Healthcare Triage News: The Trump Administration Has Many Options to Undermine Obamacare
While the Senate and the House haven’t been very effective in passing a repeal of Obamacare, the ACA’s provisions are still at risk. There’s a lot that Donald Trump’s administration can do (or not do) to undermine Obamacare’s provisions and marketplaces.
http://www.healthcaredive.com/news/hhs-general-counsel-candidate-vows-to-uphold-aca/448682/
While all of the Republican attempts to repeal the ACA have thus far failed, its supporters are still worried about threats, including from President Donald Trump, to sabotage the exchange markets. Trump said he wanted the ACA to “implode” and force senators to the negotiating table.
Charrow’s expressed willingness to defend the ACA could certainly come into play if he is approved. His boss would be HHS Secretary Tom Price, who is a vocal opponent of the ACA. If confirmed, Charrow may need to stand up to both his boss and the president.
The most immediate concern for the ACA is cost-sharing reduction (CSR) payments to payers, which Trump called a “bailout” for insurance companies. Payers say that without those subsidies they will need to raise rates or leave the ACA market. Because of the uncertainty, some payers have increased rates by more than 20% for 2018, dropped out of the market or cut down on their footprint.
The issue appears to be in limbo for now, with Congress out for its annual summer break and Trump beginning a 17-day vacation.
The Senate Finance Committee didn’t vote on the Charrow’s nomination, but we’ll soon know whether his statements were enough to quell Democratic fears.
Republican governors are working with the Trump administration to do something Congress couldn’t accomplish: fundamentally alter their state Medicaid programs.
At least six states with GOP governors— Arkansas, Kentucky, Arizona, Maine, Wisconsin and Indiana — have already drafted plans meant to introduce new rules people would have to meet to be eligible for Medicaid, which provides healthcare to low-income Americans and those with certain disabilities.
Some want to add work requirements or introduce drug testing for recipients. Others want to raise premium prices.
The Trump administration has to approve the plans. Some approvals could come in weeks.
Critics say the proposed changes will leave fewer people on Medicaid and hurt the poor and vulnerable.
“There are limits on what’s allowable, and tying eligibility to work or drug testing or some of these other things is not consistent with what should be allowed,” said Judith Solomon, vice president for health policy at the liberal-leaning Centers on Budget and Policy Priorities.
“That said, we know we now have an administration that likely thinks differently, and we could see some changes in that regard,” she said.
Proponents argue the changes, which would waive federal requirements under Medicaid, are an important tool in trimming the fast-rising costs of the program.
They say Medicaid recipients should have some “skin in the game” — an incentive to transition from government support to full-time employment.
“Medicaid is Pac-Manning state budgets right now. It’s taking money away from education, transportation, in expansion and non-expansion states alike. It is eating their budgets,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.
In the past, waivers have been granted to test new ways of delivering care and expanding Medicaid coverage. The only real requirements are that the waivers be budget neutral and promote the objectives of the Medicaid program.
Health and Human Services Secretary Tom Price, a former Republican congressman from Georgia and a vocal ObamaCare critic, has enormous flexibility in deciding what that means.
In March, Price and Seema Verma, who helms the Centers for Medicare and Medicaid Services, sent a letter to governors saying the administration would allow work requirements, larger premiums and other waiver provisions.
It was a dramatic departure from the Obama administration and “an open invitation” for states, said Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.
“By and large, Obama let states use waivers to expand the number of people in the Medicaid program,” Archambault said.
The Trump administration seems poised to do the opposite.
Critics say the proposed requirements go beyond the authority of the executive branch, but Archambault said the statute on what’s allowed is extremely broad, meaning the administration has the authority to approve most, if not all of the proposals.
Republicans in Congress have been deeply divided over Medicaid, with conservatives seeking to cut spending on the program but centrists from states where it was expanded under ObamaCare pushing back.
The House and Senate’s ObamaCare repeal bills sought to drastically cut back Medicaid spending by capping federal financing and ending ObamaCare’s enhanced federal funding for coverage expansion. The bills also would have given states the option of imposing work requirements.
Medicaid waivers can’t change the program’s financing the way a federal law could, but several state waivers filed months ago include a work requirement as a way to trim spending.
Work requirements “will have the result of cutting state Medicaid costs because fewer people will be on Medicaid,” said Deborah Bachrach, a partner at Manatt Health and former Medicaid director of New York.
To date, no state has received an approval for a waiver requiring people to work to be eligible for Medicaid. If the Trump administration approves of one, most experts think other states will get similar requirements approved quickly.
“If and when Kentucky and Arizona get approval … you’ll see a bunch of other Republican states copycat,” Archambault said.
Other changes, if approved, include lowering the eligibility levels for coverage and a time limit for being on Medicaid.
Arkansas recently filed a waiver request to lower the Medicaid eligibility level while still receiving extra federal money as a Medicaid expansion state. It’s the first state to make such a request of the Trump administration; some states tried similar requests during the Obama administration and were denied.
Wisconsin would like to screen all and test some applicants for drugs. Those who test positive for drugs would be required to receive treatment; those who refuse to be screened or take a test would be ineligible for Medicaid benefits.
The state also wants to impose a 48-month limit on Medicaid eligibility, unless the person is working.
“My biggest concern is that the state is going to create a lot of new red tape and expense that is going to suppress Medicaid participation and increase total healthcare costs by putting greater reliance on hospital and emergency departments,” Jon Peacock, research director for Wisconsin-based Kids Forward, said.
Experts warn certain controversial provisions, if implemented, could be targets for lawsuits.
“Some of these waivers are pushing the boundaries of what has been approved before, and that could lead to potential litigation,” Rudowitz said.
https://www.reuters.com/article/us-usa-healthcare-idUSKBN1AI28L
Democratic and Republican U.S. governors on Wednesday urged the Trump administration, as well as Congress, to continue funding payments to health insurance companies that make Obamacare plans affordable, calling it critical to stabilizing the insurance marketplace.
Republican President Donald Trump, frustrated that Obamacare survived attempts to repeal it, has threatened to cut off about $8 billion in subsidies that help control costs for low-income Americans under the Affordable Care Act, Democratic former President Barack Obama’s signature domestic initiative.
“The Administration has the opportunity to stabilize the health insurance market across our nation and ensure that our residents can continue to access affordable health care coverage,” said a statement by the Health and Human Services Committee of the National Governors Association.
“A first critical step … is to fully fund CSRs (cost-sharing reduction payments) for the remainder of calendar year 2017 through 2018,” the statement said, adding this was needed as Congress and the administration address long-term reform efforts.
The committee is led by Virginia Governor Terry McAuliffe, a Democrat, and Massachusetts Governor Charlie Baker, a Republican. Earlier this year, the governors sent a letter calling on Congress to fully fund the cost-sharing payments.
Some Congressional Republicans have joined Democrats in urging Trump to continue the payments. Republican Senator Lamar Alexander, chairman of the health committee, said Tuesday the president should pay the subsidies through September while lawmakers work on bipartisan legislation to fund the outlays for another year.
But the Senate’s No. 2 Republican John Cornyn hesitated when asked Wednesday if he would support such legislation.
“I’ve said before that I’m not in favor of throwing money at insurance companies without reform, so that’s going to be the nature of the conversation,” Cornyn told reporters outside his office.
Asked what reforms he’d like to see, Cornyn mentioned the “skinny” Obamacare repeal bill the Senate voted down last week. Among other things, it would have repealed the requirement that every American have health insurance or pay a penalty.
Insurers say that the cost-sharing payments are passed onto customers in the form of lower deductibles and co-pays that make care more affordable for low income Americans.
Insurers are finalizing 2018 premium rates for the individual Obamacare market, with many saying their decision hinges on government guarantees for cost-sharing subsidies.
Molina Healthcare Inc said on Wednesday it would stop selling Obamacare plans in Utah and Wisconsin, joining a slew of health insurers that have exited Obamacare markets amid uncertainty over the healthcare law.
Anthem Inc, one of the largest sellers of these plans in 2017, has pared back offerings or mostly exited five states including California and may exit more.
White House budget director Mick Mulvaney told CNN the administration was still considering whether to end cost-sharing subsidies.
A bipartisan Senate effort to continue federal payments to insurers and avert a costly rattling of health insurance markets faces a dicey future. The uncertainty shows that last week’s wreck of the Republican drive to repeal the Affordable Care Act hasn’t blunted the issue’s sharp-edged politics.
President Donald Trump is threatening to halt the payments in hopes of forcing Democrats to negotiate an end to the Obama-era law. The insurance industry and lawmakers from both parties say blocking the money would lead insurers to raise premiums for people buying individual policies and might induce companies to abandon some markets.
Into the fray has stepped Sen. Lamar Alexander, R-Tenn., chairman of the Senate Health, Education, Labor and Pensions Committee.
He said he will work with the committee’s top Democrat, Sen. Patty Murray of Washington state, on a bill next month that would pay insurers through 2018. In exchange, he wants Democrats to agree to make it easier for states to choose their own health coverage standards that insurers must provide, and not heed consumer-friendly requirements of former President Barack Obama’s law.
While that is an idea Democrats say they will discuss, it’s unclear whether the two parties can reach a deal.
For the GOP’s failed effort to repeal and replace Obama’s overhaul, Senate Republicans used special rules allowing passage by a simple majority. But this developing bill would need 60 votes to succeed. Republicans hold a 52-48 advantage in the Senate, which means Democratic backing will be crucial.
Democrats will be reluctant to strike an agreement that would pull back far on Obama’s protections, which include a set of services insurers must cover and guarantees that premiums for healthy and seriously ill people are equal.
“It’s going to be hard to get common ground,” said Sen. Chris Murphy, D-Conn., a committee member. “Republicans are going to want some initial flexibility” for coverage requirements, “and that’s not an easy thing to achieve.”
Republicans are divided, too.
Many, including Trump, have called the payments an insurers’ bailout. Conservatives are reluctant to continue payments to help sustain a law the GOP has pledged for years to toss out.
“I was a total repeal guy,” said Sen. Richard Shelby, R-Ala. “I don’t know if I want to prop it up.”
Added GOP Sen. Ted Cruz of Texas: “I think it’s a mistake to bail out insurance companies.”
Obama’s law requires insurers to reduce out-of-pocket costs such as deductibles and copayments for millions of low- and middle-income customers. It also requires the government to reimburse insurers for those costs.
But a federal court found that Congress hasn’t properly approved money to do that. Both Obama and Trump have continued making the payments as the case has dragged on.
Besides the outright opponents, some Republicans say they would be reluctant to support an Alexander bill unless whatever eased regulations Democrats agree to are worthwhile. It’s unclear what Alexander or other Republicans are willing to accept.
“We certainly should get some structural change to bring down premiums in exchange for that,” said Sen. Ron Johnson, R-Wis. “We can’t just throw money at the problem.”
That echoes what Senate Majority Leader Mitch McConnell, R-Ky., said last Friday after the Senate rejected the third health proposal he advanced, effectively sinking the repeal effort.
“Bailing out insurance companies with no thought of any kind of reform is not something I want to be part of,” McConnell said.
Alexander said Wednesday that he has kept McConnell apprised of his effort. Asked if he had received a commitment that McConnell would bring such legislation to the full Senate, Alexander said, “Well, he doesn’t know what bill we’re going to have.”
But Alexander does have allies.
“We’ll eventually repeal Obamacare and put something in its place,” said Sen. John Kennedy, R-La. “In the meantime, I think it’s very important not to see any Americans get hurt.”
If the GOP divisions persist, McConnell and House Speaker Paul Ryan, R-Wis., might have to decide whether to have votes on legislation opposed by substantial numbers of Republicans. That’s always an uncomfortable proposition for party leaders.
“That’s a question for McConnell,” said the second-ranking Democratic senator, Illinois’ Dick Durbin, said asked whether he thought the GOP leader would allow a vote on a bill opposed by many Republicans.
Durbin said if Republicans are truly concerned about keeping insurance markets stable, “they have to do something.”
Would Ryan support a measure like Alexander’s?
The speaker “believes repeal and replace is the best course of action and that the Senate needs to act,” spokeswoman AshLee Strong said.
President Donald Trump’s bold threat to push “Obamacare” into collapse may get harder to carry out after a new court ruling.
The procedural decision late Tuesday by a federal appeals panel in Washington has implications for millions of consumers. The judges said that a group of states can defend the legality of government “cost-sharing” subsidies for copays and deductibles under the Affordable Care Act if the Trump administration decides to stop paying the money.
Trump has been threatening to do just that for months, and he amped up his warnings after the GOP’s drive to repeal and replace “Obamacare” fell apart in the Senate last week. The subsidies help keep premiums in check, but they are under a legal cloud because of a dispute over the wording of the ACA. Trump has speculated that he could force Democrats to make a deal on health care by stopping the payments.
The court’s decision is “a check on the ability of the president to sabotage the Affordable Care Act in one very important way,” said Tim Jost, professor emeritus at Washington and Lee University School of Law in Virginia, a supporter of the ACA who has followed the issue closely.
Because of the ruling, legal experts said, states can now sue if the administration cuts off the subsidies. Also, they said, the president won’t be able to claim he’s merely following the will of a lower court that found Congress had not properly approved the money.
“We’re not going to wait to find out what Donald Trump wants to do,” said California Attorney General Xavier Becerra, who is helping steer the states’ involvement. “My team is ready to defend these subsidies in court.”
The Justice Department had no comment. The White House re-issued an earlier statement saying, “the president is working with his staff and his Cabinet to consider the issues raised by the … payments.”
Trump has made his feelings clear on Twitter. “If ObamaCare is hurting people, & it is, why shouldn’t it hurt the insurance companies,” he tweeted early Monday.
He elaborated in an earlier tweet, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies…will end very soon!”
In a twist, the appeals court panel seemed to take such statements into account in granting 17 states and the District of Columbia the ability to intervene on behalf of consumers.
The judges’ decision said states’ doubts that the administration could adequately defend their interests in court were fanned by “accumulating public statements by high-level officials…about a potential change in position.”
“He’s really a terrible client, President Trump is,” University of Michigan law professor Nicholas Bagley said. “The states point to his public statements and say, ‘Are you kidding me? We know the president is poised to throw us under the bus and we know because he said so.’”
The health law requires insurers to help low-income consumers with their copays and deductibles. Nearly 3 in 5 HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The annual cost to the government is about $7 billion.
The law also specifies that the government shall reimburse insurers for the cost-sharing assistance that they provide.
Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the health law, by providing a congressional “appropriation.”
House Republicans trying to thwart the ACA sued the Obama administration, arguing that the law lacked specific language appropriating the cost-sharing subsidies.
A district court judge agreed with House Republicans, and now the case is before the U.S. appeals court in Washington
If Trump makes good on his threat, experts estimate that premiums for a standard “silver” plan would increase by about 19 percent. And more insurers might decide to leave already shaky markets.
In Congress, some prominent lawmakers in both parties are saying they hope to provide at least a temporary guarantee for the subsidies before open enrollment season for 2018 starts Nov. 1.
http://www.sacbee.com/news/local/health-and-medicine/article165045532.html
Now that California, 16 other states and the District of Columbia have been given legal standing in a critical court appeal, California Attorney General Xavier Becerra said Wednesday they will fight to preserve the federal funds that underpin their Obamacare health exchanges if the Trump administration bows out of the lawsuit.
“My team is ready to defend these (federal) subsidies in court,” Becerra said. “We’re going to do everything we can to work with whoever is interested, whether it’s the Trump administration or Congress, to make sure that we continue to provide people with affordable health care. … We’re not going to go back to the days when health care was for the healthy or the wealthy.”
In this legal case, Republicans in the U.S. House of Representatives filed suit in 2014 against then-Secretary of Health and Human Services Sylvia Burwell, asserting that she had overstepped her authority by appropriating billions of dollars to cover discounts that insurers were mandated to give low-income consumers under the Patient Protection and Affordable Care Act, commonly called Obamacare.
While the Affordable Care Act promised reimbursement for the discounts, it provided no mechanism to pay the so-called cost-sharing reductions. Last year, U.S. District Judge Rosemary M. Collyer ruled that, while Congress clearly authorized the program, it had not appropriated funds and thus it was unconstitutional to pay the subsidies. However, she put her decision on hold, pending appeal to the U.S. Court of Appeals for the District of Columbia Circuit.
The dean of the UC Davis School of Law, Kevin R. Johnson, said the states could argue that since Congress mandated the cost-sharing program, that body should be compelled to provide the funding that states and insurers need to make it work.
Becerra, a Democrat who represented the 34th congressional district from 2013 to 2017, said the states would argue that Congress did contemplate the cost-sharing subsidies. “I say that, not only as someone who will argue that in court, I say that as a former member of Congress who helped draft the legislation,” Becerra said.
Becerra said he and other attorneys general filed a motion to join the appeal in May because they thought the president wasn’t going to protect health insurance marketplaces such as Covered California. Before and after the U.S. Senate failed to pass legislation to repeal the Affordable Care Act, Trump has tweeted that he and the Republican leadership should “let Obamacare implode” and then broker a deal.
“You could smell it. You could read it in tweets,” Becerra said. “When we intervened in May, we saw no one was really standing up for the millions of American families that rely upon the Affordable Care Act insurance plans to be able to send their kids to doctors and believe that they could afford to have their child in a hospital. The record is replete with evidence that the Trump administration is not willing to defend the Affordable Care Act.”
The appeals court ruled Tuesday that the states had standing in the lawsuit. Becerra said his office will work in concert with attorneys general in New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, and Washington, and the District of Columbia. Ten of the states are led by Democratic governors and seven by Republicans.
Because of ongoing uncertainty about the availability of federal funds, Covered California announced Tuesday that it was planning to impose a surcharge on premiums for those consumers whose copayments and deductibles qualified for the insurer discounts.
While the action sounds ominous for the 650,000 silver-tier policy holders it affects, it is actually a bit of creative accounting that protects them from seeing sharp increases in payments and ensures financial stability for insurers. The health law imposes a cap on out-of-pocket costs for those consumers, whose incomes cannot exceed 250 percent of the federal poverty level. Under the Affordable Care Act, the federal government must pick up costs once consumer spending hits that out-of-pocket ceiling.
The insurers still discount copayments and deductibles on a sliding scale linked to income, and the premiums provide enough funding to cover those discounts on the front end rather than after care is provided.
Peter Lee, executive director of Covered California, has said California will move forward with the plan if an annual appropriation is not made for cost-sharing reductions. All rate changes are subject to state regulatory approval.
“We hope that we do not need to implement this work-around that would cause unnecessary confusion and ultimately cost the federal government more than it would to continue to make the payments directly,” Lee said.
President Trump has said he wants to “let Obamacare implode” as a way to force Democrats to negotiate a deal over replacing the Affordable Care Act. How real is that threat, and how imminent?
Here are some key questions and answers.
Not entirely, and not all at once, but the administration does have the ability to cause some amount of chaos in certain parts of the healthcare system.
At least some administration officials believe that if more people have trouble getting coverage, pressure will increase on Congress to either repeal the Affordable Care Act entirely or make big changes in it. So far, Republicans have not been able to agree on a plan to do that.
Two different government programs help provide coverage for low- and middle-income working-age people and children. One is the marketplace for individual healthcare plans, which the Affordable Care Act created. The other is Medicaid, which the law expanded.
There’s not much the administration can do to undermine Medicaid without getting a law through Congress, at least in the short term. It’s a program jointly run by the states and the federal government, and the states have a lot of authority over what is covered and who benefits.
The individual marketplace is more at risk.
Medicaid is far larger. Roughly 75 million Americans are covered by Medicaid and the related Children’s Health Insurance Program. That’s more than 1 in 5 Americans.
About 10 million people have purchased coverage on the Obamacare marketplaces in 2017. Remember that most working-age Americans get health insurance through their jobs.
Under the law, low- and middle-income people buying health plans on the marketplaces can get government subsidies to make premiums more affordable.
Think of this in two buckets. Some actions the administration could take would passively allow the marketplaces to become less stable. That would cause a slow erosion.
There are also steps they could take to actively sabotage the markets, which could cause trouble much faster.
Officials could stop marketing and outreach efforts that encourage people to sign up during open enrollment periods. They could refuse to enforce the requirement that people buy insurance or pay a tax — a step that officials already have said they will take. And they could stop trying to keep insurance companies in the markets.
None of those actions would cause the markets to collapse overnight, but they would destabilize them over time by driving out healthy people, which causes costs to rise, which in turn drives out more healthy people. That’s what’s known as a death spiral, and it could happen at least in some parts of the country eventually.
The biggest issue involves money that has the bureaucratic-sounding name of cost-sharing reductions.
Basically, the government tells insurers that they need to hold down the insurance deductibles and co-payments that they charge low-income people.
That costs the insurers money. To make the insurers whole, the government is supposed to reimburse them. For more detail, here’s an explainer.
Every month, Washington sends insurers checks that total close to $600 million. And every month since he took office, Trump has raised the possibility that he might cut the money off, although he hasn’t actually done so.
Some insurers would raise premiums to cover the higher costs, as several have already said they plan to do. Others would probably pull out entirely and stop selling insurance in the individual market.
In late August.
Yes, and it’s quite possible that they will since many Republican members of Congress fear that chaos in the markets would be bad for their constituents, not to mention their political futures.
Only in some fairly limited areas. As of July, 38 counties in the U.S. with about 25,000 people covered by individual policies were at risk of having no insurer in the coming year, according to a study of insurance company data by the Kaiser Family Foundation. Those counties were located in three states: Nevada, Indiana and Ohio.
But about one-fifth of consumers live in a county with just one insurer, Kaiser’s data showed. That number has grown a lot since last year.
The places with only one insurer are mostly rural and concentrated in a few states, mostly in the South and Southwest, although Alaska is also heavily affected.
That’s largely because rural areas, where the population is spread out and doctors and hospitals are more scarce, cost more to insure.
Yes, that’s one reason why Republican members of Congress have been as concerned as Democrats about the issue.
It also reflects the fact that many Republican states have actively impeded the Affordable Care Act from working. Not surprisingly, those states are among the ones with the biggest problems.
Trump has said in his tweets and speeches that he believes the public would blame Democrats because they’re the ones who put the Affordable Care Act into place.
Few Republican lawmakers are confident that’s true, and recent polling indicates that the public holds the Republicans responsible since they control both houses of Congress and the White House.
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.
• 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.”
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.
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.
HENRY KOTULA 