With Senate Republicans failing to pass legislation in early August to repeal the Affordable Care Act (ACA), many questions remain about the law’s future and the health insurance coverage of millions of Americans. Here’s a summary of key things to look out for as lawmakers and the Trump Administration decide what to do next:
- Cost-sharing reduction subsidies: To pressure lawmakers to pass a health care bill, President Trump has threatened to end federal payments to insurers that reduce out-of-pocket costs (i.e., deductibles and copayments) for low-income customers with ACA plans. Ending the payments would destabilize the individual market because insurers could choose to exit the ACA markets or significantly increase premiums to cover the lost subsidies. Members of Congress from both parties have stressed the importance of continuing the cost-sharing reduction payments, but the uncertainty surrounding them will weigh heavily on insurers as they make final adjustments to their proposed premiums and make final decisions in September on whether or not they will sell ACA plans in 2018.
- What happens in the Senate: Based on public statements and press reports about private discussions, Senate GOP leaders are not giving any indication that they will take up an ACA repeal bill again anytime soon. Some rank-and-file Republicans still would like to try, and Sens. Bill Cassidy (R-LA) and Lindsay Graham (R-SC) have offered a repeal and replace plan that would take some of the current ACA funding and convert it to block grants for the states to spend on health care-related purposes. The senators believe this could be a path forward on reform because it would give states an option to either continue with the ACA or scrap it and implement their own systems for providing coverage. But this plan would likely run into the same the roadblocks as previous GOP repeal and replace bills because it contains elements that moderates and conservatives have objected to: It would end the Medicaid expansion and convert Medicaid funding to a per capita cap, eliminate subsidies that help consumers purchase coverage, and keep most of the ACA’s taxes.
- Bipartisan fixes to stabilize ACA marketplaces: The Senate Health, Education, Labor and Pensions (HELP) Committee will hold hearings the week of Sept. 4 to develop legislation to stabilize the ACA individual insurance market. Committee Chairman Lamar Alexander (R-TN) and ranking member Patty Murray (D-WA) emphasized that the panel’s work will be bipartisan, and the hearings will feature a range of health policy experts.
In the House of Representatives, a bipartisan group of about 40 members from the “Problem Solvers” caucus unveiled a five-point plan to shore up the ACA marketplaces. It calls for ensuring cost-sharing reduction payments; creating a dedicated “stability fund” that would most likely be used for reinsurance; exempting employers with less than 500 employees from the employer mandate; repealing the medical device tax; and providing technical changes and clear guidelines to allow insurers to sell plans across state lines.
Any bipartisan legislation to stabilize the ACA marketplaces would need the backing of House and Senate GOP leadership to bring it to a vote, which is far from certain given the partisan gridlock.