By Julie Rovner, Kaiser Health News
As some insurers angle for hefty premium hikes and concerns grow that more Americans will wind up uninsured, the federal health law is likely — once again — to play big in both parties' strategies for the contentious 2018 election.
Candidates are already honing talking points: Is the current dysfunction the result of the law or of GOP attempts to dismantle it?
The impact of changes to the law made by Republicans over the past year — modifications short of the “repeal and replace" they promised — is becoming clear. Initial announcements show health insurers in several states are seeking big increases in premiums for next year for people who buy their own insurance. That is renewing concerns about the potential for “bare" counties that will have no insurer selling coverage and hints that the number of uninsured Americans could again be on the rise.
“It's sort of Insurance 101," said Sabrina Corlette, a research professor at Georgetown University's Health Policy Institute. Insurers “are facing a smaller and sicker risk pool as a result of both Trump administration and congressional action, and that means higher premiums," she said.
“A number of policy changes definitely impacted rates," said Jeanette Thornton, a senior vice president for the trade group America's Health Insurance Plans.
Among those changes are the elimination of the tax penalty for those who forgo insurance, included in December's tax overhaul, and President Donald Trump's cancellation of federal payments to insurers who provide discounts to some low-income customers.
Democrats say they will make sure voters know that Republicans deserve the blame.
“Senate Democrats will be on the floor of the U.S. Senate every week talking to the American public about these rate increases and make sure they know about this campaign of sabotage," said Sen. Chris Murphy (D-Conn.).
Republicans, however, say Democrats are at fault for blocking bipartisan legislation, which might not even have had enough GOP votes to pass. The effort sought to stabilize the Affordable Care Act's marketplace through measures such as setting up reinsurance funding to help keep an individual insurer from facing devastating losses and guarantees for insurers to help pay their share of the out-of-pocket expenses for low-income customers.
“Democrats could have worked with us to lower premiums by as much as 40 percent but instead choose to cling to an unworkable law," Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor and Pensions Committee, said on the Senate floor Tuesday. “So if you have an insurance premium that is going up 40 percent next year, on top of an over 105 percent increase since 2013, you can thank a Democrat."
The heightened political rhetoric comes after the first two states unveiled insurance company premium requests for policies on the individual market for 2019.
These are not final rates, but they give an idea of what premiums for next year might be for people who don't get insurance through their job or the government and buy their own coverage on the individual market.
That market included about 15.6 million people, both inside and outside the ACA insurance marketplaces, in the final quarter of 2017, according to the consulting firm Mark Farrah Associates.
State deadlines for filing next year's rates run from May through July. Once insurers have made their initial premium requests, state regulators negotiate final rates before open enrollment begins in the fall.
In Virginia and Maryland, insurers are seeking a wide range of significant increases, from about 15 percent for some plans up to more than 91 percent for one Maryland PPO.
Analysts are not surprised by the requested rate hikes and predict more to come. The first requests in past years have often moderated before being finalized, but this year's political uncertainties could play a bigger role.
The Congressional Budget Office estimated that the elimination of the tax penalty for people without health insurance, which was included in last December's tax law, by itself would result in premium increases of around 10 percent per year. That's because without the prospect of a fine, healthier people would be more likely to forgo coverage, making the pool of people who continue to buy insurance sicker and more expensive for insurers.
Separately, Trump roiled the individual insurance market by canceling federal “cost-sharing reduction" payments for moderate-income insurance buyers.
The administration is also trying to extend the availability of short-term insurance plans, which frequently offer only bare-bones coverage, and “association health plans," which can provide cheaper alternatives for those who are considered healthy. But such plans don't include all the benefits of ACA plans. Analysts say both types of options would draw even more healthy people out of ACA plans.
The insurance industry acknowledges the actions have boosted next year's rates.
Chet Burrell, the CEO of CareFirst Blue Cross Blue Shield, which serves both Maryland and Virginia markets, told The Washington Post that “continuing actions on the part of the administration to systematically undermine the market … make it almost impossible to carry out the mission."
AHIP's Thornton cautioned that it is still early in the process and many things could change. Maryland, for example, has passed legislation to create a “reinsurance" pool that could substantially lower premiums for next year. It still requires formal permission from the Trump administration, however.
And while Congress could still help ameliorate next year's increases, that appears increasingly unlikely.
In a sign that the bipartisanship that characterized the effort last fall has broken down, Alexander said in his Senate speech that he plans to move on to other health issues, including ways to address the opioid crisis.
“Given Democrats' attitude, I know of nothing the Republicans and Democrats can agree on to stabilize the individual health insurance market," he said.
Sen. Susan Collins (R-Maine), who was promised a vote on her bipartisan bill by Senate Majority Leader Mitch McConnell (R-Ky.) that never materialized, now blames Democrats.
In a column she wrote for her home-state Portland Press-Herald late last month, Collins said Democrats refused to accept additional restrictions on abortion funding.
“Although federal funding has not been used to pay for elective abortions for decades, some Democrats reopened the long-settled debate on the Hyde Amendment in order to block these much-needed insurance reforms," she wrote.
Democrats, however, say it was Republicans who reopened the abortion debate by demanding language to create new, permanent restrictions that could eliminate abortion even in private insurance plans.
Even so, some say they still hope consensus may be reached.
“Patients and families deserve better than the higher costs and dysfunction they are getting under Trumpcare by sabotage," Sen. Patty Murray (D-Wash.) told reporters Tuesday. “And as soon as Republicans are ready to work again in a bipartisan way and act actually to lower families' costs, Democrats will be at the table."
By Julie Rovner, Kaiser Health News