Republicans Are Crying About Obamacare Problems They Helped Create

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The Republican case for repealing the Affordable Care Act and moving swiftly to enact a replacement plan largely rests on oft-repeated arguments that the law is floundering so badly, urgent action is needed.

President Donald Trump uses terms like disastrous and failing. House Speaker Paul Ryan (R-Wis.) calls repeal-and-replace a rescue mission, because the law has a fatal conceit a design flaw that means insurers arent attracting enough young and healthy people to cover the costs of customers with big medical bills.

The health insurance markets regulated by the Affordable Care Act are actually in better shape than Republicans admit. Just this week, the Congressional Budget Office said the marketplaces were on their way to stability.

But the struggles that Trump and fellow Republicans describe in their speeches are real enough. Particularly in states like Arizona and Tennessee, premiums have shot up and insurers have fled, leaving few choices for consumers.

What Republicans fail to mention is that many of these problems are the handiwork of state and federal Republican officials who spent years undermining the law, contributing to the conditions they now say oblige them to dismantle it.

These efforts are not by any means the only reason so many insurers have struggled. But they have played a significant role.

Defunding Risk Corridors

When Democrats wrote the Affordable Care Act, they understood that insurers might initially have a hard time figuring out where to set prices. Because insurers hadnt sold these kinds of policies (with comprehensive benefits) under these conditions (without exclusions for pre-existing conditions), they didnt have actuarial data on which to base pricing decisions.

In order to reassure insurers that might hesitate to enter the markets amid such unknowns, and in order to protect them against crippling losses, the laws architects created a risk corridor program, in which the government promised to reimburse insurers, mostly, for excessive losses. (Insurers that misjudged in the other direction, and had unexpected windfalls, would pay part of that money into the program.)

The idea was not novel. Medicare Part D, the program that provides seniors with prescription drug coverage, also has a risk corridor program. And it has never been controversial even though its a permanent part of the program, unlike the temporary one in the Affordable Care Act.

But conservative groups targeted the program, calling it a bailout for health insurance companies, despite the fact that it was included in the law from the beginning. Sen. Marco Rubio (R-Fla.) picked up the mantle and led a crusade to undercut the programs funding.

In 2014, Rubio got his proposal into the year-end spending agreement and President Barack Obama, feeling the rest of the legislation was necessary to keep the government functioning, signed it. Later, during a presidential debate, Rubio even bragged about it.

Congress not funding the risk corridor program was the most consistent issue Kevin Counihan, former HHS official, on what he heard from insurance executives

Insurers ended up filing $8.3 billion in claims for 2014 and 2015, but the program ended up paying out just $362 million. Several insurers have since sued to get the money they claim to be owed, and one has already won its case. But its not clear they will ever get the money.

Kevin Counihan, who ran for the Obama administration after overseeing Connecticuts health insurance exchange, said he heard about risk corridors all the time last year, while he was meeting with insurers about participation for 2017.

Congress not funding the risk-corridor program was the most consistent issue, Counihan said. Many carriers established their 2014 and 2015 rates with the assumption that the government would make good on this part of the law. Not doing so hurt both their financials, our credibility, and their boards commitment to remain in the program.

And this is about more than just health insurance companies losing money. The true purpose of these payments is to reduce premiums by allowing insurers to charge lower rates, knowing theyre protected if they get hit with higher-than-expected costs. Premiums were 10 percent to 14 percent lower in 2014, and 6 percent to 11 percent lower in 2015, because of this program, according to the American Academy of Actuaries.

Insurance companies got no payments from this fund for 2015 because the government had no money left. The realization that this money wouldnt be available again for 2016 and 2017 contributed to insurers decisions to institute large premium increases this year and, likely, more rate hikes next year.

Blocking the Medicaid Expansion

The theory of the Affordable Care Acts coverage expansion was pretty simple. People with incomes above 133 percent of the poverty line, or about $32,000 for a family of four, would buy coverage through the exchanges, where low- and middle-income people can apply for tax credits to reduce their premiums. People with incomes below that threshold would get coverage through Medicaid, once states took advantage of new federal funding to expand eligibility.

The theory didnt count on the Supreme Court, which in 2012 affirmed that states have the right to reject the money to expand Medicaid and keep the limited eligibility they had before. Initially, more than half the states did precisely that. All had Republican governors or majority-Republican legislatures, although a number of GOP-led states, like Arizona and North Dakota, did adopt the expansion.

The immediate consequence of refusing to expand Medicaid was to deprive millions of Americans living in those states of insurance. But those decisions also had a spillover effect.

Exchanges in these states are picking up more of the lowest-income customers the ones with incomes between 100 percent and 133 percent of the poverty line, or between $24,600 and $32,718 for a family of four. (Under the law, people with incomes below the poverty line are not eligible for the subsidies.) It might not sound like a big deal, but it had a direct impact on premiums for everyone.

Those extra enrollees tended to be in worse health than the rest of the population. In states that did not expand Medicaid, these people ended up signing up for exchange plans where their relatively high medical bills drove up costs for the insurers, eventually contributing to losses and higher premiums for all customers.

On the whole, rates in expansion states were about 7 percent lower than in non-expansion states, according to a Department of Health and Human Services study that controlled for demographics and other factors.

Undermining Outreach

Enrolling a sufficiently large population in the new insurance plans was always going to be a challenge, because many of the uninsured had little experience shopping for and buying coverage and because, particularly among middle-class consumers, the prices were in many cases going to seem high.

And while the federal government took on some of that responsibility, state officials had a special role to play, because they retain a lot of regulatory authority over insurance and, crucially, they better understood the idiosyncrasies of their insurance markets and their states residents.

Some states, typically the ones that had decided to create their own exchanges, promoted enrollment enthusiastically. But other states didnt offer support. A few again, all with Republicans in power actually did their best to make enrollment difficult.

Georgias insurance commissioner, Ralph Hudgens, put it unusually bluntly. Let me tell you what were doing, he said in August 2013, just two months before the first open enrollment period. Everything in our power to be an obstructionist. Hudgens also said, Im not going to do anything in my power to make this law successful. In other words, rather than assist Georgians who elected him with getting health coverage, Hudgens prioritized resisting Obama.

The impact of these efforts isnt clear. But enrollment in states that ran their own exchanges, which is a pretty good proxy for enrollment enthusiasm, was moderately higher overall than in states that relied on, according to a 2016 paper by economists Molly Frean, Jonathan Gruber, and Benjamin Sommers.

One constant for the early years of the Affordable Care Act was enthusiastic support from Washington. That obviously changed in January, when Trump became president and open enrollment for this year was entering its final days.

The very day Trump was inaugurated, he issued an executive order instructing agencies to relax Affordable Care Act rules. The IRS responded a short while later by announcing it wouldnt fully enforce the laws individual mandate, which has the potential to suppress enrollment among healthy people who need the coverage less.

The end of open enrollment period has historically seen a surge of signups, as people rush to meet the deadline, and the late signups tend to be healthier on average, helping the risk pool. But the Trump administration canceled some planned digital and television advertising and, this year, only about 400,000 people signed up in the final two weeks. In the same period last year, 700,000 did.

That drop may help explain why, this year, overall signups for policies fell slightly this year.Its also a reminder that the kind of people who have been trying to undermine Obamacare are now in charge of it. They may yet do more damage, unless they manage to repeal it altogether.

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