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 health-care 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 (R-Tenn.), 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 mindset 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 CEO 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.”
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