Top Takeaways from this week – (1) CBO released a report today finding that ACA premiums will rise 15 percent next year due to marketplace uncertainty; (2) the Senate HELP Committee held the final two hearings on market stabilization; (3) Sens. Graham, Cassidy, Heller and Johnson introduced their repeal and replacement proposal; and (4) Sen. Sanders introduced a single-payer bill.

This week, the Senate HELP and Finance Committees held several hearings focused on shoring up the individual insurance markets and addressing healthcare costs. Yet despite the bipartisan nature of the discussions, two other, far more partisan health reform proposals were introduced on Wednesday, potentially complicating the path forward for a narrow, bipartisan fix to provide immediate relief for the 2018 plan year.

Congressional Budget Office –

Today, the Congressional Budget Office (CBO) released a report on federal subsidies for health insurance coverage for people under the age of 65, finding that premiums for the ACA’s benchmark plans will increase by an average of 15 percent in plan year 2018 primarily because of “short-term market uncertainty.” It also projects lower enrollment into exchange plans “because of announced reductions in federal advertising, outreach, the enrollment period, and other enrollment efforts…” Report:

Congressional Activity –

Market Stabilization

The Senate HELP Committee held two more hearings this week on market stabilization, hearing from a wide range of healthcare stakeholder representing state exchanges, health care issuers, providers and others. Much of the conversation again centered on the need for appropriations for cost-sharing reduction (CSR) payments, streamlining the 1332 waiver process and providing states more flexibility under 1332s, establishing a reinsurance program, and giving all consumers the option to purchase catastrophic coverage.

Senate HELP Committee Chair Alexander (R-TN) has continued to call for a narrow legislative package solely consisting of one-year of payments for cost-sharing reductions to issuers and greater flexibility on 1332 waivers. Chair Alexander has said he supports maintaining the law’s guardrails that protect against pre-existing coverage exclusions and rating, but believe states should have more flexibility on benefit design, noting that “real state flexibility means giving states more authority to offer a larger variety of health insurance plans with a larger variety of benefits and payment rules.” However, Democrats are opposed to upending the consumer protections built into 1332 waivers, and have called for other interventions to stabilize the markets, such as a federally-funded reinsurance program. Chair Alexander is hoping to gain consensus among Committee members in the coming days, with the hope of introducing legislative text by the end of next week and completing work by the end of the month. Opening statements from the Chair: and Ranking Member: and

Meanwhile, the Finance Committee held a hearing on Tuesday on healthcare costs and coverage, in which Committee Chair Hatch (R-UT) called for a bipartisan approach to addressing the individual insurance markets, but warned that “We can’t simply invest more resources into a broken system and hope that it fixes itself over time,” adding that putting money into the system to maintain CSRs without fixing the systemic problem would set up “yet another cliff, and likely another partisan showdown in the future.” He also argued that the stabilization package should include a repeal of the medical device tax, the health insurance tax, and the excise tax on high-priced insurance plans, known as the Cadillac tax. He also called for “rolling back or at least amending” the ACA’s individual and employer mandates. Opening Statements from the Chair and Ranking Member: and

Given the recent spate of bipartisan discussion occurring in the Senate, Democrats on the House Ways & Means Committee wrote a letter to Chair Brady (R-TX) requesting that the Committee “likewise hold bipartisan hearings to set the course for expeditious action to stabilize the individual insurance markets and lower costs.” Letter:

ACA Repeal and Replacement

Yesterday, Sens. Graham (R-SC), Cassidy (R-LA), Heller (R-NV), and Johnson (R-WI) released legislative text for their proposal, which would amend the Better Care Reconciliation Act to block grant ACA funding  to states to develop their own solutions to their healthcare markets. The proposed Market-Based Grant Program would replace the ACA’s funding structures for Medicaid expansion, premium tax credits, cost-sharing reductions, and basic health plans. New enrollment in Medicaid expansion would end by 2020, and like the BCRA, Medicaid financing would change to per-capita capped payments starting in fiscal year 2020. Press release: FAQ: Section-by-section:  Bill text:

In announcing the proposal, Sen. Graham urged Republicans to support the proposal, arguing “There’s a lot of fight left in the Republican Party. The idea that the Republican Party has done its best to repeal and replace Obamacare is a joke,” and adding, “If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen because everything else has failed except this approach, which will work. Single-payer healthcare for all is inevitable if we fail.” Sen. Johnson, who is Chair of the Senate Homeland Security and Governmental Affairs Committee said he would hold a hearing on the plan by September 30 if the HELP and Finance Committees do not take it up.

Today, Sen. Graham said the bill has support from 47-48 Senators, however it remains to be seen whether the backers can pull together the necessary 50 votes needed by September 30 when the budget reconciliation instructions expire. Sen. Paul (R-KY), who has called for a clean repeal of the ACA, called the Graham-Cassidy plan a “bad idea,” as it keeps the ACA’s taxes and most of its regulations in place, and argued that passing the bill would “probably” be worse than not passing anything by the end of September. Sens. Collins (R-ME) and Murkowski (R-AK) have not yet commented on the bill, but given it retains much of the same structure as the BCRA, they are not likely to support it.

In commenting on the bill yesterday the President noted his support but stopped short of full endorsement, noting only that “I sincerely hope that Senators Graham and Cassidy have found a way to address the Obamacare crisis.”

Meanwhile, on September 12, House Committee on Energy & Commerce, Subcommittee on Health Chair Burgess (R-TX) and House Ways & Means Committee Chair Brady (R-TX) introduced H.R. 3725, which would repeal the ACA’s individual mandate. Press release: Bill text:


As Congress debates whether to stabilize the individual insurance markets or largely repeal and replace the ACA, several Democrats have introduced a third option: single payer. On Wednesday, Sen. Sanders (I-VT) and 16 Democratic cosponsors introduced the Medicare for All Act (S. 1804), which would establish a Medicare-for-all national health insurance program, called the Universal Medicare Program (UMP). The UMP would guarantee patients the freedom to choose their healthcare provider, eliminate cost-sharing, and would transition all individuals currently in Medicare, Medicaid, the Federal Health Employee Benefit Plan, CHIP, the federal exchanges into a single national program. The bill would also prohibit the sale of private health insurance, employer-sponsored insurance, and retiree coverage if that coverage duplicates payment for any item or service covered under the UMP. The plan would go into effect January 1 of the first year after enactment for children and those over the age of 55, and by the fourth calendar year after enactment it would include all Americans. While the plan does not specify how to pay for the system, Sen. Sanders did release a white paper providing a set of financing options. Press release: Summary: Section-by-section:  Financing options: Bill text:

Democratic leadership has declined to back the bill, with House Minority Leader Pelosi (D-CA) commenting that “Right now, I’m protecting the Affordable Care Act,” adding that, “None of these other things…can really prevail unless we have the Affordable Care Act.”

Republicans have been largely critical of the legislation. Sen. Barrasso (R-WY) sent a letter to the CBO asking for a full cost estimate of Sen. Sander’s proposal, noting that he was “deeply concerned that Senator Sanders’ Medicare-for-All legislation is not only a government takeover of health care, but would also put financial burdens on the American people that they cannot sustain.” President Trump also weighed in, tweeting “Bernie Sanders is pushing hard for a single payer healthcare plan – a curse on the U.S. & its people. I told Republicans to approve healthcare fast or this would happen. But don’t worry, I will veto because I love our country & its people.” Sen. Barrasso Press release: Letter:

Additionally, on Tuesday, Rep. Higgins (D-NY) and 34 Democratic cosponsors introduced the Medicare Buy-In and Health Care Stabilization Act (H.R. 3748), which would provide for an option for individuals who are ages 50-64 to buy into Medicare and would provide for health insurance market stabilization. Press release:

Administration Activity –

On Monday, Democrats on the House Energy & Commerce Committee sent a letter to HHS Secretary Price and CMS Administrator Verma raising concerns over the Administration’s plans to roll back funding for the ACA’s Navigator program and to cut funding for open enrollment marketing and advertisement. Press release:  Letter:

Also on Monday, the Administration marked Oregon’s section 1332 waiver as complete, beginning the 30-day public comment period. Oregon is requesting to implement a state-based reinsurance program to stabilize its individual insurance marketplace. To fund the reinsurance program, Oregon is seeking federal pass-through funds, provided by savings from federal subsidy funds, which “are estimated to be in excess of $30 million per year through 2027.” Comments are due by October 11. CMS Letter: Waiver:

Yesterday, CMS released an updated Health Insurance Exchanges Issuer County Map, which shows that nationwide no issuers are projected to participate in the exchange in 63 counties during the upcoming plan year, while 1,472 counties are expected to only be covered by one issuer. Press release: Map: