clock menu more-arrow no yes mobile

Filed under:

The Senate's new Obamacare stabilization deal faces a lot of unanswered questions

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

We have an Obamacare stabilization deal. Republican Sen. Lamar Alexander, who had been working with Democratic Sen. Patty Murray for the past few months, announced it this afternoon.

This would be the gist, per they summary I obtained and conversations with lobbyists:

  • Funding for cost-sharing reduction payments for the rest of 2017, 2018, and 2019
  • Funding for state Obamacare outreach
  • Expanded eligibility for the law's catastrophic plans, which is currently limited to people under age 30
  • Some more state flexibility under the Obamacare 1332 waiver program, streamlined approvals, and longer waiver length

But that outline comes with a lot of caveats and TBDs.

1) We don't have the fine print yet

Alexander and Murray might have a deal, but they don't have a bill. (Murray told Kaiser Health News's Julie Rovner they were "still ironing out a few details.)

"They merely have an agreement in concept only" is how one lobbyist put it to me.

The details are going to matter, particularly on the 1332 waivers. Obamacare created guardrails in the waiver program, which required any state plans to provide coverage that was as "comprehensive" as what the health care law offers. Alexander talked about revising that standard to "comparable affordability."

Senators are also promising to prevent "double dipping" — which presumably means plans reaping both increased premiums after they hiked rates to account for no CSRs and then the CSRs that the bill funds.

The specifics will matter a lot for both those provisions, as well as the precise effect on the market from expanded catastrophic coverage.

2) We don’t know if it can pass Congress

Alexander and Murray are two senators. They need 49 more. The big question is whether Senate Republican leaders, who already scuttled the duo’s talks once in favor of another Obamacare repeal bill, will want a majority of their own conference on board before they bring a bill stabilizing the law to the Senate floor.

“I will not tell you that we have a majority of all the Republicans yet,” Sen. Mike Rounds, who supports the deal, told reporters. “I think we’re getting closer.”

Even if the bill gets out of the Senate, the House would have to agree to it. There are early signs of trouble.

"The GOP should focus on repealing & replacing Obamacare, not trying to save it. This bailout is unacceptable,” Rep. Mark Walker (R-NC), who leads the influential Republican Study Committee, said in a statement.

Then you have President Trump. On Tuesday, he sounded positive about a short-term stabilization plan. Will that still be true tomorrow?

3) The damage to 2018 rates is probably already done

Contracts for the federal marketplace are signed, sealed, and delivered. Insurers have already hiked their premiums for next year, after months of Trump threats to cut off the cost-sharing reductions, which he finally did last week.

We did see states and plans react quickly to Trump’s decision. It’s possible they could change course quickly again if Congress acts fast. (Also remember: Most people will be protected from higher premiums by Obamacare’s tax subsidies.)

But don’t bet on it. My sources believe the Alexander-Murray deal’s only chance of passage would be if it’s folded into a bigger government spending/debt limit package in December.

Nevertheless, this plan, if it comes to pass, isn’t nothing. It’s a sign of good-faith legislating, and by taking the CSR threats off the table for 2019, it could have a real effect on rates down the road.

But it isn’t going to fix things right away or all on its own.

Quote of the Day

Motive matters, with respect to whether the president exercises his power legally. If the president exercises his discretion to further the purpose of a statute, he complies with the take care clause. If he uses his power pretextually or unreasonably, he violates the Constitution. President Trump’s motives are unambiguous.

Yale's Abbe Gluck on the constitutionality of Trump's Obamacare sabotage. I feel like I get asked a few times a week how Trump can take the actions he has to undercut the health care law. Isn't Obamacare the law of the land? I never had a good answer (and I'm not a lawyer). But in this piece for Vox, Gluck makes the case that Trump's undermining of the ACA does in fact run afoul of the Constitution's "take care" clause.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

Analysis and longer reads

  • “Trump leaning toward former pharma exec for health secretary”:“President Donald Trump is leaning toward nominating Alex Azar, a former pharmaceutical industry executive and George W. Bush administration official, to serve as Health and Human Services secretary, according to two White House officials.” —Andrew Restuccia, Eliana Johnson, Sarah Karlin-Smith, and Josh Dawsey, Politico
  • “The Health Plans Trump Backs Have a Long History of Disputes”:“The short-term medical plans promoted in President Donald Trump’s new executive order on health care have a long history of customer disputes over pre-existing conditions and denied claims — just the sort of scenarios that were being weeded out by Obamacare.” —Erik Larson and Zachary Tracer, Bloomberg
  • “UnitedHealth Revenue Grows Despite ACA Exit”: “UnitedHealth Group Inc.’s core insurance and health-services businesses grew in its latest quarter, despite a dent in revenue caused by the company’s decision to pull out of most Affordable Care Act markets.” —Allison Prang and Anna Wilde Mathews, Wall Street Journal

Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.