It’s not Oba­macare any­more... it’s all ours

Woonsocket Call - - Opinion - By DREW ALT­MAN and LARRY LEVITT Alt­man is pres­i­dent and chief ex­ec­u­tive of the Henry J. Kaiser Fam­ily Foun­da­tion. Levitt is se­nior vice pres­i­dent of the Kaiser Foun­da­tion.

Repub­li­cans failed to re­peal and re­place the Af­ford­able Care Act early Fri­day be­cause of di­vi­sions within their own ranks, and be­cause they tried not only to re­peal and re­place the ACA but also to cut and cap the Med­i­caid pro­gram, gen­er­at­ing op­po­si­tion from many red-state gov­er­nors and their sen­a­tors.

But most of all, they failed be­cause they built their var­i­ous plans on the false claim — busted by the Con­gres­sional Bud­get Of­fice — that they could main­tain the same cov­er­age lev­els as the ACA and lower pre­mi­ums and de­ductibles, while at the same time slash­ing about a tril­lion dol­lars from Med­i­caid and ACA sub­si­dies and soft­en­ing the ACA's con­sumer pro­tec­tion reg­u­la­tions. Had they suc­ceeded, they would have won a big short-term vic­tory with their base, which strongly sup­ports re­peal, but suf­fered the con­se­quences in sub­se­quent elec­tions as the same vot­ers lost cov­er­age or were hit with higher pre­mi­ums and de­ductibles.

The chal­lenge now is to sta­bi­lize the ACA's in­sur­ance mar­ket­places. They are not in free fall or im­plod­ing, as Pres­i­dent Trump sug­gests, and in most mar­kets in­surer prof­its have been im­prov­ing. But th­ese are frag­ile mar­kets, es­pe­cially in ru­ral ar­eas, and there are 38 "bare coun­ties" where no in­surer cur­rently in­tends to par­tic­i­pate in 2018. About 20 per­cent of mar­ket­place en­rollees have ac­cess to only one in­surer, with the big­gest prob­lems in ru­ral ar­eas.

In­sur­ers have sub­mit­ted their ini­tial rates to state reg­u­la­tors for 2018, and in some ar­eas, the in­creases are steep. Th­ese com­pa­nies are hedg­ing their bets in the face of un­cer­tainty em­a­nat­ing from Wash­ing­ton, and who can blame them? Now, with am­bi­gu­ity over leg­isla­tive ac­tion to re­peal and re­place the law lifted, the re­main­ing un­cer­tainty is whether Congress and the ad­min­is­tra­tion will take steps to sta­bi­lize mar­kets or in­stead un­der­mine them.

The im­me­di­ate ques­tion is whether the ad­min­is­tra­tion will im­ple­ment the law as in­tended or, in a sense, en­act "skinny re­peal" through ad­min­is­tra­tive ac­tion. To sta­bi­lize the mar­ket­places, the ad­min­is­tra­tion would need to en­force the in­di­vid­ual man­date as in­tended, com­mit to pro­vid­ing pay­ments to in­sur­ers that com­pen­sate for re­duc­ing cost­shar­ing for low-in­come en­rollees, and con­tinue to pro­vide out­reach funds to sup­port en­roll­ment and con­sumer ed­u­ca­tion ac­tiv­i­ties.

In­sur­ers need to fi­nal­ize their 2018 rates soon and sign con­tracts with the fed­eral mar­ket­place by the end of Septem­ber, so clar­ity on the $7 bil­lion in cost-shar­ing pay­ments to in­sur­ers is key. If they're not made, in­sur­ers will need to raise pre­mi­ums by about 19 per­cent, or they might just de­cide to exit the mar­ket en­tirely. Th­ese pay­ments are sub­ject to a law­suit filed the House, so Congress might need to step in and as­sure that the pay­ments will con­tinue.

It is un­clear whether Repub­li­cans and Democrats can work to­gether on nar­row leg­is­la­tion to sta­bi­lize the mar­ket­places with­out once again open­ing up a broader de­bate about the ACA. Repub­li­can bills in­cluded sig­nif­i­cant fed­eral funds to help in­sur­ers cover the cost of high­risk pa­tients, an idea that was also part of the ACA for its first three years of im­ple­men­ta­tion. Th­ese rein­sur­ance or risk-shar­ing pools would bring pre­mi­ums down, es­pe­cially for mid­dle-class con­sumers not el­i­gi­ble for tax cred­its in the mar­ket­places, a pri­mary goal for both par­ties.

Con­ser­va­tives may be re­sis­tant to such spend­ing, so Congress might also con­sider ideas they ad­vo­cated in the re­cent de­bate, such as al­low­ing pre­mi­ums to be paid from health sav­ings ac­counts. This, too, would pro­vide pre­mium re­lief to mid­dle-class peo­ple buy­ing their own in­sur­ance.

Still, only 7 per­cent of the Amer­i­can peo­ple get their in­sur­ance through the in­di­vid­ual mar­ket. Find­ing con­sen­sus on the nar­row is­sue of sta­bi­liz­ing this slice of the health in­sur­ance sys­tem should be pos­si­ble if the larger, par­ti­san de­bate about Oba­macare is truly over.

But one thing is clear: 59 per­cent of the pub­lic says Pres­i­dent Trump and the Repub­li­cans are now in con­trol of gov­ern­ment and are re­spon­si­ble for mak­ing the ACA work, and 74 per­cent says they should "do what they can to make the law work."

It's ap­par­ent what needs to be done to sta­bi­lize the mar­ket­places and who owns the ACA go­ing for­ward. It's no longer Oba­macare; it's now just the na­tion's health in­sur­ance sys­tem.

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