How some lawmakers see a way to work together on health care

Arizona Sen. John McCain, who defied illness this week and traveled to Washington to give the GOP health plan a decisive push forward, instead has dealt it a death blow. He shocked his Republican colleagues early Friday morning with his vote against their “skinny repeal” – and gave Democrats hope that now the parties can work together to fix the Affordable Care Act (ACA).

“I urge my colleagues to trust each other, stop political games& put health needs of American ppl 1st. We can do this,” he tweeted out Friday morning, in the bipartisan spirit that brought this maverick politician applause in a speech before the full Senate on Tuesday.

Regaining trust is a very tall order in a Congress that just went through six months of a highly partisan effort by Republicans to fulfill their campaign promise to repeal and replace Obamacare. The parties have plenty of reasons not to cooperate, including raw feelings, deep ideological differences over health policy, and the midterm elections of 2018. Meanwhile, President Trump has reiterated his oft-repeated message to let Obamacare implode.

But several Democrats and Republicans in both chambers, feeling the urgency of the partial collapse of Obamacare and anticipating that the GOP repeal effort might fail, have been talking quietly behind the scenes. They, along with outside experts, can see several ways to help the law, both in the short- and longer-term, from an immediate infusion of federal funds to adjustments to the individual mandate.

A bipartisan group of about 40 representatives in the House, known as the Problem-Solvers caucus, has been gathering regularly to talk about health care. And Sen. Lamar Alexander (R) of Tennessee, chairman of the Senate committee that deals with health issues, is open to hearings on the law and is already trading ideas with his ranking committee member, Sen. Patty Murray (D) of Washington.

There’s no question that Obamacare is in trouble. Premiums are rising and about 25,000 customers buying individual insurance on the law’s private market exchanges face the possibility that no insurers will cover them next year.

“First of all, both sides understand how critical it is for us to stabilize the market,” says Sen. Joe Manchin (D) of West Virginia in an interview. He is perhaps the most conservative Democrat in the Senate and someone who has been in touch with Republican colleagues on health care.

Senator Manchin and others offer these ideas, among many, that could help steady the insurance exchanges in the near term, increase health-care access, and lower costs.

A cash infusion?

One reason the insurance exchanges are in flux has to do with something known as cost-sharing reductions.

Under the ACA, the federal government is required to help certain lower-income patients reduce the cost of their deductibles and co-pays. Federal subsidies for these reductions are seen as crucial to insurers being able to provide plans to such patients.

Amidst a legal challenge, the Trump administration has rattled insurers by going month-to-month on this federal spending. If insurers receive no guarantee of payment for their “cost-shares,” then “the markets in several states will be in very bad states and premiums will go up almost everywhere,” says Timothy Stoltzfus Jost, a health-care expert and emeritus professor at the Washington and Lee University School of Law in Lexington, Va.

Either the administration needs to give a clear signal that it intends to keep up the payments, or Congress needs to act, says Professor Jost.

Democrats and some Republicans also urge extending and funding “reinsurance” that protects insurers from big losses from high-cost patients. The law’s reinsurance provision expired in 2016.

Senate majority leader Mitch McConnell (R) of Kentucky warned that Republicans would oppose any “bailout” of insurers without “reforms.”

But the GOP’s House and Senate bills included variations on reinsurance – as well as a “stabilization” fund – so there is room for common ground.

“We should look at reinsurance,” said Senate minority leader Charles Schumer (D) of New York in a press conference Friday, pointing to a Democratic bill that would make this backstop for insurers permanent.

He also gave a shout-out to a bill by Democrat Claire McCaskill of Missouri that would allow people stuck in markets abandoned by insurers to buy coverage on the same exchange that members of Congress and their staffs use.

Moving in the GOP's direction

Democrats are going to have to “give Republicans some wins,” says Billy Wynne, former health policy counsel to the Senate Finance Committee.

They could, for instance, do more to encourage Health Savings Accounts, maybe using them to pay premiums or provide subsidies. They could back getting rid of some Obamacare taxes – such as the so-called “Cadillac tax” on high-end employer plans and the tax on medical devices, which already have some bipartisan support. Then there’s the question of finding offsets to make up for that lost revenue, however.

And they might find an alternative to the much-maligned individual mandate by embracing “automatic enrollment” with an opt-out possibility – an idea put forward by Republican Sens. Susan Collins of Maine and Bill Cassidy of Louisiana.

“We know from our experience with retirement programs that most people stay in” when there is auto-enrollment, says Senator Collins, who along with McCain and Sen. Lisa Murkowski of Alaska voted against the GOP measure early Friday morning.

Make better use of existing provisions

Most Americans are probably unfamiliar with two existing waivers in current law that give states a great deal of flexibility, known as 1332 and 1115. Under 1332, states could actually drop the individual and employer mandates if they wanted to – as long as they still fulfill the conditions of Obamacare.

Last year, Alaska successfully used Obamacare’s 1332 provision in a narrow way to create a reinsurance program that significantly controlled its rise in premium costs. Insurance rates were expected to rise by more than 40 percent in 2017. Instead, they only rose by about 7 percent.

The other waiver, 1115, allows states to get creative with Medicaid. Senators Collins and Manchin point to Indiana as a potential state model. The Hoosier State has both lowered costs per beneficiary and improved health outcomes, according to Collins.

“It’s clear the ACA has serious flaws that require us to act,” said the Mainer in an interview on Friday. “We’re on the verge of a crisis as far as the stability of the market is concerned.”

This week she held an informal dinner with some Democrats and Republicans to just get together and explore ideas, she said. “There are some good options out there” and she is encouraged by Senator Schumer’s cooperative tone after the GOP bill went down last night.

“It was very different from his highly inflammatory previous speeches he’s given … and I was very glad to hear it,” she said.
And the mood of Republicans? There are still divisions and hard feelings within the caucus, she said. “But I don't think doing nothing is an option.”