Here’s the fundamental barrier to shoring up Obamacare’s marketplaces for next year: Virtually nobody sees it in their political interest.

Democrats desperately needed the Affordable Care Act to thrive while they still controlled the White House. But with President Barack Obama gone, and GOP majorities in the House and Senate, they’re pretty much off the hook — at least, according to polls showing 60 percent of Americans find Republicans responsible for the ACA.

As for Republicans, they’re still deeply bitter they weren’t able to repeal one iota of Obamacare despite their high-drama effort over the spring and summer. Many members have spent too many years characterizing the extra Obamacare subsidies now at stake as improper insurer “bailouts” to get excited about funding them, even though providing them could somewhat improve otherwise skyrocketing rates next year.

This is the sticky reality that Sen. Lamar Alexander (R-Tenn.) faces as he tries to negotiate a deal over the next few days with his Democratic counterpart Patty Murray (Wash.) to reimburse insurers in 2018 — and maybe beyond that — for extra discounts they must provide the lowest-income enrollees (a.k.a. cost-sharing reductions).

“I simply won’t be able to persuade the Republican majority in the Senate, the Republican majority in the House, and the Republican president to extend the cost-sharing payments without giving states meaningful flexibility,” Alexander said yesterday at the fourth and final HELP hearing this month on the ACA marketplaces.

From Alexander: 

Alexander has been in the Senate for more than a decade. He’s chairman of the powerful Health, Education, Labor and Pensions Committee. He’s generally viewed as having the ear of Majority Leader Mitch McConnell (R-Ky.). Yet he’s operating as something of a solo pilot at this point. Here’s what he would need to do before the end of next week to achieve a CSR funding bill that could affect 2018 rates:

1. Convince Democrats to give states a bit more flexibility in how they structure their marketplaces (through a provision in the ACA known as a 1332 waiver) — possibly by easing actuarial value requirements so consumers can buy leaner plans if they want to. Include this flexibility in a larger bill funding the CSRs.

2. Persuade Republicans that a compromise bill includes enough conservative changes to the ACA that they have cover to support it — even though by voting for it they'd be acquiescing to a request from Democrats. 

Of course, that’s oversimplifying the issue a bit. There are several other policy demands swirling around — Murray wants to fund CSRs for at least two years, pump another $15 billion into an ACA reinsurance program and would like assurances that Republicans will maintain outreach around the impending open enrollment season.

Alexander prefers a one-year time frame for providing CSRs and wants ideally to scale back the ACA’s essential health benefits. But Murray has said — and again emphasized yesterday — that the latter is a non-starter for Democrats.

“Some of the proposals I’ve heard discussed … undermine essential health benefits and take us back to a time when plans didn’t cover maternity care, substance use disorder treatment, mental health or prescription drugs,” Murray said at yesterday’s hearing. “That would be unacceptable, and I don’t think either side expects that we settle those larger issues in this current negotiation.”

Paring back essential health benefits was also opposed by some moderate Republicans during the epic Obamacare debate, with some who ultimately opposed the measure that was defeated expressing serious concerns about lifting the requirements, which ensure Americans have access to a range of specific health services in whatever plan they choose.

Publicly, Democrats are issuing dire warnings to Republicans about the damage to the Obamacare marketplaces if insurers don't get long-time certainty about the subsidy payments and have to swallow the cost of the discounts all on their own. But if Republicans try to attach any big ACA changes that Democrats don't like to any solution, it's unlikely Democrats would go along with such a plan.

Rep. Sandy Levin (Mich.), previously the top Democrat on the House Ways and Means Committee, criticized chairman Kevin Brady (R-Texas) for not holding hearings on CSRs a la Alexander:

House Minority Whip Steny Hoyer (D-Md.) had this to say about the administration's month-to-month approach:

From Rep. Debbie Dingell (D-Mich.): 

House Minority Leader Nancy Pelosi (D-Calif.) is also pressuring Republicans to step up and fund the payments permanently, per CNN's Phil Mattingly:

It’s pretty much down to the wire at this point. A week from next Wednesday (or, Sept. 26), insurers in all but a dozen or so states (the ones using instead of running their own marketplaces) must sign final contracts for the plans they’ll sell to millions of Americans next year.

If Alexander and Murray are going to succeed, their time is growing short to get any legislation through Congress and to President Trump. Alexander said yesterday that he hopes to announce an agreement early next week. Staffers said he and Murray planned to meet after Thursday’s hearing to work on a compromise.

But it’s Alexander — not Murray — who is in a tight spot. Other Senate Republicans are piling on the pressure for Alexander to reject legislation that only funds the CSRs without also enacting other changes to the ACA.

Most prominent among these is Sen. Orrin G. Hatch (R-Utah), who wrote last week in a Washington Post op-ed that a “no-strings bailout would be extremely short-sighted.”

“Some are working on an approach that amounts to little more than a congressional bailout of Obamacare, including pumping tens of billions of dollars into the already failing system in the form of cost-sharing reduction payments,” Hatch wrote.

McConnell himself appeared deeply skeptical about funding the CSRs in a floor speech in late July, right after the Senate’s repeal-and-replace effort failed.

“I bet I’m pretty safe in saying, for most of the people on this side of the aisle, that bailing out insurance companies — bailing out insurance companies with no thought of any kind of reform — is not something I want to be part of,” McConnell said at the time.

Considering all the obstacles at play, there’s a good chance that McConnell won’t get a chance.


AHH: Health and Human Services officials have informed grass-roots groups helping with ACA enrollment that their "navigator" grants will be reduced by as much as 92 percent, The Post's Juliet Eilperin and Amy Goldstein report. The groups were braced for some slashing since the Trump administration announced two weeks ago that it would shrink overall program funding by 41 percent and slash the department’s ACA advertising budget from $100 million to $10 million. 

"HHS officials in the Trump administration have repeatedly questioned the value of paying navigators," Juliet and Amy write. "They note that these groups received $62.5 million last year but signed up less than 1 percent of total enrollees. Seventeen of them enrolled less than 100 consumers each, according to the department, at an average cost of nearly $5,000 per enrollee."

“Navigators have been notified of their awards for the upcoming open enrollment period,” HHS spokesman Matt Lloyd said, “and the next step is for the grantees to work … to align their activities to the awarded amount and accept the terms of the contract.”

But advocates of the navigator program said yesterday that the deep cuts -- which were made official late Wednesday -- would undermine work to help consumers get insurance coverage once open enrollment begins Nov. 1. And the depth of some funding reductions raised questions about those state programs’ viability and the fairness of the administration’s method for deciding how much money each group gets.

OOF: If Republicans fail to pass an Obamacare repeal bill before the end of the month -- when the budget reconciliation bill they're using as a vehicle expires -- they'll be "a bunch of liars," says Rep. Louie Gohmert. The Texas Republican said yesterday that he and other Republicans will pressure the Senate to pass a health-care bill so that the party doesn't go back on its long-standing promise to repeal and replace the ACA.

"We have until Sept. 30 to keep from being about as big a bunch of liars as has ever been in Congress," Gohmert said on the House floor, per the Washington Examiner.

OUCH: Dozens of nursing homes across Florida remained without power yesterday, nearly a week after Hurricane Irma began knocking out electricity for millions statewide. The most dangerous outcome of the lingering outages was seen in Hollywood, Fla., where eight people died at a nursing home and more than 100 others were evacuated to hospitals on Wednesday after generators failed and the air conditioning went out, The Post's Leonard Shapiro, Mark Berman, Katie Zezima and Aaron C. Davis report.

"In dozens of counties spanning the state, 45 nursing homes continued to wait for the power to return as of Thursday night, according to the Florida Department of Health," they report. "While it was not clear how many of the thousands of people residing in those homes remained there during the outages, the smothering heat in Florida this week created an additional source of danger for an already vulnerable population.

"Hollywood's Memorial Regional Hospital was among the hospitals treating patients brought in with dehydration, heat exhaustion and severe respiratory conditions....When the first few nursing home victims were brought into Memorial's emergency room early Wednesday morning, Judy Frum, the hospital's chief nursing officer, was informed and 'it immediately sent up some red flags,'" my colleagues report. "Frum walked over to the nursing home and said what she encountered was 'not like anything I have ever seen.'" 

"There were many people in distress," Frum said. "They had extremely high temperatures. … Many of their staff were trying to assist patients. It was very warm. I saw a lot of patients who had been compromised. … It will stay with me for a very long time."


--Never mind that President Trump once praised Canada's single-payer health-care system. Trump called the similar proposal that Sen. Bernie Sanders (I-Vt.) released this week a "curse" on the country -- and even blamed Republicans in Congress for opening the door to it by failing to repeal and replace Obamacare.

--Sanders won't succeed in his endeavor this Congress. But there's certainly momentum behind it, with 16 Senate Democrats signing onto his bill in the biggest show of support for a U.S. single-payer system since the 1970s. Yesterday, Sanders built on his momentum in an unusual way: a 32-minute interview with a Canadian doctor, my colleague Dave Weigel reports.

“We have a very, very exciting show!” Sanders said, kicking off his occasional podcast and introducing Danielle Martin, a Toronto physician and academic. “She’s kind of a household name in America now.”

Sanders’s push for universal health care has often included praise for America’s northern neighbor -- something rare in American politics, where branding an idea foreign can hurt its popularity, Dave notes.

"Democrats, wary of being accused of foreign schemes, have had their own complicated relationship with Canada," Dave writes. "As he sold the Affordable Care Act in 2009 and 2010, President Barack Obama was careful to portray it as uniquely American....For decades, but especially since he ran for president, Sanders has flipped the script. If 'every other major country in the world,' as he puts it, has an insurance program, America is falling behind by failing to provide the same."

“I live 50 miles south of the Canadian border,” Sanders wrote in the New York Times, as part of his legislative launch. “For decades, every man, woman and child in Canada has been guaranteed health care through a single-payer, publicly funded health care program. This system has not only improved the lives of the Canadian people but has also saved families and businesses an immense amount of money.”


--Washington has been mostly focused this week on Deferred Action for Childhood Arrivals (DACA), the Trump administration's changes to the program and its efforts to forge a deal with Democrats on immigration and border security. But that's pleasing neither medical groups, nor even some Republicans. Trump’s attention should be on repealing and replacing Obamacare, Sen. Lindsey O. Graham (R-S.C.) said yesterday.

“For strong border security, I would be willing to let the DREAM Act kids have legal status. They have no place to go other than America. So border security for DACA kids, legal status, makes plenty of sense. I applaud the president wanting to try to fix this problem,” Graham said on Fox News. “But here’s what I tell the president. We've got six months to deal with the DREAM Act kids. You’ve got 17 days to repeal and replace Obamacare.”

--And 70 medical organizations, led by the Association of American Medical Colleges, urged congressional leadership to provide a legal pathway to permanent residency for those with DACA status. 

"By providing a legal pathway to permanent residency for undocumented Americans brought to the U.S. as children, Congress can help our country produce a diverse and culturally responsive health care workforce to meet the needs of underserved populations, improve cultural awareness, and promote health equity,"  the groups wrote. "With the nation’s population growing and becoming increasingly diverse, it is crucial that the health professions workforce respond to the changing demographics of the country to mitigate racial, ethnic, and socioeconomic health disparities."

--And here's a zinger from the Congressional Budget Office. Yesterday, it released an estimate with the Joint Committee on Taxation that higher ACA premiums next year will cause 2 million more people than expected to become uninsured. Still, the availability of subsidies will shield most people from higher costs and help stabilize the marketplaces through the next decade, CBO said.

"Those subsidies — combined with the effects of the individual mandate, which requires most people to have insurance or pay a penalty, and other factors — are anticipated to result in demand for insurance by enough people, including people with low healthcare expenditures, that the number of insurers in the marketplaces would stabilize and insurers would be willing to sell nongroup policies in almost all areas of the country throughout the next decade," CBO writes.

--A few other good reads from The Post and beyond:

States that expanded Medicaid continue to see bigger drops in the numbers of uninsured.
Philip Bump
It could help them shift the public’s target back to the Democrats.
FDA Commissioner Scott Gottlieb said Thursday that his agency is focused on boosting pharmaceutical competition when it comes to the hot-button topic of drug prices.
The rapid growth of Catholic-affiliated hospitals in the U.S. could significantly reduce access to inpatient sterilization procedures, a new study says.

Coming Up

  • The Hill hosts an event on “innovating to improve patient health” on October 4.

Congressional Democrats introduce their proposed Childcare for Working Families Act: 

What is single-payer health care? Here's what you need to know:

Senate Minority Leader Chuck Schumer (D-N.Y.) was caught on a hot mic saying "Trump likes us:"

President Trump and Vice President Pence hand out sandwiches in Florida after Irma: 

Selena Gomez reveals she received a kidney transplant:

Seth Meyers takes a closer look at President Trump and Democrats' discussion of a DACA deal: