GOP Looks to Price for Next Steps on Obamacare

Now that the House GOP has abandoned its legislation to repeal Obamacare, experts expect the administration to take the lead on health policy.

President Trump and Health and Human Services Secretary Tom Price
AP Photo/J. Scott Applewhite
Erin Durkin
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Erin Durkin
March 27, 2017, 8 p.m.

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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