Industry groups support ACA fix as Trump sends mixed signals

The deal to fund the Affordable Care Act (ACA)’s halted cost-sharing reduction subsidies while expanding the state waiver process has the support of several major healthcare groups along with 10 governors and 24 senators. President Donald Trump, however, hasn’t been clear on whether he’ll support the bill as-is.

The legislation has been dubbed Alexander-Murray Plan after its chief architects, Sens. Lamar Alexander, R-Tennessee, and Patty Murray, D-Washington. It would fund the subsidies known as CSRs, which aim to keep out-of-pocket costs lower for low-income ACA exchange customers, for two years after HHS said it couldn’t lawfully make the payments. For Republicans, it offers additional “flexibility” on the ACA’s Section 1332 waivers, changing the definition of allowable changes to plan design to offering “comparable” affordability rather than a standarda of being “as affordable as” existing exchange plans. It would also require HHS to offer model waiver plans for states to speed up the approval process.

“This is a first step,” Alexander said on the Senate floor. "Improve it, and pass it sooner rather than later.”

24 senators—12 from each party—have signed on as co-sponsors, including Sen. Lindsay Graham, R-South Carolina, who sponsored the last attempt to repeal the ACA, and the trio of Republicans who opposed “skinny repeal” in July: Sens. Susan Collins of Maine, John McCain of Arizona and Lisa Murkowski of Alaska. 10 governors, four Republicans, five Democrats and one independent, urged Congress to pass the plan in a letter to congressional leaders. 

The American Medical Association came out in support of the deal, saying the multiyear funding of CSRs is “needed to stabilize the individual and non-group” markets and praising the additional options for state waivers without touching the ACA’s protections for people with pre-existing conditions. The American College of Emergency Physicians also urged members of Congress to support a deal which was crafted by members of both parties, in contrast the Republican-only repeal bills.

“This approach is proof that lawmakers on both sides can collaborate on patient-centered solutions that help improve our entire health care system,” ACEP President Becky Parker, MD, said in a statement. “By providing this important short-term stability, policymakers, physicians, providers, and other stakeholders and experts can continue working to address the other challenges facing our health care system.”

Complicating these efforts is where Trump stands on the bill. When it was first announced on Oct. 17, he appeared to support it as a “short-term solution.” Later that night, however, he said Congress “must find a solution to the Obamacare mess instead of providing bailouts to insurance companies.” Then on Oct. 18, he tweeted he supported “the process” but not the bill because insurers “have made a fortune” under the ACA—even though major insurers have cited hundreds of millions of dollars in losses as reasons for scaling back their exchange participation.

The official position of the White House is Trump won’t support the bill in its current form. The Hill reported the Trump administration is asking for several changes, including “relief” from the ACA’s individual and employer mandates and new insurance options like those Trump proposed in his executive order, which would allow plans which comply with the ACA regulations on required benefits and covering people with pre-existing conditions.

"In order for the White House to support similar legislation, it must provide immediate benefits to American families, workers and small businesses," an unnamed White House official said to The Hill.

POLITCO reported it may take several months for the bill to pass, possibly being included in an end of the year package to fund the federal government—which would come after customers on the exchanges have to select their coverage for 2018 with higher premiums that reflect the lack of CSRs. Open enrollment on the ACA exchanges begins Nov. 1.