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Collins: Trump’s threat to end ObamaCare payments won’t change my vote

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Collins: Trump’s threat to end ObamaCare payments won’t change my vote

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Sen. Susan Collins (R-Maine) said President Trump’s threats to cut off funding for key ObamaCare payments won’t change her vote on the GOP’s plan to repeal it.

CNN’s Jake Tapper asked Collins during an appearance on “State of the Union” Sunday if Trump’s threats to cut off the cost-sharing reduction (CSR) payments, as well as his apparent threat to cut off the healthcare benefits of members of Congress if they don’t pass a new bill, would change her vote.

“It would not affect my vote on healthcare, but it’s an example of why we need to act: to make sure that those payments, which are not an insurance company bailout, but rather help people who are very low-income afford their out-of-pocket costs toward their deductibles and their co-pays,” Collins said.

“It really would be detrimental to some of the most vulnerable citizens if those payments were cut off.”

Collins joined fellow Republican Sens. Lisa Murkowski (Alaska) and John McCain (Ariz.) in voting against Senate Republicans’ “skinny repeal” of ObamaCare in the early hours of Friday morning.

After returning home after her “no” vote, Collins received applause and cheers from passengers at an airport in Maine.

“It was just amazing. I’ve never had that happen in the 20 years that I’ve been privileged to serve in the Senate. So it was very encouraging and affirming, especially after arriving back home after a very difficult time,” she said.

Trump has previously threatened to withhold the CSR payments, which lower the amount some individuals have to pay for deductibles, copayments and insurance.

The president also targeted Murkowski last week, tweeting that she “really let the Republicans, and our country, down” after she voted no on a motion to proceed to debate on a GOP healthcare bill.

After the health care bill failure, what’s next for Congress and the Affordable Care Act?

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http://www.politifact.com/truth-o-meter/article/2017/jul/28/after-health-care-bill-failure-whats-next/

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In a dramatic, late-night vote, the Senate narrowly rejected an effort to repeal portions of the Affordable Care Act. Does that mean the effort to repeal and replace the law — a cornerstone of the Republican agenda for seven years — is over?

Where Senate Majority Leader Mitch McConnell, R-Ky., is concerned, it’s foolish to write off any possibility, said Josh Ryan, a political scientist at Utah State University.

“Every time we thought it was over, he thought of a different legislative maneuver and, except for one shocking vote by Sen. John McCain, it would have worked,” Ryan said. “I don’t think it’s likely, but I wouldn’t count McConnell out just yet.”

That said, key senators have not given early indications that they plan to pursue that approach, and experts, including Ryan, agreed that there are likelier scenarios than a full repeal-and-replace bill.

What are the possible options?

• Do nothing and wait for health markets to deteriorate enough that lawmakers are pressured to act.

“Congress and the administration could do as little as possible to help support the marketplaces, or even take active steps to destabilize them, such as not funding cost-sharing reductions or not actively enforcing the individual mandate,” said Christine Eibner, a senior economist at the RAND Corp. “They could then attempt to pass a bill hoping that — if the marketplaces are in dire straits, more senators will be willing to vote to repeal and replace.”

Eibner noted that President Donald Trump seems to be advocating for this approach on Twitter, where he wrote “let ObamaCare implode, then deal!”

• Look for common ground where a bipartisan approach could work.

Senate Minority Leader Charles Schumer, D-N.Y., said after the vote that he is open to working with the Republicans on a plan.

“Nobody has said Obamacare is perfect. Nobody has said our health care system doesn’t need fixing. The problem was when they started, when they tried to just pull the rug out from under the existing health care system,” Schumer said at a July 28 press conference. “So, change it, improve it, but don’t just take a knife and try to destroy it and put nothing in its place. And so, we can work together.”

What areas might a bipartisan approach address?

Joseph R. Antos, a health policy specialist at the conservative American Enterprise Institute, said he doesn’t see much likelihood of changes beyond well-established political and financial boundaries. “Don’t look for any significant changes from what is now in place,” he said. “Any attempt to do more will only reopen the fresh political wounds on both sides.”

Here are some areas that might fit this description.

• Shore up cost-sharing reductions under the Affordable Care Act.

Insurers are on the hook for these subsidies, which are given to eligible Affordable Care Act enrollees, regardless of whether the federal government reimburses them. But they have been a bone of contention between Republicans and Democrats, leading to uncertainty about whether the federal spigot will remain on.

“The single reason most insurers cite for withdrawing from marketplaces, or for requesting higher premiums to continue participating in marketplaces, is the uncertainty over whether the federal government will reimburse them for cost-sharing subsidies,” said Linda Blumberg, who studies health care policy at the Urban Institute.

There is evidence that both parties could find common ground here, Antos said. A two-year extension of payments was in the Senate Republican health care proposal known as BCRA.

• Add a reinsurance program.

Reinsurance helps protect private, non-group insurers so they can pay off unusually high claims from their enrollees, thus enabling them to stay in business. Reinsurance was part of the Affordable Care Act for its first three years but no longer is.

Blumberg said making reinsurance a permanent part of the law could bring down premiums and help insurer confidence and participation.

Reinsurance could be funded either through direct public support or through a tax levied on insurers, which was the method used during the first few years of the Affordable Care Act, Eibner said. She added that Alaska recently reduced premiums through a state-funded reinsurance program.

• Find a way to lower premiums for young, healthy Americans.

There is widespread agreement that, if more young and healthy people were to join the marketplaces, premiums would fall. Eibner suggested a few options for doing that. Congress could allow insurers to charge older people five times as much as younger people, rather than three times as much, or it could enhance tax credits for young people, she said.

• Do more to encourage the use of catastrophic coverage.

Such plans don’t kick in until an enrollee has a very expensive condition. The downside is that if someone signs up for these plans and gets seriously ill, they would have to pay a significant amount from their own pocket. The upside is that premiums would be lower, and it might open new opportunities for insurers in certain markets.

Currently, such plans are only available in the Affordable Care Act marketplaces for younger adults and individuals who can demonstrate financial need. But one of the provisions pursued by Senate Republicans would have widened access to these plans. “It’s possible that this provision could be revived as part of bipartisan legislation,” Eibner said.

Would your plan cover John McCain’s treatment?

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https://www.healthinsurance.org/blog/2017/07/25/would-your-plan-cover-john-mccains-treatment/

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The Arizona Senator’s health plan will ensure top-notch glioblastoma treatment, but how would Americans with other health coverage fare?

Last week, we heard the sad news that Senator John McCain has been diagnosed with glioblastoma. McCain had surgery at Phoenix’s Mayo Clinic in mid-July, and it’s expected that he’ll also receive chemotherapy and radiation, along with other potential treatments. Senator McCain has proven time and again that he’s tough as nails, and appears to be facing this latest battle head-on. One thing that he likely has on his side is top-notch health insurance.

McCain is 80, which means he’s presumably been on Medicare for 15 years. Currently serving federal lawmakers are able to obtain employer-subsidized coverage in the Washington DC small-business exchange, and they can have this coverage in addition to Medicare.

How good is McCain’s coverage?

McCain hasn’t said publicly exactly what insurance he has, and his office has not responded to my inquiry. But the most likely scenario is that he has Medicare plus employer-sponsored coverage through the DC exchange – a very comprehensive benefits package.

There are certainly lots of other people who have similar coverage arrangements – either because they’re still working after turning 65, like McCain, or because they receive generous retiree health benefits that supplement their Medicare coverage. For those who don’t, there are private Medicare supplements available that cover virtually all of the out-of-pocket costs associated with Medicare.

But health coverage in the United States is a bit of a mixed bag, with some people having much better coverage than others. A serious illness tends to shine a spotlight on the flaws that exist in some health plans, so let’s take a look at how the average American facing a glioblastoma diagnosis would fare under various health plans.

Employer-sponsored health insurance

Most employer-sponsored health insurance plans provide pretty solid health coverage. According to a 2016 Kaiser Family Foundation analysis, the average deductible for covered workers was about $1,500, and that doesn’t count the 17 percent of covered workers whose plans had no deductible at all.

In addition, the average employer paid more than two-thirds of the total premiums. And the tax exclusion of employer-sponsored insurance premiums amounts to a subsidy that cost the federal government $250 billion in fiscal year 2016.

However, employer-sponsored health insurance is, by definition, linked to employment. A person going through a serious illness like glioblastoma might not be able to continue working, depending on the specifics of the treatment.

As long as the employer has at least 20 employees, the employee will be able to continue the coverage under COBRA for 18 months, even if he or she is unable to work. But COBRA is expensive, as the employer contribution to the premiums and the tax exclusion of the premiums are eliminated. (COBRA premiums are counted as a medical expense for the purpose of itemized medical deductions, but only expenses that exceed 10 percent of your income can be deducted this way.)

Although most employer-sponsored plans provide good coverage, that’s due in part to the ACA. It was not uncommon – particularly in low-wage, high turnover industries – for employers to offer “mini-meds” before the ACA, with exceedingly low benefit caps. (The ACA’s ban on lifetime and annual benefit limits means that these plans are no longer offered to employees.)

A mini-med with a $2,000 or $5,000 annual benefit maximum would not have done much in the face of glioblastoma. Vox reported that just the initial craniotomy to remove a blood clot above Senator McCain’s eye would likely have been billed at more than $76,000. And that was before the cancer diagnosis.

ACA-compliant individual market coverage

The pre-ACA individual market included plenty of solid plans. But dubious coverage also abounded, and regulations varied considerably from one state to another.

The ACA imposed a bevy of regulations on the individual health insurance market, bringing all new (as of 2014) plans up at least a basic minimum standard. Individual major medical coverage can no longer be sold without the ACA’s essential health benefits.

And for those benefits, insurers cannot limit how much they’ll pay during a year or over the course of an insured’s lifetime. (Sadly, another Arizona resident with cancer, Arijit Guha, died in 2013 at age 32. Guha’s health insurance plan had a $300,000 lifetime cap – which is no longer allowed, thanks to the ACA – and his treatment, including chemotherapy that cost $11,000 per session, quickly exceeded that limit.)

Individual-market plans also cannot discriminate against people with pre-existing conditions, either by charging them higher prices or declining their applications (both of those were standard practice in nearly every state prior to 2014). Notably, Senator McCain has a history of melanoma, which would have virtually guaranteed a declined application in the individual market pre-ACA if he had been in need of non-group coverage for some reason.

A person with ACA-compliant individual market coverage would have solid coverage for glioblastoma. The maximum out-of-pocket costs during 2017 would be $7,150, although most plans have out-of-pocket maximums below that threshold. And 57 percent of people who enrolled through the exchanges in 2017 have cost-sharing subsidies, which further reduce the out-of-pocket costs.

The American Cancer Society explains in more detail how the ACA improves access to care for people with cancer. But the short story is that a person facing glioblastoma with a 2017 individual health insurance policy has a much more secure financial safety net than someone with the same diagnosis a decade ago.

Medicaid

Medicaid provides comprehensive coverage. Although the benefits available under traditional Medicaid vary from one state to another, Medicaid expansion coverage is required to include the ACA’s essential health benefits. (The Senate’s Better Care Reconciliation Act – BCRA – would eliminate this requirement after 2019.)

Medicaid has minimal cost-sharing, limited to no more than 5 percent of a family’s annual income.

It’s true that compared with private health insurance and Medicare, fewer medical providers accept Medicaid. But the majority do work with Medicaid. (According to a Kaiser Family Foundation analysis, about 69 percent of office-based physicians accept new Medicaid patients, while about 85 percent accept new privately-insured patients.)

Short-term health insurance

The ACA implemented regulations that apply to virtually all types of health insurance. But some plans are not regulated by the law, including short-term health insurance.

As evidenced by the name, short-term plans are limited in their duration. As of 2017, a short-term plan can last no more than three months, although people who remain healthy can purchase a second short-term plan after the first one ends.

Short-term plans do not cover pre-existing conditions. So if you were to be diagnosed with glioblastoma while covered under a short-term plan, the first thing the insurer would do is go back through your medical records to make sure that you didn’t have any symptoms prior to enrolling in the plan.

Assuming you were healthy before you enrolled, your short-term plan would start to cover your treatments. But you would be facing a looming and inflexible coverage termination date, along with annual and lifetime benefit maximums. Short-term plans vary considerably in quality – some have lifetime benefit maximums of $250,000 or less, while others provide benefits well in excess of a million dollars. In the case of a glioblastoma diagnosis, coverage would end when the policy reached its predetermined end date, or when you hit your benefit maximum – whichever happened first.

Either way, you’d want to hope that you had other coverage already lined up and ready to go at that point. The cancer diagnosis would make it impossible to obtain another short-term policy.

And since a short-term plan is not considered minimum essential coverage, the termination of the short-term policy would not trigger a special enrollment period for individual or employer-sponsored insurance. You would still be able to enroll in a regular individual-market plan, or an employer plan if you’re eligible for one, during regular annual open enrollment. But you might experience a significant gap in coverage, which can be disastrous in the middle of cancer treatment.

A limited-benefit plan

Limited-benefit plans are another category of coverage that’s not regulated by the ACA (despite attempts by the Obama Administration to place some regulations on certain types of fixed indemnity coverage).

Fixed indemnity means that the plan pays a specific dollar amount if the insured has a covered claim. For example, the plan might pay $1,000 per day for hospitalization, or $50 for a doctor visit. There’s no cap on how much the patient has to pay, and these plans often have very low annual and lifetime benefit limits.

So imagine a plan that will pay $2,000 per day for hospitalization, for up to 25 days. It will also pay $2,500 for an outpatient surgical procedure and $2,500 for an inpatient surgical procedure. And it will pay $625 for anesthesia, but it does not cover prescriptions (these numbers are from a real plan currently available in the limited benefit market).

Remember that McCain’s craniotomy – before the glioblastoma was even diagnosed – likely cost $70,000. He was home very soon after the surgery, so if he was hospitalized at all, it wasn’t more than a day or two. A limited benefit plan like the one described above would have paid $2,000 for each day in the hospital (which amounts to zero dollars if the procedure didn’t result in an inpatient stay), $2,500 for the surgery, and $625 for the anesthesia. That would leave a sizeable chunk of the $70,000 bill as the patient’s responsibility.

And all of that is before the treatment for the glioblastoma even begins.

A Cruz Amendment plan

In mid-July, Senator Ted Cruz introduced an amendment to the BCRA aimed at reducing regulations on health insurance plans. The Cruz Amendment, if included in the BCRA, would allow insurers to offer non-ACA-compliant plans as long as they also offered at least one Silver plan, one Gold plan, and one plan that complies with the BCRA’s benchmark standards (58 percent actuarial value).

The non-compliant plans would likely range from decent to terrible, since they would have wide latitude in terms of the consumer protections they’d be able to waive. Essentially, it would be a return to the pre-ACA days when there was more of an “anything goes” approach to health insurance. Plans would be available without essential health benefits, would not have to cover pre-existing conditions, and could be offered with higher out-of-pocket limits than ACA compliant plans.

These plans would likely appeal to healthy people, as they would be less expensive than ACA compliant plans. But a person who seems perfectly healthy can be diagnosed with glioblastoma, at which point the holes in the coverage become glaringly apparent.

What about those who lack McCain’s coverage

In glioblastoma, Senator McCain is facing a fierce battle, and our hearts go out to him and his family. But thanks to McCain’s health coverage, he won’t have to worry about how to pay for his treatment. I’m glad he has that health coverage.

Senator McCain is not alone in his battle. There are more than 12,000 Americans who will be diagnosed with glioblastoma this year. Unfortunately, many of them do not have the level of health coverage that McCain has. Even with the best health insurance, the diagnosis plunges each family into an immensely challenging situation. With lesser – or no – coverage, the challenge becomes even more insurmountable.

Nobody deserves cancer. And nobody deserves to have to fight cancer with less-than-adequate health insurance. With our current medical know-how, we can’t keep everyone from getting cancer. But we can make sure that as many people as possible are covered by high-quality health insurance. We owe it to all the lesser-known John McCains out there to work towards that goal.

That means pushing back against any sort of “reform” that would result in fewer people with insurance. It also means rejecting proposals that would allow junk insurance plans to flood the market, lulling consumers into a false sense of security – until they’re diagnosed with brain cancer.

 

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

Repeal and Delay

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

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

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

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

Repeal and Replace (I)

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

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

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

Repeal and Replace (II)

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

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

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

Punt to the States

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

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

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

What Trump can do to cripple ObamaCare

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What Trump can do to cripple ObamaCare

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

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

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

Here are four ways Trump could cripple the law.

Stop the cost-sharing subsidies.

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

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

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

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

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

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

Stop enforcing the individual mandate.

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

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

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

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

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

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

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

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

Stop advertising and outreach.

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

The Trump administration has taken the opposite approach.

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

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

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

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

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

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

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

Use administrative flexibility.

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

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

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

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

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

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

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

Trump’s war of attrition against Obamacare

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http://www.politico.com/story/2017/07/21/trumps-war-of-attrition-against-obamacare-240777?utm_campaign=CHL%3A%20Daily%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54498266&_hsenc=p2ANqtz-9ek2u9ksxXcgIEhuqarS0spfhGiKMzLANnn_6r5sJmtFLcRJplq-a0Zqexn1eqaf_s9_sbG_p8WdTzuQUliN0eqfaVBA&_hsmi=54498266

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Republican plan to ‘repeal and delay’ will leave millions more Americans uninsured

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http://www.politico.com/interactives/2017/republican-obamacare-repeal-uninsured-double/?lo=ap_a1

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Majority Leader Mitch McConnell wants to hold a vote on a bill that would repeal major parts of Obamacare and give Republicans two years to pass a replacement. A new CBO report finds that repealing Obamacare without a replacement would result in 32 million more Americans losing health insurance over a decade — far deeper coverage losses than any of the health plans Republicans have proposed. Further, 75 percent of Americans would live in areas without any insurers selling coverage in the individual market by 2026.

The latest GOP health plan would strike:

  •  Individual mandate
  •  Insurance subsidies
  •  Medicaid expansion
  •  Planned Parenthood funding

The bill would effectively kill Obamacare’s individual and employer coverage mandates, strike health insurance subsidies, roll back Medicaid expansion and defund Planned Parenthood.

Repealing Obamacare would more than double the number of Americans without health insurance.

Under Obamacare, 10 percentof Americans would lack health insurance.

But if Republicans repeal Obamacare, the number could grow to 21 percent by 2026.

NOTE: Data includes Americans under 65 who do not have health insurance and does not include persons who are Medicare-eligible.
SOURCE: Congressional Budget Office

The uninsured rate plunged under the ACA, but would now skyrocket

ACARepeal ACA0510152025%1997201020172026Before the ACAACA passed10%21%
NOTE: Data includes Americans under 65 who do not have health insurance
SOURCE: National Center for Health Statistics and the Congressional Budget Office

In the first year alone, nearly 17 million more people would no longer have insurance — or (16 percent) of Americans. That includes 10 million fewer buying plans on the individual market, 4 million fewer people covered through Medicaid, and 2 million fewer with job-based coverage.

But once Medicaid expansion and subsidies were repealed (roughly two years after enactment), the number of uninsured Americans would increase by 27 million in 2020. By 2026, about 59 million people or 21 percent of Americans would be uninsured.

Capitol Hill health bill drama is leaving Obamacare exchanges in limbo

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Capitol Hill health bill drama is leaving Obamacare exchanges in limbo

Question mark heap on table concept for confusion,

 

California’s Obamacare exchange scrubbed its annual rate announcement this week, the latest sign of how the ongoing political drama over the Affordable Care Act is roiling insurance markets nationwide.

The exchange, Covered California, might not wrap up negotiations with insurers and announce 2018 premiums for its 1.4 million customers until mid-August — about a month later than usual. Similar scenarios are playing out across the country as state officials and insurers demand clarity on health care rules and funding, with deadlines fast approaching for the start of open enrollment this fall.

“It’s insane,” said John Baackes, CEO of L.A. Care Health Plan, which has about 26,000 customers on the California exchange. “Here we are in the middle of July and we don’t even know what rules we will be operating under for open enrollment. It is not how you want to run a business.”

Consumers could face sharply higher premiums and fewer choices if more health insurers leave the insurance marketplaces due to lingering uncertainty. State and industry officials around the United States are concerned that the federal government could stop funding so-called cost-sharing subsidies that reduce out-of-pocket costs for low-income consumers. And they worry the Trump administration won’t enforce the individual mandate that requires people to purchase health coverage or pay a penalty.

Amid those concerns, there was a sense of relief Tuesday among many exchange officials and insurers after the U.S. Senate’s latest attempt to replace the Affordable Care Act failed.

Two large insurer trade groups bluntly warned last week that parts of the Senate plan were “unworkable” and could plunge the market into chaos. In a letter to the Senate, America’s Health Insurance Plans and the Blue Cross Blue Shield Association particularly objected to an amendment by Sen. Ted Cruz (R-Texas) that would have allowed insurers to sell bare-bones health plans to people who wanted cheaper premiums. That provision, the insurers said, would split the market between the healthy and the sick, driving up costs for people with pre-existing conditions.

However, the Republicans’ failure to pass that ACA replacement plan did not resolve questions swirling around the current health law.

Tuesday, President Donald Trump expressed disappointment at the outcome in the Senate, telling reporters, “We’ll let Obamacare fail and then the Democrats are going to come to us and they’re going to say, ‘How do we fix it?’”

Some Senate Republicans struck a more conciliatory tone, suggesting that lawmakers should work on a bipartisan measure that would help stabilize the individual insurance markets.

Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pensions, said he plans to hold hearings in the coming weeks on ways to shore up the individual insurance market. Lawmakers may look at creating a new stabilization fund that helps compensate insurers for higher-cost patients. Such a fund would be similar to one that existed during the first three years of the ACA exchanges.

Some insurance industry executives welcomed the talk of bipartisanship, but they said action must be taken quickly to resolve key issues affecting consumers.

“We are running out of time and we need a resolution on what we are charging for 2018,” said Gary Cohen, vice president of public affairs at Blue Shield of California in San Francisco, the largest Covered California insurer by enrollment.

Cohen, who helped launch the exchanges in 2014 as an official in the Obama administration, noted that the Republican bills in both the House and Senate included money for reinsurance that can help lower premiums industry wide. Those provisions are among the “immediate steps Congress and the Trump administration need to take in order for markets to provide coverage that is affordable.”

A federal reinsurance program helps compensate insurers for the high costs incurred by the sickest patients. That, in turn, allows health plans to keep their overall premiums lower and attract healthier customers into the insurance pool.

Lawmakers could also appropriate federal funds for the cost-sharing subsidies, which have a price tag of about $7 billion a year. Those payments, made directly to insurers, help reduce deductibles and other out-of-pocket costs for policyholders who earn up to 250 percent of the federal poverty level. This year, that’s up to about $29,000 for an individual or around $61,000 for a family of four. More than half of the people enrolled on exchanges nationwide qualify for this financial assistance.

Without it, many consumers would face annual deductibles of $2,000 or more when visiting the doctor or undergoing medical tests. That would make people far less likely to sign up with participating insurers.

Conservatives generally oppose the subsidies, calling them a bailout of the insurance industry and arguing that the Obama administration didn’t have the authority to pay them. Trump has repeatedly threatened to cut off those cost-sharing subsidies as well.

With their future up in the air, some states, including California and Pennsylvania, allowed insurers to submit two sets of proposed premiums. One filing reflects continued federal funding of those subsidies, and a separate one assumes they are eliminated and their cost is included in health plan premiums.

In Pennsylvania, premiums next year without the subsidies would increase by an average of 20 percent, compared with 9 percent if they remained intact.

Pennsylvania Insurance Commissioner Teresa Miller said the market in her state would be in good shape without the uncertainty over federal policy. “The only thing right now keeping everyone on edge is what’s going to happen in Washington, D.C.,” Miller said. “If things calm down in D.C. and if we don’t see further changes, then Pennsylvania’s market really is stabilizing.”

On Tuesday, Covered California said the two different rate filings its health plans submitted will be released Aug. 1. The exchange may announce that same day what the final premiums are, or it could postpone the decision for several more weeks if Congress has begun to pursue fixes to the ACA.

“This decision is based on the ongoing federal uncertainty around the repeal and replacement attempts of the Affordable Care Act and the dramatic potential impacts such uncertainty has on the rates and on California consumers,” the exchange said in a statement.

A recent analysis commissioned by Covered California estimated that premiums for silver-tier plans would jump by 16.6 percent if the federal government stopped paying for the cost-sharing subsidies. That would be in addition to normal increases meant to cover rising medical costs. An exchange spokeswoman declined to comment further Tuesday, citing the ongoing developments in Washington.

In the Florida exchange market, health insurers have sought an average rate increase of nearly 18 percent. But Florida Blue, the state’s largest health insurer, said those rates would go even higher if the cost-sharing reduction payments disappeared.

Robert Laszewski, an industry consultant in Virginia and a frequent ACA critic, said the exchange markets aren’t imploding, despite what the Trump administration has often said. But their premiums will continue to rise unless more young and healthy people are persuaded to buy coverage, he said.

“I think most insurance companies will at least break even, or even make a profit, in 2018,” Laszewski said. “Coverage will be ‘stable,’ but it will stabilize at a horrific premium rate level.”

CBO: ObamaCare repeal without replace would cost 32 million insurance

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CBO: ObamaCare repeal without replace would cost 32 million insurance

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Repealing ObamaCare without a replacement would result in 32 million people losing their insurance in the next 10 years, according to the Congressional Budget Office.
The bill, much of which would take effect in 2020, would also massively increase insurance premiums. According to the CBO, average premiums would increase by about 25 percent in 2018 alone. The increase would reach about 50 percent in 2020, and premiums would increase nearly 100 percent by 2026, CBO said.
Senate Republicans said this week they would consider voting on repeal only, after it appeared their replacement legislation had failed. However, negotiations attempting to revive repeal and replace continue and senators are scheduled to huddle Wednesday night to discuss if there’s a path forward.
The unfavorable score of the repeal-only bill could help jumpstart discussions about returning to the repeal-and-replace legislation.

A previous CBO score of the Senate’s repeal-and-replace bill estimated that 22 million people would lose insurance over the next decade.

The CBO hasn’t released a score on the most recent revision, which includes a controversial amendment from Sen. Ted Cruz (R-Texas).

The Senate will vote next week on a motion to proceed, though it’s not clear which bill Majority Leader Mitch McConnell (R-Ky.) wants to move to — a straight repeal or the repeal-and-replace legislation that seemed dead just days ago.

Both the House and Senate passed the “repeal-only” bill in 2015 that was vetoed by President Obama. Among other provisions, the “repeal only” bill would eliminate: ObamaCare’s individual and employer mandates, the Medicaid expansion, and subsidies for low-income individuals.

It would retain the requirements that protect people with pre-existing conditions from discrimination and would continue to require insurers to offer specific benefits.

According to the CBO “eliminating the penalty associated with the individual mandate and the subsidies for insurance while retaining the market regulations would destabilize the nongroup market, and the effect would worsen over time.”

Republicans have argued that they need to repeal and replace ObamaCare to “rescue” the growing number of people who live in counties with no insurers on the healthcare exchanges. But according to the CBO, repeal-only would make the problem worse.

The repeal-only bill would cause insurers to begin dropping out of the marketplace as soon as next year, the CBO said. It would also leave about half of the nation’s population without any ObamaCare insurers by 2020, a figure that would increase to about three-quarters of the population by 2026.

The BCRA is dead, but don’t take your eye off Capitol Hill

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The healthcare industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare is off the table for Congress. Here’s what to watch.

The bulk of the Affordable Care Act (ACA) has survived the latest Republican efforts to repeal it, as Senate leaders were forced to admit Tuesday their best chance to fulfill years of campaign promises to gut the law has floundered.

The Senate plan to replace the ACA sank Tuesday night when the total number of Republicans opposing the bill rose to four. Republican Senate Leader Mitch McConnell immediately pivoted to an effort to repeal the ACAwithout a replacement plan. Only hours later, however, that plan also became unrealistic, as moderate Republicans said such a move would be too risky and they would not vote for it.

Industry groups were happy with the news. Scores of policy experts and healthcare professionals had railed against both the Senate and House bills to replace the ACA. Congressional Budget Office estimates found they would take away health insurance coverage for more than 20 million people. Both proposals also drastically cut Medicaid and eliminated protections for people with pre-existing conditions.

Millions more uninsured would have caused a hefty increase in uncompensated care costs for hospitals. The Commonwealth Fund estimated both replacement bills would have meant nearly a million healthcare jobs lost by 2026.

The industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare will be off the table in Congress. Here’s what to watch.

Stabilizing the individual market

The most immediate concern for payers with ACA repeal out of the picture is cost-sharing reduction (CSR) payments and the stabilization of the individual market. McConnell has said legislation to help shore up the market would be needed if the Senate’s Better Care and Reconciliation Act (BCRA) failed. But at least one lawmaker — Senate Majority Whip John Cornyn — said Tuesday he would “not be part of any bailout of insurance companies.”

President Donald Trump said Tuesday that Republicans should “let Obamacare fail” and pin the blame on Democrats. This would likely mean withholding CSRs, a position Trump has repeatedly advocated.

CSRs are meant to help insurers pay for beneficiaries with more care needs and therefore higher costs. They help payers keep a balanced risk pool. Congress and the White House have so far refused to commit to the payments for next year, and insurance companies pulling out of the ACA exchange markets have cited that inaction as a major reason for withdrawal.

The Trump administration still has to decide whether to continue defending a lawsuit against the White House from House Republicans claiming the Obama administration was paying the CSRs without proper appropriation. Payers are hoping Republicans agree to commit to future CSRs with a clearly above-board fund.

Republicans who balk at the CSRs may try to push their own ideas for how to stabilize the market. They have previously proposed changing the age band to allow insurers to charge older people more and tightening requirements for special enrollment periods. The BCRA included $112 billion to help payers stabilize the market, but that funding lasted only two years and assumed the other numerous changes the BCRA called for would go into effect.

Payers would much prefer a commitment to funding CSRs with a clearly above-board fund. That would certainly help steady the ACA marketplaces, but Republican rhetoric about the markets’ “death spiral” is overblown. The CBO has said the individual market would remain stable in most areas under current law, and a Kaiser Family Foundation report showed that payers are regaining profitability in the market while stability is increasing.

Executive actions

The White House will likely be making its own plans in case efforts in Congress fall through.

Trump has said very little about healthcare policy during his time in office. Other than a few tweets, Trump didn’t participate in vote-wrangling for the ACA replacement bills and didn’t make much use of his bully pulpit.

He held a celebratory press conference in the Rose Garden when the House passed its ACA replacement bill and also supported the BCRA. When the Senate bill failed, he immediately called for a repeal without replacement, but the administration didn’t elaborate on when a replacement might come or what it would look like.

Trump has already issued one major executive order on healthcare. Immediately after taking office, he told federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement that of the Act that would impose a fiscal burden on any state or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, purchasers of health insurance, or makers of medical devices, products, or medication.”

The IRS under Trump is still technically enforcing the individual mandate, although it also accepted tax returns that don’t indicate whether the filer has health insurance. With the failure to replace the ACA in Congress, Trump could push for complete abandonment of the requirement. Without the mandate, healthy people who don’t need much care would be less likely to get coverage and risk pools would become more unstable.

HHS has already indicated it will allow more state waivers under the ACA, letting states dictate what benefits are required and how people qualify for Medicaid. Conservative states have started planning waiver applications with aspects like a requirement that Medicaid beneficiaries have a job.

The administration could also weaken the ACA by refusing to publicize it. Immediately after Trump took office, the government scaled back advertising for the ACA open enrollment period. This led to fewer signups in the typically busy final days of enrollment. Without a push for young and healthy people to enroll, risk pools could again get off balance.

It hasn’t meant much yet, but with repeal off the table for now, the administration could push for more use of the order. Executive action could be tricky, however, as HHS remains understaffed.

Bipartisan options

Although Republicans and Democrats are far apart on nearly every aspect of healthcare reform, they could find that working together is their only chance of getting anything passed.

One jumping off point could be the bill put forward earlier this year by two of the more moderate Senate Republicans. It would repeal the individual and federal mandates as well as essential health benefits, but keep some aspects of the ACA, like a ban on coverage caps. It would also allow states to implement their own alternative plans, possibly with federal assistance.

Giving more control to state governments — a tactic embraced by HHS Secretary Tom Price — appeals to the left in some ways, but Democrats and patient advocates will oppose any weakening of protections for people with pre-existing and chronic conditions. Republican plans that throw out coverage mandates cannot guarantee such protections because they can easily create unbalanced risk pools.

One initiative that has nearly universal support is MACRA, as well as the movement toward value-based care in general. As providers deal with implementing MACRA payment model changes, Congress may be asked to make some tweaks or delays.

It’s unlikely any major healthcare changes in the near future will be bipartisan, but lawmakers willing to reach across the aisle could try to tackle some smaller issues.

CHIP reauthorization

Another chance to pass healthcare legislation will come at the end of September when the Children’s Health Insurance Program (CHIP) is set to expire. Lawmakers want to ensure the program continues, but may also see it as a possible vehicle for other bills. Republicans have already delayed hearings on renewing CHIP as they’ve debated how to move forward on healthcare changes.

This could be the route for a bill to stabilize the individual market. Republicans and Democrats may try to use this opportunity to push through other changes, but any delay that threatens the continuation of CHIP will be heavily criticized.