Across all income levels, two-thirds of U.S. adults cite health insurance costs as a stressor, according to a report from the American Psychological Association.
APA’s report, “Stress in America: Uncertainty About Health Care,” examines responses from 3,440 adults who completed an online survey by The Harris Poll from Aug. 2 to Aug. 31, 2017.
Here are three things to know from the report.
1. Sixty-three percent of adults said uncertainty about their future health and the health of others is a stressor.
2. Personal health concerns or health problems affecting family members reflect a “very” or “somewhat” significant source of stress for 60 percent of respondents.
3. On a 10-point scale, where 1 is “little or no stress” and 10 is “a great deal of stress,” uninsured respondents reported average stress levels of 5.6. This is compared to insured adults, who reported average stress levels of 4.7.
In the search for ways to bring down American health-care spending, there are certain ideas that are close to dogma. Chief among them: If you provide health insurance to people, they will stop overusing the emergency room.
“A lot of people just didn’t bother getting health insurance at all. And when they got sick, they’d have to go to the emergency room,” President Obama said in a 2016 speech. “But the emergency room is the most expensive place to get care. And because you weren’t insured, the hospital would have to give you the care free, and they would have to then make up for those costs by charging everybody else more money.”
The idea that uninsured people are clogging emergency rooms looks more and more like a myth, according to a recent study published in Health Affairs. Uninsured adults used the emergency room at very similar rates to people with insurance — and much less than people on Medicaid. Providing insurance to people can have many benefits, but driving down emergency room utilization doesn’t appear to be one of them.
“It would be nice if giving people insurance did get them so healthy and so much access to other care that they didn’t need to go to the emergency department, but that does not seem to be the case,” said Katherine Baicker, dean of the University of Chicago’s Harris School of Public Policy. “It seems clear to me that expanding insurance, in and of itself, does not contain spending. It increases spending, by giving people who had very limited access to care the ability to get their health-care needs met.”
Another Health Affairs study poked a hole in a different health-care mantra: that the key to cutting spending is to coordinate care for high-risk patients with chronic diseases, to keep them out of the hospital.
The study examined accountable care organizations, groups of hospitals and doctors that work together to improve health care and reduce costs. There were savings overall, but they weren’t mostly from reductions in spending on high-risk patients. The researchers measured some modest increases in hospitalizations for avoidable procedures, one of the categories of care that would be expected to be affected by efforts to help high-risk patients stay well.
These studies both chip away at ideas that stem from the overarching belief that improving the quality of health care will also save money.
“It turns out, when you do the math, it’s just very tough to save money when you’re doing things to improve quality. It’s very hard to save a dollar when you spend a dollar,” said J. Michael McWilliams, a professor of health-care policy at Harvard Medical School. “Why has this become such a widespread notion — that we can sort of coordinate our way out of the cost problem? One reason is that it’s a much easier conversation to have: We can all subscribe to this notion of prevention saves money and care coordination saves money — and we don’t have to talk about regulating prices, or breaking up monopolies.”
By now, it shouldn’t be a surprise that getting health coverage doesn’t drive down emergency room usage. A provocative study four years ago found that expanding Medicaid in Oregon had caused emergency room visits to increase. A follow-up study last year found the surge in ER visits wasn’t temporary at least two years out.
The study did find one possible reason the myth hasn’t died. Uninsured people used other kinds of care — such as visits to a doctor or other hospital departments — far less than insured people. That could contribute to the perception that they’re using the emergency room more, since they are so rarely seen in other care settings.
There are reasonable arguments for providing health coverage to uninsured people and helping chronically sick people better manage their diseases. But policymakers often return to the idea that such interventions will improve quality and costs, in one swoop — even as the evidence points to another conclusion.
“Just because something sounds true doesn’t mean that it is,” Baicker and Amitabh Chandra of the Harvard Kennedy School of Government wrote in a recent article in the New England Journal of Medicine calling for the use of more evidence in health policy. “And magical thinking won’t improve our health care system.”
The Republicans’ tax overhaul plan, which is expected to become law soon, has negative credit implications for nonprofit hospitals and health systems, according to Moody’s Investors Service.
Here are three ways the tax bill will hurt nonprofit hospitals and health systems.
1. The tax bill will repeal the ACA’s individual insurance mandate. This will cause the uninsured population to rise and raise uncompensated care costs, which will negatively affect healthcare organizations’ operating margins and cash flow, according to Moody’s.
2. The tax plan’s limits on tax-exempt refundings is negative for all issuers of tax-exempt debt, including nonprofit hospitals and health systems, as these financings have been used to reduce long-term borrowing costs and take advantage of lower interest rates, according to Moody’s.
3. The tax bill will slash the corporate tax rate to 21 percent from 35 percent. This change has negative implications for nonprofit hospitals and health systems, as it “makes tax-exempt bonds a less attractive investment for banks and other financial institutions, which will weaken demand, especially for direct bank loans and private placements,” according to Moody’s.
Killing the mandate doesn’t gut the health care law. Most likely, it will muddle along, because the rest of it is broadly popular.
In July and again in September, Republicans narrowly failed to repeal the Affordable Care Act. But their newly passed tax legislation included a provision getting rid of Obamacare’s mandate requiring Americans to buy insurance, and President Donald Trump immediately declared victory in the partisan health care wars. “When the individual mandate is being repealed, that means Obamacare is being repealed,” he crowed at a Cabinet meeting on Wednesday. “We have essentially repealed Obamacare.”
Well, no. The individual mandate is only part of Obamacare. It wasn’t even included in the original health care plan that Barack Obama unveiled during the 2008 campaign. The mandate did become an important element of Obamacare, and the only specific element that a majority of the public opposed. But the more generous elements of the program—like a major expansion of Medicaid, significant government subsidies for private insurance premiums, and strict protections for pre-existing conditions—are still popular, and still the law of the land.
“The death of Obamacare has been exaggerated,” says Larry Levitt, who oversees health reform studies at the Kaiser Family Foundation. “Eliminating the mandate creates uncertainty, but all the benefits for people remain in place.”
The Republican ecstasy and Democratic gloom over the death of the mandate reflects the most consistent misperception over the seven-plus years of Affordable Care Act debates, the incorrect assumption that the “Obamacare exchanges,” where Americans can buy private insurance, are synonymous with Obamacare. The vast majority of Americans who get their coverage through Medicare, Medicaid or their employers shouldn’t be affected. Yes, killing the mandate could cause problems for the remaining 6 percent of Americans who have to buy insurance on the open market, but nearly half will remain eligible for subsidies that would insulate them from any premium hikes.
Repealing the tax penalties for Americans who don’t buy insurance would not repeal Obamacare’s perks for Americans who do—like the ban on annual and lifetime caps that insurers previously used to cut off coverage for their sickest customers, or the provision allowing parents to keep their children on their plans until they turn 26. And it would not repeal Obamacare’s “delivery reforms” that are quietly transforming the financial incentives in the medical system, gradually shifting reimbursements to reward the quality rather than quantity of care. The growth of U.S. health care costs has slowed dramatically since the launch of Obamacare, and the elimination of the mandate should not significantly affect that trend.
In fact, during the 2008 campaign, Obama was the only Democratic candidate whose health plan did not include a mandate, because he was the only Democratic candidate who thought the main problem with health care was its cost. “It’s just too expensive,” he explained at an Iowa event in May 2007. Insurance premiums had almost doubled during the George W. Bush era, and Obama believed that was the reason so many Americans were uninsured. He doubted it would be worth the political heartburn to try to force people to buy insurance they couldn’t afford.
But Obama eventually embraced the argument that a mandate was necessary to ensure that young and healthy Americans bought insurance. The fear was that otherwise, insurance markets dominated by the old and sick (who would enjoy the law’s new protections for pre-existing conditions) would have produced even higher premiums, and might scare insurers away from serving Americans who don’t get coverage through their jobs or the government. Killing the mandate will be a step in that direction, boosting Trump’s heighten-the-contradictions effort to sabotage the functioning of Obamacare to build support for a more sweeping repeal.
That effort has already produced some damaging results for the exchanges. Insurers have increased their premiums for 2018, repeatedly citing uncertainty over Trump’s efforts to blow up Obamacare as well as his decision to cut off promised payments to insurers who cover lower-income families. Several insurers left the exchanges even before the elimination of the mandate, and others could follow.
But the widespread warnings that wide swaths of America would have no insurers on the exchanges were wrong; there are zero “bare counties” with no insurers for 2018. And a Kaiser review found the exchanges have gotten more profitable for insurers this year,despite Trump’s efforts to damage them. This year’s enrollment period appears to have gone fairly well even though the Trump administration shortened it by half and slashed its promotional budget.
The fear is that eliminating the mandate could produce a “death spiral” for the exchanges, where higher premiums scare away healthier customers, leading to even higher premiums and even sicker customers—until eventually,the insurers decide to bail. It could also encourage insurers to try to lure healthier customers with cheaper but skimpier plans that don’t provide protections for pre-existing conditions, since those customers would no longer have to pay a tax penalty.
But it is also possible that younger and healthier customers who initially bought insurance because they were required to do so will now buy insurance because they want to; surveys show that more than 75 five percent of Americans covered on the exchanges are happy with their coverage. And as a political matter, repealing the unpopular mandate could make it even harder for Republicans to pass legislation repealing insurance protections, Medicaid expansions and the rest of Obamacare, because the rest of Obamacare is popular. It’s not surprising that Republicans managed to kill the law’s vegetables, but it won’t be as easy to kill dessert.
Trump thinks congressional Democrats will soon be begging him to come up with a replacement for Obamacare, and even many Republicans who don’t embrace that fantasy believe the demise of the mandate will ratchet up pressure for a permanent solution to a seven-year political war. It could happen. But there hasn’t been a lot of bipartisanship in Washington lately, and after the Doug Jones upset in Alabama, it seems unlikely that a Senate with one fewer Republican will be more amenable to a Republican-only repeal bill.
The most likely outcome seems to be at least a few more years of Obamacare muddling through, and at least a few more years of Obamacare political warfare.
As President Donald Trump completes his first year in office, Americans are increasingly concerned about health care, and their faith that government can fix it has fallen.
A new poll by The Associated Press-NORC Center for Public Affairs Research finds that 48 percent named health care as a top problem for the government to focus on in the next year, up 17 points in the last two years.
The poll allows Americans to name up to five priorities and found a wide range of top concerns, including taxes, immigration and the environment. But aside from health care, no single issue was named by more than 31 percent.
And 7 in 10 of those who named health care as a top problem said they had little to no confidence that government can improve matters. The public was less pessimistic in last year’s edition of the poll, when just over half said they lacked confidence in the problem-solving ability of lawmakers and government institutions.
“We are way up there on the cost, and as far as giving good health care, we are way down,” said Rebekah Bustamante of San Antonio, a retired medical imaging technician. “Now in health care, you’re a number.”
Bustamante said she voted for Trump, but “he’s learning on the job, and he’s got a long way to go.”
Trump initially promised his own plan that would deliver “insurance for everybody” and “great” health care, “much less expensive and much better.” But the White House never released a health care proposal from the president.
GOP legislation to repeal and replace former President Barack Obama’s health care law failed in Congress, although the tax bill scraps the Obama requirement that most people get health insurance. Bloodied on both sides, Republicans and Democrats seem to have battled to an uneasy draw on health care.
Meanwhile, conflicting policy signals from Washington, including an abrupt White House decision to cancel insurer subsidies, roiled insurance markets. Premiums on health plans purchased by individuals jumped by double digits. Progress reducing the number of uninsured stalled, and one major survey found an uptick this year.
“There is zero bipartisanship, and it’s frustrating,” said Eric Staab, a high school teacher from Topeka, Kansas. “It seems like we have thrown everything at this dartboard, and nothing is improving the coverage.”
Rumblings of discontent have political repercussions for next year’s midterm elections and the presidential contest in 2020, said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health, who follows opinion trends on health care.
“It’s the issue that won’t go away,” said Blendon. “Given the news cycle, taxes should be first, the economy should be second, and this health care thing should be buried.”
Three in 10 Americans listed taxes among their top priorities, about double the percentage who said that last year. About a quarter mentioned immigration, and just under 2 in 10 mentioned environmental issues and education. Meanwhile, concerns about unemployment plunged to 14 percent, about half the mentions as last year.
Health care was by far the top issue mentioned by Democrats and independents. Republicans were about equally likely to mention immigration, health care and taxes.
Democrats were more likely than Republicans to say they have little to no confidence that the government will make progress on health care, 84 percent to 57 percent.
The reason health care doesn’t fade away is that costs aren’t getting any more manageable, said some people who took part in the AP-NORC survey.
Bustamante said she is planning a trip to Mexico for some dental work, because she can obtain quality service for much less there. “Thank God I live in Texas, where getting to Mexico isn’t that far away,” she said. “But everybody doesn’t have that option.”
ShyJuan Clemons of Merrillville, Indiana, said he’s currently uninsured because his previous health plan was costing too much money for the benefit he got from it. He faced his insurance plan’s annual deductible when he went to the doctor, so he’d wind up paying out-of-pocket for visits, on top of premiums.
“You are not constantly worried about taxes, but you are constantly worried about health care — be it major or minor,” said Clemons, a personal care attendant who works with disabled people. “You catch a cold, and you just think about it in passing — ‘I hope it doesn’t develop into a problem.'”
Clemons, a Democrat, said he’s disappointed that Trump and Republicans in Congress seem to be trying to tear down “Obamacare” instead of building on it. “I would like to see them make the thing run smoothly so we can do better, instead of just trying to cripple it,” he said.
The lack of confidence in the ability of government to find pragmatic solutions extended to other problems in the AP-NORC poll, including climate change, immigration, and terrorism.
Just 23 percent said that Trump has kept the promises he made while running for president, while 30 percent said he’s tried and failed, and 45 percent said he has not kept his promises at all.
Nearly 2 in 3 said they were pessimistic about the state of politics in the U.S. About half were downbeat about the nation’s system of government, and 55 percent said America’s best days are behind.
The House and Senate have agreed upon a unified tax overhaul bill, putting Republicans on the fast track to pass legislation that has significant implications for the health insurance industry.
For one, the compromise tax bill will repeal the Affordable Care Act’s individual mandate penalty, Senate Majority Leader Mitch McConnell said in a statement on Wednesday. To McConnell, axing the mandate will offer “relief to low- and middle-income Americans who have struggled under an unpopular and unworkable law.”
Health insurers and the healthcare industry at large have opposed removing the key ACA provision without a viable alternative to encourage healthy consumers to buy coverage, arguing that doing so will destabilize the individual markets. Indeed, the Congressional Budget Office has estimated that repealing the mandate would increase the number of uninsured people by 13 million over the next 10 years and hike individual market premiums by 10% during most years of that decade.
Yet while the individual mandate repeal is problematic for insurers that do business on the ACA exchanges, nearly all insurance companies stand to gain from the GOP tax bill overall, according to Leerink Partners analyst Ana Gupte, Ph.D. She estimates that insurers can capture about 10% to 15% of the potential 25% upside from the legislation, subject to regulatory constraints such as medical loss ratio rules and competitive pricing constraints.
Likely the biggest gain for insurers is the fact that, per the New York Times, the compromise bill sets the corporate tax rate at 21%—significantly lower than the current rate of 35%.
Though the House and Senate have ironed out the differences in their bills, the final version still must be approved by both chambers. GOP leaders have but two votes to spare in the Senate, and will likely have to include two bipartisan measures to shore up the ACA in Congress’ year-end spending bill to win the support of Sen. Susan Collins, R-Maine.
Collins said on Wednesday that Vice President Mike Pence assured her that those measures would make it into the spending bill, according to The Hill. Yet some House conservatives have expressed opposition to the bills, which would provide funding for cost-sharing reduction payments and state-based reinsurance programs, among other provisions.
Meanwhile, the results of the headline-grabbing Senate race in Alabama have put a major crimp in Republicans’ plans to retry repealing the ACA. Once Democrat Doug Jones officially takes his seat, the GOP will have an even slimmer majority in the Senate, where the defection of a handful of moderate Republicans was already enough to kill several repeal bills earlier this year.
Earlier this month, the Senate passed legislation that would overhaul the tax code, make dramatic changes to federal health care policy, and undermine the budgets of Medicaid and Medicare, two pillars of the American health care system. The House and Senate are now trying to reconcile their two tax bills. Each passed the legislation on a party-line vote, with one Republican voting against the bill in the Senate.
Congress is now one step away from passing a tax bill that will have a profound effect on the health and well-being of Americans for a generation. No one should forget that, to get this close, the Senate rushed to approve a deeply unpopular proposal with little transparency and due diligence — and no bipartisanship. Left unchecked, these actions will harm millions of Americans — and American democracy itself.
Even though the legislation has been framed as a tax bill, it is very much a health care bill. The Senate bill would eliminate the Affordable Care Act’s individual health insurance mandate, which would lead to the destabilization of the individual health insurance market. The Congressional Budget Office (CBO) projects that this change alone would increase individual premiums by 10% a year and cause as many as 13 million Americans to join the ranks of the uninsured by the end of the next decade. In California, the uninsured population would grow by 1.7 million people. Congress may still pass separate legislation to restore some stability to the individual market, but the leading proposals are too modest to prevent much damage.
Seismic Impact
On its own, the language in the tax bills would trigger a major earthquake in the health care system, and the aftershocks of this tax bill would be just as dangerous. By eliminating more than $1 trillion of federal revenue, the administration and congressional leaders are manufacturing a budget crisis that would likely lead to automatic cuts to Medicare under federal rules. The CBO, which examined the House bill, has estimated that those cuts could be around $25 billion a year. Republican leaders have also indicated they intend to use the revenue shortfall that they are engineering with this tax bill to seek deep cuts in safety-net programs, starting with Medicaid.
This isn’t merely about what the legislation will do to health care, because it also would exacerbate inequality and worsen health disparities in this country. Under both the House and Senate bills, low- and middle-income families would pay more in taxes and have a harder time paying not just for health care, but also for food, housing, child care, education, and other basic needs. When people struggle so much to make ends meet, they suffer more from illness and die younger. And if inequality keeps getting worse, it will undermine the economic, social, and political stability upon which our nation depends.
The burden on Californians would be particularly heavy. Our families would no longer be able to deduct what they pay in state and local taxes on their federal tax returns. This change alone would take more than $112 billion a year out of the pockets of hardworking Californians — more than any other state. The fact that Californians would be paying more in federal taxes would inevitably put new pressure on our state and municipal governments to reduce their taxes. Under that scenario, it is not hard to imagine a new wave of painful state and local budget cuts.
The irony is that California actually has the power to stop this runaway train. If the entire California congressional delegation worked together to protect their constituents, and if they were united and strong, they could prevent many — if not all — of the worst provisions in the tax bills from becoming law.
This moment is a test of leadership. Nothing less than the health of our people — and our democracy — are at stake.
U.S. health care spending increased to $3.3 trillion in 2016, with out-of-pocket health care costs borne directly by consumersrising 3.9 percent — the fastest rate of growth since 2007.
The findings, published Wednesday by Health Affairs, are considered the authoritative breakdown of American health care spending and are prepared each year by the Centers for Medicare and Medicaid Services.
The overall rate of increase in health care spending experienced a slight slowdown over the previous year, driven in part by the expected moderation in growth after the expansion of insurance coverage through the Affordable Care Act. There was also a sharp decrease in the growth of prescription drug expenditures, as hepatitis C treatment costs have declined and fewer patients are receiving them.
But even as spending growth slowed, health expenditures swallowed a greater part of the economy, with health expenditures making up 17.9 percent share of gross domestic product in 2016.
The slowdown in spending growth — a 4.3 percent increase in 2016, following a 5.8 percent growth the previous year — stemmed from changes in a broad array of health care sectors.
That ranged from slower growth in Medicaid spending after the surge in enrollment caused by the Affordable Care Act expansion, to a marked slowdown in prescription drug spending growth that had been pushed higher by the approval of a new, expensive treatment for hepatitis C in 2013.
A shift toward insurance plans that transfer more of the burden of health care costs onto patients helped fuel the rise in out-of-pocket costs. In 2016, 29 percent of people who receive insurance through employers were enrolled in high-deductible plans, up from 20 percent in 2014. The size of the deductibles also increased over this time period, a 12 percent increase in 2016 for individual plans, compared with a 7 percent increase in 2014.
Out-of-pocket spending grew the most on medical equipment and supplies and decreased slightly for prescription drugs, according to the analysis.
The most noticeable change was a big slowdown in prescription drug spending growth, which made up 10 percent of the total spending, or $328.6 billion. (That spending number does not include drugs administered by physicians or hospitals.)
That decrease highlights the effect that expensive new treatments used by large numbers of people can have on national spending. A new generation of expensive hepatitis C drugs drove national drug spending 12.4 percent higher in 2014 and 8.9 percent higher in 2015. In 2016, the prescription drug spending increased by 1.3 percent, closer to the rates in the years before the new drugs were approved.
The authors of the report attributed that trend not just to hepatitis C drugs. There were also fewer new, brand name drugs approved in 2016 — 22 new drugs, compared with 45 the previous year. Another factor was a slowdown in the growth of spending on insulin, a lifesaving drug for people with diabetes, in Medicare.
Insulin prices have been under intense scrutiny as drugmakers have increased the list prices of insulin while claiming the true cost to patients has remained flat due to discounts and rebates
Health care spending has been buffeted by unusual changes during the past decade. There was a historic slowdown in growth due to the Great Recession, and then the Affordable Care Act’s expansion of health insurance coverage fueled spending.
The authors said this year’s trend of slower growth could be a sign that things were returning to normal.
“Future health expenditure trends are expected to be mostly influenced by changes in economic conditions and demographics, as has historically been the case,” the authors wrote.
House and Senate negotiators thrashing out differences over a major tax bill are likely to eliminate the insurance coverage mandate at the heart of the Affordable Care Act, lawmakers say.
But a deal struck by Senate Republican leaders and Senator Susan Collins of Maine to mitigate the effect of the repeal has been all but rejected by House Republicans, potentially jeopardizing Ms. Collins’s final yes vote.
“I don’t think the American people voted for bailing out big insurance,” said Representative Dave Brat, Republican of Virginia, who opposes a separate measure to lower insurance premiums that Ms. Collins thought she had secured.
“Mandating people to buy a product was a bad idea to begin with,” said Representative Rob Woodall, Republican of Georgia. “We made people do something that was supposed to be good for them. But they are telling us by the millions how much they dislike the mandate.”
Representative Kevin Brady of Texas, the chief architect of the House tax bill, asked whether he was receptive to the idea of eliminating the penalties for going without insurance, said, “I certainly am.”
The individual mandate was originally considered indispensable to the Affordable Care Act, a way to induce healthy people to buy insurance and thus to hold down insurance premiums for sicker customers. The Obama administration successfully defended the mandate in the Supreme Court. But recent economic research suggests that the effect of the mandate on coverage is somewhat smaller than previously thought.
With little more than a week remaining until the annual open enrollment period ends, 3.6 million people have selected health plans for 2018 in the 39 states that use the federal marketplace, the Trump administration reported Wednesday. That is 22 percent higher than at this point last year, despite uncertainty about the mandate’s future and efforts by Republicans and the administration to undermine the law.
But because the sign-up period is only half as long, it appears likely that enrollment will end up lower than in the last period.
Without a mandate, some healthy people are likely to go without coverage, leaving sicker people in the market, and prices are likely to rise more than they otherwise would. The Congressional Budget Office said last month that repealing the individual mandate would increase average premiums on the individual market about 10 percent, and it estimated that the number of people without health insurance would rise by 13 million.
Regardless, the requirement has proved to be one of the most unpopular parts of the 2010 law, and House Republicans were happy to see it go. Representative Richard Hudson, Republican of North Carolina, called the Senate provision “a great move.”
The repeal also frees up money that Congress can use to reduce tax rates. The budget office said it would save the federal government more than $300 billion over 10 years — mainly because fewer people would have Medicaid or subsidized private insurance.
The mandate repeal’s effect on health insurance markets did concern Ms. Collins, and to win her vote for the Senate tax bill, the Senate majority leader, Mitch McConnell of Kentucky, offered her a deal, in writing: He would support two bipartisan bills to stabilize markets and hold down premiums, in the absence of the individual mandate.
One bill would provide money to continue paying subsidies to insurance companies in 2018 and 2019 to compensate them for reducing out-of-pocket costs for low-income people. President Trump cut off the “cost sharing” subsidies in October, more than a year after a federal judge ruled that the payments were unconstitutional because Congress had never explicitly provided money for them. The payments would resume under this measure, drafted by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington State.
The second bill would provide $5 billion a year for grants to states in 2018 and 2019. States could use the money to help pay the largest health claims, through a backstop known as reinsurance, or to establish high-risk pools to help cover sick people.
Ms. Collins has released a copy of her agreement with Mr. McConnell in which he pledged to support passage of the two measures before the end of the year. His signature was displayed prominently at the top of the first page. But the deal has landed with a thud in the House, where Republicans appear loath to support legislation that they view as propping up a health law that they have pledged to repeal.
“Our members wince at voting to sustain a system that none of them supported,” said Representative Tom Cole, Republican of Oklahoma.
The Senate could attach the Alexander-Murray legislation to a government funding measure, hoping that Republicans in the House would be willing to swallow it as part of a measure to avoid a government shutdown. But Mr. Cole said House Republicans would be “very offended” at such an approach.
“I don’t think we’re in the mood to be blackmailed by anybody,” he said.
Mr. Brat, a member of the conservative Freedom Caucus, assailed the deal with Ms. Collins as an example of horse trading that is characteristic of the Washington swamp that he said voters had repudiated.
Likewise, Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said of the Alexander-Murray bill, “There’s no appetite for that over here.”
Ms. Collins said on Wednesday that she believed the House would “take a serious look” at the two bills intended to hold down insurance premiums and that Mr. Trump, in several recent meetings, had assured her that he also supported those bills.
“I don’t think this effort is over by any means,” Ms. Collins said.
For Democrats, eliminating the insurance mandate penalties provides yet another reason to oppose the tax bill.
“The individual mandate is at the heart of the Affordable Care Act,” said Representative James E. Clyburn, Democrat of South Carolina. “Repealing it, as the G.O.P. tax scam does, is a deliberate attempt to undercut the law, create chaos in the health insurance marketplaces, increase premiums and decrease choice and coverage.”
Ms. Murray indicated that even if Ms. Collins secures her deal, Democrats would remain steadfast.
“Our bill, the Alexander-Murray bill, was designed to shore up the existing health care system,” not to “solve the new problems in this awful Republican tax bill,” she said.
Meanwhile, the damage to the Affordable Care Act may already have been done. Daniel Bouton, an enrollment counselor in Dallas, said he worried that the Trump administration’s decision to cut advertising for open enrollment had prevented millions of people from learning about the shortened sign-up period. He also said that the Senate’s recent vote to undo the individual mandate as part of its tax bill would discourage people from signing up.
“You’re going to have people who say, ‘Well, perfect, I don’t have to buy insurance anymore,’” Mr. Bouton said.
House Speaker Paul Ryan (R-Wis.) on Wednesday said House Republicans will aim to cut spending on Medicare, Medicaid and welfare programs next year as a way to trim the federal deficit.
“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an interview on Ross Kaminsky’s talk radio show.
Health-care entitlements such as Medicare and Medicaid “are the big drivers of debt,” Ryan said, “so we spend more time on the health-care entitlements, because that’s really where the problem lies, fiscally speaking.”
Ryan said he’s been speaking privately with President Trump, who is beginning to warm to the idea of slowing the spending growth in entitlements.
During his campaign, Trump repeatedly promised not to cut Medicare, Medicaid or Social Security.
“I think the president is understanding choice and competition works everywhere, especially in Medicare,” Ryan said.
House and Senate Republicans are currently working on their plans for tax reform, which are estimated to add more than $1 trillion to the deficit. Democrats have voiced concerns that the legislation could lead to cuts to the social safety net.
Ryan is one of a growing number of GOP leaders who have mentioned the need for Congress to cut entitlement spending next year.
Last week, House Ways and Means Committee Chairman Kevin Brady (R-Texas) said that once the tax bill was done, “welfare reform” was up next.
Sen. Marco Rubio (R-Fla.), last week, said “instituting structural changes to Social Security and Medicare for the future” will be the best way to reduce spending and generate economic growth.
Rep. Jeb Hensarling (R-Texas), chairman of the House Financial Services Committee, told Bloomberg TV that “the most important thing we can do with respect to the national debt, what we need to do, is obviously reform current entitlement programs for future generations.”
Ryan also mentioned that he wants to work on changing the welfare system, and Republicans have in the past expressed a desire to add work requirements to programs such as food stamps.
Speaking on the Senate floor while debating the tax bill last week, Senate Finance Committee Chairman Orrin Hatch (R-Utah) said he had a “rough time wanting to spend billions and billions and trillions of dollars to help people who won’t help themselves, won’t lift a finger and expect the federal government to do everything.”
His comments were echoed by Ryan.
“We have a welfare system that’s trapping people in poverty and effectively paying people not to work,” Ryan said Wednesday. “We’ve got to work on that.”
HENRY KOTULA 