ACA or­der rat­tles sys­tem

Trump’s move to rein in law fu­els un­cer­tainty


Pres­i­dent Trump’s ex­ec­u­tive or­der in­struct­ing fed­eral agencies to grant re­lief to con­stituen­cies af­fected by the Af­ford­able Care Act has be­gun to re­ver­ber­ate through­out the na­tion’s health­care sys­tem, in­ject­ing fur­ther un­cer­tainty into an al­ready un­set­tled in­sur­ance land­scape.

The po­lit­i­cal sig­nal of the or­der, which Trump signed just hours af­ter be­ing sworn into of­fice, was clear: Even be­fore the Repub­li­can-led Congress acts to re­peal the 2010 law, the new ad­min­is­tra­tion will move swiftly to un­wind as many el­e­ments as it can on its own — el­e­ments that have changed how 20 mil­lion Amer­i­cans get health cov­er­age and what ben­e­fits in­sur­ers must of­fer some of their cus­tomers.

But the prac­ti­cal im­pli­ca­tions of Trump’s ac­tion on Fri­day are harder to de­ci­pher. Its lan­guage in­structs all fed­eral agencies to “waive, de­fer, grant ex­emp­tions from or de­lay” any part of the law that im­poses a fi­nan­cial or reg­u­la­tory bur­den on those af­fected by it. That would cover con­sumers, doc­tors, hos­pi­tals and other providers, as well as in­sur­ers and drug com­pa­nies.

The prospect of what could flow from pulling back or elim­i­nat­ing ad­min­is­tra­tive rules — in­clud­ing no longer en­forc­ing the in­di­vid­ual man­date, which re­quires Amer­i­cans to get cov­er­age or pay an an­nual penalty, and

end­ing health plans’ “es­sen­tial ben­e­fits” — could af­fect how many peo­ple sign up on the Af­ford­able Care Act mar­ket­places be­fore open en­roll­ment ends Jan. 31 for 2017 cov­er­age, as well as how many com­pa­nies de­cide to par­tic­i­pate next year.

Robert Laszewski, pres­i­dent of the con­sult­ing firm Health Pol­icy and Strat­egy As­so­ciates, called the ex­ec­u­tive or­der a “bomb” lobbed into the law’s “al­ready shaky” in­sur­ance mar­ket. Given the time it will take Repub­li­cans to fash­ion a re­place­ment, he ex­pects that fed­eral and state in­sur­ance ex­changes will con­tinue to op­er­ate at least through 2018.

“In­stead of send­ing a sig­nal that there’s go­ing to be an or­derly tran­si­tion, they’ve sent a sig­nal that it’s go­ing to be a dis­or­derly tran­si­tion,” said Laszewski, a long­time critic of the law, which is also known as Oba­macare. “How does the Trump ad­min­is­tra­tion think this is not go­ing to make the sit­u­a­tion worse?”

Teresa Miller, Penn­syl­va­nia’s in­sur­ance com­mis­sioner, said Satur­day that sev­eral in­sur­ers on her state’s ex­change “se­ri­ously con­sid­ered leav­ing the mar­ket last year” and that Trump’s ac­tion could pro­pel them to in­deed aban­don it in 2018. In fact, she added, some have raised the pos­si­bil­ity of with­draw­ing from the ACA’s ex­changes dur­ing 2017, which would mean con­sumers could keep their plans but no longer re­ceive fed­eral sub­si­dies to help them af­ford the cov­er­age.

“That would cre­ate a night­mare sce­nario,” Miller said.

As of this year, nearly a third of all coun­ties na­tion­wide have just one in­surer in the fed­eral mar­ket­place, and al­most two-thirds have two or fewer in­sur­ers.

The White House did not re­turn re­quests for com­ment over the week­end.

On Capi­tol Hill, Repub­li­can lead­ers of­fered cau­tious praise for the pres­i­dent’s ex­ec­u­tive or­der. Yet more broadly, the GOP re­mains in a state of un­cer­tainty on health care, with un­re­solved ques­tions about the path for­ward.

Sen. La­mar Alexan­der (RTenn.), the chair­man of the Health, Ed­u­ca­tion, La­bor and Pen­sions Com­mit­tee, was briefed on the de­tails of Trump’s or­der only Thurs­day, ac­cord­ing to a GOP aide who spoke on the con­di­tion of anonymity to de­scribe pri­vate talks.

Alexan­der said in a state­ment late Fri­day that Trump was “right to make the ur­gent work of res­cu­ing Amer­i­cans trapped in a col­laps­ing Oba­macare sys­tem a top pri­or­ity on his first day in of­fice.”

Se­nate Ma­jor­ity Leader Mitch McCon­nell (R-Ky.), speak­ing on “Fox News Sun­day with Chris Wal­lace,” fo­cused pri­mar­ily on what Trump could do through ex­ec­u­tive ac­tion.

“Pres­i­dent Obama im­ple­mented a lot of Oba­macare him­self, so Pres­i­dent Trump will be able to undo a lot of it him­self,” McCon­nell said. Asked whether he knew what the new pres­i­dent’s re­place­ment plan is, he said Se­nate Repub­li­cans are work­ing with the ad­min­is­tra­tion “to have an or­derly process.”

The GOP-led House and Se­nate have passed a bud­get mea­sure that was de­signed to serve as a ve­hi­cle for re­peal­ing key parts of the law. But they have yet to rally around a con­sen­sus idea for when and what to do to re­place it. They were placed un­der fur­ther pres­sure to act quickly af­ter Trump vowed “in­sur­ance for ev­ery­body” in a re­cent in­ter­view with The Wash­ing­ton Post.

A key Trump ally said Sun­day that the pres­i­dent’s de­ci­sion to sign the or­der on his first day in of­fice, cou­pled with his re­cent com­ments about mov­ing swiftly on re­peal­ing and re­plac­ing the law, has ap­plied pres­sure on GOP law­mak­ers to act faster than they might have ini­tially planned.

“I think Trump has con­sis­tently moved that nee­dle with the mind-set of our con­fer­ence,” Rep. Chris Collins (R-N.Y.) said.

Demo­cratic lead­ers, how­ever, are cast­ing the ex­ec­u­tive or­der as ev­i­dence that Repub­li­cans are in a state of dis­ar­ray on health care.

“They don’t know what to do. They can re­peal, but they don’t have a plan for re­place,” Se­nate Mi­nor­ity Leader Charles E. Schumer (N.Y.) said in an in­ter­view that aired Sun­day morn­ing on CNN’s “State of the Union.” “The pres­i­dent’s ex­ec­u­tive or­der just mir­rored that.”

At least pub­licly, the in­sur­ance in­dus­try’s re­ac­tion has been muted. Amer­ica’s Health In­sur­ance Plans spokes­woman Kris­tine Grow, whose group rep­re­sents nearly 1,300 in­sur­ers, said in an email Satur­day that it is “too soon to tell” what the ex­ec­u­tive or­der will mean for the in­dus­try.

“There is no ques­tion the in­di­vid­ual health-care mar­ket has been chal­lenged from the start,” Grow said. “The pres­i­dent said he would take swift ac­tion to move our coun­try to im­prove it, and he has.”

A key ques­tion fol­low­ing Trump’s or­der is what ac­tions Repub­li­can-led states might take to with­draw from key pro­vi­sions of the law. Flor­ida Gov. Rick Scott’s (R) of­fice said Satur­day that he was re­view­ing his op­tions.

Jackie Schutz, a Scott spokes­woman, said the gover­nor “ap­pre­ci­ates” that the new ad­min­is­tra­tion is “swiftly tak­ing ac­tion.” But as to how and when Scott would seek to take ad­van­tage of it, “we’re still look­ing into it to see what it specif­i­cally means to Flor­ida,” Schutz said.

Ohio Gov. John Ka­sich (R), who met with Se­nate Fi­nance Com­mit­tee Or­rin G. Hatch (R-Utah) and nearly a dozen other GOP gov­er­nors on Thurs­day to dis­cuss the fu­ture of Med­i­caid, said af­ter­ward that there are “some fun­da­men­tal things that we can do that can set­tle peo­ple down so they are not wor­ried they are go­ing to lose their cov­er­age but that at the same time bring sig­nif­i­cant changes to the Oba­macare pack­age.”

Ka­sich, who ex­panded Med­i­caid in his state un­der the Af­ford­able Care Act, said that one op­tion he fa­vors is par­ing Med­i­caid cov­er­age to peo­ple with in­comes up to 100 per­cent of the poverty level, rather than the cur­rent 138 per­cent, and then let­ting those above 100 per­cent go on the mar­ket­place to get cov­er­age.

Asked whether he could guar­an­tee that none of his con­stituents would lose health-care cov­er­age, Ka­sich re­sponded, “I can’t guar­an­tee any­thing.”

Even if the new ad­min­is­tra­tion is ea­ger to grant waivers to states, it does not have the po­lit­i­cal ap­pointees in place at the Health and Hu­man Ser­vices and Trea­sury de­part­ments to do so.

But tim­ing is im­por­tant. While the ex­act dead­line varies de­pend­ing on the state, in­sur­ers gen­er­ally must de­cide by the spring whether to par­tic­i­pate in Af­ford­able Care Act mar­ket­places for the next year and, if so, pro­pose the rates they would like to charge.

Their de­ci­sions could be complicate­d if the pres­i­dent’s or­der re­sults in rule changes that af­fect the ben­e­fits those health plans must in­clude — or al­ters rules in other ways that, in turn, prompt fewer healthy cus­tomers to seek cov­er­age through the mar­ket­places.

Chris Jen­nings, who served as a se­nior White House ad­viser on health care in the Clin­ton and Obama ad­min­is­tra­tions, said that in the health-care arena, “more than any other do­mes­tic pol­icy, de­tails mat­ter. Plans, they live off a comma, or an in­cen­tive, or a dis­in­cen­tive, or a penalty, or an en­force­ment mech­a­nism.”

Ceci Con­nolly, pres­i­dent and chief ex­ec­u­tive of the Al­liance of Com­mu­nity Health Plans, said her mem­bers are in a par­tic­u­larly dif­fi­cult po­si­tion be­cause they are un­like large na­tional com­pa­nies that can “pick and choose” which mar­kets they op­er­ate in un­der the fed­eral ex­change.

“Lo­cal non­profit plans are in their com­mu­ni­ties, so they can’t look around for cer­tain mar­kets and pull out of ones that they don’t like,” said Con­nolly, who added that her group’s “biggest con­cern” is that some con­sumers might stop pay­ing their pre­mi­ums if they be­lieve they will not be pe­nal­ized for lack­ing cov­er­age.

That could lead to hos­pi­tal and doc­tor vis­its that would not be re­im­bursed, which then would im­pose costs on providers and in­sur­ers more broadly.

With fewer than 10 days to go in the cur­rent en­roll­ment pe­riod, Mila Kof­man, ex­ec­u­tive di­rec­tor of the D.C. Health Ben­e­fit Ex­change Au­thor­ity, said that “all of this dis­cus­sion of whether or not peo­ple will have ac­cess to af­ford­able qual­ity health in­sur­ance is very un­set­tling.”

Some res­i­dents have asked Kof­man whether she can as­sure them they will get the same health ben­e­fits if Congress and the ad­min­is­tra­tion over­haul the sys­tem in the com­ing months. “I tell them, ‘ Sign up. We will cer­tainly do ev­ery­thing we can to en­sure that you’ll have ac­cess to qual­ity health in­sur­ance.’ ”

Yet Mona Man­gat, a solo prac­ti­tioner in al­lergy and im­munol­ogy in St. Peters­burg, Fla., is not sure what to say when pa­tients ask her whether they will be able to af­ford the kind of pre­scrip­tions and ser­vices they have taken ad­van­tage of un­der the Af­ford­able Care Act.

“Un­for­tu­nately, I don’t have an an­swer for them,” Man­gat said. “I say, ‘ Oh my God, I don’t know what’s go­ing to hap­pen.’ ”


Vice Pres­i­dent Pence watches as Pres­i­dent Trump pre­pares to sign his first ex­ec­u­tive or­der in the Oval Of­fice telling fed­eral agen­cies to roll back parts of the Af­ford­able Care Act.

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