The Affordable Care Act, often called Obamacare, has had more narrow escapes than the legendary Harry Houdini. But although a law created solely by Democrats has amazingly survived in a Republican political landscape, its long-term survival is not yet fully assured.
Obamacare’s latest escape was from a Senate bill by Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La.. that would have abolished the ACA exchanges under which people purchase medical insurance and replaced them with block grants to states. The bill was dropped after it became clear it lacked the votes to pass.
The No. 1 problem now facing Obamacare is rising premiums for individuals insured under the ACA. Jittery insurers are now finalizing — and in most cases increasing — premiums for 2018 before the next open enrollment period begins on Nov. 1. State regulators have approved rate increases as high as 57 percent in Georgia and 45 percent in Florida.
The insurance companies are making decisions in the dark, not knowing if the Trump administration will continue paying for subsidies that enable insurers to lower deductibles and other costs. Although President Donald Trump so far has made monthly payments to insurers to pay these subsidies, he’s given mixed signals as to whether he will continue doing so.
Meanwhile, Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., are trying to mobilize support for a law that would make these payments mandatory.
Alexander-Murray has been slow to get off the ground because this bipartisan effort was put on hold in September while Graham-Cassidy was being considered. Although Graham-Cassidy was dropped, it cost Alexander-Murray momentum, and the Senate has since moved on to other issues.
Obamacare is also under pressure because the Trump administration has reduced the open enrollment period for signing up for an ACA policy by half, to 45 days, and slashed the advertising budget to promote enrollment to $10,000 from $100,000.
Five states and the District of Columbia that operate their own health insurance exchanges are trying to compensate. California, Colorado, Massachusetts, Minnesota and Washington have extended their open enrollment periods beyond the Dec. 31 federal cutoff.
Covered California, one of the most robust state exchanges, will have the longest enrollment period, to Jan 31, 2018.
States are also trying to ease the financial burdens of the 9 million Americans who buy health insurance without government subsidies and the millions more who might do so if policies were less expensive.
Iowa, Minnesota and Oklahoma have submitted proposals that would let them provide cheaper polices with scaled-down coverage.
Alaska this year began paying for 33 costly medical conditions, including HIV. This held the premium increase this year to 7 percent.
Alaska’s most significant achievement was to set up a program of “reinsurance” in which the state assumes some risks now borne by insurance companies. This has kept premium increases below the national average, albeit at a cost to taxpayers.
Minnesota will adopt a similar plan in 2018 that is expected to stabilize premiums at current levels or lower them slightly, a welcome change in the Gopher State after years of double-digit increases.
Evaluating reinsurance, The Economist wrote: “The model is tried and tested; the federal government provided reinsurance for the first three years of Obamacare.”
For all its problems, the Affordable Care Act has an impressive record of survival. Republicans threatened to abolish it almost from the moment it became law eight years ago. After the GOP gained control in 2010, the House of Representatives passed more than 50 bills to repeal the ACA. The only bill that also passed the Senate was vetoed by President Barack Obama.
Repeal seemed likely, however, after Trump won the presidential election while the GOP retained control of both houses of Congress.
House Speaker Paul Ryan, R-Wis., and Senate Majority Leader Mitch McConnell, R-Ky., proposed repealing the ACA immediately and allowing a two-year grace period in which Congress would decide upon a replacement. According to The Hill, they did not have a ready-made replacement available because they had not anticipated that Trump would defeat Hillary Clinton.
Trump was wary about leaving health care up in the air for two years. He told CBS’ 60 Minutes he wanted repeal and replace done simultaneously. In retrospect, this decision may have saved the ACA because Republicans soon found they disagreed on what a replacement bill should contain.
They were particularly divided on Medicaid, the federal-state program that provides health care to low-income people and the disabled. Obamacare expanded Medicaid for states willing to do so, adding an estimated 16 million people to the rolls.
Together with the Children’s Health Insurance Program, Medicaid now covers 70 million people, more than a fifth of all Americans.
When Ryan brought a repeal-and-replace bill to the House floor on March 24, it was voted down, to his chagrin. He made changes demanded by House conservatives, and the bill passed the House on May 4.
But the changes had made the bill unpalatable to the Senate, where Republicans hold a narrow 52-48 majority. With all Democrats opposed, McConnell could afford to lose only two Republicans, producing a 50-50 tie that Vice President Mike Pence could break in favor of the repeal-and-replace bill.
After several senators declared the House bill dead on arrival, McConnell decided to draft a new bill, composed by a 13-member working group on which there were no female senators.
The group worked behind closed doors. Neither the House nor the Senate held public hearings even though health-care providers were clamoring to testify. In contrast, more than 40 public hearings were held before the Affordable Care Act was passed.
The Better Care Reconciliation Act that emerged from the Senate working group in June pleased neither conservatives nor moderates. The nonpartisan Congressional Budget Office estimated that the bill would cost 22 million people their health insurance by 2026.
Conservatives delayed a vote on the bill for weeks, and the vote was further delayed when Sen. John McCain, R-Ariz., underwent emergency surgery for a brain tumor.
When McConnell finally brought the bill to the floor on July 25, he was barely able to muster enough support to debate it. Sen. Susan Collins, R-Maine, saying that thousands of people who would lose insurance in her state, voted against the debate. So did Sen. Lisa Murkowski, R-Alaska, who said the bill would add to Alaska’s already high health costs.
Pence broke a 50-50 tie, enabling the debate to proceed.
After the Senate rejected various versions of the measure, McConnell proposed a so-called “skinny” bill, which repealed ACA provisions requiring individuals to have health insurance and employers to offer it, defunded Planned Parenthood for a year, and gave states some flexibility on insurance rules.
Even with Collins and Murkowski in opposition, McConnell believed he could get to 50 votes and rely on Pence’s vote to pass the bill. But McCain capped a dramatic post-midnight speech by voting no. He said the bill had not been the result of an open and orderly process.
That was the last recorded vote on Obamacare. As a disappointed McConnell moved on, Graham and Cassidy decided to make a last try. But they were hurried by a ruling of U.S. Senate parliamentarian Elizabeth MacDonough, who said the provision allowing repeal by 51 votes was part of a budget resolution that expired on Sept. 30.
Graham said later he thought the effort might have succeeded with more time, but three days before the deadline he and Cassidy decided not to seek a vote after Sen. Rand Paul, R-Ky., joined Collins and McCain in opposition.
After the collapse of Graham-Cassidy, a disappointed Trump predicted that Obamacare would eventually be repealed, perhaps in 2018. But this won’t be easy.
The draft of a 2018 budget resolution drawn up by congressional Republicans does not contain language allowing repeal of Obamacare with 51 votes. Unless this is changed, any repeal bill introduced next year would need 60 votes to protect it from a Democratic filibuster.
Trump opened the door to another tantalizing possibility last month when he reached out to Democratic congressional leaders for help in extending the debt ceiling and keeping the government open.
Could this portend cooperation with congressional leaders of both parties to stabilize the soaring costs of health insurance, as Alexander and Murray propose? Stay tuned. The saga of the Affordable Care Act is far from over.
— Lou Cannon, a Summerland resident, is a longtime national political writer and acclaimed presidential biographer. His most recent book — co-authored with his son, Carl — is Reagan’s Disciple: George W. Bush’s Troubled Quest for a Presidential Legacy. Cannon also is an editorial adviser to State Net Capitol Journal, which published this column originally. Click here to read previous columns. The opinions expressed are his own.
