The attempt to repeal Obamacare may be over for now, but the fight over the future of the law is still bogging down other health care agenda items and making it difficult for President Trump and his fellow Republicans to pursue new policies.
Increasingly in recent weeks, the White House and House and Senate GOP leaders don’t appear to be in sync when it comes to their health-policy goals.
“I think it’s challenging right now for the Republicans in Congress to create a game plan in health care,” said Ilisa Halpern Paul, president of the District Policy Group.
Lawmakers’ attempts to renew expired funding for the Children’s Health Insurance Program and community health centers illustrate the different approaches of House and Senate committees of jurisdiction—and the drag caused by the unresolved debate over Obamacare.
The House Energy and Commerce Committee cleared legislation for both programs with controversial offsets, including increasing premiums for high-income Medicare beneficiaries and cutting $6.35 billion from the Affordable Care Act’s Prevention and Public Health Fund. The Senate Finance Committee, meanwhile, has cleared language to renew CHIP funding, but has not figured out how to pay for it.
At the same time, the administration—led by a president who has complained repeatedly about the Hill GOP’s inability to pass Obamacare repeal—has been taking policy steps of its own.
But the way in which Trump has proceeded with changing the system has sent mixed signals to lawmakers and made it difficult to establish long-term plans. By not making firm commitments to key parts of the ACA, such as cost-sharing-reduction payments to help insurers cover low-income customers, the administration has created uncertainty for lawmakers.
The administration has been making cost-sharing payments on a monthly basis. Senate health leaders sought to guarantee these payments for a longer period of time as part of a bipartisan agreement, but lawmakers have not reached a deal. “The system runs, [but] it runs more episodically,” said Thomas Miller, a resident fellow at the American Enterprise Institute.
Trump is planning an executive order that would expand access to association health plans that are exempt from many of the ACA’s coverage requirements.
“They’ll be able to buy—they’ll be able to cross state lines and they will get great, competitive health care, and it will cost the United States nothing, take care of a big percentage of the people we’re talking about, too,” Trump told reporters Tuesday. “With Congress the way it is, I decided to take it upon myself, so we’ll be announcing that soon as far as the signing is concerned.”
It is not surprising to see a president use his executive tools, but there has not been a consistent strategy, said Molly Reynolds, a fellow in governance studies at the Brookings Institution. “In a better-functioning administration, there may be more exchange of information between White House and Congress,” she said.
Reynolds noted that Trump has not helped bridge intraparty divides. “If members don’t find Trump useful in any way in their legislative process … that makes it harder for them to legislate when there are already divides within the party,” she said.
At the same time, the president reached out to Senate Democratic Leader Chuck Schumer last week to discuss a health care deal. “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!” Trump tweeted Saturday.
Trump’s call caused some consternation among Republicans, many of whom are uninterested in any ACA negotiations with Democrats.
The inconsistent signaling from the administration extends to other parts of Obamacare. Earlier in the year, the Health and Human Services Department had urged governors to take advantage of the existing waivers to make changes to their marketplaces and lower premiums.
“State Innovation Waivers that implement high-risk pool/state-operated reinsurance programs may be an opportunity for states to lower premiums for consumers, improve market stability, and increase consumer choice,” asserted then-HHS Secretary Tom Price.
But more recently, The Washington Post reported, Trump urged the rejection of a waiver for Iowa, a state led by a Republican governor. Additionally, Oklahoma withdrew a proposed waiver, citing a lack of a timely approval, and Minnesota, while getting approval for its waiver to establish a reinsurance program, was also dealt a severe cut to its Basic Health Program, which provides coverage for low-income people.
“I have believed the President’s and your repeated encouragement of states to undertake new initiatives that will improve the quality and affordability of their citizens’ healthcare,” Minnesota Gov. Mark Dayton wrote to Price in September. “Unfortunately, Minnesota’s experience with its … Waiver application has been the opposite; it has been nightmarish.”
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