About 5 weeks ago I noted that organizations representing pretty much the entire healthcare industry sent urgent letters to Donald Trump, HHS Secretary Tom Price, Treasury Secretary Steven Mnuchin, OMB Director Mick Mulveney and current CMS Administrator Seema Verma...basically, every major healthcare-related administration figure...practically begging them to fund the goddamned Cost Sharing Reduction reimbursements.

They made it crystal clear how vitally important doing this was, and Trump grudgingly went ahead and made the April payment, then later indicated that he was "probably" going to keep reimbursing carriers for the CSR funds legally owed to them on an ongoing basis, at least until the House vs. Price (formerly House vs. Burwell) lawsuit appeal process was completed.

Unfortunately, this a) didn't resolve the underlying problem (namely, that even if he makes good on his promise, CSR payments are still in danger at some point down the road depending on how the final court ruling turns out), and b) it became moot earlier today when, according to Politico, Trump has since changed his mind and now plans on stopping the CSR reimbursements after all.

On top of all this, the clock has continued ticking, filing deadlines for the 2018 Open Enrollment Period have already passed for a few states, and there's little time to spare...so the big guns have decided to turn their sights on Congress instead...and this time even more major players are joining in.

First up: The National Association of Insurance Commissioners, which yesterday sent the following letter to Republican and Democratic Senate leaders including Mitch McConnell, John Cornyn, Chuck Schumer and Dick Durban (as well as to OMB Director Mick Mulvaney) (emphasis mine):

On behalf of the nation’s state insurance commissioners, the primary regulators of U.S. insurance markets, we write today to urge the Senate to act quickly to stabilize the individual health insurance markets. Your immediate action is critical to the viability of the individual health insurance markets in a significant number of states across the country.

As the Senate considers legislation to repeal or reform the Affordable Care Act, state regulators are concerned that key changes will not be made in time to preserve sustainable individual health insurance markets in many states. Specifically, we urge the Senate to: 1) ensure the cost-sharing reduction (CSR) payments are fully funded in 2017 and 2018; and, 2) provide sufficient and sustained market stabilization funding to states for the establishment of reinsurance programs or high risk pool programs. These two actions alone would go a long way toward stabilizing the individual markets in our states while legislative replacement and reform options are debated.

In our April 19th letter to the Senate we noted that: “State regulators have had numerous discussions with health insurance carriers in their states about rates and participation in the individual market in 2018. As you know, there is increasing concern that more carriers will pull out of this market and rates will continue to rise, leaving consumers with fewer and more expensive options, if they have any options at all. This is not a theoretical argument – carriers have already left the individual market in several states, and too many counties have only one carrier remaining”

The time to act is now. Carriers are currently developing their rates for 2018 and making the decision whether to participate on the Exchanges, or even off the Exchanges, in 2018. Guaranteed payments for the CSR program and market stabilization funds will help increase consumer options and make coverage more affordable.

Of course, state regulators also remain committed to working collaboratively with the Senate on a non-partisan basis to address the longer-term issues related to health insurance. As your partners in government, we look forward to working with you as we all seek to make health insurance coverage more affordable and accessible.

The letter was signed by the four state Insurance Commissioners from Maine, Wisconsin, Tennessee and South Carolina. I'm willing to bet the last three of wthese folks are Republicans.

Next up: Attorneys General, Solicitor Generals and so forth for 16 States, including California, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, New York, Pennsylvania, Vermont and Washington, which yesterday collectively moved to intervene legally in House v. Price. University of Michigan Law Professor and ACA legal expert Nicholas Bagley posted a tweetstorm this morning which summed things up:

1/ 16 states have moved to intervene in House v. Price, the appeal on cost-sharing reductions.

2/ Will the motion be granted? It’s complicated. The law on whether to allow intervention on appeal is surprisingly unsettled.

3/ I *think* the states should be allowed to intervene, but I’ll have to noodle more on that. More next week.

4/ If intervention is allowed, however, it’s a game-changer. Trump couldn’t unilaterally dismiss the appeal; the states could keep it alive.

5/ That means the injunction (which stops the cost-sharing payments) couldn’t take effect until the appeal is heard and decided.

6/ Because there’s a strong likelihood that the D.C. Circuit will dismiss on standing grounds, insurers could breathe a bit easier.

7/ Uncertainty would persist: the D.C. Circuit could always surprise us and decide the standing question in the House’s favor.

8/ So 2018 premiums would still have to rise in response to the risk that payments might stop sometime next year.

fin/ Still, allowing intervention would reduce the immediate threat. Which is why I’ll be watching the motion closely.

Finally, there's the coalition of healthcare industry organizations which sent the first letter to the Trump Administration 5 weeks ago. Here's who I'm talking about:

America’s Health Insurance Plans
American Academy of Family Physicians
American Benefits Council
American Hospital Association
American Medical Association
Blue Cross Blue Shield Association
Federation of American Hospitals
U.S. Chamber of Commerce

Yes, that's right: The U.S. Chamber of friggin' Commerce is on this list.

Here's their new letter, this time addressed to, once again, Mitch McConnell, John Cornyn, Chuck Schumer and Dick Durbin (some emphasis mine, some theirs):

As providers of healthcare and coverage to hundreds of millions of Americans, we are writing again to you as leaders in Congress to express our serious concerns about the continued uncertainty around funding for cost-sharing reduction (CSR) payments. There now is clear evidence that this uncertainty is undermining the individual insurance market for 2018 and stands to negatively impact millions of people.

We urge Congress to take action now to guarantee a steady stream of CSR funding through 2018. Such action would represent a strong, positive step for all consumers who buy their own insurance by eliminating the single most destabilizing factor causing double-digit premium increases for 2018.

Millions of Americans do not receive health insurance through an employer, Medicare or Medicaid. The individual market is their only option for getting coverage. Unless CSRs are funded, a tremendous number of Americans will simply go without coverage and move to the ranks of the uninsured. This threatens not just their own health and financial stability, but also the economic stability of their communities.

We recognize and understand the Senate is working on legislation that includes provisions intended to promote short-term stability in the individual market. However, in light of 2018 filing deadlines, most of which fall on or before the June 21st deadline for federally facilitated marketplaces, health plans have only a few more weeks to decide whether and how to participate in this market. In several states, the deadline to file products and initial rates has already passed.

Earlier this week, the National Association of Insurance Commissioners (NAIC) again expressed grave concerns to Congressional leaders about the impact of CSR funding uncertainty. Simply put, continued uncertainty, particularly the lack of clarity around CSR payments, has led several insurers to conclude that they cannot participate for 2018. Those who will participate are responding to the market uncertainty with premium requests that are as much as 60 percent higher than last year.

Millions of American consumers and taxpayers will soon feel the impact:

  • Consumers who purchase their own insurance will have few, if any, coverage choices. As a result, millions of people will become uninsured.
  • With more uninsured, providers will experience more uncompensated care which will further strain their ability to meet the needs of their communities and will raise costs for everyone, including employers who sponsor group health plans for their employees.
  • Taxpayers will pay billions of extra dollars in costs due to higher premium subsidies—in fact, recent studies have found overall federal costs will be 23 percent higher.

Congress must take action now to fund CSR payments. At this point, only Congressional action can help consumers. We remain committed to working with you toward immediate stability and longer-term, effective, market-based solutions that best serve the American people.

How much clearer can they be about this issue? How unbelievably dense must the Congressional GOP be not to grasp the magnitude of what would happen if the CSR reimbursements were to be cut off? I realize that not every member of Congress can be expected to fully understand the intricacies of health insurance, but in this case it's not that difficult to grasp and it's been explained to them in exhaustive detail, repeatedly, by multiple reliable sources, along with the potentially explosive results of them not heeding the warnings.

On the other hand, the GOP also voted for and supported Donald Trump for President of the United States.

We're so screwed.