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A simple guide to the critical next 4 months for Obamacare

The big upcoming dates for the health care law.

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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.

Obamacare repeal has been put on ice. The Senate failed to pass three different bills, and while a few senators and the White House are trying to keep the dream alive, senior Senate Republicans sound ready to move on. At the very least, everything is on hold until September.

So for now, our attention turns to the Trump administration. They have many decisions to make between now and November, when people will start signing up for 2018 coverage on Obamacare's marketplaces.

Will they make the federal payments that help reduce out-of-pocket costs for lower-income customers, known as cost-sharing reductions? Will they enforce the individual mandate? Will they undertake a good-faith effort to help people enroll in coverage?

It will be a lot to track in the next few months. To make it easier, here are some key dates to know.

August 21: next round of CSR payments to be made

The Trump administration has been making the CSR payments to insurers on a month-to-month basis, while constantly threatening to cut them off. It has a little more time to decide what to do about this month's payments. Top Republicans in Congress want the administration to keep paying them.

September 4: Senate starts hearings on individual market

Sen. Lamar Alexander (R-TN), who chairs the health committee, announced he would hold hearings starting this week to look at "actions Congress should take to stabilize and strengthen the individual health insurance market."

The goal, he said, would be for Congress to take action to help the 2018 markets. That could include funding for the CSR payments for at least one year and other provisions.

September 6: health insurers make final adjustments to their proposed 2018 premiums

This deadline was originally set for August 16, but the Trump administration pushed it back a few weeks in recognition of insurers’ uncertainty about the market.

Which is why some clarity from the Trump administration or Congress on the CSR payments, which compensate insurers for providing mandatory discounts on out-of-pocket costs for lower-income customers, would come in handy.

Some insurers are already proposing bigger premium increases for fear that the administration will pull the payments, which it can do because of an ongoing lawsuit. Those that haven't might do it now if Trump says he won't make the payments.

They might also boost premiums if the Trump administration announces it would not enforce the individual mandate, as HHS Secretary Tom Price has hinted. The fear is that the lack of a mandate would discourage healthy people from signing up, leaving the marketplaces with sicker enrollees and higher costs.

"Those steps would be like spreading nails in the road," Larry Levitt at the Kaiser Family Foundation told me.

September 20: another round of CSR payments to be made

If Trump doesn't pull the CSR payments in August, he could still do it in September.

The catch is that Congress will have been back in town for a few weeks at this point. Lawmakers could approve the payments themselves and take the issue out of Trump's hands. There have been bipartisan talks about funding the subsidies, but no concrete action yet.

September 27: insurers make final decisions about whether to sell Obamacare plans in 2018

This is pretty much the drop-dead date for insurers to decide whether to participate in Obamacare markets next year. They'll make those decisions based on how much uncertainty they are willing to put up with from the Trump administration — too much and you could see insurers flee en masse, which would spell doom for the marketplaces.

So far, the trend-line of the past month has been positive. While there are a few counties with no plans and many more with only one option — and those are big problems! — empty markets in Missouri and Ohio have been filled recently.

There is one catch, as an actuarial friend of VoxCare flagged to me. If something happens after September 27 but before open enrollment — like if this were the time that Trump decides to pull the CSR payments — plans might still be able to drop out of the market.

November: open enrollment for the Obamacare marketplaces

The culmination of all of the above. The only remaining question is whether the Trump administration actually tries to help people sign up for coverage or whether it uses its resources for ... other purposes.

There is one universe in which the Trump administration pays the CSR subsidies, enforces the individual mandate, and guides a successful open enrollment.

There is another in which the administration cuts off the CSR payments and won't enforce the mandate, premiums rise and more counties lose insurers altogether, and the federal government actually makes it harder for people to enroll in health insurance.

We'll find out soon which one we're living in.