By Julie Rovner
September
26, 2017
Republicans
officially pulled the plug on their last-ditch effort to repeal and replace the
Affordable Care Act on Tuesday.
“We
don’t have the votes,” said Sen. Bill Cassidy (R-La.) after a closed-door
meeting of Senate Republicans. “And since we don’t have the votes, we’ve made
the decision to postpone the vote.” Cassidy, along with Sen. Lindsey
Graham (S.C.) put together the proposal they hoped could pass the Senate.
As of
Sunday, though, the Senate will no longer be able to pass a health law overhaul
bill with only a simple majority. That means the bill is effectively dead, for
now.
That
message was underscored by Senate Majority Leader Mitch McConnell (R-Ky.), who
said “where we go from here is tax reform.”
But
that does not mean all is smooth sailing for the ACA. Here are five ongoing
challenges the law faces.
1.
Insurers still face tremendous uncertainty.
Wednesday
is the deadline for health insurers to finalize rates for the 2018 individual
market open enrollment season, which starts Nov. 1. Yet there has been no
resolution to the question of whether the federal government will continue to
reimburse insurers for subsidies known as “cost-sharing reductions.” Those are
payments insurers are required to provide to moderate-income enrollees to help
them afford deductibles and out-of-pocket costs. The law says the federal
government is supposed to make those payments, but a lawsuit has left
that an open question, and the Trump administration has
repeatedly threatened to stop making the payments.
Without
reimbursement of those subsidies, Pennsylvania Health and Human Services
Secretary Teresa Miller told the Senate Finance Committee Monday that insurers
in her state “reported they would need to request a statewide average increase
of 20.3 percent” in health plan premium costs. Those increases are similar
nationwide.
A
bipartisan effort led by Senate Health, Education, Labor and Pensions Committee
Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.) to advance
legislation to affirmatively fund the payments was reportedly progressing
until Republican leaders stopped them to
concentrate on efforts to pass the Graham-Cassidy legislation.
But
they now appear back at it again.
Murray
said Tuesday she is “ready to keep working on the bipartisan path that could
lead to results.”
Alexander
similarly released a statement that he would “consult” with Murray and others
“on a limited bipartisan plan that could be enacted into law to help lower
premiums and make insurance available to the 18 million Americans in the
individual market in 2018 and 2019.”
2. The
Trump administration has cut funding for efforts to sign people up for
insurance.
Administration
officials announced earlier this month major cuts to the
“navigator” program, which provides funding to community groups that guide
people through the complex task of signing up for health insurance through the
online marketplaces. Some groups are losing more than 90 percent of their
budgets.
The
cuts have forced many groups to lay off workers just
before open enrollment begins and limit areas they serve.
3. The
2018 enrollment period is half the length of 2017’s, and now it will be shorter
still.
Trump
officials are also slashing by 90 percent the advertising budget that reminds
people about open enrollment and how to sign up — from $100 million to $10
million.
Those
cuts are even more significant this year because, for the first time since the
law’s implementation, open enrollment for healthcare.gov starts in November,
rather than December, and lasts only 45 days.
“Most
people don’t know the open enrollment dates, and they don’t know that the
deadline this year is Dec. 15, not Jan. 31, like last year,” wrote Lori Lodes,
who ran outreach for the ACA in the Obama administration, in a recent op-ed.
However,
in California and a handful of other
states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as
well as the District of Columbia — consumers will have extra time
to choose their health plans for next year, thanks to a special
exemption from the federal rule.
In
California, people shopping for 2018
coverage in the state’s exchange, Covered California, will still have
the full three months they’ve had in recent years, starting on Nov. 1 and ending
Jan. 31. And the state Legislature last week passed a bill,
currently awaiting the signature of Gov. Jerry Brown, that would
ensure a three-month enrollment window for consumers seeking coverage in 2019
and beyond.
California also
parted ways with the federal government over advertising. The board of
Covered California agreed last month to increase its marketing budget by
$5.3 million, bringing the total to $111.5 million for 2017-18. The additional
money will pay for more radio and television spots, and more direct mail to
consumers.
Trump
administration officials said they don’t think advertising is cost-effective,
but Lodes wrote that “my office produced reams of data that proved the overall
effectiveness of outreach advertising.”
Additionally,
HHS announced late last week that it will shut down healthcare.gov for maintenance
from 12 a.m. to 12 p.m. every Sunday during open enrollment except for Dec. 10
– a step critics say could further undermine enrollment efforts.
4. The
Trump administration is dragging its feet on giving states flexibility to
stabilize their markets.
Back in
March, Health and Human Services Secretary Tom Price and Centers for Medicare
& Medicaid Services chief Seema Verma, who oversees the ACA, sent a letter to states encouraging
them to use the law’s waiver process to improve the functioning of their
individual insurance markets. In particular, they suggested states could create
“reinsurance” programs that would help lower premiums by providing a payment
mechanism for the most expensive patients.
But
when Minnesota took up that invitation,
the administration delayed its response. When it finally did grant permission
last week, HHS also informed the state that it will lose significant funding
for a program that provides insurance to the state’s low-income residents.
Gov.
Mark Dayton, a former Democratic senator, said in a letter to Price that
“we have now been informed that Minnesota would lose more federal Basic Health
Plan funding than we would receive in federal support for reinsurance,” and
described the entire waiver process as “nightmarish.”
5.
Republicans could take another shot at a full overhaul next year — or even this
year.
While
the acknowledgment that the GOP lacks the votes to overhaul the health law
means an immediate vote will not happen, the Republicans have potentially two
more shots to try to pass a bill with a simple majority vote.
What
triggers the ability to pass a bill in the Senate without threat of filibuster
is a formal budget resolution.
Republicans have still not passed a budget resolution for fiscal 2018, which
begins Oct. 1. The upcoming resolution is expected to call for a major tax cut
bill. Some Republicans, notably Graham himself, have suggested adding health
language to that resolution, which would be allowed. But it would complicate
efforts for both bills.
More
likely is that Republicans could try again for a health overhaul via its fiscal
2019 budget resolution, which is due next April. That would leave them only a
few months before the 2018 elections. Still, it’s possible, particularly if
they can use the time to reach consensus.
That is
clearly what sponsors of the latest GOP bill have in mind.
“We’re
on a path to pass” his bill, Graham told reporters. “It’s just a matter of
when. It will be in this Congress, under a better process.”
This
story was produced by Kaiser Health
News, an editorially independent program of the Kaiser Family Foundation.
Julie
Rovner: jrovner@kff.org,
@jrovner
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