Hospital executives lobby senators who could swing the vote on ACA repeal

By Mara Lee  | June 29, 2017

Some hospital executives in states with senators critical to passing a healthcare reform bill have made their opposition to the legislation known and they're keeping a laser focus on Medicaid expansion.

Doug Bentz, CEO of Roane General Hospital in Spencer, W.Va., said he met with Republican Sen. Shelly Moore Capito in person about 10 days ago, along with about a dozen other hospital executives, and said he'd be on a conference call with her again Thursday.

Bentz said he's known Capito for 15 years. "She's got to be under a tremendous amount of pressure" to vote yes, he said. He added: "I've got confidence in her. There's nothing about her actions in the past that would lead her to abandon the Medicaid expansion population."

Both the Senate and House bills propose larger overhauls to Medicaid and what the Affordable Care Act did to promote expansion for newly eligible adults than repealing Obamacare or many of its provisions.

That's why Bentz and his colleagues are going for a full-court press on lawmakers who could make or break the proposed legislation.

Republicans cannot count on a single Democratic vote, so Senate Majority leader Mitch McConnell can afford to lose only two Republicans and still pass the bill. Some provisions in the original draft seemed targeted to swaying moderates—such as exempting Alaska from a provision designed to lower federal Medicaid dollars in high-spending states.

But McConnell is trying to add more to nail down the majority. A White House aide told Axios the bill could pass after McConnell "bribes" these senators with promises of funding some of their pet projects.

Bentz, for one, said he only talked to Capito about the importance of the Medicaid expanded population. He said it would be wrong to say it's vital to the hospital's continued success. Instead, he said, "It's vital to our continued existence." Before the expansion, Bentz' critical-access hospital and its outpatient primary-care practices weren't paid for what they did 12% of the time. That has fallen to 1.5%.

He said a longer-phase out of the enhanced match as currently proposed in the Senate bill is not enough. Nor is $45 billion in opiate addiction funding over 10 years, an increase of $43 billion from the original draft.

In fiscal 2015, spending on Medicaid expansion was nearly $58 billion, nearly all of it by the federal government.

And West Virginia might not be able to make up the difference between funding 10% of its expansion costs and 26% after the enhanced match ended.

"I think they would want to, but I'm not sure they can," Bentz said. He said the state just had a "very ugly budget process to fill in the holes this year."

West Virginia has the second-highest federal Medicaid match in the country, because of the low incomes earned there.

The majority of Roane General's beds are nursing home beds—35 of the 60—but Bentz hasn't even brought up what a per-capita cap with a growth rate linked to inflation would do to the facility. He said 90% to 95% of the long-term-care beds are covered by Medicaid.

In Toledo, Ohio, Kevin Webb, chief acute and post-acute care officer at ProMedica, has not met with Sen. Rob Portman, the state's Republican senator, but has emailed him about repeal and replace.

"The Senate version calls for gradually rolling back the Medicaid expansion over a number of years, and I think that's a big mistake," he said.

About 700,000 adults became eligible for Medicaid in Ohio through the expansion. Although Webb pointed to Ohio's opiate epidemic—the state has the most fatal overdoses in the country—as a reason to keep the enhanced match for the expansion, he said more funding for treatment would not be an adequate substitute.

"I think that's just shooting your left foot to save your right foot," he said. "It seems crazy to me."

Webb said Portman responded to his email, saying "he's obviously concerned about people losing coverage."

Mercy Health, which has 23 hospitals across Ohio and Kentucky, declined to say whether anyone from the Catholic system had lobbied Portman on the bill, in person or otherwise. Instead, a spokeswoman said: "Mercy Health leaders are actively engaged in discussions with political and religious leaders, and that will continue." She said there is a common message for both Kentucky and Ohio politicians.

McConnell represents Kentucky. So does Rand Paul, who says he can't support the bill because it doesn't do enough to eliminate Obamacare provisions.

In Tennessee, where Republican Sen. Bob Corker has said he has problems with the bill, a Maury Regional Medical Center executive emailed him and fellow Republican Sen. Lamar Alexander, but the hospital did not disclose what was said.

Kansas Republican Jerry Moran is another senator who has said he can't support the first draft of the Senate bill, but it's not clear whether he thinks it's too generous or not generous enough compared with current law.

"I remain committed to working with my colleagues and continuing conversations with patients and providers in Kansas to find a path forward that truly repeals and replaces Obamacare with a plan that makes certain Kansans will have access to more affordable and better quality healthcare," he said Tuesday.

Goodland Regional Hospital CEO Bill Widener said he hasn't met with Moran on the healthcare bill, but if he did, he would tell him the proposed per-capita cap for Medicaid "would be a disaster for rural health."

Goodland Regional is a 25-bed rural critical access hospital. He said roughly 20% of Goodland's revenue comes from Medicaid. Uncollectable bills from patients is equal to about 5% of services, he said. Kansas did not expand Medicaid to adults without children at home, and Widener said he wishes it had.

If reimbursement falls as states try to manage cost-shifting from the federal government under a per-capita cap, Widener is worried more doctors will refuse to see Medicaid patients, which will only mean more people will enter the healthcare system at the ER.

Mara Lee covers developments in health care policy in Congress and around Washington. This is her second time covering the Hill. In a previous life, she covered Midwestern delegations for Scripps and Gannett newspapers in Indiana and Michigan. Over her 20-year-plus-career, she’s spent more time outside the Beltway, both as a business reporter for The Hartford Courant and nine years in Ohio, mostly at the Dayton Daily News. She won an award for coverage of Oxycontin addiction Ohio in 2003, as well as for Census, business and breaking news coverage in Ohio and Connecticut. She’s a Virginia native, and graduated from the University of North Carolina-Chapel Hill. Twitter handle: MaraRhymesSarah

http://www.modernhealthcare.com/article/20170629/NEWS/170629865?utm_source=modernhealthcare&utm_medium=email&utm_content=20170629-NEWS-170629865&utm_campaign=dose

Should GOP Health Bill Prevail, Say Bye-Bye To Insurance Rebates

By Julie Appleby July 5, 2017

If Senate GOP leaders have their way, the check may not be in the mail.

Many consumers collected unexpected rebates after the Affordable Care Act became law, possibly with a note explaining why: Their insurer spent more of their revenue from premiums on administration and profits than the law allowed, so it was payback time.

More than $2.4 billion has been returned to customers since the provision went into effect in 2011, averaging about $138 per family in 2015.

Those rebates could end under the Senate proposal — now on hold until after the July Fourth holiday — to repeal the ACA.

Insurers consider the requirement — known as the medical loss ratio (MLR) — onerous, and some had to change the way they do business because of it. To be sure, the rule didn’t resonate much with consumers, even if they received a rebate, because the amounts were relatively small, possibly enough to cover a family dinner out.

The MLR has fans among policy experts, who say it pushes insurers to be more efficient and creates a better value.

 “When they struggle to pay premiums, when they’re making those sacrifices, [consumers] want most of the value of those premiums to go to actual medical care,” said Mila Kofman, a former insurance commissioner in Maine, who now runs the D.C. Health Benefit Exchange Authority.

Like much else related to the ACA, the provision was controversial from the start. It states that insurers can spend no more than 15 percent of their customer revenue on administration and profits when selling large group plans to employers, or 20 percent for individual coverage. If plans exceed this mark, they have to pay back the excess, either to employers or to people who bought coverage from them on the individual market. Employers who got rebates for their work-based plans could decide how to redistribute the money as long as it was used to benefit employees.

The Senate GOP health proposal, the Better Care Reconciliation Act, would end that requirement in 2019 and let states decide whether to continue such limits and rebates.

In some ways, this change would be a gift to insurers.

The provision, as is, “limits their profitability” and, along with other factors, may have contributed to an exodus of plans from some markets, explained Christopher Condeluci, of CC Law & Policy in Washington.

“By allowing states to craft more flexible” rules, the Senate measure may make it “easier for insurers to operate,” said Condeluci, who served as tax and benefits counsel to the U.S. Senate Finance Committee when the ACA was being drafted.

From the start, insurers argued the one-size-fits-all rule was too strict and sought the broadest possible definition of medical expenses. Supporters maintained it could help slow premium increases or at least make them more in line with the underlying growth of medical costs. This point is “really important,” said Tim Jost, an emeritus law professor who studies the health care law and serves as a consumer advocate before the National Association of Insurance Commissioners.

When the ACA took effect, health care inflation had slowed, but “insurers were still regularly raising premiums far above the actual growth in claims,” he said. “They were making a huge profit.”

The first year the provision was in effect, insurers paid more than $591 million in rebates for policies covering more than 8.8 million customers, averaging $98 per family. Not all insurers exceeded the limit, and the amount of rebates varied by insurer and state.

Over time, the number of customers in plans that exceeded the limit fell but was still nearly 5 million at last count.

The reason: Insurers both trimmed administrative costs and, in some cases — especially in the individual market — saw their spending on sicker-than-expected customers rise, making it less likely they would exceed limits. Indeed, some insurers were spending more than 90 percent of revenue on medical costs by 2014, according to a report by the Urban Institute and the Robert Wood Johnson Foundation. Some insurers have also reported losses on their individual market coverage.

Before the ACA, many states set rules on how much of their premium revenue insurers must spend on medical care — although those rules often did not apply to job-based insurance. The amounts varied, and they were often lower than what the ACA requires. North Dakota, for example, required 55 percent of revenue be spent on medical care, while New Jersey set the percentage at 80, according to a 2010 issue brief in the journal Health Affairs.

Like many other aspects of the Senate bill, the impact on consumers would vary by state.

The Congressional Budget Office, in its review of the bill, predicted that about half of people live in states that would maintain the current requirement. Others would loosen it and allow a greater share of premium costs to go toward administrative costs and profits. “In those states, in areas with little competition among insurers, the provision would cause insurers to raise premiums and would increase federal costs for subsidies through the marketplaces,” noted the CBO. The analysis also said the provision would have “little effect” on the number of people who have insurance.

http://khn.org/news/should-gop-health-bill-prevail-say-bye-bye-to-insurance-rebates/?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=53878834&_hsenc=p2ANqtz-9NrB9e4x4gSUAo0CbQMHfhtxx3jw_Lfm-vlmKRJb9E3YBZ5lAyRVT9X2yLKvWJlGN2lXNKD5_q1MZyDuZnLSFdutuehw&_hsmi=53878834

Cardiac arrest incidence in Oregon dropped after Medicaid expansion

By Maria Castellucci  | June 30, 2017

After Oregon expanded its Medicaid program in 2014, cardiac arrests significantly dropped among newly covered residents around Portland, according to a new study.

The number of out-of-hospital cardiac arrests in among people age 45-64 in Multnomah County, Ore., dropped by 17% after Medicaid expansion, researchers said in a new study published in the Journal of the American Heart Association. The county, which includes Portland, Oregon's largest city, has about 290,800 residents.

Lower incidence of cardiac arrest likely occurred because those with insurance are more likely to receive routine, preventive care that can mitigate their risks for cardiac disease as well as cardiac arrest, said Dr. Sumeet Chugh, an author of the study and associate director of the Heart Institute at Cedars-Sinai in Los Angeles.

"There is no question that having health insurance leads to a better quality of life and lower mortality, overall," Chugh said. "If you take a severe condition like cardiac arrest, that is mostly lethal, health insurance makes a difference."

Cardiac arrest is the leading cause of unexpected death in the U.S. and affects about 320,000 people per year, according to the American Heart Association. The fatality rate of an out-of-hospital cardiac arrest is also incredibly high, at about 70% to 90%.

The authors chose to focus on Oregon because the state adopted Medicaid expansion earlier, and the state had a study on sudden unexpected deaths that provided comprehensive details on cardiac arrest incidents in the Portland area.

More middle-aged Multnomah County residents acquired health insurance through Medicaid than other means, with an approximate 6.5 percentage-point increase after Medicaid expansion, from 7% to 13.5%. Insurance through direct-purchasing rose from 8.2% to 10% in the same period.

Although middle-aged individuals saw a drop in out-of-hospital cardiac arrests, those over age 65 didn't see a similar decline, the study found. This is likely because that population benefits from near-universal coverage under Medicare, Chugh said.

It's difficult to know whether other areas saw similar benefits to Medicaid expansion, and Chugh said more research will shed light on the impact insurance can have on patient health.

Medicaid expansion is one of the hot topics under debate as the Senate revises its bill to repeal and replace the Affordable Care Act. The Better Care Reconciliation Act proposes to roll back Medicaid expansion, and the Congressional Budget Office says the plan will leave 22 million more people uninsured by 2026. That has become a sticking point for lawmakers, patient advocacy groups and providers.

"Studies like this should be considered as these very important decisions are in the process of being made," Chugh said.

Maria Castellucci is a general assignment reporter covering spot news for Modern Healthcare’s website and print edition. She writes about finances, acquisitions and other healthcare topics in markets across the country. Castellucci is a graduate of Columbia College Chicago and started working at Modern Healthcare in September 2015.

http://www.modernhealthcare.com/article/20170630/NEWS/170639995?utm_source=modernhealthcare&utm_medium=email&utm_content=20170630-NEWS-170639995&utm_campaign=am

Judge orders Illinois to pay more toward Medicaid bills

By Associated Press  | June 30, 2017

A federal judge has ordered the state of Illinois to pay $286 million more toward Medicaid bills every month and an additional $1 billion during the next year.

U.S. District Judge Joan Lefkow's ruling on Friday came after lawyers representing Medicaid patients and attorneys for the state were unable to agree on a plan to pay down a $3 billion backlog owed to health care providers. Illinois is entering a third year without a budget.

The ruling requires the state to start promptly paying all new Medicaid bills. Lefkow also ruled the state must pay down $2 billion of the backlog in payments over the course of the coming fiscal year.

Comptroller Susana Mendoza says the ruling would cause her to likely cut payments to pension funds, state payroll or local governments. She said payments to bond holders won't be interrupted.

http://www.modernhealthcare.com/article/20170630/NEWS/170639986?utm_source=modernhealthcare&utm_medium=email&utm_content=20170630-NEWS-170639986&utm_campaign=am

Centene to sell marketplace plans in Missouri's 'bare' counties in 2018

By Shelby Livingston  | June 30, 2017

Centene Corp. will sell individual health insurance exchange plans in 40 Missouri counties next year, including dozens of counties that were at risk of having no marketplace options in 2018.

The St. Louis-based insurer is one of a few health plans moving into markets that other insurers ditched because of financial losses and ongoing regulatory uncertainty over healthcare reform.

The CMS under the Trump administration has held up recent marketplace retreats by insurers Anthem and Aetna as a sign that Affordable Care Act marketplaces have failed. The agency earlier this week projected 49 counties will have no exchange options next year. If no marketplace health plan is available, consumers wouldn't have access to the federal financial subsidies that reduce premiums and lower out-of-pocket costs.

But those gaps in coverage are starting to be filled. Now 36 U.S. counties in Indiana, Ohio and Nevada are at risk of having no marketplace insurers, according to the Kaiser Family Foundation, which tracks insurer participation. In those "bare" counties, 23,390 people are enrolled in exchange coverage.

Centene, which serves 1.2 million marketplace members, previously announced it would start offering coverage on exchanges in Kansas, Missouri and Nevada, while expanding its footprint in the six states where it currently sells plans. It's still unclear which Nevada and Kansas counties Centene will enter.

Centene is one of a few insurers that have managed to turn a profit on the exchanges, thanks to its experience managing the care of low-income Medicaid members and its narrow-network, low-premium plans.

Meanwhile, Indianapolis-based Anthem on Wednesday announced it would exit all but three counties in Nevada. The move would affect just 8% of its Nevada marketplace membership, a company spokeswoman said.

Anthem, which covers 1.1 million exchange members, previously said it would exit marketplaces in Indiana and Wisconsin, following an earlier announcement to drop out of Ohio. Also on Wednesday, Nevada's Prominence Health Plan said it would exit the state's marketplace completely. All together, 14 rural Nevada counties and 8,000 residents face having no access to subsidized individual coverage.

Like Centene, other insurers are expanding their exchange presence in a time of uncertainty. Oscar Health filed to expand into certain counties in Ohio, New Jersey and Tennessee. The startup, founded by Joshua Kushner, previously sold plans in New Jersey but exited the market this year. Oscar will also expand its footprint in California and Texas and will keep selling plans in New York. In 2017, Oscar covered about 105,000 members.

Earlier this month, small Midwest health insurer Medica said it would sell marketplace plans statewide in Iowa. Iowa was at risk of having no insurers after Aetna and Wellmark Blue Cross and Blue Shield announced they would exit the exchanges in 2018. Medica will also be the single insurer on Nebraska's health exchange after Aetna's exit.

Shelby Livingston is an insurance reporter. Before joining Modern Healthcare in 2016, she covered employee benefits at Business Insurance magazine. She has a master’s degree in journalism from Northwestern University’s Medill School of Journalism and a bachelor’s in English from Clemson University.

http://www.modernhealthcare.com/article/20170630/NEWS/170639992?utm_source=modernhealthcare&utm_medium=email&utm_content=20170630-NEWS-170639992&utm_campaign=am

Exchange insurers may seek enrollment caps to stay afloat

By Virgil Dickson  | June 30, 2017

As uncertainty swirls around the future of the Affordable Care Act, insurers interested in continuing to offer plans on the exchanges may seek to cap enrollment in an effort to stay financially afloat.

Insurers have retreated from the exchanges in the past few years, and those that have remained are seeing their enrollment increase. But the influx of members hasn't led to rising profits, as many exchange enrollees are saddled with ailments that are expensive to treat.

The issue is only expected to worsen next year as 36 counties in Indiana, Ohio and Nevada are at risk of having no marketplace insurers, according to the Kaiser Family Foundation, which tracks insurer participation. The CMS projected that as many as 1,200 counties, nearly 40% of counties nationwide, could have only one issuer in 2018.

Community Health Choice, a Houston-based insurer, has seen its exchange enrollment explode over the past few years, said Karen Love, the plan's executive vice president and chief operating officer. Community now enrolls 145,000 exchange members, up from 40,000 two years ago.

Community, Blue Cross and Blue Shield of Texas and Molina Healthcare were the only three insurers in Houston to offer plans on this year's exchange, down from seven insurance companies in 2016.

Love said she is worried about reports that plans that dropped out of HealthCare.gov last year are also planning to end their off-exchange individual market plans as well.

"Those people are going to need somewhere to go," Love said at the Association for Community Affiliated Plans CEO summit in Washington, D.C. on Friday.

Given the federal and state requirements of risk-based surplus funds her plan must keep on hand, Love said Community Health Choice can't handle many more sign-ups. The funds that plans must set aside are taken from the profit margin, which has not increased as new members have enrolled.

"We can't financially take another big influx of members," Love said. "We would like to very much stay on the marketplace and keep our current members, but not take on many new members in 2018."

To that end, her plan is considering asking the CMS to allow them to cap their 2018 enrollment. Her state insurance commissioners would also have to sign off on the request. If approved, her health plan would still be considered on the marketplace and thus eligible for federal financial subsidies. However, uninsured consumers searching HealthCare.gov would not see her plan listed.

While rare, the request is not unprecedented. In Minnesota, HealthPartners, Medica and UCare all had enrollment caps this year. Medica also had a cap on its Kansas plan on HealthCare.gov.

If Community Health Choice requests a cap for 2018, it won't be alone. Other plans are also planning to seek such permission, according to Scott Weltz, a principal and consulting actuary at Milliman.

He wouldn't disclose which plans are seeking caps, due to client privilege, but said that like Community, they are smaller regional plans in markets where other plans have dropped out.

"Small regional plans don't have the capacity to suddenly jump from 10,000 to 100,000 members," Weltz said. "They are requesting these enrollment caps so they can manage their growth."

Advocates are concerned about what the trend could mean for access to care. The upcoming open enrollment is already shortened from three months to six weeks and it's unclear what other options consumers would have if their enrollment is denied because of a cap, said Sandy Ahn, an associate research professor at Georgetown's Health Policy Institute.

"Between the shortened time and all the policy changes, this was already going to be a very confusing open enrollment period," she said.

Virgil Dickson reports from Washington on the federal regulatory agencies. His experience before joining Modern Healthcare in 2013 includes serving as the Washington-based correspondent for PRWeek and as an editor/reporter for FDA News. Dickson earned a bachelor's degree from DePaul University in 2007.

http://www.modernhealthcare.com/article/20170630/NEWS/170639989?utm_source=modernhealthcare&utm_medium=email&utm_content=20170630-NEWS-170639989&utm_campaign=am

Cruz insurance proposal underscores trouble with protecting pre-existing conditions

By Harris Meyer  | June 30, 2017

Health insurers are nervous about a new deregulation proposal by Texas Sen. Ted Cruz that could be added to the Senate Republicans' struggling legislation to repeal and replace the Affordable Care Act.

Cruz, who has withheld his support for the Senate GOP bill, suggested Wednesday that he could back the bill if it's revised to include his idea. He wants to allow insurers to sell individual-market plans that don't meet the ACA's popular consumer protections-as long as they offer at least one plan in the same market that complies with those mandates. He argues that would make premiums more affordable.

Insurance groups and policy experts warn, however, that this approach would create instability in the individual market by fragmenting the risk pool and driving up premiums for sicker people who need expensive care. They say it would turn the market for ACA-compliant plans into a de facto high-risk pool, but without an adequate, dedicated funding stream to make that model viable.

"Insurers are concerned that would make it challenging to keep premiums low for everyone," said an insurance industry official who did not want to be named.

"The sick would be attracted to generous plans, while the healthy would be attracted to cheaper plans, with the knowledge they could always move into more generous plans if they got sick," said Craig Garthwaite, a health insurance expert at Northwestern University. "That kind of adverse selection makes pricing and offering insurance very hard."

Cruz's proposal would mean insurers could sidestep ACA rules requiring that they accept all customers regardless of pre-existing conditions; vary premiums based only on age, charging older people up to five times more than younger people under the Senate bill (compared with a limit of three times more under the ACA); set no annual or lifetime benefit limit; and offer 10 minimum essential benefits in all plans.

Political observers say Cruz's proposal could help bring about a compromise between Senate ultraconservatives and moderates and enable Majority Leader Mitch McConnell to get the minimum 50 Republican votes he needs to pass the bill when senators return from recess July 11.

It might persuade Cruz and other ultraconservatives to go along with the moderates' demand for more funding for Medicaid and tax credits. It also could ease passage in the House, where a GOP ultraconservative leader said he likes Cruz's proposal.

It's not known whether McConnell will include Cruz's proposal in the revised bill he plans to send to the Congressional Budget Office for a new evaluation of its cost and coverage impact. But senior Senate Republicans said they're open to the proposal.

"There's some value" to the idea in terms of "giving people more options and more freedom to get the policy that they want," Sen. John Thune of South Dakota, the third-ranking Republican told Bloomberg News.

But the proposal highlights the tension between Republicans who want to abolish the ACA's protections for consumers with the goal of lowering premiums, and those who want to preserve them as much as possible to ensure coverage for people with pre-existing medical conditions. That's a key reason Republicans are struggling to get 50 votes to pass their bill.

Cruz's proposal "would lead to adverse selection in the marketplace, and it would vitiate the important consumer protection of having a prohibition against annual and lifetime caps," Republican Sen. Susan Collins of Maine, a moderate who has voiced strong doubts about the bill, told Bloomberg.

There also are doubts about whether Cruz's proposal would comply with Senate rules, which require all provisions of a budget reconciliation bill to have a budgetary impact as their main purpose.

In an interview with Vox, Cruz acknowledged the insurance market segmentation issues his proposal could cause. But he argued that sicker people still would be able to afford more-expensive ACA-compliant plans because the Senate bill would continue to offer them premium tax credits.

Even if he's right, people with higher incomes who don't qualify for those tax credits and who have costly medical conditions could be priced out, experts say. The Senate bill limits tax credits to people with incomes up to 350% of the federal poverty level, down from 400% under the ACA, thus offering financial help to fewer Americans.

Affordability for higher-income consumers who don't qualify for subsidies has been a major concern under the ACA. That problem could get worse under Cruz's proposal.

Insurance groups reacted cautiously to Cruz's proposal. "We admire the senator's efforts to think creatively and would be very happy to discuss the idea in greater detail, as many unanswered questions remain," said Ceci Connolly, CEO of the Alliance of Community Health Plans.

The proposal is a variation of provisions in the House and Senate repeal-and-replace bills to give states flexibility to let insurers sell plans that operate outside the ACA's consumer-protection rules. And its effects likely would be similar.

The Congressional Budget office said Monday that the Senate bill's provision allowing states to waive ACA rules such as essential benefits would lead to higher premiums and higher out-of-pocket costs for people who need services no longer included in essential benefits. Some people would forgo needed services because of those higher costs, it said.

Garthwaite said Cruz's proposal spotlights the tough dilemma Republicans face as they struggle to replace the ACA's intricate framework of subsidies and regulations with a more conservative, free-market model. They want to keep the law's protections for people with pre-existing conditions, but they're unwilling to accept the other parts of the law making that possible.

"Cruz is a very smart man and I think he can understand this," he said. "But facts are inconvenient. "We'd like the world to be one way, and that's just not the way the world is."

Harris Meyer is a senior reporter providing news and analysis on a broad range of healthcare topics. He served as managing editor of Modern Healthcare from 2013 to 2015. His more than three decades of journalism experience includes freelance reporting for Health Affairs, Kaiser Health News and other publications; law editor at the Daily Business Review in Miami; staff writer at the New Times alternative weekly in Fort Lauderdale, Fla.; senior writer at Hospitals & Health Networks; national correspondent at American Medical News; and health unit researcher at WMAQ-TV News in Chicago. A graduate of Northwestern University, Meyer won the 2000 Gerald Loeb Award for Distinguished Business and Financial Journalism.

http://www.modernhealthcare.com/article/20170630/NEWS/170639991?utm_source=modernhealthcare&utm_medium=email&utm_content=20170630-NEWS-170639991&utm_campaign=am