parts of the country. “Direct care workers are instrumental in supporting and assisting people across the country, particularly seniors and people with disabilities,” said Rep. Scott. “Moreover, if we invest in the direct care workforce, we invest in a rapidly growing and in-demand field. Growing the number of direct care workers is simply a win-win for investing in both the health of our communities and the jobs of tomorrow.”

PHI, a leading national organization representing and supporting direct care workers, is strongly backing Rep. Scott’s efforts: “Direct care workers are a critical part of delivering quality, person-centered long-term care, and we support this national effort to increase training, improve retention, and enhance the overall quality of jobs for this workforce,” noted Daniel R. Wilson, director of federal affairs.

Additionally, on July 27 Rep. Matt Cartwright of Pennsylvania’s 17th congressional district introduced the Improving Care for Vulnerable Older Citizens through Workforce Advancement Act. “This bill would improve both the quality of jobs for direct care workers nationwide, as well as the care they deliver, by helping to create expanded roles with sufficient training and compensation, and by helping them support people with increased complex conditions, such as Alzheimer’s and related dementias, congestive heart failure, diabetes, and other chronic conditions,”said PHI President Jodi M. Sturgeon.

Creating a System that Can Meet the Needs of Aging Americans

Together, these bills represent crucially needed investments in thinking through how to train more men and women who can serve on the frontlines of a multi-generational society in an era of mass longevity. With a majority of women now in the workforce and smaller and more scattered families quickly becoming the norm, the availability of traditional family caregivers—middle-aged women—is shrinking rapidly. This is giving rise to an urgent need to create a more flexible, community-focused workforce that is prepared to provide targeted supports in home settings on an as-needed basis to an increasing proportion of elders and individuals with disabilities.

Beyond the workforce, there is a need for more policy analysis and research to adapt and revamp existing social insurance programs that are still organized around delivering episodic medical services, and with financing protocols that are designed to pay providers and organizations without regard to the population’s need for ongoing services across a given geographic region or community. Making this shift—from provider-centric financing models to population health models—will also require tweaking payment rules to reward comprehensive, longitudinal services that include long-term care; adjusting performance metrics to emphasize population health and incorporate key social determinants of health factors; better information technology to foster communication across multiple providers and with individuals living at home and their family caregivers; and development of ways to accurately measure need, quality, and supply of services at a community level, with the help of local leaders and experts.

There are signs that lawmakers may rise to the challenge of helping to forge solutions to these issues. In the House, an ad hoc “problem solvers caucus” has surfaced with a set of initial ideas for fixing state exchanges, and the group of roughly 40 lawmakers may continue to hold discussions about other topics. There is solid bipartisan, bicameral work being done in the Assisting Caregivers Today (ACT) caucus on long-term care issues. Parallel caucuses focusing on Alzheimer’s and other types of cognitive impairment have already made excellent contributions to development of policy on “cure” and “care.” These and other budding efforts have the capability, if further developed, to begin contributing ideas necessary to address larger-scale systems challenges in ways that can inspire and complement the work of researchers, advocates, families, providers and stakeholders.

Between now and 2030, the U.S. will change profoundly as mass longevity becomes a central dynamic. To prepare, now is the time to invest and build for long-term care, not disinvest; to map existing assets and use current programs as platforms for improving and making more efficient; and to generally acknowledge gaps and focus work on addressing common goals in a long-lived society.

In summary, evidence-based, high-value health care reform is greatly aided by congressional bipartisanship, but more is needed. To create a value-based system requires the combined efforts of many. Now that bipartisanship is breaking out, let’s get to it!

 

Put Out The Fire Instead Of Burning Exchanges To The Ground: Extend Cost-Sharing Reduction Payments

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https://www.forbes.com/sites/billfrist/2017/08/03/put-out-the-fire-instead-of-burning-exchanges-to-the-ground-extend-cost-sharing-reduction-payments/#46afbeb21bc9

Eight years ago, former Democratic Senator John Breaux and I wrote: “Given the acrimony that’s developed over efforts to reform our nation’s health insurance system, many Americans wonder whether true bipartisan agreement on health reform can ever be possible. In short, it can.” Back then, we watched contentious debate over what came to be known as Obamacare, and we never saw bipartisanship materialize. But in 2003 we both participated in creating and enacting the bipartisan Medicare Modernization Act that established the enormously successful Medicare Part D. Bipartisanship was alive then. We missed an opportunity eight years ago, but over the next few weeks we have another prime chance.

The healthcare (and health) of 11 million Americans hangs in the balance. This may sound like a small portion of America’s insured population, and as a percentage it is, but these are all people we know. The 6 percent of Americans who buy their insurance on the individual market are the small business people, contract workers, entrepreneurs, musicians, stay-at-home parents, job seekers, and the millions of Americans who can’t receive coverage through their employers. They are Republicans, Democrats, and Independents. Trump supporters and Hillary voters. And their ability to purchase coverage on the exchanges is in jeopardy, as mixed signals from Congress and the Administration have left insurers scrambling to decide whether to hike already costly premiums or pull out entirely—triggering the beginnings of collapse in some regions.

In my home state of Tennessee, two thirds of our 95 counties are projected to only have one insurer in 2018, while hundreds of counties nationwide at are risk of having no insurer offering individual coverage at all. Waiting for collapse may force Congress to the negotiating table as some have suggested, but it would hurt many innocent, poor, and sick people in the process.

The American people agree. A Kaiser Family Foundation surveyfound three-quarters of the public—including over half of Trump supporters—want the President and his administration to do what they can to make the Affordable Care Act work rather than trying to make it fail so they can replace it later.

My former colleague and current Chairman of the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP), Senator Lamar Alexander, said, “There are a number of issues with the American health care system, but if your house is on fire, you want to put out the fire, and the fire in this case is the individual health insurance market.”

The first step in extinguishing this fire is to extend the cost-sharing reduction (CSR) payments. These are the payments President Donald Trump has repeatedly threatened to cut off, creating serious uncertainty and instability in the markets. The Affordable Care Act requires insurance companies to offer discounts to lower-income consumers on the exchanges (those who make 100 – 250 percent of the Federal Poverty Level, or roughly $30,000 for an individual or $60,000 for a family of four). Thus would be a money-losing proposition for insurers without the federal reimbursement provided by the CSR payments. If insurers don’t get reimbursed through the CSRs, they will drop out of the market or raise rates significantly to cover their projected $7 billion loss. States that did not expand Medicaid—which are more likely to have Republican elected leadership and Trump voters—will be hardest hit, since they have a greater number of low-income individuals reliant on the individual market.

Some have termed the CSR payments “bailouts” for insurers, but the irony is that failure to extend them will actually cost taxpayers 23% more than the savings generated by their elimination. According to the Kaiser Family Foundation, the resulting premium hikes would trigger automatic increases in the size of premium tax credits paid by the federal government, totaling a net increase cost of $2.3 billion for fiscal year 2018.

Extending these payments not only makes sound fiscal sense, it will help millions of Americans maintain access to health care coverage and give Congress the breathing room necessary to craft meaningful reforms to the system that accounts for nearly one-fifth of our economy.

In the last few days, we have seen hopeful signs of bipartisanship returning to Washington, with the Senate HELP Committee announcing hearings in September with input from all committee members, to the bipartisan House Problem Solvers Caucus coming forward with a short-term plan for stabilization supported by over 40 Republicans and Democrats. We are seeing growing support for the use of waivers to establish reinsurance programs for high-cost, high-need individuals – as has been proposed in Alaska and Minnesota—and for a “stabilization fund” for states to be used in multiple ways including premium support or reinsurance. These are bipartisan concepts that appeal to both red and blue states and deserve serious debate in Congress. As Senator John McCain wisely said on the Senate floor last week, “The Obama administration and congressional Democrats shouldn’t have forced through Congress without any opposition support a social and economic change as massive as Obamacare. And we shouldn’t do the same with ours.” Any lasting, successful reform to our healthcare system depends on a bipartisan solution,and we must stabilize the markets now to give our Congress time to begin these negotiations in earnest.

Since last March I have co-chaired with former Senator Tom Daschle a bipartisan group of healthcare leaders at the Bipartisan Policy Center (BPC). This politically diverse group of five Republicans and five Democrats have consistently called for a two-year extension of the CSR payments. We reiterate that call again today. Time is of the essence. Right now, insurers are filing corrections to their 2018 plan rates and petitioning states to change their service areas. Final premium prices are due August 16, and by September 27 health insurers must sign the final marketplace participation contracts. Many insurers, with the uncertainty of whether CSR payments will continue, have initially filed two different pricing options. Without more certainty of extension, they will use the higher rates that are nearly double what they would be if the CSR payments were continued. Or worse, they may simply pull out altogether at the last minute if the payments are still in jeopardy when these deadlines hit (four major insurers—Anthem, Cigna, Health Care Service Corp and Molina Healthcare—have all said they are weighing pulling out).

At the BPC we have held numerous roundtables and listening sessions with insurers, providers, healthcare leaders, state policymakers, and those on the ground implementing care, and routinely the number one recommendation to stabilize markets in the short-term is to extend the CSR payments . The White House has indicated it plans to make a decision this week, and I urge President Trump to heed the advice of our nation’s healthcare industry and policy leaders, as well as the very real needs of 11 million Americans, and allow payments to continue . It would also avoid ensnaring the Administration in costly lawsuits with states over the payments, which a federal appeals court ruled on August 1st could be permitted.

It’s time to stop the partisan sniping and get to work on crafting sound policy. We should put out the fire and begin to rebuild, instead of letting it all burn to the ground.

Let’s Stop the Bickering and Fix the Health Care System

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If either of us were building the American health care system from scratch, we’d probably end up in different places.

We have contrasting ideas — one of us is a Democrat, the other a Republican — about what ails the system and how to reshape it. But this is not the time for more partisan fighting. It’s time to build a better system, even if incrementally, because that’s what the American people deserve. It’s time to put aside blame and stabilize a health care marketplace where premiums are expected to rise by more than 15 percent in most states and millions of people are worried about obtaining or affording coverage.

This week the 43-member House Problem Solvers Caucus — which we lead and which is almost evenly split between Democrats and Republicans — released a carefully drafted compromise to shore up the struggling insurance exchanges.

Ultimately, everyone had to give a little and endorse provisions that purists in both our parties may not like. This is how American democracy is supposed to work, even if it has not for quite some time.

Our proposal first focuses on the most urgent crisis: the skyrocketing cost of individual health insurance premiums. The Trump administration is considering suspending cost-sharing payments that defray out-of-pocket payments like deductibles and co-payments for people earning less than 250 percent of the poverty line. Because of uncertainty about this subsidy, insurers have said premiums could rise by 15 percent or more. On Aug. 16, insurers must submit their 2018 rates to state regulators for approval; many may be forced to leave the individual marketplace altogether.

Our plan would stabilize markets by making the cost-sharing payments mandatory and thereby prevent rates from rising sharply.

Second, we provide a relief valve to help states deal with the high cost of pre-existing and chronic conditions. The costliest 5 percent of patients account for nearly half of all health care spending in the country. We propose a dedicated stability fund — essentially a form of reinsurance — that states could use to reduce premiums and limit losses for providing coverage for these high-cost patients.

Third, our proposal provides relief to certain businesses from the mandate that they provide insurance to full-time employees. It also defines “full time” as a 40-hour workweek to discourage businesses from manipulating employees’ weekly hours to skirt the mandate. More than 90 percent of large businesses offered health care before the Affordable Care Act, and studies show that they would continue to do so under this change; others would move to find employee coverage in the individual marketplace.

Fourth, our plan eliminates the Medical Device Tax, an excise charge of 2.3 percent that is often passed onto consumers and reduces funds for research and development. And finally, we provide states with additional flexibility to enter into agreements — such as enabling the sale of insurance across state lines — that would provide more choice and lower costs.

This proposal would not increase the federal deficit, offering several options to offset the new spending.

Our plan isn’t intended to rectify everything that’s wrong with American health care. We aim to solve an immediate problem and move past a seven-year stalemate in Washington that has featured Republicans trying to repeal the current health care law, Democrats trying to preserve it and neither side willing to discuss anything in between.

That approach has led us to our current moment, in which no one is happy with the status quo, least of all the American people, whose trust and confidence in Washington weakens every day that we spend fighting instead of solving real problems.

Health care is one of those problems — and a textbook example of why we formed the Problem Solvers Caucus this year. We all knew the partisanship in Washington had gotten out of control and felt the need to create a bipartisan group committed to getting to “yes” on important issues. We have agreed to vote together for any policy proposal that garners the support of 75 percent of the entire Problem Solvers Caucus, as well as 51 percent of both the Democrats and Republicans in the caucus.

If Washington does not act to stabilize the insurance exchanges, many families we represent will lose coverage or be hit with premiums they can’t afford. This isn’t conjecture.

If that does happen, people will be justifiably livid that Republicans and Democrats in Congress did nothing to stop a train wreck we all saw coming.

There is a growing recognition on Capitol Hill that something must be done, as evidenced by this week’s announcement from Senator Lamar Alexander — the Tennessee Republican who is chairman of the Senate Health, Education, Labor and Pensions Committee — that he will soon hold hearings focused on repairing the individual insurance market.

Our proposal isn’t perfect, but it represents the first and only serious bipartisan health care proposal released in this Congress. We hope our colleagues in the House and Senate, as well as the White House, will use our plan as the foundation for the health care solution that America desperately needs and deserves.

Outside Of Washington, There Is A New Vital Center In Health Care Reform

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http://healthaffairs.org/blog/2017/07/31/outside-of-washington-there-is-a-new-vital-center-in-health-care-reform/

Larissa Pisney of Denver joins others during a protest outside the office of U.S. Rep. Mike Coffman, R-Colo., over the health care overhaul bill up for a vote in the U.S. House Thursday, May 4, 2017, in Aurora, Colo. (AP Photo/David Zalubowski)

Republicans in Congress are mired in political quicksand. Following passage of the Affordable Care Act (ACA) in 2010, they locked themselves into a promise to repeal and replace it at the behest of ultra-conservative donors and party activists who control the GOP’s nomination process. Since 2010, however, Americans and rank-and-file Republicans increasingly came to expect help meeting the rising costs of medical care and insurance and to accept the ACA’s tangible programs to address these concrete challenges.

The Democrats created their own political trap. They passed the ACA on the promise of making health care affordable but deductibles and rising premiums continued to present a burden to many Americans.

Both parties are missing, however, the vital center on health reform that has formed since 2010. Americans are frustrated with Democrats for not delivering on their promise of affordability, and they are now alarmed with Republican efforts to repeal—instead of improve—the ACA’s coverage of costs.

Tracking Changes In Public Opinion

Most public opinion polls are unable to track these changes in opinion about health care because they are only snapshots, drawn from a moment in time. To remedy this, we have been gathering panel data, tracking the views of the same group of Americans every two years since the ACA’s passage in 2010. This equips us to study how individuals respond to the ACA as they experience or learn more about the law’s provisions over time. Specifically, we conducted four waves of interviews in the two-month period leading up to national elections from 2010 to 2016 when health reform received heightened attention; this avoided the risk of choosing an arbitrary month when health reform might have arbitrarily lost or gained salience.

The first wave was conducted by the Survey Research Institute (SRI) at Cornell University and consisted of a national sample of 1,200 adults. Abt SRBI (now part of Abt Associates) conducted the last three waves, returning to the same individuals. All waves asked identical questions and were administered by telephone, using only landlines in 2010 and adding mobile phones in 2012, 2014, and 2016. Forty-nine percent of the original 2010 survey (587 individuals) responded to all four waves. Survey weights were applied to each survey to match representative demographic targets and allow us to generalize from our panel to the adult population in the United States.

Why Americans Dislike Health Reform

Republicans have been eager to highlight the unpopularity of the Affordable Care Act, also known as “Obamacare.” Exhibit 1 shows that unfavorable assessments of the ACA have steadily increased since its passage. Unfavorability rose from 44 percent in 2010 to 58 percent in 2016.

Exhibit 1: Increasingly Unfavorable Views Of The Affordable Care Act (Percent)

Question: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Exhibit 1 presents the “unfavorable” responses.

Why are Americans increasingly disenchanted with the ACA? The public’s displeasure emanates to a large extent from frustrations with health care costs. Democrats promised to lower the costs of medical care and insurance with the enactment of the ACA. They did succeed to slow the rate of increase in national health care spending and insulate most subsidized enrollees in its insurance Marketplace from premium increases, as the Congressional Budget Office reports (Note 1). Yet, the costs of medical care remain high, and premiums and deductibles are out of the reach of some Americans.

The source of the public’s rising frustration with health care costs is picked up in Exhibit 2. The first grouping of bars on the left shows increasing frustration with costs for medical treatments that are not covered by insurers. By 2016, 14 percent expressed dissatisfaction with the amount and number of treatments that their insurance covered, a 6-point increase from 2014. One-third of Americans also expressed dissatisfaction in 2016 with the out-of-pocket costs that they were forced to pay because of gaps in their insurance coverage, as shown in the middle cluster. This is an 8-point increase from 2014.

Exhibit 2: Rising Concerns About Affordability (Percent)

Question: Several questions asked respondents to indicate their satisfaction or dissatisfaction with individual features of the health care system—“The number and kind of treatments your health insurance will cover” and “The amount you spend out of pocket on health care costs your insurance doesn’t cover.” A separate item asked respondents to indicate their agreement or disagreement with the statement: “Public officials care about making health care more affordable for people like me.” (Exhibit 2 shows “disagreement” with the statement.)

The public’s disappointment with the persistent burden of health care costs leads it to blame lawmakers for a lack of responsiveness. The bars on the right in Exhibit 2 indicate that a growing majority of Americans disagree with the statement that, “Public officials care about making health care more affordable for people like me.” Fifty-eight percent of Americans disagreed with this statement in 2016, a 10-point increase since 2012.

In addition, the sense that the ACA has not delivered the affordability that Democrats promised may help account for the sharply stronger conclusion in recent years that the ACA’s taxes present a heavier burden. Exhibit 3 shows that the proportion of Americans who believe that their taxes have increased a lot or a little has risen from 43 percent in 2012 to 56 percent in 2016. This growing perception that the ACA has increased taxes rests on inaccurate assumptions. The ACA’s financing primarily relies on two taxes on individuals whose yearly income exceeds $200,000 or for married couples earning more than $250,000—an increase in Medicare’s tax on earnings by 0.9 percent and a new 3.8 percent tax on capital gains from investments. These taxes fall on less than 2 percent of tax filers, according to the non-partisan Tax Policy Center (Note 2).

Exhibit 3: Growing Perception That The Affordable Care Act Increased Taxes (Percent)

Question: “Do you think that the new health care law enacted in 2010 has increased the taxes that you pay, decreased the taxes that you pay, or has it had no impact on the taxes that you pay?”

Americans Oppose Repeal Because They Appreciate The Effects Of Health Reform

Considering the strong public disapproval of repeal, President Donald Trump and congressional Republicans are discovering that it is a mistake to equate the public’s frustrations with the ACA with support for repealing its programs. When respondents reported “unfavorable” views of the law, we followed up with a question asking them whether they would prefer either “repeal[ing] [the ACA] as soon as possible,” or “giving the law more time to have a chance to work, with lawmakers making necessary changes along the way.” In Exhibit 4, we combined those who favored giving it “a chance to work” with those who expressed “favorable” overall views of the law. This shows that since 2010 more Americans favored the law or wanted to give it time to be improved than backed repeal. Although support for repeal inched up since 2010, a greater percentage of Americans consistently favored the ACA and improving it over repeal by a 41-to-37 margin in 2010 and by 49-to-43 in 2016.

Exhibit 4: More Americans Prefer To Keep And Improve The Affordable Care Act Than Repeal It (Percent)

Question: This figure is based on two survey questions. The first is the following: “As you may know, a major health care bill was signed into law in 2010. Given what you know about this law, do you have a generally favorable or generally unfavorable opinion of it, or do you have a neutral opinion, neither favorable nor unfavorable?” Respondents who had an unfavorable view were asked a second question about their view about the law’s future: “The law should be given more time to have a chance to work, with lawmakers making necessary changes along the way, OR the law should be repealed as soon as possible?” The repeal bar reports responses from the second question; the other bar adds together favorable responses in the first question with the “law should be given more time” responses.

Support for keeping and improving the ACA stems from a growing appreciation for its concrete effects. Exhibit 5 shows that rising percentages pinpoint the ACA’s tangible programs as having either “a great deal” or “quite a bit” of an impact on themselves and their family (other options included “some,” “a little,” and “none”). There is greater recognition in 2016 compared to 2010 or 2012 of the impact of allowing parents with insurance to continue to cover their children until they are 26 years old. More than one in five Americans now report that the ACA expanded their access to health insurance. In addition, nearly one in four Americans, 24 percent, voiced appreciation for the impact of the ACA’s assistance to seniors to pay for prescription medications. Moreover, recognition of a personal impact resulting from the ACA’s tax credits and other subsidies to help people purchase health insurance has remained stable since 2014 and is higher than in earlier years.

Exhibit 5: Rising Appreciation Of The Impact Of The Affordable Care Act (Percent)

Question: “I’m going to read to you a list of some of the features of the health care law that was enacted in 2010. For each one, please answer this question: “How much of an impact has this feature had on you and your family: a great deal, quite a bit, some, a little, none?” Respondents are asked about the following features of health reform: coverage of adult children on their parents’ insurance plans until they are 26 years old; access to health insurance or medical care supported or provided by government; help for seniors to pay for prescription drugs; and tax credits and other subsidies to help people pay for health insurance. Exhibit 5 combines “a great deal” and “quite a bit.”

The New Vital Center On Health Reform

Overall evaluations of the ACA follow the partisan pattern that is familiar today: 68 percent of Democrats have favorable views versus 9 percent of Republicans. What stands out, however, is that the ACA’s tangible effects are starting to loosen rigid partisan dividing lines. Exhibit 6 shows the percentage of Americans reporting a personal impact from at least one of the four provisions presented in Exhibit 5. Democratic elected officials enacted the ACA, and, not surprisingly, majorities of rank-and-file Democrats have generally singled out the law’s effects from early on: 51 percent of Democrats reported an impact from at least one of the law’s features in 2010; by 2016, this recognition remained largely stable, inching up to 54 percent. Strikingly, however, the percentage of Republicans perceiving an impact on themselves or their families has increased by 8 percentage points, from 26 percent in 2010 to 34 percent in 2016 despite vociferous GOP attacks on the ACA. Among independents, the proportion soared by 23 points, from 28 percent to 51 percent. These findings indicate that appreciation for the ACA has expanded beyond the ranks of Democratic partisans who were predisposed to favor it; growing numbers of Americans across the political spectrum increasingly value the impacts of health reform in their own lives.

Exhibit 6. Widening Appreciation Of The Affordable Care Act’s Impact (Percent Reporting Impact Of A New Benefit)

Exhibit 6 presents the percentage of respondents who reported that at least one of the four provisions presented in Exhibit 5 had a “great deal” or “quite a bit” of impact on themselves or their family.

The crux of the public discontent with the ACA—and the repeal proposals by Republicans—is the amount paid for insurance coverage. Respondents to the survey appear to share the complaint of ACA critics that insurance costs are too high. After high expectations following the ACA’s enactment, satisfaction with the cost of health coverage has dropped by 10 points—from 73 percent satisfied in 2010 to 63 percent in 2016. This general assessment misses, however, a crucial condition—whether or not individuals are covered by government programs such as Medicare, Medicaid, or a subsidy financed by the ACA. We found a striking pattern among Republicans, Democrats, and independents: By a margin of 20 points or more, individuals with government coverage were consistently more satisfied with the cost of insurance than those who rely on private health plans. For instance, 79 percent of Republicans with government coverage were content with insurance costs as compared to 56 percent without this coverage. Independents outside the sway of either major party expressed the highest satisfaction when experiencing government coverage (100 percent) and exhibit the largest gap between those covered and those without coverage (41 points).

In short, Republican public officials continue to spotlight what they perceive as the disappointment of Americans with ACA coverage, but the reality is that the most dissatisfied are those who lack government insurance. In fact, most Americans (including Republicans) who benefit from government insurance are content with their coverage.

Health Reform’s New Vital Center

Public opinion toward the ACA has been poorly understood because of an apparent contradiction. On the one hand, a growing share of the public harbor unfavorable views of the ACA as a whole, and proponents of repeal have seized on this dissatisfaction to claim a popular mandate. On the other hand, the discontent of Americans stemmed from disappointment with the ACA for not satisfying their expectations of genuine protection from the burden of costs. Far from wanting to be rid of the ACA, Americans are looking to it to deliver more effective protection.

In the immediate aftermath of World War II, the historian Arthur Schlesinger, Jr., wrote of the “vital center” about the direction of America that was supported by both major political parties and most Americans. Despite today’s fractiousness in Washington over health reform, everyday Americans are converging toward a new vital center of support for health care reform.

Awareness of the ACA’s tangible impacts fits into a robust notion of collective responsibility instead of the individualist approach advocated by conservatives. Since the ACA’s passage, nearly nine out of 10 Americans have consistently embraced access to health care as a “basic right.” Not surprisingly, nearly all Democrats embrace the principle of health care as a right. What stands out is that rank-and-file Republicans overwhelming and increasingly hold the same view—rising from 64 percent in 2010 to 72 percent in 2016. Contrary to the position of Washington Republicans, establishing health care as a birthright owed to Americans is now widely shared. Republican proposals, such as those that would allow states to opt out of some of the ACA’s core consumer protections (including those guaranteeing coverage for individuals with preexisting medical conditions), may well tap into this strain of public opinion and provoke broad opposition.

Elected officials in Washington and, particularly, steadfast opponents of health reform are sliding to the margins of public opinion. The daily problems that Americans face in paying for medical care and insurance mean that pragmatism is trumping ideology. In the past, federal lawmakers responded to broad public agreement and worked across the aisle to improve the flaws in the original legislation that produced Social Security in 1935 and Medicare in 1965. The question today is whether Washington can return to that pragmatic tradition and catch up to the emerging vital center in Americans’ attitudes toward health reform.

Note 1

Congressional Budget Office. American Health Care Act: cost estimate. Washington (DC): CBO; 2017 Mar 13.

Note 2

Tax Policy Center. Tax units above and below the $250,000/$200,000 threshold, 2013–2022. Washington (DC): TPC; 2012 Nov 26

Five tough decisions for the GOP on healthcare

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Five tough decisions for the GOP on healthcare

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Republicans have left Washington for the August recess with healthcare decisions hanging overhead, many of which must be addressed by the end of September.

Here are five decisions looming for the GOP.

  1. Should there be one more effort at ObamaCare repeal?

While the GOP attempt at repealing ObamaCare has stalled for now, some in the party are not giving up.

“This ain’t over by a long shot … we won’t rest until we end the ObamaCare nightmare once and for all,” Vice President Pence said at the Tennessee GOP 2017 Statesmen’s Dinner Thursday, according to a pool report.

Yet Republicans are running out of time to take action, as the legislative vehicle they were using to gut the health law and avoid a Democratic filibuster expires at the end of September.

Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) are pushing a new plan to redirect money currently spent on providing coverage through ObamaCare and instead give it to states to spend as they choose.

They have been meeting with White House officials, who are also pushing Congress not to give up on repeal.

“I hope that our leadership will pay attention to this effort because the idea of leaving ObamaCare without a replacement is pretty naive,” Graham said this week.

Still, Senate GOP leadership has largely signaled they are moving on from repeal for now, with the legislative session in September likely to be dominated by work on funding the government and raising the debt ceiling.

And there are so far no signs that any of the three GOP “no” votes who sunk repeal, Sens. Lisa Murkowski (Alaska), Susan Collins (Maine), or John McCain (Ariz.), are changing their minds.

However, Graham said he is working with conservative Sens. Mike Lee (R-Utah) and Ted Cruz (R-Texas) to try to incorporate their ideas on repealing ObamaCare regulations into the plan.

And Majority Leader Mitch McConnell (R-Ky.) left the door open to bringing repeal back in some form, noting the fast-track procedure being used to avoid a filibuster had not expired.

“There’s still an opportunity to do that,” he said.

  1. Should we work with Democrats?

Lawmakers are ramping up bipartisan talks on the next steps for healthcare legislation, some more enthusiastically than others.

Sen. Mike Rounds (R-S.D.) said that following the failure of the Senate GOP’s ObamaCare repeal vote, Democrats have been more willing to talk with Republicans about ways to fix the law.

“Both sides are moving a little bit more to the middle,” Rounds said. “The discussions I’m having have been positive with Democrats, saying ‘look we are open to these changes, we will listen, we will work with you.’”

Sen. Roy Blunt (R-Mo.), a member of the GOP leadership, told The Hill he still wants to repeal ObamaCare “and start over, but that doesn’t mean an effort to hold up the collapsing structure in the short term isn’t the right thing to do.”

Both the Senate’s Health and Finance committees plan to hold bipartisan hearings in September when lawmakers return from recess.

Sen. Lamar Alexander (R-Tenn.) — the chairman of the Health, Education, Labor and Pensions Committee — said the goal is for the panel to craft a bipartisan, short-term proposal by mid-September, as insurers must sign contracts saying they’ll sell plans on the federal exchange by the end of that month.

Finance Committee Chairman Orrin Hatch (R-Utah) did not suggest the panel would produce legislation, but said there was bipartisan interest in a hearing.

“We’ve also heard a lot of demands from members of the committee for a healthcare hearing. I intend to do that as well shortly after the recess,” Hatch said Thursday.

But it’s not clear that the renewed interest in bipartisanship will yield legislation.

Alexander’s committee runs the ideological gamut from conservative Sen. Rand Paul (R-Ky) to progressive Sens. Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.).

Getting everyone behind a bill could prove a tall order, especially as some Republicans like Paul are committed to repealing ObamaCare, not repairing it.

  1. Should we back legislation to make key payments to insurers?

Insurers are desperate to know whether they’re going to continue to receive critical ObamaCare payments from the federal government.

President Trump has threatened to halt the payments, which compensate insurers for subsidizing out-of-pockets costs for certain healthcare consumers.

But Congress could take the matter out of his hands by authorizing the payments the administration has been making on a monthly basis, which total about $7 billion for fiscal 2017.

Even if Trump doesn’t halt the cost-sharing reduction payments, a yearlong appropriation from Congress would give insurers certainty that they’ll continue to receive the funds.

Republicans are divided on what to do.

Many say the ObamaCare marketplaces need to be stabilized and are open to funding the payments. Alexander took the first concrete step forward to do so, saying that any stabilization package his committee produces should fund the payments.

But conservatives are vehemently opposed.

“I think it is a mistake to simply go forward with bailouts for big insurance companies,” Cruz said. “For whatever reason, the Democrats’ central priority seems to be providing billions of dollars in subsidies and bailouts to giant insurance companies.”

  1. What’s to be done with CHIP?

Time is of the essence for Congress to reauthorize the Children’s Health Insurance Program (CHIP). Funding is set to expire Sept. 30.

CHIP has historically had bipartisan support, and the Senate Finance Committee announced on Thursday it would hold a post-recess hearing on CHIP.

Congress last reauthorized the CHIP program in 2015 as part of a broader health package.

However, for Republicans still searching for a way to pass provisions of their failed ObamaCare repeal legislation, the authorizing legislation may be a tempting vehicle.

If CHIP funding expires, states will be forced to make difficult decisions about coverage. Millions of families would have to find other sources of insurance for their children at a time of uncertainty around the stability, availability and affordability of other types of coverage.

  1. What’s to be done with ‘bare’ counties?

Insurance commissioners have a big fear: That the ObamaCare health marketplaces will open for business, but people in some areas won’t have any plans to choose from.

This scenario has never happened before, but as of Friday, 17 counties have zero insurers committed to their exchange, according to Kaiser Family Foundation.

The deadline to participate is looming. Insurers sign contracts with the federal government at the end of September, saying they’ll offer plans on the ObamaCare exchanges.

If the Senate Health Committee is able to meet its goal — hammering out a bipartisan short-term stabilization bill by mid-September — then that could help prevent more insurers from fleeing the marketplaces.

And behind the scenes, insurance commissioners have been offeringinsurers previously unheard of flexibilities to keep or entice them into the marketplaces.

Congress is aware of the situation, and has proposed several other solutions.

One bill from Tennessee’s Republican senators, Bob Corker and Alexander, would let people use their ObamaCare subsidies to purchase plans off the exchange — that is, if they live in a “bare county” without any ObamaCare plans to buy.

A counter bill from Sen. Claire McCaskill (D-Mo.) would allow those in bare counties to buy coverage on Washington, D.C.’s exchange, where Congress members and their staff purchase insurance.

Bipartisan drive to pay health insurers faces Senate hurdles

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http://abcnews.go.com/Health/wireStory/bipartisan-drive-pay-health-insurers-faces-senate-hurdles-48995691

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A bipartisan Senate effort to continue federal payments to insurers and avert a costly rattling of health insurance markets faces a dicey future. The uncertainty shows that last week’s wreck of the Republican drive to repeal the Affordable Care Act hasn’t blunted the issue’s sharp-edged politics.

President Donald Trump is threatening to halt the payments in hopes of forcing Democrats to negotiate an end to the Obama-era law. The insurance industry and lawmakers from both parties say blocking the money would lead insurers to raise premiums for people buying individual policies and might induce companies to abandon some markets.

Into the fray has stepped Sen. Lamar Alexander, R-Tenn., chairman of the Senate Health, Education, Labor and Pensions Committee.

He said he will work with the committee’s top Democrat, Sen. Patty Murray of Washington state, on a bill next month that would pay insurers through 2018. In exchange, he wants Democrats to agree to make it easier for states to choose their own health coverage standards that insurers must provide, and not heed consumer-friendly requirements of former President Barack Obama’s law.

While that is an idea Democrats say they will discuss, it’s unclear whether the two parties can reach a deal.

For the GOP’s failed effort to repeal and replace Obama’s overhaul, Senate Republicans used special rules allowing passage by a simple majority. But this developing bill would need 60 votes to succeed. Republicans hold a 52-48 advantage in the Senate, which means Democratic backing will be crucial.

Democrats will be reluctant to strike an agreement that would pull back far on Obama’s protections, which include a set of services insurers must cover and guarantees that premiums for healthy and seriously ill people are equal.

“It’s going to be hard to get common ground,” said Sen. Chris Murphy, D-Conn., a committee member. “Republicans are going to want some initial flexibility” for coverage requirements, “and that’s not an easy thing to achieve.”

Republicans are divided, too.

Many, including Trump, have called the payments an insurers’ bailout. Conservatives are reluctant to continue payments to help sustain a law the GOP has pledged for years to toss out.

“I was a total repeal guy,” said Sen. Richard Shelby, R-Ala. “I don’t know if I want to prop it up.”

Added GOP Sen. Ted Cruz of Texas: “I think it’s a mistake to bail out insurance companies.”

Obama’s law requires insurers to reduce out-of-pocket costs such as deductibles and copayments for millions of low- and middle-income customers. It also requires the government to reimburse insurers for those costs.

But a federal court found that Congress hasn’t properly approved money to do that. Both Obama and Trump have continued making the payments as the case has dragged on.

Besides the outright opponents, some Republicans say they would be reluctant to support an Alexander bill unless whatever eased regulations Democrats agree to are worthwhile. It’s unclear what Alexander or other Republicans are willing to accept.

“We certainly should get some structural change to bring down premiums in exchange for that,” said Sen. Ron Johnson, R-Wis. “We can’t just throw money at the problem.”

That echoes what Senate Majority Leader Mitch McConnell, R-Ky., said last Friday after the Senate rejected the third health proposal he advanced, effectively sinking the repeal effort.

“Bailing out insurance companies with no thought of any kind of reform is not something I want to be part of,” McConnell said.

Alexander said Wednesday that he has kept McConnell apprised of his effort. Asked if he had received a commitment that McConnell would bring such legislation to the full Senate, Alexander said, “Well, he doesn’t know what bill we’re going to have.”

But Alexander does have allies.

“We’ll eventually repeal Obamacare and put something in its place,” said Sen. John Kennedy, R-La. “In the meantime, I think it’s very important not to see any Americans get hurt.”

If the GOP divisions persist, McConnell and House Speaker Paul Ryan, R-Wis., might have to decide whether to have votes on legislation opposed by substantial numbers of Republicans. That’s always an uncomfortable proposition for party leaders.

“That’s a question for McConnell,” said the second-ranking Democratic senator, Illinois’ Dick Durbin, said asked whether he thought the GOP leader would allow a vote on a bill opposed by many Republicans.

Durbin said if Republicans are truly concerned about keeping insurance markets stable, “they have to do something.”

Would Ryan support a measure like Alexander’s?

The speaker “believes repeal and replace is the best course of action and that the Senate needs to act,” spokeswoman AshLee Strong said.

Court complicates Trump’s threat to cut ‘Obamacare’ funds

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https://www.washingtonpost.com/politics/federal_government/trump-on-tricky-legal-ground-with-obamacare-threat/2017/08/01/436cfc8e-771e-11e7-8c17-533c52b2f014_story.html?utm_term=.35d0bd8ec053

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President Donald Trump’s bold threat to push “Obamacare” into collapse may get harder to carry out after a new court ruling.

The procedural decision late Tuesday by a federal appeals panel in Washington has implications for millions of consumers. The judges said that a group of states can defend the legality of government “cost-sharing” subsidies for copays and deductibles under the Affordable Care Act if the Trump administration decides to stop paying the money.

Trump has been threatening to do just that for months, and he amped up his warnings after the GOP’s drive to repeal and replace “Obamacare” fell apart in the Senate last week. The subsidies help keep premiums in check, but they are under a legal cloud because of a dispute over the wording of the ACA. Trump has speculated that he could force Democrats to make a deal on health care by stopping the payments.

The court’s decision is “a check on the ability of the president to sabotage the Affordable Care Act in one very important way,” said Tim Jost, professor emeritus at Washington and Lee University School of Law in Virginia, a supporter of the ACA who has followed the issue closely.

Because of the ruling, legal experts said, states can now sue if the administration cuts off the subsidies. Also, they said, the president won’t be able to claim he’s merely following the will of a lower court that found Congress had not properly approved the money.

“We’re not going to wait to find out what Donald Trump wants to do,” said California Attorney General Xavier Becerra, who is helping steer the states’ involvement. “My team is ready to defend these subsidies in court.”

The Justice Department had no comment. The White House re-issued an earlier statement saying, “the president is working with his staff and his Cabinet to consider the issues raised by the … payments.”

Trump has made his feelings clear on Twitter. “If ObamaCare is hurting people, & it is, why shouldn’t it hurt the insurance companies,” he tweeted early Monday.

He elaborated in an earlier tweet, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies…will end very soon!”

In a twist, the appeals court panel seemed to take such statements into account in granting 17 states and the District of Columbia the ability to intervene on behalf of consumers.

The judges’ decision said states’ doubts that the administration could adequately defend their interests in court were fanned by “accumulating public statements by high-level officials…about a potential change in position.”

“He’s really a terrible client, President Trump is,” University of Michigan law professor Nicholas Bagley said. “The states point to his public statements and say, ‘Are you kidding me? We know the president is poised to throw us under the bus and we know because he said so.’”

The health law requires insurers to help low-income consumers with their copays and deductibles. Nearly 3 in 5 HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The annual cost to the government is about $7 billion.

The law also specifies that the government shall reimburse insurers for the cost-sharing assistance that they provide.

Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the health law, by providing a congressional “appropriation.”

House Republicans trying to thwart the ACA sued the Obama administration, arguing that the law lacked specific language appropriating the cost-sharing subsidies.

A district court judge agreed with House Republicans, and now the case is before the U.S. appeals court in Washington

If Trump makes good on his threat, experts estimate that premiums for a standard “silver” plan would increase by about 19 percent. And more insurers might decide to leave already shaky markets.

In Congress, some prominent lawmakers in both parties are saying they hope to provide at least a temporary guarantee for the subsidies before open enrollment season for 2018 starts Nov. 1.

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

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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.