UPDATE: CELEBRATE A FEW HOURS. Then come back and read this.

TRUMP'S PLAN B: Do everything he can to sabotage the ACA, then blame Democrats.


Robert Costa in the Washington Post:

President Trump called my cellphone to say that the health-care bill was dead

President Trump called me on my cellphone on Friday afternoon at 3:31 p.m. At first I thought it was a reader with a complaint since it was a blocked number.

Instead, it was the president calling from the Oval Office. His voice was even, his tone muted. He did not bury the lede.

“Hello, Bob,” Trump began. “So, we just pulled it.”

...The Democrats, he said, were to blame.

...Trump said he would not put the bill on the floor in the coming weeks. Instead, he is willing to wait and watch the current law continue and, in his view, encounter problems. And he believes Democrats will eventually want to work with him on some kind of legislative fix to Obamacare, although he did not say when that would be.

“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. And they will come to us, we won’t have to come to them,” he said. “After Obamacare explodes.”

“The beauty,” Trump continued, “is that they own Obamacare. So when it explodes they come to us and we make one beautiful deal for the people.”

My question for the president: Are you really willing to wait to re-engage on health care until the Democrats come and ask for your help?

...“Hey, we could have done this,” he said. “But we couldn’t get one Democrat vote, not one. So that means they own Obamacare and when that explodes, they will come to us wanting to save whatever is left and we’ll make a real deal.”

...“You’re right,” he said. “I’m a team player but I’ve also said the best thing politically is to let Obamacare explode.”

...As he waits for Democrats, I asked, what’s next on health care, if anything, policy-wise?

“Time will tell. Obamacare is in for some rough days. You understand that. It’s in for some rough, rough days,” Trump said.

He added, “I’ll fix it as it explodes.

As I noted this morning, while there are real problems with the actual wording of the ACA itself (some of which are fairly significant)...

Other problems, however, were deliberate sabotage on the part of the Republican Party:

  • First, of course, the fact that Congressional Republicans have refused to help fix any of the "original law" bullet points for seven years.
  • Obstructing Navigators, confusing the public with nonsense about "death panels", refusing to provide accurate information (or any information at all) to potential enrollees about their options, etc etc.
  • THE RISK CORRIDOR MASSACRE, which helped wipe out over a dozen Co-Op start-ups, kicked 800,000 people off their policies, hurt competition and caused a domino effect of other carriers jacking up rates dramatically in many states

...So, you have a combination of all of the above, tremendous uncertainty and a ticking clock, and an administration which has already openly stated that they intend on sabotaging the law as much as possible.

If you're an insurance carrier CEO or board member, then assuming the individual market isn't a major part of your business...how likely are you to stick around next year regardless of whether the AHCA passes or not?

Again, the ACA, as it stands, is mostly working pretty well for most enrollees in most parts of the country...but there are real problems which need to be addressed.

Trump is stating, point blank, that he has absolutely zero plans on resolving any of those issues.

He's also instructed Tom Price and the HHS Dept. to not only not do anything to resolve them, but to go out of his way to do everything he can to hurt them.

What are some of these possibilities? The list is endless. Over at Politico, Dan Diamond has already written up a good piece:

Enrollment could be dampened even more if the administration decides to do little or no advertising next year.

“If the [Trump] administration decides not to run TV ads in the future, this would be concerning," said University of Minnesota professor Sarah Gollust, who has studied TV ads and enrollment. "Particularly so if state governments follow their lead in also cutting their budgets for marketing and outreach — and if enrollment advocates and non-profits cannot pick up the slack."

Tom Price has already announced plans to cut the 2018 Open Enrollment Period from 3 months to just 7 weeks. This in and of itself isn't necessarily a terrible move...but what about 4 weeks? What about 2 weeks? What if the budget for HealthCare.Gov's operations is slashed...understaffing the support phone lines or underpowering the servers? These are similar to the voter suppression techniques that many Republican-held states have been using for years (allocating fewer voting machines in certain precincts, cutting back on early voting days, shortening election day hourse and so forth).

Some of the damage has already been done, and requires nothing more than irresponsible statements on the part of Trump and/or Price:

Trump’s own musings about simply letting Obamacare “fail” — a concept he first openly raised in January — have sent shock waves through the health care industry. Humana has pulled out of the ACA’s exchanges for next year, and other companies warn that the uncertainty may drive them away — though Trump also has met with insurance executives about transitioning to a post-Obamacare system.

“There are simply too many unknowns with the marketplace program to commit to our participation beyond 2017," Mario Molina, CEO of Molina Healthcare — one of the most successful insurers on the ACA exchanges — said on an investor conference call in February and reiterated to POLITICO last week.

...Some former Obama officials say that the changes, particularly extra verification requirements for people who sign up outside the usual enrollment season, may backfire and actually drive health plan customers away.

Then there's the other doomsday possibilities, like Trump issuing an executive order stopping payment on CSR reimbursement payments to carriers.

I'll be addressing all of this and much more in the near future, of course, including my own suggestions for how the ACA should be changed to repair/improve the situation.

For the moment, however, I'm very tired, it's a beautiful Friday afternoon, and I'm going to go play with my kid for a few hours. I think I've earned it.

UPDATE 3/26/17: I just re-read this piece and realized that I made a major error in listing the CSR reimbursement issue last, as almost an afterthought, instead of making it the #1 focus.

Here's the link explaining the backstory again, but the bottom line is this:

  • In addition to the 9 million+ people receiving APTC assistance for their premiums, around 7 million also receive CSR assistance, which cuts their deductibles/co-pays down to size.
  • Unlike APTC assistance, with CSR, the insurance carriers cover the balance, and then the HHS Dept. reimburses the insurance carriers for the expense.
  • Due to a lawsuit filed by the House Republicans, and a federal judge who has ruled (for now) in favor of the GOP's case, those CSR payments are currently in legal limbo until the case works its way up to the Supreme Court (think "King vs. Burwell Jr.", but with a slightly stronger case)
  • The payments are being allowed to continue month to month for the time being, but Donald Trump could instruct the HHS Dept. to stop defending the payments.
  • If that happens, there's an "exit clause" in the carrier contracts which would allow them to immediately terminate the policies in question. And by "immediately", I mean "the end of that month", which could theoretically be as early as April 30th at this point, I believe, assuming the April reimbursements are cancelled. That would mean a good 7 million people losing their policies almost instantly.
  • Those terminations may be prevented by state laws preventing such things...but even in that instance, I guarantee that pretty much every carrier would flee the exchanges for 2018, and would likely leave the entire individual market (off-exchange as well) next year.

Again, the specifics are more complicated, but this is my understanding of how the worst-case scenario could play out.

If the President was anyone other than Donald Trump--even another Republican--I can't fathom that they would pull the plug on the CSR payments, even if they also wanted to repeal the ACA entirely--they'd urge Congress to amend the ACA to resolve the legal question and ensure CSR payments (at least for another year, for instance, until the SCOTUS hears the case) rather than throw the entire market into disarray. While the GOP would obviously try to blame the wording of the law and the Democrats for the ensuing carnage, the ACA is entirely in their hands now; come 2018 it would be awfully difficult to try and pin the blame on an obscure legal argument dating 8 years earlier, especially when it would take about 5 minutes to fix the problem.

Hell, the House Republicans are so terrified about the fallout if the above were to happen that they've even asked the court WHICH RULED IN THEIR FAVOR to delay the final ruling until the larger healthcare/ACA debate has been worked out:

To buy President-elect Donald Trump time to craft an Affordable Care Act replacement, House Republicans have asked a federal appellate court to delay considering the Obama administration's appeal in a case that could end some payments to health plans and throw the individual insurance market into chaos.

The House Republicans' general counsel filed a motion Thursday to temporarily hold in abeyance all briefings in the appeal of a federal district court's May ruling in House v. Burwell that the Obama administration illegally compensated insurers for reducing low-income enrollees' cost-sharing responsibilities. A U.S. District Court judge nominated by President George W. Bush unexpectedly held that the payments were unconstitutional because Congress had not appropriated the money.

...If those cost-sharing reduction payments were eliminated, as House Republicans have sought, insurers either would have to sharply raise premiums or exit the ACA exchange markets, since the law requires them to reduce cost-sharing burdens for eligible members in silver plans.

The incoming Trump administration and congressional Republican leaders have promised to quickly repeal most of the ACA. But some Republicans and health policy experts fear that any hasty, drastic moves would crash the individual insurance markets. They warn that ending the cost-sharing reductions without any replacement system might panic insurers by causing them to lose lots of money.

That's right: The GOP is scrambling to reverse THEIR OWN LAWSUIT because they just realized what a disaster winning it would cause (again, just like a "win" in King v. Burwell would have been a couple of years back).

But this is Donald Trump we're talking about. All bets are off.