Schrödinger's Catastrophe.

Over at Politico, Paul Demko has an extensive article (with an assist from Adam Cancryn, Jennifer Haberkorn and Rachana Pradhan) which confirms many of the things I've been saying for awhile now...although it also weakens one of my arguments as well. In an odd way, that's entirely in keeping with the overall theme of the article itself. That is, every one of the following statements appears to be true simultaneously:

  • The Trump administration is deliberately sabotaging the ACA exchanges.
  • The Trump administration is sort of trying to shore up the ACA exchanges.
  • Congressional Republicans are full-speed ahead on repealing the ACA.
  • Congressional Republicans are putting the brakes on repealing the ACA.
  • The Individual Market isn't in a Death Sprial yet, but could be next year.
  • The Individual Market is already in a Death Spiral in some states but doing just fine in others.
  • A full replacement plan is ready to go at any moment.
  • A full replacement plan hasn't even made it past the first stages yet.

As Demko puts it:

The Trump administration, which hasn’t yet delivered its promised repeal and replace plan to Congress, is sending mixed signals. One minute it’s weakening Obamacare by taking steps that dampened enrollment. Another minute it’s trying to entice insurers to stick around long enough to transition to an eventual GOP replacement — but with steps that industry analysts say may fall short.

“I don’t know that it’s going to keep insurers in if they were otherwise inclined to exit,” said Caroline Pearson, an expert on the Obamacare marketplaces at consulting firm Avalere Health.

...The administration’s zigzags haven’t placated worried insurers, who see another year of red ink from enrollees that are older and sicker than they had expected. Congress’ paralysis on repeal and replacement translates into precisely the kind of uncertainly that makes risk-averse insurers want to run for cover. And Trump’s executive order, signed just hours after his inauguration, unnerved the health plans with its call for government agencies to abolish as much of the law as possible through administrative action. That fueled fears that his administration won’t enforce the individual mandate requiring most Americans to get coverage.

“There’s no way of knowing from outside if the left hand doesn’t know what the right hand is doing or if the Trump administration is somewhat conflicted,” said Larry Levitt, senior vice president at the Kaiser Family Foundation.

It's a great article which cuts to the heart of it: The ACA exchanges are in deep trouble in states like Tennessee, Oklahoma and Arizona...but seem to be doing just fine (or are at least in pretty stable) in others like California, Washington and Michigan.

Hell, even the New Rules posted by CMS earlier today reflect the schizophrenia going on in the Trumpublican world. They issued new "carrier-friendly" directives to slash the next Open Enrollment Period in half and crack down on SEP signups (which, by the way, could potentially backfire in terms of risk pool impact)...but at the same time, haven't said a peep about the two biggest issues keeping the carriers from staying on board: Reversing the Risk Corridor Massacre and Cost Sharing Revenue Reimbursement debacles, both of which were initiated by the Republicans in the first place.

In addition, Trump has also apparently put the kibosh on a plan to beef up IRS enforcement of the individual mandate (although that's not a reversal of an existing policy, it's just stopping the implementation of none):

The tax agency has stopped requiring individual filers to indicate whether they maintained health coverage or paid the mandate penalty as required under the law

How much difference does a single line on a tax form make? For Obamacare's individual mandate, the answer might be quite a lot.

Following President Donald Trump's executive order instructing agencies to provide relief from the health law, the Internal Revenue Service appears to be taking a more lax approach to the coverage requirement.

...Correction: The IRS did not reject silent returns last year, as this story originally indicated. The plan was to go into effect this year, for 2016 returns, but the IRS reversed course on February 3. Reason regrets the error.

The Politico article even points out the conflicting "death spiral" landscape: On the one hand, Humana has already bailed, Molina is very jumpy and the CEO of Aenta used the "DS" term openly this morning. On the other hand, Aenta has already been busted flat-out lying about their profitability in the exchanges, and Humana just had their mega-merger (with Aetna) killed off, so there could be more to the story there. In addition:

Despite the headlines generated by Humana — which had already exited much of the market before this year — most health care experts don’t see a death spiral. Blue Cross Blue Shield plans dominate the markets in many states, and so far those plans aren’t pulling out.

But Anthem, which sells Blue-branded plans in 14 states, has warned that it may reconsider participation if steps aren’t taken to improve the market’s financial viability..

...Jeff Goldsmith, a veteran health care consultant, said Bertolini’s apocalyptic rhetoric is a bargaining tool to impel Congress and the Trump administration to make insurer-friendly changes to the markets.

Remember, Bertolini's credibility on this topic isn't exactly at a high point right now...and Aetna HASN'T left the OFF-exchange market in most states, meaning that they could still theoretically jump back on the exchange next year if they really wanted to, so Goldsmith's take might have some merit. Then again, it could potentially be an Occam's Razor situation: The risk pools in some states really are in imminent danger and the carriers are bailing as a result.

I noted the other day that with the clock already ticking on the 2018 enrollment season, the GOP has to make up it's mind on one of two courses of action: Either "Steal the Credit!" (ie, FIX the problems with the ACA exchanges--including the ones caused by them as well as those already inherent in the law, which Hillary Clinton had hoped to do if she had taken office) or "Blame the Victim!" (i.e., do everything possible to sabotage/undermine the exchanges, then claim innocence when they completely collapse and pin all of the blame on the law itself).

Instead, Trump/the GOP seem to be hell bent on doing both at the same time...and at this point seem very likely to fail at both. Their "fixes" may well end up backfiring on them, while their "blame Obama!" mantra is gonna ring pretty hollow 9 months from now given how blatant their projection on this strategy has been all along.

NOTE: Updated to remove reference to HHS Sec. Tom Price re. the IRS policy change & included quote from Reason article.