Health care deal in works?

GOP hope­ful, but some ex­perts doubt that pact can be reached

The Dallas Morning News - - FRONT PAGE - By KATIE LES­LIE Wash­ing­ton Bureau kleslie@dal­las­news.com

WASH­ING­TON — De­spite the sharp di­vi­sions that sand­bagged Repub­li­can ef­forts to over­haul Oba­macare last month, many GOP lead­ers, in­clud­ing Pres­i­dent Don­ald Trump, are hold­ing on to hope that a deal can be reached when Congress re­turns from a two-week re­cess.

“I think it can be passed. It should be passed,” said Rep. Joe Bar­ton, a Repub­li­can from Ar­ling­ton, in an in­ter­view this week.

But while me­dia re­ports sug­gest law­mak­ers are near­ing a com­pro­mise, some health care ex­perts are skep­ti­cal, pre­dict­ing Oba­macare will reach cri­sis level be­fore Congress acts.

There are such “fun­da­men­tal di­vi­sions and di­chotomies be­tween the dif­fer­ent branches of the Repub­li­can con­fer­ence, you have to get a sense that if one isn’t a bar­rier to reach­ing an agree­ment, they’ll come up with an­other one that will work,” said Tom Miller, a res­i­dent fel­low with the con­ser­va­tive Amer­i­can En­ter­prise In­sti­tute.

Trump’s first pass at over­haul­ing the Af­ford­able Care Act col­lapsed in March when Speaker Paul Ryan with­drew his bill, the Amer­i­can Health Care Act, amid dis­agree­ments be­tween con­ser­va­tive and mod­er­ates.

Still, a pres­i­dent ea­ger for a po­lit­i­cal win urged vot­ers in Wis­con­sin this week to pres­sure law­mak­ers to pass the bill. And on Thurs­day, Trump told re­porters that the GOP’s plan “gets bet­ter and bet­ter and bet­ter, and it’s got­ten re­ally, re­ally good and a lot of peo­ple are lik­ing it a lot.”

Pos­si­ble com­pro­mise

The GOP has been work­ing to re­solve di­vi­sions be­tween the con­ser­va­tive House Free­dom Cau­cus and mod­er­ate Repub­li­cans over how much flex­i­bil­ity to give states on reg­u­la­tions in­volv­ing pre-ex­ist­ing con­di­tion pro­tec­tions.

While Trump and many mod­er­ates want to keep that pop­u­lar el­e­ment of Oba­macare, GOP lead­ers — who have re­mained in ne­go­ti­a­tions over the re­cess — are mulling a com­pro­mise with con­ser­va­tives that would al­low states to opt out of the “com­mu­nity rat­ing provi­sion.” The provi­sion lim­its pre­mi­ums by re­quir­ing in­sur­ers to price poli­cies based on a com­mu­nity rat­ing in­stead of med­i­cal un­der­writ­ing.

Repub­li­cans also are grap­pling over whether to al­low states to opt out of an­other provi­sion gov­ern­ing es­sen­tial health ben­e­fits — a list of ser­vices in­sur­ers must pro­vide un­der the ACA — if they can prove that do­ing so would re­duce pre­mi­ums or in­crease the num­ber of in­sured.

Some mem­bers of the Free­dom Cau­cus fa­vor al­low­ing states to opt out of the com­mu­nity rat­ing provi­sion, say­ing it leads to higher health care costs.

But pro­po­nents of it, in­clud­ing many mod­er­ates, point out that while in­sur­ers can’t turn away a sick per­son, they could charge so much as to make care un­af­ford­able. Some re­main skep­ti­cal of the con­ser­va­tive so­lu­tion to use high-risk pools to sub­si­dize that cov­er­age.

It’s un­clear what states would even seek to opt out, par­tic­u­larly as the Trump ad­min­is­tra­tion has al­ready of­fered “in­no­va­tion waivers” to help states pur­sue health care al­ter­na­tives to the ACA.

Stacey Pogue, a se­nior pol­icy an­a­lyst with the left-lean­ing Cen­ter for Pub­lic Pol­icy Pri­or­i­ties in Austin, warns that do­ing away with the com­mu­nity rat­ing pro­tec­tion could harm Tex­ans.

In the years be­fore the ACA, in­sur­ers re­ported av­er­age an­nual per-per­son pre­mi­ums of $3,000 to $4,000, but max­i­mum per-per­son pre­mi­ums of $30,000, she re­cently wrote, us­ing 2006 data from the Texas Depart­ment of In­sur­ance.

“Our his­tory in Texas shows clearly that a guar­an­teed ‘of­fer’ of cov­er­age with no pric­ing pro­tec­tions is es­sen­tially mean­ing­less,” Pogue wrote.

Rep. Tom Reed, a mod­er­ate Repub­li­can from New York, sounded op­ti­mistic about al­low­ing states to seek a waiver as long as their al­ter­na­tive pro­posal achieves the same ef­fect as the com­mu­nity rat­ing pro­tec­tions. “That may be a sweet spot” for com­pro­mise, he said this week.

Michael Can­non, di­rec­tor of health pol­icy stud­ies with the lib­er­tar­ian Cato In­sti­tute, ar­gues that Free­dom Cau­cus mem­bers can’t af­ford to com­pro­mise on com­mu­nity rat­ing, which he called the “cen­ter­piece” of Oba­macare. “You can’t say you want to re­peal Oba­macare but not re­peal it,” he said.

He pre­dicts Repub­li­cans won’t be able to reach a com­pro­mise un­til more in­sur­ers with­draw from the in­di­vid­ual mar­ket­place, leav­ing Amer­i­cans who rely on the ACA with even fewer choices and po­ten­tially higher costs.

“Who will cave at that point? I don’t know,” he said. “Usu­ally the ones who want to limit gov­ern­ment cave first.”

But Bar­ton, a mem­ber of the Free­dom Cau­cus who sup­ported Ryan’s bill, says the cri­sis is al­ready hap­pen­ing. In the past year alone, nine in­sur­ers with­drew from the Texas ex­change, ac­cord­ing to data from the Depart­ment of Health and Hu­man Ser­vices.

“The health ex­change mar­kets are close to col­lapse,” Bar­ton said. “We should try to de­liver on our cam­paign prom­ise, pe­riod.”

In­surer sub­si­dies at is­sue

Trump could speed up that process, ex­perts note, if he fol­lows through on threats to stop fund­ing the ACA’s cost­shar­ing sub­si­dies. The funds, re­mit­ted to in­sur­ers, help re­duce health care costs for some of the coun­try’s poor­est cov­ered by Oba­macare.

House Repub­li­cans sued former Pres­i­dent Barack Obama over the pay­ments be­cause Congress didn’t first ap­prove the funds. Last year, a fed­eral judge agreed but let the sub­si­dies con­tinue while the Obama ad­min­is­tra­tion ap­pealed the de­ci­sion. The is­sue could come to a head next week when Congress re­con­venes to pass a short-term spend­ing bill.

The Kaiser Fam­ily Foun­da­tion es­ti­mates that pre­mi­ums would need to in­crease by nearly 20 per­cent in some ex­change plans should Trump halt the pay­ments.

Trump is bet­ting that do­ing so could force Democrats to come to the ne­go­ti­at­ing ta­ble, telling The Wall Street Jour­nal that while he doesn’t “want peo­ple to get hurt,” he be­lieves that “Democrats will start call­ing me and ne­go­ti­at­ing.”

Can­non, the Cato scholar, said end­ing the sub­si­dies could work in Trump’s fa­vor by re­veal­ing the true cost of Oba­macare cov­er­age.

But Repub­li­cans would also risk own­ing the col­lapse, Kaiser polling sug­gests. More than 60 per­cent of peo­ple said that be­cause Trump and the Repub­li­cans are in power, they’re re­spon­si­ble for prob­lems with the ACA, an early April sur­vey by Kaiser found.

About 1.1 mil­lion Tex­ans re­ceive in­sur­ance through the ACA mar­ket­place, with the ma­jor­ity liv­ing in Repub­li­can­held dis­tricts. That means GOP law­mak­ers could feel the heat.

Bar­ton was less con­vinced that Repub­li­cans would face the fall­out.

“Cer­tainly the Democrats would ar­gue we would, but we’d ar­gue they’re the ones who made the mess,” he said. “The Amer­i­can peo­ple would make the de­ci­sion who owns it.”

Lewisville Rep. Michael Burgess, a mem­ber of the En­ergy and Com­merce Com­mit­tee that helped craft the orig­i­nal bill, said he hopes the House can agree to a com­pro­mise, even if it’s not per­fect. “And if the wizards in the Se­nate are able to make it a much bet­ter prod­uct, then God bless them,” he said this week.

But Dal­las Rep. Pete Ses­sions, who sup­ported Ryan’s bill but also has pro­posed his own mea­sure that would mod­ify Oba­macare, sounded less than hope­ful.

“At some point, there’s go­ing to have to be a re­al­iza­tion that fix­ing health care, as op­posed to an al­ter­na­tive, is what will get peo­ple’s votes,” he said.

Rick Bowmer/The Associated Press

Peo­ple re­acted to Rep. Ja­son Chaf­fetz, R-Utah, dur­ing a town hall meet­ing in Fe­bru­ary. Sev­eral Repub­li­cans have been con­fronted by an­gry con­stituents who want to see Oba­macare re­paired rather than re­pealed.

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