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Trump is turning CSR payments into a soap opera

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Scoop: former Healthcare.gov chief executive to Centene

Kevin Counihan, who spent two years running Healthcare.gov for the Obama administration, has joined Centene, a health insurer betting big on Obamacare future.

Centene has famously (well, famously within health policy circles!) expanded into the marketplace as other bigger health plans like Anthem and United have fled. It makes sense that an Obamacare architect would join a health insurance company that wants to sell Obamacare coverage. Read my full story here.

On Obamacare subsidies, it's Trump versus the world

The Trump administration has spent months flirting with halting cost-sharing reduction payments, the $8 billion fund that reduces copays and deductibles for low-income Obamacare enrollees.

That ambiguity continues today. Mick Mulvaney, who directs the Office of Management and Budget, told CNN in an interview that the administration continues to review the decision on a "month-by-month basis."

This is problematic for the Affordable Care Act because insurance doesn't run on a month-to-month schedule. Insurance plans need to decide really soon what premiums they'll charge for all of 2018. They would like to know now whether to expect the CSR payments to come through, or if they need to raise premiums to account for a new hole in their budgets.

Insurance companies have spent months now begging the administration to commit to making these payments through the end of next year. This week, though, they got some new allies.

Republican legislators have become more vocal in advocating for CSR payments. Members of Congress expect (rightly so) that premiums would spike if Trump were to cut off the CSR payments immediately — and don't think their voters would be thrilled with such a development. They've begun to push Trump to make these payments, as well as discuss a congressional appropriation for this program in 2018.

“Without payment of those cost-sharing reductions, Americans will be hurt,” Sen. Lamar Alexander (R-TN), who chairs the Senate health committee, said Tuesday.

Senate Republicans, as my VoxCare co-author Dylan Scott writes today, "are scrambling to pass legislation that would take the explosive issue out of the president’s hands, and in the meantime, they are pleading with Trump not to sabotage Obamacare."

Governors — Republicans and Democrats — want the White House to provide more certainty. A bipartisan group of governors sent the White House a letter Tuesday urging the continued payments.

"The Administration has the opportunity to stabilize the health insurance market across our nation and ensure that our residents can continue to access affordable health care coverage," the statement from the Health and Human Services Committee of the National Governors Association said.

Governors have good reason to push for more continuation of these payments. We're starting to see the 2018 Obamacare premiums come out, and in many cases, insurers say they will charge higher prices if these payments don't come through.

In Arizona, the largest health insurance plan says it will raise premiums 7 percent if the CSRs aren't paid — but 0 percent if they are. In California, certain health plans will have a 12.4 percent CSR "surcharge" unless the Trump administration clarifies within the next month that it intends to make these payments.

We're seeing more lobbying now because the CSR issue is getting more real. Just the fact that Trump is wavering on CSR payments — even if he continues to pay each and every one, as he has done so far — is already changing how Obamacare works.

The Trump administration is making its decisions "month by month," but insurance plans don't have that luxury. They have to set premiums for an entire year within the next month or so. Most of the insurance executives I've spoken to in the past few weeks are planning to assume the CSR payments are not coming unless they see some big change on behalf of the White House. This means they will set higher prices — and neither legislators nor governors are happy about that prospect.

Map of the Day

Molina exits the Wisconsin marketplace, leaving one county bare. Bloomberg's Hannah Recht broke the news Wednesday afternoon that Molina, which has generally been bullish on Obamacare, has pulled out of the 30 Wisconsin counties where it currently sells coverage for 2018.

The one bare spot is Menominee County, which has an estimated 37 Obamacare enrollees.

Molina is a health plan that has been through a bit of turmoil lately. Its two top executives (both sons of the plan's founder, C. David Molina) were abruptly ousted from the firm earlier this year. It's possible we could see additional Molina exits as other states announce their 2018 rates.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • "Senate Republicans Rebuff Donald Trump’s Health-Care Push": “Senate Republicans made clear on Tuesday that they want to chart their own course to focus on a tax overhaul and critical fiscal legislation, bypassing requests from President Donald Trump and White House officials to keep health care their top legislative priority.” —Siobhan Hughes, Natalie Andrews, and Janet Hook, Wall Street Journal
  • "Governors press Trump to make ObamaCare payments": “Governors from both parties are calling on the Trump administration to fully fund key subsidies to insurers under ObamaCare. President Trump is threatening to cancel the payments, known as cost-sharing reductions (CSRs), as he talks of how ObamaCare will 'implode.'” —Nathaniel Weixel, the Hill
  • "Court ruling could help keep Obamacare subsidies": “A federal appeals court issued a ruling Tuesday that could help preserve a key subsidy that benefits health insurers and millions of Americans under the Affordable Care Act. The ruling could make it more difficult for the White House to carry out recent threats by President Trump to cut off the payments, giving legal standing to a new set of the payments’ ­defenders.” —Amy Goldstein, the Washington Post

Analysis and longer reads

  • "If Trump Kills Obamacare Subsidies, Hospitals Face Unpaid Medical Bills": "Hospitals could see a wave of unpaid medical bills should Donald Trump decide against funding the cost-sharing subsidies that low-income Americans use to pay out-of-pocket costs under the Affordable Care Act." —Bruce Japsen, Forbes
  • "Covered California Expects 12.5% Average Rate Rise In 2018": “Covered California health insurance premiums will jump by a statewide average of 12.5 percent next year, amid continuing uncertainty over the future of the Affordable Care Act, the state’s Obamacare exchange said Tuesday.” —Emily Bazar and Anna Gorman, Kaiser Health News
  • "Some Dems Now Running on Single Payer Healthcare ... Do They Have a Shot?": "Single payer sounds costly and is also just one subset of the multiple universal healthcare structures so there are multiple opportunities to divert conversations onto side tangents. But even with all of that confusion, a number of polls show that the majority of the American people support government run, universal healthcare." —David Pakman, Huffington Post

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