Sabotaging the ACA

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The uncertainty around whether the Trump administration will continue these payments — known as cost-sharing-reduction payments — has left insurers jittery and contemplating leaving the individual insurance exchanges created by the Affordable Care Act, or Obamacare. Trump has put CSR payments on the table in an attempt to persuade Democrats to negotiate with him on replacing the ACA.

But cutting off the payments could mean higher premiums and a dearth of choices for insurance, experts say. "Ending the cost-sharing payments would be a clear signal from the Trump administration that they are not aiming to run the ACA marketplace effectively, so insurers would likely just throw up their hands and leave the market," Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank, told Business Insider in April. "The uncertainty and ambiguity is already giving insurers pause about staying in the market for 2018." 

Cost-sharing-reduction payments are made to insurers to offset some of their costs for providing discount insurance plans to Americans who earn up to 200% of the federal poverty limit. Under Obamacare, plans on the individual exchanges must cover a minimum set of healthcare procedures and contain some pricing limitations. That helps ensure that out-of-pocket costs aren't astronomically high for poorer people — and that the plans have a minimum standard of what they cover. The requirements, however, mean insurers typically lose money on these plans. To help offset this, the ACA provides about $7 billion to insurers to incentivize them to continue to offer the plans to lower-income people.

Trump threatens CSR Obamacare payments, Congress insurance - Business Insider

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On Thursday morning, President Trump retweeted a tweet from his favorite morning show about how “Insurers [are] seeking huge premium hikes on ObamaCare plans.” Had Trump read the article, however, he would’ve seen that the story Fox & Friends highlighted on its program actually blamed him for those rate hikes... 

The Trump administration continues to be noncommittal about whether the federal government will continue to pay the cost-sharing reduction (CSR) payments for low-income people who purchase health insurance on the Obamacare exchanges. According to the Journal, uncertainty surrounding the CSR payments and whether the Trump administration will enforce Obamacare’s individual mandate are the primary drivers of higher premiums on the exchanges.

Trump retweets story blaming his policies for Obamacare price increases – ThinkProgress

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President Donald Trump's threats to withhold key health law subsidies could cause Obamacare competition to decline and premiums to rise 20 percent, a new Congressional Budget Office report estimates.

The nonpartisan office released a report Tuesday, in which it analyzed what would happen if the Trump administration announced this month that it would not pay cost-sharing reduction subsidies, which reduce copayments and deductibles for low-income Obamacare enrollees, in 2018.
Trump has repeatedly threatened to withhold these subsidies in order to cause the Affordable Care Act to implode.

The CBO does not think the marketplace would fall into shambles if these payments were withheld. Instead, it would hobble along with higher prices and less competition. And, in a weird twist, the move would actually cost the government $194 billion over the next decade. How does ending a funding stream cost the government money? A bit of background is helpful. Obamacare has two types of insurance subsidies:

• Premium subsidies, which reduce the cost of monthly premiums for Obamacare enrollees who earn less than 400 percent of the poverty line
  
• Cost-sharing reduction subsidies, which reduce the cost of copayments and deductibles for Obamacare enrollees who earn less than 250 percent of the poverty line
  

CBO says Trump's Obamacare sabotage would cost $194 billion, drive up premiums 20% - Vox

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The Government Accountability Office (GAO) is looking into allegations that the Department of Health and Human Services (HHS) used federal funds earmarked for ObamaCare to push for the law’s repeal. They are doing so at the request of Democrats, who asked the GAO in June to look into whether tweets from HHS supporting the GOP's healthcare bill violated a law prohibiting agencies from using appropriated money to advocate for or against legislation. 

“GAO accepts your request as work that is within the scope of its authority,” reads the letter from Katherine Siggerud, the agency’s director of congressional relations, to Sen. Patty Murray (D-Wash.), one of the lawmakers asking for a review. While the correspondence is a month old, the GAO’s reply had not yet been made public. The Washington Post obtained and posted both letters on Thursday. .

GAO looking into improper HHS healthcare tweets | TheHill

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The best-known 1332 waiver was in the works in Vermont, which sought to create a universal single-player plan but eventually dropped it when the state decided the finances wouldn't work. That showed us one possible end of the spectrum. But now, under the Trump administration, Republican-led states are starting to give us a better idea of how they could use waivers to make Obamacare more conservative.

The Wall Street Journal and Washington Examiner have good summaries of Iowa's new proposal. It might be the most ambitious to be submitted to the feds so far; other states have largely limited their proposals to reinsurance, which would help insurers recoup their costs to stabilize the insurance market. Iowa has bigger ideas. The state wants to:

• Standardize the benefits for plans on the marketplace, eliminating the tiered bronze, silver, gold, and platinum options under Obamacare
  
• Transition from the existing subsidies, which limit your premiums to a percentage of your income, to a flat dollar amount based on income and age
  
• Eliminate cost-sharing reductions, the law's payments to health insurers that compensate them for reducing out-of-pocket costs for their lower-income customers
  
• Create a reinsurance program for insurers of high-cost enrollees, in part using money saved from the CSRs
  

Red states are developing some really big ideas about how to waive Obamacare - Vox

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"I don’t think we can force people to sign up for a program." I attended a briefing yesterday with a Trump administration official (one condition was we had to quote the person this way), and the big topic of discussion was what the administration was willing to do to help people sign up for health coverage under Obamacare in 2018.

That answer stuck out to me. Even as the nation's uninsured rate hits an all-time low, the administration still portrays the law as failing and waves away accusations that it is helping foster uncertainty by, for example, refusing to commit to making key payments to insurers.

"We want people to have health care," the official said toward the end, answering a basic question about whether they wanted the Obamacare markets to work. "We want the individual marketplace to function, and it’s not functioning today." We didn't get a lot of specifics about open enrollment. But there was little indication that the administration was preparing a robust outreach program. Experts have told me that a muted enrollment campaign could have serious consequences for the law's markets..


But the administration has also taken steps to restrict enrollment, like shortening the open enrollment period. TPM has also reported that Latino groups that had working relationships with the Obama White House to help sign that population up for coverage have been cut off by the new regime. Then, as we heard Wednesday, the administration isn't exactly committing to a major outreach campaign. "The surest way to kill the exchanges is to keep them a secret," Jost said. "Sick people will find them, but getting younger and healthier people enrolled is the problem."

Experts believe the Trump administration has already demonstrated it could have a real impact on Obamacare sign-ups. Enrollment for 2017 was tracking ahead of 2016, Larry Levitt at the Kaiser Family Foundation told me, until President Trump was sworn in with a little more than a week left for sign-ups. Enrollment trailed off at the end, which is doubly strange because there is usually a surge of enrollees around the deadline. Trump might have complicated issues by signing an executive order on his first day, which, while lacking many details, sent a message that the new administration would look for ways to scale back enforcement of the ACA. "Something definitely happened," Levitt said. "It's hard to say for sure exactly what caused the drop-off, but prime candidates are the scaling back of outreach and confusion among potential enrollees following the president's executive order."

Trump’s next chance to undercut Obamacare is almost here - Vox

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The Trump administration is slashing funding for ObamaCare enrollment outreach.  Department of Health and Human Services (HHS) officials announced on a call with reporters Thursday that funding for advertising and other outreach for ObamaCare enrollment will be cut from $100 million last year to $10 million this year.

Trump to slash ObamaCare outreach funding | TheHill

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The Trump administration has, quite brazenly, moved into Obamacare sabotage mode — hurting the most vulnerable participants as it puts the law itself at risk. Health and Human Services announced Thursday it would cut the Obamacare sign-up budget by 72 percent. Advertising funding will fall from $100 million to $10 million for the 2018 enrollment season. In-person outreach dollars will decline from $62.5 million to $36 million.

The Affordable Care Act’s success hinges on a large number of healthy people enrolling in marketplace coverage. These policy changes only make senses as ones that would undermine that goal. Experts expect that less outreach and less advertising will lead to fewer people enrolling in coverage, and those most likely to be left behind are the young, healthy enrollees who hold down premiums for everyone else.

This is what Obamacare sabotage looks like - Vox

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Kentucky provides a great test case for what happens when Obamacare transfers from a supportive administration that goes all-in on enrollment to a hostile one that cuts back on outreach. When Obamacare enrollment started in 2014, Kentucky was held up as a sterling example of what the law could be. Democratic Gov. Steve Beshear set up one of the best-working marketplaces in the country and the state pushed to sign up as many people as possible for Medicaid and private coverage.

By the end of 2015, as Beshear's tenure came to a close, Kentucky had tied Arkansas for the biggest drop in the uninsured rate under Obamacare, from 20.4 percent to 7.5 percent in two years. But that December, Beshear left office and a stalwart anti-Obamacare Republican, Matt Bevin, became governor. He abruptly cut off any state funding for Obamacare advertising, leading to four weeks of enrollment without any ad support.

That's where a quartet of researchers associated with the Robert Wood Johnson Foundation and the Wesleyan Media Project come in. They took a look at the difference between strong outreach for the law and the bare minimum — an imperfect but still telling analogue to what Obamacare will experience nationwide this coming year.

Using advertising data from the Wesleyan Media Project and data from Kentucky's marketplace, the researchers (who summarized their findings at the Incidental Economist) compared the first two years with robust advertising to the period without ads and found that there would have been:

• 450,000 fewer page views per week on the website for the state Obamacare marketplace without TV advertising;
  
• 20,000 fewer unique visitors per week to the website without TV advertising; and
  
• no notable change in calls to the marketplace's call center.
  

The researchers — University of North Carolina's Paul Shafer, the Wesleyan Media Project's Erika Franklin Fowler and Laura Baum, and the University of Minnesota's Sarah Gollust — summarized their findings like this: "Our analysis tells us that state-sponsored television advertising was a substantial driver of information-seeking behavior in Kentucky during open enrollment –– a critical step to getting consumers to shop for plans, understand their eligibility for premium tax credits or Medicaid, and enroll in coverage."

While correlation does not causation, it should be noted that Obamacare enrollment fell from 106,300 in 2015 (under Beshear) to 93,700 in 2016 (when Bevin took over partway through enrollment) to 81,200 in 2017 (the first full enrollment period under Bevin). Shafer told me they are working to quantify the impact on applications submitted and final enrollment.

The connection is strengthened when you account for other research that links increased Obamacare advertising with higher enrollment. We also saw Obamacare sign-ups tail off earlier this year after Trump cut off advertising in the last days of open enrollment.

What happens when you cut Obamacare advertising? Let’s ask Kentucky. - Vox

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The sabotage is forcing the Dems hands..

The critical difference is Donald Trump and, to an extent, the broader Republican Party. Their relentless efforts to undermine the Affordable Care Act are undermining the “pragmatic” rationale Democratic leaders offered in 2009 for pursuing universal coverage through a system reliant on private insurance. The hope was that by aligning with key industry priorities, they could not only minimize short-term disruption but earn Republican Party buy-in and stabilize the system. It hasn’t worked. And the extent to which Trump is doing everything in his power to undermine the ACA’s marketplaces underscores that it won’t.

Donald Trump is making the single-payer push inevitable - Vox