Through their public statements and lack of action to address the crumbling health insurance exchanges that they have done their best to weaken, Republicans in Washington have made it clear that they are planning to use the risk that millions of Americans might soon lose access to health care as leverage to pass their own version of health insurance reform.
On Friday morning, in an interview with conservative radio host Hugh Hewitt, House Speaker Paul Ryan avoided the key question that health policy experts have been shouting from the rooftops for months.
“What happens, Speaker Ryan, in those places where the individual market has completely collapsed until the AHCA comes along?” Hewitt asked.
The subtext of Hewitt’s question was that, as both men well know, there is no guarantee that the Republican-controlled Congress is going to be able to come to agreement on a health care reform bill at all. The American Health Care Act, which barely cleared the House of Representatives, isn’t even going to be taken up by the Senate. (Indeed, it hasn’t even been reported to the upper chamber yet, because of uncertainty about whether it will meet budgetary requirements.)
The AHCA contained measures that some Republican senators have described as unacceptably harsh. The Senate GOP leadership can only afford to lose two votes for a bill that is unlikely to gain any Democratic support in the narrowly-divided Senate, which means that it will need to be modified in order to secure their votes. But in the House, conservatives have warned that any changes to their plan to end the ACA’s Medicaid expansion and cut spending will cost their votes.
Hewitt’s question reflected the reality that there is a very predictable crisis coming, and it will likely strike before the GOP can pass and implement a replacement for current law. What are Republicans, who control all the levers of power in Washington, going to do about it?
As Hewitt and Ryan also know, there are obvious measures that the federal government could take to stabilize the health insurance exchanges in the near term. Agreeing to enforce the ACA’s individual mandate and to continue paying subsidies meant to compensate insurers for offering below-market-rate premiums to poor Americans (known as cost-sharing reductions) are just two examples.
For Ryan, the looming disaster for millions of Americans is not a crisis to be addressed, but a political opportunity to be exploited. In his answer to Hewitt, he revealed that the plan is not to take the obvious steps that would help stabilize the insurance exchanges, but rather to allow the system to continue heading toward disaster, and hope that the threat of millions of Americans losing their health care creates enough pressure to pass a Republican health care reform measure.
Referring to the many counties in the U.S. where most or all insurers are no longer offering plans on the exchanges, he said, “That’s why I believe there’s a sense of urgency. Until we get our bill to replace it passed, they won’t have anything.”
He continued, “So the law really actually is collapsing. People will get hurt and harmed if we don’t replace it, and that is why we believe there’s a sense of urgency. This really is a rescue mission. We are on the mission of rescuing the collapsing individual market in health care.”
Except that the disaster that the GOP is ostensibly rescuing the American people from is one of their own making. Like someone setting a house on fire so that he can “save” the people inside, the GOP is willfully creating a situation that makes remaining on the health insurance exchanges an untenable proposition for insurance companies.
In a devastating article in The Los Angeles Times Friday, Noam N. Levey interviewed the chief executives of multiple health insurance companies, who made it clear that the reason why their companies are jacking up premiums or leaving the insurance exchanges entirely is the atmosphere of confusion and uncertainty created by Republicans in Washington, and President Donald Trump in particular.
“[T]he Trump administration has significantly exacerbated turmoil in the marketplaces in recent months, contributing to rising premiums and the threat of marketplaces exits,” Levey writes.
The feeling is the same among state-level insurance regulators and public health professionals.
“According to many officials, it is the Trump administration that is driving much of the current instability by refusing to commit to steps to keep markets running, such as funding aid for low-income consumers or enforcing penalties for people who go without insurance,” Levey writes.
The idea of using the collapse of the ACA as leverage is not new, and it is not a strategy that necessarily originated in the halls of Congress. The most powerful Republican in the country, President Trump, threatened on many occasions to simply let the system collapse -- helped out by a large dose of malign neglect -- in order to force Democrats to the bargaining table.
The idea that to Republicans this is all transactional politics rather than something with huge effects on people’s lives was reinforced by another piece of reporting from Levey. In the same article, he revealed that when health insurance executives met last month with Centers for Medicare and Medicaid Services administrator Seema Verma, they were left with the impression that the administration was willing to make a trade -- they would continue paying the cost-sharing reductions if the insurers would publicly declare support for the AHCA, which was still working its way through the House.
The administration later denied that Verma had offered such an arrangement, but the denial rings a little hollow when the supposed deal is of a piece with the kind of strategy so openly advocated by Ryan and Trump, currently the two most powerful Republicans in the country.