Tag Archives: Sabotaging ACA

Down to the Wire: Indecision on ACA Cost-Sharing Reduction Payments Creates Confusion for States

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http://www.commonwealthfund.org/publications/blog/2017/sep/cost-sharing-reduction-payment-indecision

Among the Trump administration’s first promises was to give states more flexibility and control over their health insurance markets than they had had during the Obama years. To date, however, the administration has offered states only uncertainty about what to expect in 2018, which has made it difficult to set premium rates. In particular, state officials are struggling to keep their insurance markets afloat in the face of the Trump administration’s continued indecision over whether to reimburse insurance companies for Affordable Care Act (ACA) cost-sharing reduction (CSR) plans. And time is running out.

No Clarity About Future Payments

Under the ACA, insurers are required to offer plans with reduced cost-sharing for out-of-pocket expenses like copayments and deductibles to eligible low-income enrollees; the government then reimburses insurers for the higher cost of those plans. The Trump administration has threatened to cut off those reimbursements, which for 2018 were projected to reach $8 billion. If these reimbursements do terminate at the end of this year, the Congressional Budget Office has estimated that 2018 premiums will rise by an average of 20 percent. This projection is consistent with similar estimates from the Kaiser Family Foundation and insurers’ own proposed 2018 rates, which were submitted to states this summer.

While the administration has continued to make the monthly CSR reimbursements so far, federal officials have not committed to any future payments. The Trump administration has extended the deadline for finalizing premium rates to September 20, 2017, but even that deadline is fast approaching. Once rates are finalized by states, insurers are locked into them for the full calendar year.

State Decisions Will Drive Insurer Participation and Costs for Consumers and Taxpayers

Whether insurers continue to participate in the ACA marketplaces and what consumers — and federal taxpayers — ultimately pay could depend on the actions of 50 different state insurance commissioners (plus D.C.). Yet, as noted, these state regulators and insurers are in a race against the clock to develop, review, and implement 2018 premium rates that reflect insurers’ likely costs as accurately as possible.

To date, state departments of insurance have given insurers different directives about how to set their premium rates for next year. The variation in these directives will result in different — and potentially significant — consequences for consumers, insurers, and federal taxpayers.

At least one state insurance department, Maryland’s, is currently requiring insurers to submit 2018 premium rates assuming they will be reimbursed for CSR plans throughout 2018. This approach has the advantage of helping to keep rate increases in check for consumers, particularly those not eligible for the tax credit subsidies that shelter low- and moderate-income enrollees from premium hikes. But this directive also carries big risks. If the Trump administration cuts the CSR reimbursements and insurers don’t have sufficient time to submit new rates, then they will face significant financial losses and some (if not all) will likely exit the market, leaving consumers without coverage options.

Other states, such as in New York and Utah, have required or allowed insurers to assume they won’t be reimbursed for CSR plans in 2018. While this means big premium increases for many consumers, it gives insurers more confidence to participate in the market by protecting them from major financial losses. At the same time, if the Trump administration decides to keep the CSR reimbursements going (or if Congress steps in to appropriate the necessary funds), these insurers will reap a windfall, financed largely by federal taxpayers through the ACA’s premium tax credits. Yet more state insurance departments, such as in Arkansas, California, Michigan, and New Mexico, have tried to hedge their bets by asking insurers to submit two sets of rate requests — one assuming CSR reimbursements will be paid, one assuming they won’t.

Still other states have not yet provided directives or reassurances to their insurers, essentially leaving it up to each company to decide how to respond to the uncertainty over CSRs. However, allowing each insurer to decide for themselves could lead to significant market disruption. For example, if one insurer sets premiums assuming they will be paid CSRs, but others in the market increase premiums assuming they will not, it will drive enrollment to the lower-cost plan at the expense of its competitors, placing that insurer at risk of insolvency if the CSRs are not paid.

Looking Ahead

Most observers have hoped that federal policymakers would announce a decision on CSRs one way or another in time for insurers to adjust premium rates for 2018. But as the deadline for finalizing rates looms, it is less and less likely that states will have the clear federal signal they need to decide how to best regulate their insurance markets and review proposed premiums for the upcoming year. Without clarity from federal officials or commitment from Congress to continue funding for CSRs, state insurance departments and insurers will need to make some high stakes bets on the future of these markets by setting premiums that may be too high or too low. Ultimately, the risk of losing these bets will be borne primarily by consumers and federal taxpayers.

How to turn healthcare’s single-payer threat into a reality

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http://www.modernhealthcare.com/article/20170913/NEWS/170919942

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What’s behind the renewed enthusiasm in the Democratic Party for Sen. Bernie Sanders’ single-payer healthcare bill? The GOP still controls both houses of Congress and the White House. The Affordable Care Act still faces an existential crisis.

Unless something is done in the next few weeks to shore up the exchanges for 2018 and reverse HHS’ mean-spirited efforts to undermine enrollment, the enormous progress made over the past four years—last week the Census Bureau announced the nation’s uninsured rate had dropped sharply over that period to 8.8%—will begin to reverse. For those desperately working to avert the immediate danger, single-payer advocacy is a distraction.

Unfortunately, the logic of contemporary politics made the current push for single-payer inevitable. President Donald Trump and the tea party set the table. They proved that in a populist moment, extreme positions that cater to a sliver of the electorate are a viable path to electoral success.

Expect left-wing challengers supporting single-payer to win numerous Democratic House and Senate primaries next spring. A wave election typical of first-term, off-year elections will lead to a single-payer caucus in the next Congress with as much power as the tea party caucus had after the wave of election of 2010.

Single-payer looms as their threat. If you destroy President Barack Obama’s grand compromise-his eponymous plan relied on private insurers and preserved the employer-based system- the fire next time will get rid of both.

Unlike the tea party, single-payer advocates have history on their side. The U.S. over the last half century has moved inexorably toward universal coverage: Medicare and Medicaid; the Children’s Health Insurance Program; the ACA. It will get there one way or another.

Sanders asked the right question in his op-ed last week in the New York Times. “Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?”

Polls now report growing support for single-payer health insurance. When asked if the government has the responsibility to guarantee access to healthcare for all Americans, nearly 60% answer yes. In other words, a clear majority of Americans now say yes to Sanders’ question.

It’s not just a human-rights issue. Universal access through universal insurance coverage is a necessary if insufficient component of getting healthcare costs under control. It is also a building block for restoring the nation’s economic competitiveness, especially in areas of the country suffering from a prolonged decline. No region can thrive unless it has a well-educated, healthy workforce.

Industrialized countries diverged in how they achieved universal coverage. Some chose a government-funded, single-payer system. Others chose well-regulated private insurers. Still others chose a combination of the two.

The U.S., because its employers used health benefits to get around World War II’s wage-and-price controls, accidentally chose a mixed system. It was the erosion of the employer-based system that led to Obamacare.

Sanders and his 15 Senate co-sponsors propose to eliminate the employer-based system entirely. He would gradually expand Medicare to cover everyone over four years.

The legislation is silent on how to transfer the $1.1 trillion spent by employers on health insurance to government coffers, necessary to defray the cost of his plan. He doesn’t address how he would counter the tremendous opposition that disrupting the existing system would draw from employers and their workers, including those in many unions.

Sanders decries the lack of progressive think tanks to come up with answers to those and other transition questions. But the problem isn’t the absence of good ideas. It’s the absence of fertile soil in which those ideas can grow.

That will change rapidly if Republicans succeed in repealing Obamacare, or undermine it and send the uninsured rate soaring again. That, and only that, will turn the single-payer threat into the last viable path to universal coverage.

Hospital Impact—The only thing clear about healthcare policy is the continued lack of clarity

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http://www.fiercehealthcare.com/hospitals/hospital-impact-only-thing-clear-about-healthcare-policy-continuing-lack-clarity?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWldFeE1XUXlPRFE0TlRneCIsInQiOiJ5dzRsZ1IwekxcL2FMZnN3NkJIOHZGbnpNV1RPcmtMNmdPd1MwV0RLUXNBSXl6QzJnK0s0NktPVzBLOUtRRjF1K0puZzZMZG95dERnN2VUcVRpeForakRVZVJsXC9GWllyU1g1Rk9ZY2pERVRQcjVyT1wvQkMycXdobjd5UnNKa2p3NiJ9

Executive looking out window

For healthcare leaders, it’s discouraging that federal policy decisions seem to be made at the last minute without much planning or consideration of unintended consequences.

I spent my Labor Day vacation in Monterrey, California, watching the waves crash into the sand and wondering what the future of healthcare will look like in the coming months and years. Some clarity is emerging that we have not seen in the past, and I feel comfortable making some observations and predictions:

  • Congress will not revisit the repeal and replacement of the Affordable Care Act before the end of the year. It is simply dealing with far too many other issues—passing a budget, raising the debt ceiling, approving disaster aid for Harvey and Irma, not to mention its desire for tax reform—that lawmakers must address.
  • While the Senate HELP committee is attempting a bipartisan effort to shore up the ACA, the issues listed above will make it almost impossible for such a law to be passed during this session.
  • The leadership of the Department of Health and Human Services ideologically opposes the very concept of the ACA and is also responsible for implementing the law. The tension between those two facts will lead to confusion and uncertainty for those of us in healthcare.
  • The passage of the ACA changed the terms of debate around healthcare reform. Granting health insurance to more than 20 million Americans has now shifted public opinion so that a solid majority believes the federal government should ensure that its citizens have insurance.
  • The ACA is not failing, but going forward it can be undermined without congressional action.

As a former anatomic pathologist, I am always interested in postmortem examination of failures, and the failure of Republicans to repeal the ACA ranks high in any list of stunning political disasters. Pundits have identified several possible causes:

  • Republicans never had a clear replacement plan or goal.
  • Taking away benefits from 22 million Americans is politically unpopular.
  • The ACA was not in a “death spiral.”
  • The president did not exert necessary leadership to get GOP senators to support his unpopular position.
  • Republican governors who had expanded Medicaid did not support the effort.
  • Organized opposition to repeal led to most Americans not supporting repeal.

Autopsy results always arrive too late for those of us who are still alive, and it is more important for those of us in healthcare to interpret the mixed messages coming out of HHS and Congress so that our organizations can continue to care for patients under the current system.

HHS seems willing and eager to let states experiment with healthcare reform. Alaska has received approval for $323 million over five years to subsidize insurance carriers and stabilize its individual ACA marketplace. Iowa is likely to receive approval for a radical 1332 waiver approach to healthcare reform in the Hawkeye state, and other states are preparing waiver submissions.

Meanwhile, HHS actions that seem to undermine the ACA include refusing to guarantee cost-sharing reduction subsidies to insurance companies and slashing the budget to support ACA enrollment for 2018. HHS recently announced advertising budget cuts of 90% for 2018 and the navigator program cuts of 40%.

A recent study—detailed in a post on The Incidental Economist blog—compared Kentucky ACA enrollment under a Democratic governor who supported advertising and a Republican governor who cut advertising. It found that lack of TV advertising led to 450,000 fewer page views on the ACA website and 20,000 fewer unique visits to the enrollment website.

ACA supporters, meanwhile, have recently put together a private enrollment campaign for 2018 to fill in the gap created by HHS decisions, Axios reported.

Last week, the Senate HELP Committee heard from state insurance commissioners and governorsabout ideas to stabilize the ACA marketplaces. They include:

  • Funding the cost-sharing reduction subsidies to insurance companies.
  • Facilitating reinsurance programs.
  • Expanding the ACA 1332 waiver programs to let states innovate.
  • Funding enrollment activities such as advertising and navigator programs.

Although health policy experts largely support these recommendations, it is hard to see how such a divided Congress could pass such proposals. Even if such legislation were approved, it would likely come too late to impact health insurance company decisions for 2018.

So, as of early September, we are left with the ACA continuing to be the law of the land, but with those in charge of the federal government not entirely supporting its success. Healthcare organizations have difficulty caring for patients when the rules keep changing and when clarity is hard to come by. It is also discouraging that decisions seem to be made at the last minute without much planning or consideration for unintended consequences.

That said, we still need to keep taking care of patients. My advice is to:

  • Continue to prepare for the transition from fee-for-service to value-based payments, but be aware that the Trump administration might slow down this process.
  • Continue to cut unnecessary costs.
  • Continue to improve the measurable quality of the care you give.
  • Participate in efforts in your individual states to innovate through waiver programs.
  • Collaborate with your physicians who are confused by all the uncertainty.
  • Keep up to date with the frequent changes that nobody can predict.

 

 

Healthcare Triage News: Congress is Back, and Healthcare Should Be on the To-do List

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Healthcare Triage News: Congress is Back, and Healthcare Should Be on the To-do List

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Congress is back in session, and it has a full month ahead. They have to deal with hurricanes, raise the debt limit, fund the government, keep us out of war, AND they want to talk about cutting taxes, too. With all this going on, it’s going to be hard to get anything done around healthcare, but there’s lots that needs to be done.

The Same Agency That Runs Obamacare Is Using Taxpayer Money to Undermine It

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The Trump administration said on Thursday that it would slash spending on advertising and promotion for the Affordable Care Act, but it has already been waging a multipronged campaign against it.

Despite several failed efforts by Republican lawmakers to repeal it, the Affordable Care Act remains the law of the land. But the Department of Health and Human Services — an agency with a legal responsibility to administer the law — has used taxpayer dollars to oppose it.

Legal experts say that while it is common for a new administration to reinterpret an existing law, it is unusual to take steps to undermine it. Here are three ways the health department has campaigned against Obamacare.

1. REDIRECTING PROMOTIONAL FUNDING

Instead of using its outreach budget to promote the Affordable Care Act, the department made videos critical of the law.

In June, the health department posted 23 video testimonialson YouTube from people who said they had been “burdened by Obamacare,” including families, health care professionals and small business owners.

While it’s not certain where the money for the videos came from, several former health officials who worked in the Obama administration said that they suspect it came from the budget meant to promote the Affordable Care Act.

“There’s no other budget that makes sense,” said Lori Lodes, who oversaw outreach efforts under Mr. Obama.

The Trump administration defended the videos, saying that they were produced to inform Americans about the need for change so that people would have access to affordable health care.

“As evidenced by these important and educational testimonials, the status quo has made that impossible for millions of Americans,” a department spokeswoman, Alleigh Marré, said in July. “The administration is committed to reforming the current health care system to bring down the cost of coverage, expand health care choices, and strengthen the safety net for generations to come.”

The Daily Beast reported in July that one of the participants in the videos said he felt he was being pushed “for a harder line against Obamacare.”

While the health department refers to these testimonials as “educational videos” produced to inform Americans on the need to overhaul health care, some experts question whether they fit that definition.

“The lines between what is partisan, what is propaganda, and what is educational are nightmarish and subjective,” said Michael Eric Herz, a professor at the Cardozo School of Law in New York who has written about social media and the government.

2. ATTACKING THE LAW

The department targeted the Affordable Care Act with a marketing campaign as Republicans in Congress tried to repeal the legislation.

In addition to the YouTube videos, the department has used Twitter and news releases to try to discredit the health law. Since being sworn in as health secretary on February 10, Tom Price has posted on Twitter 48 infographics advocating against Obamacare, all of which bear the health department’s logo.

“Here, it’s an agency trying to destroy its own program because it opposes it,” said Kathleen Clark, a law professor at Washington University who is an expert on government ethics. “It is inconsistent with the constitutional duty to take care that the law is faithfully executed.”

The bulk of Mr. Price’s Twitter posts were from late June to mid-July, when Senate Republicans were trying to pass a bill to repeal and replace the Affordable Care Act. Once, Mr. Price tweeted five infographics in a single day.

Around the same time, the Trump administration ended $23 million worth of contracts with companies that help people sign up for coverage.

In August, five congressional Democrats wrote a letter to Mr. Price demanding detailed information about his plans for marketing and outreach. “Rather than encouraging enrollment in the marketplaces, the administration appears intent on depressing it,” the letter said.

3. DELETING INFORMATION ONLINE

The department removed useful guidance for consumers about the Affordable Care Act from its website.

Under the Obama administration, the health department’s website contained information to help consumers learn about the Affordable Care Act and how to obtain coverage through the health insurance marketplaces. Much of that information is now gone. Some was removed within hours of President Trump’s inauguration.

A link to a page about the Affordable Care Act disappeared from the health department’s home page the evening of the inauguration, according to a comparison of the sites, shown below.

The department also changed other areas of the website, removing overviews of the law and links to information on summaries of benefits, emergency services and doctor choice, making it more difficult for consumers to learn about the law.

It also appears to have erased positive references to the Affordable Care Act, including personal stories about individuals who benefited from the law.

For example, a video about a Florida man with diabetes who said he was able to enroll in coverage without worrying about his health status was removed from a page about pre-existing conditions. A link to a page about the number of young adults who gained coverage after the law took effect is also gone.

Even before President Trump took office, health insurance markets had serious problems in some states. But Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities, a liberal think tank, said the law would not be dying on its own.

“It’s these kinds of actions — pulling back on outreach and enrollment, disseminating negative propaganda about an existing law — those are the things that make the market implode,” she said.

 

 

HHS cuts ACA advertising budget by 90%

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https://www.axios.com/hhs-cuts-aca-advertising-budget-by-90-percent-2480029656.html?stream=health-care&utm_source=alert&utm_medium=email&utm_term=alerts_healthcare

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The Department of Health and Human Services announced today it’s slashing the advertising and promotional budget for the Affordable Care Act for next year. It’s planning to spend $10 million to promote the law in the open enrollment period that starts in November — compared to the $100 million the Obama administration spent last year.

Why they’re doing it: On a conference call with reporters, HHS officials argued that last year’s promotional spending — which was doubled from the year before — was ineffective because signups for new customers actually went down. They also said the $10 million budget is more in line with what Medicare Advantage and Medicare Part D spend to promote their open enrollments.

Why it matters: The Trump administration is making cost-effectiveness a major theme this year, but it’s sure to be accused of undermining ACA enrollment, given all of the Trump administration’s battles to repeal the law — and given that it also cancelled advertising for the final days of last year’s open enrollment.

One more thing: HHS is also planning to cut spending on “navigators,” who are supposed to help people enroll, by tying their funding to their effectiveness in reaching their enrollment goals last year.

Terminating Cost-Sharing Reduction Payments

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http://www.healthaffairs.org/podcasts/terminating-cost-sharing-reduction-payments

Image result for the blame game

In a WTOP-FM interview, Alan Weil assesses the CBO’s report on the impact on premiums and the deficit if CSR payments were eliminated.

 

Trump needs to stop sabotaging Obamacare — before it’s too late

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https://www.washingtonpost.com/opinions/trump-needs-to-stop-sabotaging-obamacare–before-its-too-late/2017/08/17/1c1404ba-8133-11e7-902a-2a9f2d808496_story.html?utm_term=.40564141606c

THE CONGRESSIONAL Budget Office released on Tuesday yet another damning report on health care, this time highlighting the damage President Trump will do if he continues his Obamacare sabotage campaign. Over the next few weeks, during which the government and insurers must sort out what will happen to Obamacare insurance markets next year, everyone in the administration and every member of Congress must recognize that they have no more time to entertain repeal-and-replace fantasies. The fate of the health-insurance markets on which millions of people rely hangs on their willingness to accept reality.

The Trump administration has shown some flexibility. The Department of Health and Human Services last week offered insurers an extra few weeks to file rates for next year. Earlier, Alaska got $323 million in federal money to backstop its individual insurance market in a reinsurance arrangement that could drive down premiums and serve as a model for stabilizing insurance markets across the nation. Though Mr. Trump has repeatedly vowed to let Obamacare collapse, these moves show willingness to bolster, not undermine, the insurance markets that Obamacare created.

Yet the administration has stoked more uncertainty than it has allayed, leaving the health system in peril. The White House has been deciding month-to-month whether to keep important subsidy payments flowing to insurance companies — payments that were simply assumed during the Obama administration. Without these payments, insurers would have to jack up premiums or leave Obamacare markets next year. The CBO estimated Tuesday that average premiums would jump by 20 percent next year if the Trump administration pulled them. Moreover, because of how the payments interact with other elements of the health-care system, the government would end up losing money — $194 billion over a decade.

Though it would be irrational to subvert the health-care system and the budget, Mr. Trump has repeatedly threatened to do so. His officials also have taken steps in that direction, pulling advertisements meant to encourage people to enroll in health insurance, cutting programs that helped people sign up, railing about Obamacare’s “victims” and generally insisting, against the facts, that the law is a disaster. The administration’s moves to weaken the individual mandate, which requires all Americans to carry health coverage and underpins the Obamacare system, have led insurers to contemplate increasing premiums or leaving the system.

The president wanted and failed to overhaul Obamacare. That does not excuse him from faithfully executing the law. Unless Mr. Trump wants to be blamed for health-care chaos, the administration’s mixed messages must stop. Mr. Trump should commit to keeping the subsidies going permanently, to enforcing the individual mandate and to working with Congress on a bipartisan bill that would bolster insurance markets.

The broad strokes are clear: Democrats would ensure that subsidy payments are made permanent and Republicans would get more flexibility for states in administering Obamacare. More money should also go into reinsurance programs like Alaska’s. Though such a bill might come too late to hold down 2018 premiums, serious legislative activity could persuade insurers to stay in the market, riding out next year with the promise of a more stable situation in 2019.

All of this would be easier if the administration would commit to a strategy of stewardship, not sabotage.

Trump administration, HHS stepping away from Affordable Care Act promotion, bundled payments

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http://www.healthcarefinancenews.com/news/trump-administration-hhs-stepping-away-affordable-care-act-promotion-bundled-payments?mkt_tok=eyJpIjoiWlRsaE56QTFZMk00WVdVdyIsInQiOiJPV2NZVXpmSXoxY2s2blNFdG9DYmt0UHh1bnkzc0NcL0R3YnpCcEhqdm5lWVwvNlJrN2xDVlwvUFZ5ZFBzOElGY253OGFMZWVKVnh5a3dTSDM1RFwvdFN3cklQTGd0NmN0YzFrQjIrK21WUW5UTWhaUXVUdUhZZU41dGNwcUtvYmZUaEMifQ%3D%3D

New bundled payment models for cardiac care may be on chopping block, along with changes to joint replacement.

Lacking a repeal and replacement bill for the Affordable Care Act, President Trump appears to be following through on his Twitter promise to “let Obamacare implode.”

The Trump administration and the Department of Health and Human Services is distancing itself from several groups which in the past have helped market open enrollment, according to talkingpointsmemo.

HHS has not reached out to the Latino Affordable Care Act Coalition, the United Methodist Church, the American Congress of Obstetricians and Gynecologists, the American Medical Student Association, the National Urban League, the National Latina Institute for Reproductive Health, the National Hispanic Medical Association, and the National Partnership for Women and Families, according to the report.

Open enrollment in the ACA marketplace starts November 1.

The new bundled payment model for cardiac care coordination and cardiac rehabilitation may also be on the chopping block, along with unspecified changes to the joint replacement model, according to a proposed rule published August 10 in the Office of Management and Budget.

The models were introducted by the Centers for Medicare and Medicaid Services’ Innovatoin Center, or CMMI, run by Patrick Conway, MD, who last week announced he was leaving CMS to head Blue Cross Blue Shield North Carolina.

HHS Secretary Tom Price, an orthopedic surgeon appointed by the president, has consistently voiced his opposition to mandatory bundled payment programs.

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.