As congressional Republicans pick up the pieces from their failed attempt to repeal large parts of Obamacare, experts are now turning their attention to the Trump administration and the steps it could take to dismantle the system.
Republicans had consistently contended that their repeal-and-replace bill—the one they were forced to walk away from on Friday—was part one of a three-pronged plan. Administrative actions from Health and Human Services Secretary Tom Price were intended to be step two. But now, that might be the entire plan in the near term, some experts said.
Molly Reynolds, a fellow in governance studies at the Brookings Institution, said she expects HHS to ramp up its anti-Obamacare moves in light of the repeal bill’s failure. Price will likely use his administrative power “pretty aggressively to get something accomplished even if it’s not legislation,” she said.
At least through the midterms, Republicans are likely done with big-picture health care legislation, said Robert Blendon, a professor of health policy and political analysis at Harvard University. “The question is what administratively can you do to make this a somewhat weaker and less onerous piece of legislation,” he said.
According to a January list compiled by The Incidental Economist, the Trump administration has several options. It could end Obamacare’s cost-sharing subsidies, which more than 7 million people received last year. It could refuse to settle litigation over Obamacare’s risk corridors, which help insurers defray certain losses. And it could tweak the law’s “essential health benefits”—the coverage mandates that House conservatives had hoped to repeal altogether.
Price and President Trump have already signaled their willingness to use administrative actions to roll back the Affordable Care Act.
On Day One of the new administration, Trump signed an executive order encouraging agencies to waive, defer, or grant exemptions to the law’s penalties, including the individual mandate. As a result, the Internal Revenue Service announced it will accept returns without indications of coverage status.
HHS has also released a proposed rule to help with market stabilization. It shortens the open-enrollment window, places more requirements on people trying sign up outside of that period, and allows insurers to collect unpaid back premiums from consumers who let their coverage lapse.
Price and the new Centers for Medicare and Medicaid Services administrator, Seema Verma, recently reached out to governors, promising “a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population.”
Their March 14 letter outlined plans to use existing waiver authority to review and approve programs “that build on the human dignity that comes with training, employment and independence.”
Judy Feder, a public policy professor at Georgetown University and a fellow at the Urban Institute, said HHS and CMS have the power to shift Medicaid in the direction of a block grant.
Price has separately encouraged the use of innovation waivers to help states lower premiums and improve market stability, perhaps by implementing high-risk pools or state-operated reinsurance programs.
Despite those administrative tools, House Speaker Paul Ryan acknowledged Friday that Price alone can’t enact many of conservatives’ health-policy objectives without Congress.
“For instance, risk pools,” Ryan said. “We believe the smarter way to help people with preexisting conditions get affordable coverage while bringing down the health care costs for everybody else is through reinsurance risk or risk-sharing pools, which this bill supplied for the states. That’s not now going to happen, and therefore he won’t be able to deploy that policy tool that we think is better than Obamacare.”
The failed repeal-and-replace bill also included a $115 billion fund to help states stabilize their insurance markets and ensure patients’ access to certain services.
If Congress is really worried about the health of states’ individual markets, it could still provide that sort of funding, Feder said.
But if Republicans help stabilize the current insurance market, Trump would have a harder time arguing that Obamacare doesn’t work, Blendon said.
Sen. Lamar Alexander, who heads the Senate health committee, said the House’s decision to pull its bill did not solve the problems faced by his constituents who have signed up for the insurance exchange.
“Unless Congress and the President act soon, these Tennesseans—some of the most vulnerable citizens in our state—are likely to have zero choices of insurance in 2018. … Congress has a responsibility to continue its work to solve this problem and to give more Americans more choices of lower-cost health insurance,” Alexander said in a release Friday.
Chris Jacobs, founder and CEO of the Juniper Research Group, a consulting and analytics firm, said conservatives are concerned about what will happen if Republicans walk away from their long-standing pledge to repeal the health care law. There is a worry that if they wait until after midterms, he said, “there will be no ‘after midterms.’”
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