The Trump administration won't give any specifics about how it will handle the looming enrollment season in the Obamacare marketplaces, where 10 million-plus Americans are expected to seek health coverage for 2018. The six-week sign-up period will be the first handled exclusively by an administration that's hostile to the Affordable Care Act -- and one that hoped by now to see Congress pass legislation unraveling much of the law.
In each of the past four sign-up seasons, the Obama administration was a clear cheerleader for the marketplaces, engaging in widespread marketing efforts, supporting nonprofit "navigators" who helped with community-based enrollment and loudly proclaiming the availability of insurance plans -- and federal subsidies -- to just about anyone without employer-sponsored coverage, Medicare or Medicaid.
So is the new administration -- and specifically the Department of Health and Human Services, run by former GOP Rep. Tom Price -- a friend or foe of the marketplaces? On one hand, any problems with enrollment on Healthcare.gov are likely to be blamed on the agency, which is in charge of operating and promoting it. On the other hand, Price's boss, President Trump, has been loudly declaring his ongoing animosity to Obamacare and his hopes that its marketplaces will self-implode.
Here are just some of the questions on our mind:
- Will the government contact current enrollees to alert them that sign-ups will last just 45 days, about half as long as in the past three years?
- Will HHS run call centers for consumers who need help as they look for plans?
- Will the HealthCare.gov computer system be adjusted to accommodate a possible crush of shoppers given the shorter sign-up period?
- And how will automatic enrollment be handled? In previous years, notices have been sent out in mid-December, informing customers with coverage about price changes for their current health plan and urging them to shop around. This year, Dec. 15 is when enrollment will end.
Communications staff for HHS declined to answer questions from The Health 202 about a half-dozen specific facets of the enrollment season, which will run from Nov. 1 to Dec. 15. Instead, a spokeswoman for the agency's Centers for Medicare and Medicaid Services issued a generic statement: “As open enrollment approaches, we are evaluating how to best serve the American people who access coverage on HealthCare.gov.”
An hour later, the spokeswoman, Jane Norris, requested that the statement be withdrawn, saying that she did not have permission to release it. When I asked her again for detailed answers, neither she nor anyone else at HHS responded further.
So we decided instead to ask people who might know: State officials and health-care nonprofits around the country that have received so-called "navigator" grants to promote enrollment. (The three-year navigator grants were first awarded in 2015, and recipients say HHS has indicated they'll get the final annual payment in early September.)
Many of these folks attended a two-day conference in Baltimore in June, where HHS staff held sessions about the enrollment season. One of the attendees was Daniel Bouton, manager of a consortium that helps people enroll across North Texas, who said many attendees peppered officials with questions about their advertising intentions.
“Every time the question was brought up . . . the only answer we received is they were working on it, and they hadn’t made a final decision about whether they were going to have a marketing campaign this year,” Bouton told me.
Jessie Menkens, who works for another navigator group, the Alaska Primary Care Association, had a similar account of the Baltimore meeting. At one point she asked an official about whether the administration plans to do outreach around enrollment season.
"I said pretty much – is there a commitment at this time to proceed with this outreach?” Menkens said. “They very kindly said ‘We’re not able to provide a commitment to that.’”
Menkens and others say they believe the navigator groups are more important than in years past, given the lack of commitment from the Trump administration to promoting Healthcare.gov. “There is a lot of noise coming from Washington, and it is our job to try to cut through that and provide factual and relatable information,” Menkens said.
Staff at the liberal consumer-health lobby Families USA grew accustomed over the past four years to frequent meetings with HHS staff members to talk over eligibility and related issues for open enrollments. There have been no such meetings since Trump took office, and federal officials have sometimes replied to written questions by saying no decision has yet been made, Eliot Fishman, the group’s senior director of health policy, told my colleague Amy Goldstein.
Heather Korbulic, executive director of Nevada's marketplace, is feeling daunted by a similar lack of answers. She has tried to find out whether HHS intends to contact Nevadans with ACA health plans to remind them to enroll — a particularly pressing issue because the state exchange operates under a hybrid system and pays about $5 million to rely on HealthCare.gov. She also has tried to get federal officials to provide a list of currently enrolled residents so the state can notify them directly.
“I ask this question every week,” Korbulic said. “It’s verbal, written, and to different levels of management . . . We are desperately seeking answers.”
Julie McPeak, Tennessee’s insurance commissioner and the incoming president of the National Association of Insurance Commissioners, said that she and colleagues have contacted officials at HHS, the Justice Department, the White House’s Intergovernmental Affairs office, and its Office of Management and Budget, trying to learn which part of the government would make the decision about these cost-sharing payments and when.
“And we can’t get a clear picture,” McPeak said. As a result, she noted, Tennessee cannot plan its own outreach efforts because it is impossible to provide consumers accurate information about insurance prices and choices for the coming year.
“It’s entirely opaque to us,” McPeak said.
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AHH: How does Senate Majority Leader Mitch McConnell (R-Ky.) console himself for failing to pass any sort of Obamacare pverhaul last month? By remembering that things could be worse -- Hillary Clinton could be president. On Saturday, McConnell told a gathering of Republicans in Kentucky that he chooses "not to dwell on situations where we come up a little bit short." He said he consoles himself by remembering that "Hillary Clinton could be president."
"Almost instantly, I feel better," he said, according to the AP.
McConnell also left the door open to a bipartisan effort to continue payments of extra cost-sharing subsidies to insurers to avert a costly rattling of insurance markets. "If the Democrats are willing to support some real reforms rather than just an insurance company bailout, I would be willing to take a look at it," McConnell said a few hours before a speech at the Fancy Farm picnic in western Kentucky.
OOF: That bipartisan effort is being led by Sen. Lamar Alexander (R-Tenn.), who had some candid words about President Trump on the New York Times's "The New Washington" podcast.
"As the president said, nobody knew how complicated this was," the Tennessee Republican told the NYT. "Well, he may have been the only person who didn't know that, because it's very complicated. It involves nearly 300 million Americans, many different points of view."
Alexander has set out on what he sees as a rescue mission to stabilize Obamacare marketplaces next year by guaranteeing the extra cost-sharing subsidies to insurance companies that Trump has threatened to cut off, while granting states more flexibility to offer different insurance options. He and his HELP Democratic counterpart, Sen. Patty Murray of Washington, plan hearings in September with an aim of passing minimalist legislation through Congress in the same month.
Murray, who is at home in Washington for recess, tweeted some boundary lines she won't cross in a bipartisan health-care bill:
As we work to improve health care, one thing is clear—any cuts to Medicaid would be devastating for WA state, incl. military families & vets— Senator Patty Murray (@PattyMurray) August 7, 2017
Honored to be in Tacoma w/ servicemembers & their families to hear about what’s working in health care and what’s not. pic.twitter.com/mz9ZJDT9kp— Senator Patty Murray (@PattyMurray) August 7, 2017
OUCH: Major health insurer Anthem announced it's bidding farewell to Nevada's ACA marketplace and will also stop selling Obamacare plans in nearly half of Georgia's counties next year, Reuters reports. Nevada had said in June that residents in 14 of its 17 counties would not have access to qualified health plans on the marketplace, making them so-called "bare counties." Anthem's decision to leave the state entirely does not increase the number of bare counties, Nevada Insurance Commissioner Barbara Richardson said yesterday.
Anthem said it will still offer cheaper "catastrophic plans" available off the marketplace (only available to consumers under 30 years old or with a low income) in Nevada. The insurer also said it will only offer Obamacare plans in 85 of Georgia's 159 counties. It will continue to offer plans in mostly rural counties that would otherwise not have health insurance coverage for their residents, the company said.
--Still no word from the White House on whether it will keep making payments to insurers for the cost-sharing discounts they're required to give to the lowest-income marketplace enrollees -- so state insurance commissioners are seeking a backup plan, the NYT's Robert Pear reports.
Attendees at the National Association of Insurance Commissioners summer meeting spent the weekend debating what to do if Trump stops the subsidies, causing immediate practical concerns for marketplace insurers who are already withdrawing. Without the payments, they say, consumers will face higher premiums in 2018, and even more insurers will pull back.
“It could be very damaging,” said Craig Wright, the chief actuary at the Florida Office of Insurance Regulation. “Our market wouldn’t recover.”
Many state officials expressed a sense of urgency, saying they needed to make decisions soon on 2018 rates. Trump administration officials were invited to speak in a session at the NAIC meeting and were listed in the program for at least one public session, but they did not show up at that event to provide the promised update on federal policy.
“Most of us are hoping and praying that this gets resolved,” said David Shea, a health actuary at the Virginia Bureau of Insurance. “But that’s not the case right now.”
Democrats are also raising the alarm about the damage should Trump withhold the subsidies:
Sen. Richard J. Durbin (D-Ill.):
Sen. Chris Murphy (D-Conn.):
Yet another reminder that this administration is actively working to sabotage the Affordable Care Act. https://t.co/ydZ7MnuLG8— Chris Murphy (@ChrisMurphyCT) August 7, 2017
--Here's a question we were left with after the Senate GOP failed by one vote last month to pass their "skinny repeal" bill: How did McConnell persuade moderate Sen. Dean Heller of Nevada (long expected to be one of the defectors) to vote for it? Maybe this had something to do with it: A super PAC linked to McConnell now says it will spend seven figures to defend Heller in his reelection race next year.
“We were Senator Heller’s biggest independent supporter in 2012 and we expect to be in 2018,” Steven Law, McConnell’s former chief of staff who now oversees the Senate Leadership Fund, told the Nevada Independent. “In general, senators casting tough votes have to be concerned about downstream political consequences. We will have their backs.”
Heller, who is running in a state won last year by Hillary Clinton, is considered vulnerable in both a primary and a general election, with Republican insiders acknowledging his approval numbers are likely in the 30s or low 40s. Law told The Independent that his group would invest “commensurate with what we have done in the past,” including an unsuccessful attempt to elect then-Rep/ Joseph J. Heck (R) to retiring Sen. Harry M. Reid’s (D) seat last cycle. The SLF spent $114 million last cycle, according to OpenSecrets, and was part of $88 million in outside spending in the race between Heck and now-Sen. Catherine Cortez Masto (D-Nev.).
--Meanwhile, in health-care #girlpower: Two of the three Republican senators who helped sink the "skinny repeal" bill dished on that dramatic, late-night vote. Sens. Susan Collins of Maine and Lisa Murkowski of Alaska said they were pleased to be seated next to each other in the Senate chamber as they each voted "no."
“I was very happy that Lisa was literally sitting next to me as we were voting from our seats,” Collins told CNN's Dana Bash.
“To have that weight, that responsibility knowing that your vote really is that pivotal, it does help to know that there is another kindred soul close by,” Murkowski added.
Senators Murkowski and Collins talk "no" votes on health care. "I was very happy that Lisa was ... next to me." https://t.co/AuxpwkX2rg— New Day (@NewDay) August 4, 2017
--Collins said over the weekend that health-care efforts aren't dead yet, per the Wall Street Journal. About a dozen senators from both parties have met for three private dinners to talk about a potential compromise, she said on Friday.
Remember when President Trump tweeted this?
If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!— Donald J. Trump (@realDonaldTrump) July 29, 2017
What was the president talking about? And were these really bailouts? Post fact-checker Glenn Kessler explains.
The facts: By using the term "bailouts for insurance companies," Trump was referring to “cost-sharing reduction” subsidies, known as CSRs among health-care policy experts. This was an element of the Affordable Care Act that helped lower the cost of deductibles and copays for people making less than 250 percent of the federal poverty line by requiring insurers to offer discounts.
But there was a problem in the law: Because of an apparent drafting error, the text failed to explicitly say that appropriations for the CSRs would happen automatically. The Obama administration argued that the intent was clear from the legislative record, but last year a federal judge ruled that the ACA requires the CSRs to be annually appropriated by Congress. The ruling is on appeal, but this is why Trump can threaten to end the payments.
Nevertheless, CSRs are not a bailout for insurance companies. A bailout means a company is being propped up with government money after making bad decisions. That’s not the case here. However, they could be viewed as a "bailout" for drafters of the law, according to GOP health-care policy expert Avik Roy.
“CSRs are in legal limbo is due to problems with the way the ACA was drafted, not because of dumb or irresponsible behavior by insurers,” Roy wrote. “The insurers are legally required under the Affordable Care Act to design products that pay enrollees’ claims as if they had funding for CSRs, even if Congress doesn’t appropriate the money.”
And what about this “bailout” for members of Congress Trump referred to? This refers to another section of the law that was confusingly drafted, but again the president misuses the term, Glenn writes.
The ACA requires members of Congress and at least some staffers to leave the Federal Employees Health Benefit Program and join the health-care marketplaces. That was easier said than done, in large part because congressional employees previously had received a stipend from the federal government to help pay for health-insurance premiums, whereas they generally make too much to qualify for subsidies in the exchanges. The exchanges, after all, were intended for people who previously did not get employer-provided insurance.
For lawmakers and their staffs, the loss of employer contributions would have amounted to an unintended pay cut of between $5,000 to $10,000. So a system was jury-rigged by the Obama administration, using the D.C. small-business Obamacare exchange, to allow for continued health-care stipends from the federal government. But the employer contribution was no different than under the old system.
Bottom line: President Trump is misusing the term “bailout.” Insurance companies don’t make money through cost-sharing — they are being paid back for money they’ve already spent on behalf of people who purchased their health plans. The president either doesn’t understand the process or is being purposely misleading.
A few other good reads from The Post and beyond:
- The National Association of Insurance Commissioners will continue its national meeting through Wednesday.
- The National Academy of Social Insurance will hold a seminar on Medicare, Medicaid and the individual marketplace.
- The National Business Group on Health will hold a press conference on large employers’ health care strategy.
- The House Committee on Veterans Affairs will hold a hearing on veteran care in rural areas on Thursday.
- The Center for Global Development holds an event on implementing clinical trials during epidemics on Thursday.
- Congress is on recess until September 5.
Watch Kayleigh McEnany’s “Trump TV” debut, annotated:
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Watch Jimmy Kimmel on President Trump's tweets from his New Jersey vacation: