Washington Insurance Commissioner Mike Kreidler worries about the condition of his state’s Obamacare marketplace, where insurers are requesting big rate hikes and have dropped out entirely from two of the state’s counties.

So on April 8, Kreidler laid out to the Trump administration how he thinks it could improve the situation.

Officials should promise to enforce the individual mandate to ensure healthy people buy coverage, Kreidler wrote in a letter to the Department of Health and Human Services. He also urged HHS to assure insurers it will keep paying extra cost-sharing subsidies and to consider setting up a new, federal reinsurance program to spread risk among insurers.

Take those steps to eliminate “the most significant and immediate drivers of market uncertainty” and you’d go a long way toward shoring up the state marketplaces for 2018, Kreidler wrote.

Six weeks later, Kreidler got a response back from HHS. But the agency didn’t reply to his concerns about the individual mandate to buy coverage, or the cost-sharing subsidies.

Instead, HHS’ letter back made clear that its head honcho, former Rep. Tom Price (R-Ga.) -- one of Obamacare’s harshest critics in Congress --  and its other leaders are simply following a different playbook for how to handle the marketplaces in a marked shift from the Obama years.

The agency has made some tweaks to next year’s open enrollment season, halving its duration and requiring more eligibility verification for those trying to sign up after the normal window closes, Randy Pate, deputy director of HHS’ Centers for Medicare and Medicaid Services, noted in his response back to Kriedler.

HHS is also offering states more flexibility in running their marketplaces by expanding the use of waivers already available under the Affordable Care Act, Pate wrote. Known as “1332 waivers,” these allow states to construct their own ways of delivering insurance to people, as long as they don’t result in fewer people covered or cost the federal government more.

These steps are ways to “stabilize the individual and small-group health insurance markets, provide more flexibility to states and issuers and give patients access to more coverage options,” Pate wrote.

Kreidler, a former Democratic congressman and state legislator, sees things differently. He feels the administration is taking steps to further destabilize the marketplaces – including the one he presides over – by seeming to ignore pleas from him and other insurance regulators. To top it off, Senate Republicans on Capitol Hill are working to overhaul big parts of the ACA, casting a huge shadow of uncertainty over the marketplaces and further driving out insurers.

Lately, he’s been longing for a return of the Obama administration, he told me.

“We didn’t know how good we had it,” Kreidler said. “We were always having disagreements with HHS, but they’d listen to us. Right now, I don’t think [HHS] listens to us – that’s the big difference.”

The correspondence illustrates the tension between many insurers and states and the Trump administration as the ACA marketplaces where people without employer-sponsored coverage can buy subsidized coverage flounder in many states around the country.

Washington is just one of about 15 states where many residents will have only one individual market plan – or none at all -- to choose from in 2018. In Ohio, more than 10,000 residents across 18 counties may have no insurance options. About 67,000 customers in 25 western Missouri counties are facing the consequences of no marketplace insurers next year, barring a potential entrance by the Centene.

And in Iowa, the last remaining insurer is threatening to pull out, potentially causing the state’s entire individual marketplace to collapse.

Republicans at both ends of Pennsylvania Avenue are conflicted over how much to intervene. Some have urged a passive approach, saying it’s best to let the marketplaces run their course since Republicans will soon replace the ACA anyway. Trump loves to predict that the law will collapse under its own weight:

Others feel it’s important to intervene in the interim given the likelihood that hundreds of thousands of customers may have only one plan option next year. And while Senate Majority Leader Mitch McConnell (R-Ky.) is prodding his conference toward passing a partial replacement, whether final legislation will ever make it to Trump’s desk is still very much in doubt.

The Obama administration played an aggressive role behind the scenes in assisting marketplaces last year, as they were hit by a first wave of rate hikes and insurer exits. For awhile last August it appeared there would be no insurer at all in Pinal County, Ariz., for example, until officials convinced Blue Cross Blue Shield of Arizona to open its doors there.

The Centers for Medicare and Medicaid Services didn’t respond to questions about its interaction with state marketplaces. But obsevers say the Trump administration doesn’t appear to be doing much to bolster the marketplaces.

“I see no evidence they’re taking any activist role in trying to make these markets work,” said Dan Mendelson, chief executive of Avalere Health.

Without a clear ally in the White House, state insurance commissioners are playing a big role in trying to fill in the holes themselves. Kreidler said he hopes to be able to announce early this week that he’s enticed insurers into Washington’s two counties that currently lack any.

“Right now, I’m somewhat optimistic we’re going to succeed at that,” Kreidler said.

The Ohio Department of Insurance is also trying to lure more insurers into its empty counties. Spokesman Chris Brock told The Health 202 that Ohio “will be having conversations with HHS” throughout the process.

“The department is looking at options for 2018 in those counties where there currently isn’t an insurer planning to sell on the federal exchange,” Brock said. “We’ll be working to identify coverage options for consumers, but that process will take some time.”


AHH: Many Democrats see Tuesday's special election for the seat of former Rep. Tom Price (R) -- now secretary of Health and Human Services -- as intertwined with their health-care moves, my colleague Bob Costa writes. If Democrat Jon Ossoff wins the Georgia 6th Congressional District, the likely wave of enthusiasm could rattle Trump and Republicans. If he loses to Republican Karen Handel, it could be demoralizing and reveal the challenges facing Democrats ahead of next year’s midterm elections, despite the GOP health-care proposal’s unpopularity.

OOF: Senate Democrats are planning to raise a ruckus this week as their Republican counterparts seek to move forward on an Obamacare overhaul, CNN reports.

"The Democratic leadership and rank-and-file members are planning to prevent the chamber from conducting routine business, including allowing committees to meet for extended hearings when the Senate is in session," Manu Raju and Ted Barrett report. "And they will demand an open process to consider health care when the Senate reconvenes Monday."

"If carried through, the hardball tactics would make it difficult for Republicans to schedule votes even on uncontroversial bills and nominees, further slowing down the already slow-moving body," Manu and Ted write. There's some disagreement among Democrats on how far to go, given the bipartisan atmosphere following the congressional baseball practice shooting last week. But some Dems want to escalate the fight to highlight the GOP's less than transparent process of drafting health-care legislation.

OUCH: McConnell has just this week and next if he wants to reach his goal of a health-care vote before the July 4 recess. A lot would need to happen during that time -- including actually getting legislation put together -- and Sen. Marco Rubio (R-Fla.) is skeptical of how such a bill is being drafted in secret and potentially rushed through.

“The Senate is not a place where you can just cook up something behind closed doors and rush it for a vote,” Rubio said on CBS' "Face the Nation." “So the first step in this may be crafted among a small group of people, but then everyone’s going to get to weigh in.”

Rubio's among the group of Republicans generally expected to go along with whatever repeal-and-replace legislation surfaces. Other conservatives, including Sens. Ted Cruz of Texas, Mike Lee of Utah and Rand Paul of Kentucky, are seen as the likely objectors from the right. So his comments are notable, Politico's Jen Haberkorn tweeted:


--HHS Sec. Price told medical-device makers last week that Trump has good reason to like their industry because they incentivize innovation and create jobs -- possibly hinting that the administration wouldn't be okay with an Obamacare repeal bill that retains the ACA's medical-device tax.

Speaking Friday morning to the leading association of medical-device makers (the Advanced Medical Technology Association, known as AdvaMed), Price said he was "adamantly opposed" to the tax while in Congress, according to sources in the room. The tax doesn't make sense and hurts innovation, Price told attendees. The House bill overhauling Obamacare would repeal nearly all of its taxes, including the medical-device tax, but Senate Republicans have been toying with the idea of retaining some of them -- making the industry nervous that its most-hated part of the ACA won't get erased after all.

A few more interesting reads about the Trump administration:


--Five Republican senators are being pressured by a $1.5 million ad campaign from a consumer health organization not to vote for the emerging health-care legislation, my colleague Sean Sullivan reports. "Community Catalyst Action Fund, which bills itself as a consumer health organization, is targeting Sens. Lisa Murkowski (Alaska), Jeff Flake (Ariz.), Susan Collins (Maine), Dean Heller (Nev.) and Shelley Moore Capito (W.Va.) with television and radio ads urging them to vote no," Sean writes.

"All of the lawmakers singled out by the group except Collins come from states that expanded Medicaid under the Affordable Care Act, known as Obamacare. That was a significant part of the decision to spend $1.5 million, Community Catalyst Executive Director Robert Restuccia said," Sean writes.

"The ad campaign comes as other organizations are ramping up opposition to the Senate GOP effort," he continues. "Last week, a coalition of medical and consumer groups held an event in Cleveland that was billed as the first of a series of gatherings to speak out against a bill that passed the GOP-controlled House and the direction that Republican senators appear to be heading."

--On Capitol Hill this week, expect the health-care debate to be at fever pitch. Supporters of the ACA note  that it's a pivotal time for the repeal-replace effort, as it becomes clear whether the Senate will be able to get its act together. At the same time, don't forget that any Senate bill would have to be passed by the House or otherwise merged with its version -- so there's still a long, hard road ahead regardless of what happens over the next week or two.

From Loren Adler, health-policy director at the Brookings Institution:

And conservative groups warned they might not support a Senate bill if it doesn't repeal enough of the ACA:


--We've already discussed how Democrats will intensify their attacks this week against Republicans for refusing to hold committee hearings on their health-care bill or otherwise invite any bipartisan participation. Post Fact Checker Glenn Kessler contrasts exactly what McConnell is saying about the process now with his criticisms of Democrats as they were passing the ACA back in 2010.

McConnell, on March 27, 2010“In one of the most divisive legislative debates in modern history, Democrats decided to go the partisan route and blatantly ignore the will of the people.”

McConnell now: “Unfortunately, it will have to be a Republicans-only exercise. But we’re working hard to get there.”

McConnell on Feb. 24, 2010“Democrats on Capitol Hill are working behind the scenes on a plan aimed at jamming this massive health spending bill through Congress against the clear wishes of an unsuspecting public. What they have in mind is a last-ditch legislative sleight-of-hand called reconciliation that would enable them to impose government-run health care for all on the American people, whether Americans want it or not.”

McConnell now: “There have been gazillions of hearings on this subject when they were in the majority, when we were in the majority, when we were in the majority. We understand this issue pretty well, and we’re now working on coming up with a solution.”

Did McConnell flip-flop? Yes, for which Glenn awards him an upside-down Pinocchio. 

"The ACA ultimately was passed on a partisan vote, crippling it from the start because Republicans had no incentive or inclination to ever help fix it," Glenn writes. "That is now often cited as justification for repealing the law in a strictly partisan manner."

"But it’s also clear that McConnell’s position has changed, even though he will not acknowledge it," Glenn continues. "He was against the reconciliation process for health care in 2010; he has embraced it now. He was against secrecy and closed-door dealmaking before; he now oversees the most secretive health-care bill process ever. And he was against voting on a bill that was broadly unpopular — and now he is pushing for a bill even more unpopular than the ACA in 2010."



  • Senate Democrats are reportedly planning a late-night protest against the Republican health-care effort. Sen. Richard Blumenthal (D-Conn.) is also planning an "emergency" health-care hearing.
  • The Biotechnology Innovation Organization’s International Convention starts today and continues through Thursday.

Coming Up

  • The Senate Appropriations’ Subcommittee on Agriculture, Rural Development, Food and Drug Administration and Related Agencies is holding a hearing on the FDA’s 2018 budget request on Tuesday.
  • The Bipartisan Policy Center is holding an event on Tuesday on pandemics.
  • The Congressional Neuroscience Caucus will host a briefing with the American Brain Coalition and Cure Alzheimer’s Fund on “the role of private contributions in neuroscience research” with Rep. Earl Blumenauer (D-Ore.) and Rep. Cathy McMorris Rodgers (R-Wash.) on Tuesday
  • The Ninth Annual Congressional Women’s Softball Game will take place on Wednesday.
  • FleishmanHillard is holding an event on Wednesday on health care in the Trump era.

Has Senate Majority Leader Mitch McConnell changed his mind about how to pass health-care legislation?

Watch Sen. Bernie Sanders's (I-Vt.)'s comments on how Senate Republicans are “working behind closed doors” on their health-care bill: 

Watch Sen. Marco Rubio (R-Fla.) weigh in on Senate Republicans' strategy in working on health care: 

Stephen Colbert says "somehow your health insurance is the one piece of classified information that no one has leaked yet":

See how President Trump's stalled GOP agenda is casting a shadow over the special election in Georgia: