In Bismarck, North Dakota Wednesday night, President Donald Trump called on supporters to press Congress on health care.
“You have to make sure that they do what they have to do,” said Trump. “And believe me, we haven't given up on healthcare. We haven't given up on healthcare. We never give up.”
After months of stalemate and Washington meltdowns, one team of senators has not given up either. The Senate health and education committee has returned to basic order, conducting hearings, interviewing witnesses, and seeking to make small improvements to the current law.
This week the Senate Health, Education, Labor and Pensions committee [HELP] heard from state insurance commissioners from around the country and five state governors on how to improve and stabilize those individual insurance marketplaces where many self-employed people buy their own insurance.
“My goal is to get a result on a small, bipartisan and balanced stabilization bill. Where it makes sense, we will work with other committees and members to get that result,” committee chairman Lamar Alexander, R-Tenn., said at the beginning of bipartisan hearings Wednesday. “To get a result, Democrats will have to agree to something -- more flexibility for states -- that some may be reluctant to support. And Republicans will have to agree to something -- additional funding through the Affordable Care Act -- that some may be reluctant to support. That is called a compromise.”
Alexander seems focused on strengthening and fixing parts of the current law. He said his committee has an ambitious goal of quickly passing a bill by the end of the month to improve the marketplaces that could affect the prices and rates for next year.
“This has been a pretty remarkable two days,” said Alexander said Thursday. He said the response from members on both sides of the aisle has been positive. “I think everyone is looking for a result, and when you're looking for result you don't try to rule things out you try to rule things in.”
Other committee members lamented that the bipartisan hearings have been long overdue. “I think a lot of pain and time would have been saved perhaps if we held these hearings six months ago rather than going through what we went through” said Sen. Bernie Sanders, I-Vt.
The bite-sized fixes debated during the hearings may seem small in the scope of the country’s health care system, but they could have a big impact on the more than 20 million Americans who buy their insurance on individual insurance exchanges. Alexander and Ranking Member Patty Murray, D-WA, seem to have zeroed in the following topics: Guaranteeing federal cost-sharing subsidies that help lower premiums, finding ways to get more healthy and young people signed up for coverage, making sure rural areas have more than one insurance coverage plan, and increasing state flexibility through waivers.
Funding the federal cost-sharing subsidies or reductions (CSRs)
A pressing issue for states is the funding of the Affordable Care Act’s CSRs. Obamacare requires insurance companies to provide cost-sharing plans to low-income consumers. But to offset costs to insurance companies for providing these plans, the government pays insurance companies' CSRs. The Trump administration has not said whether or not it will pay for CSRs, sparking instability in the marketplace.
“If the CSRs aren't in place they're going to have to re-price those products and they're probably going to go up by some 20% which is going to be a real problem for the people who buy,” said Gov. Charlie Baker of Massachusetts, a Republican.
Republican and Democrat lawmakers alike have called for the federal government to make those payments to help stabilize the markets.
“If this committee is genuinely concerned with stabilizing the individual marketplace, the most important step it can take in the near term is ensuring funding for the CSR payments for at least the next two years,” said Montana Gov. Steve Bullock, a Democrat.
Improving enrollment through outreach
Last week, the Trump administration announced its plans to make a 90-percent cut to the advertising budget for Obamacare during the upcoming enrollment period, saying they hope it will save funds. But lawmakers say those funds are necessary to make sure young, healthy people get signed up.
During today’s panel, all five governors expressed frustration over cuts to Obamacare’s advertising and outreach budget. “Cutting back the revenues when you're finally figuring out how to make things work ... it’s probably bad timing” said Colorado Gov. John Hickenlooper, a Democrat.
Teresa Miller, the state insurance commissioner in Pennsylvania, remarked that her state is now going to do its own version of advertising and outreach in response to the cuts.
Increasing coverage in rural areas
Market instability has prompted some insurance companies to pull out of rural areas where it is costly to provide coverage to mostly low-income consumers. Many are only covered by one insurance company.
One idea proposed during the hearing comes from a plan proposed by Gov. Hickenlooper and Gov. John Kasich of Ohio. Their idea is to let rural consumers have the option of buying into the Federal Employees Health Benefit Plans.
Sen. Murkowski of Alaska was met by applause when said she supports the idea and called it a creative option that doesn’t create any additional federal programs.
Increasing state flexibility through waivers
Alexander has called for changes to Section 1332 of the Affordable Care Act, which allows states to receive waivers and to set up their own health care programs. But states have complained that the process for those waivers is slow and cumbersome.
Lawmakers said they’re looking at waiver systems in Alaska and the special high-risk pool in Maine, both of which have helped stabilize markets in those states.
“Everyone is looking at what we are doing with leading on 1332. It's not perfect but it does provide an example,” Murkowski said. Some lawmakers have suggested a “me-too” approach to approving state waivers. If one state’s waiver is approved, other states with similar waivers could have their approval expedited.
Any hope for the Graham-Cassidy plan?
Sen. Al Franken, D-MN pressed the governors about their position on the Graham-Cassidy plan, which offers block-grants of Obamacare funding to states, and was met by skepticism by the governors.
Gov. Charlie Baker, a moderate Republican who has a background in healthcare as the former CEO of Massachusetts’ Harvard Pilgrim Health Care, said he does not support the plan because it would “dramatically negatively affect” his state with cuts and that “it assumes that cost of healthcare should be the same everywhere.”
That’s something the governors and Senators reaffirmed—that solutions shouldn’t be one size fits all.