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Obamacare had a no good, very bad week

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The threats to Obamacare’s future have become more real — and more menacing — over the past week. Senate Republicans are coalescing around an outline of a repeal plan, while health insurance plans flee the law’s marketplaces.

The result is real danger for the Affordable Care Act. Health insurance plans don’t want to stay and build business models around a program that the president says is “exploding.” Republican senators, meanwhile, are finding a way to agree on issues that only a week ago looked like intractable disagreements.

The Senate repeal plan is coming together — and looks a lot like the House repeal plan

Behind closed doors, Senate Republicans have worked out a path toward Obamacare repeal. The plans under discussion would end Medicaid expansion, causing millions of low-income Americans to lose health coverage. They may allow health insurance plans to charge higher premiums to people with preexisting conditions, too.

In other words: The emerging bill looks a whole lot like the unpopular bill the House passed last month. It creates the same group of winners (high-income, healthier people) and the same group of losers (low-income, sicker people).

The Republican plan is coming together because moderate senators are beginning to drop some of their initial repeal objections. Sens. Rob Portman (R-OH) and Shelley Moore-Capito (R-WV), for example, criticized the House bill for its deep cuts to Medicaid. But now the two senators say they could support ending Medicaid expansion on a slightly longer timeline.

“Speed and secrecy have pushed GOP senators toward compromise on policy disagreements that once appeared too great to bridge,” my colleague Dylan Scott wrote earlier today.

Health insurance plans are fleeing the Obamacare marketplaces

In the past four days, the number of counties with zero health plans signed up to sell Obamacare has doubled. There are now 38,000 Obamacare enrollees scattered across 47 counties where no insurers want to participate in the marketplaces.

Many insurers say they’ve been scared off by the uncertainty over the law’s future — whether it will be repealed and how the Trump administration will implement it.

In these places, Obamacare’s coverage expansion could vanish regardless of whether Congress passes a repeal bill. People with Obamacare subsidies would still, technically, get that help — but have no place to actually buy coverage.

The Trump administration so far seems to be standing aside as insurance plans leave. Obamacare’s collapse is part of the Republicans’ political strategy.

Republicans have political incentives not to fix Obamacare’s problems

Whenever a health insurance plan quits Obamacare, I usually receive an email from the Health and Human Services press office arguing that this is all the more reason Congress needs to repeal Obamacare. This is the statement that spokesperson Alleigh Marre sent out when Anthem quit the Ohio marketplace on Wednesday (bolding my own):

This news is heartbreaking for the millions of Ohioans who depend on access to affordable, high-quality healthcare, and this is a stark reminder that Obamacare is collapsing. Now is the time to advance real healthcare reform that empowers individuals and families with the choices and resources they need to buy a plan that meets their healthcare needs without breaking their budgets. The American people can’t afford to wait any longer.

When Republican legislators talk about why they need to repeal Obamacare, they point to the areas that are struggling to attract health insurers. They point to Obamacare’s bald spots.

When insurance executives talk about why they’re leaving, they point the finger back at the uncertainty Republicans are sowing.

Anthem cited the individual market’s “lack of overall predictability” and the “lack of certainty of funding for cost sharing reduction subsidies” in announcing its exit from Ohio on Tuesday.

When Blue Cross Blue Shield Kansas City quit on May 24, it blamed “the uncertain direction of this market.

Insurers’ exits from Obamacare don’t just mean fewer (or no) choices for the millions of Americans who rely on the law. They also give Republicans more ammo for pushing their repeal plan forward — and make the path toward passing a Senate bill an easier one to forge.

Chart of the Day

 Center on Budget and Policy Priorities

Here’s what delaying the end of Medicaid expansion looks like. Since the Senate is kicking the idea around, this chart feels quite relevant. It shows that delaying the end of Medicaid expansion still — spoiler alert! — leads to the end of Medicaid expansion.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today’s top news

  • Senate debates keeping key Obamacare insurer requirement” “Top senators said that waivers to let states opt out of a requirement called community rating are still being discussed, despite initial reports that the waivers wouldn’t include that option. Sen. John Thune, R-S.D., said Wednesday that community rating is still under discussion.” —Robert King, Washington Examiner
  • Parliamentarian threatens deadly blow to GOP healthcare bill” “The Senate parliamentarian has warned Republicans that a provision in their healthcare reform bill related to abortion is unlikely to be allowed, raising a serious threat to the legislation. The parliamentarian, Elizabeth MacDonough, has flagged language that would bar people from using new refundable tax credits for private insurance plans that cover abortion, according to Senate sources.” —Alexander Bolton, The Hill
  • New York Health Insurers Ask for 16.6% Boost to Obamacare Rates” “Health insurers in New York are seeking another year of hefty premium increases for their Affordable Care Act plans, adding fuel to the debate over the law’s future. Insurers are seeking to boost their premiums 16.6 percent on average for 2018, the state Department of Financial Services said Wednesday.” —Zachary Tracer, Bloomberg
  • FDA wants to yank an opioid painkiller over concerns about abuse” “In a bid to thwart the opioid epidemic, the Food and Drug Administration has asked Endo Pharmaceuticals to withdraw its Opana ER painkiller over concerns that the drug is too easily abused, the first time the agency has made such a move.” —Ed Silverman, STAT

Analysis and longer reads

  • The big business of health savings accounts
  • “Business has been booming as more employers steer workers into high-deductible health plans that are paired with HSAs. But there’s been longstanding criticism that HSAs are another tax shelter that don’t help lower-income people who don’t have a lot of money to set aside for medical care.” —Bob Herman, Axios
  • As Delaware Insurance Options Shrink, Families Are ‘Holding Our Breath’” “In Delaware, two insurers offered coverage through the exchange over the past three years: Aetna and Highmark Blue Cross Blue Shield, a Pennsylvania-based company. But Aetna announced last month that it was dropping out of the Delaware exchange in 2018. That could make Delaware the seventh state with only one insurer in its exchange.” —Steven Findlay, Kaiser Health News
  • How states are addressing uncertainty with 1332 waivers” “While the future of the American Health Care Act is uncertain, states continue to be interested in reforming their health care systems. We believe that states will ramp up efforts to exercise authority they have under existing law to address their state’s health care needs. While Medicaid’s 1115 waivers deservedly get the most attention, the public profile of 1332 waivers is increasing as states look to improve their health care markets.” —Heather Howard and Dan Meuse, Health Affairs

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