UPDATES: Possible CSR shocker, but has the 2018 Rate Horse already escaped from the barn?

Some Guy, September 19th:

More to the point, however: What other significance does not including CSR funding have?

Well, first of all, is it possible that they'll slip CSRs in before the vote? I suppose so, but consider this:

  • The final deadline for the insurance carriers to actually sign their contracts for 2018 is Sept. 27th, just 8 days from now.
  • The end of the 2017 fiscal year (i.e., the deadline for the GOP to try and cram through Graham-Cassidy with only 50 Senate votes) is Sept. 30th.
  • The CBO is "aiming" to provide a "preliminary assessment" of Graham-Cassidy "early next week" which I presume means Monday the 25th or Tuesday the 26th.
  • I assume the other steps (parlimentary ruling, vote-a-rama, etc) would take place on Wednesday the 27th, the same day the contracts have to be signed.
  • Yom Kippur is the evening of the 29th, running through Saturday the 30th. I can't imagine even McConnell would be that much of a dick to schedule the vote then.
  • That leaves Thursday the 28th or Friday the 29th for the actual vote itself.

That's a day or two after the carrier contracts have been signed.

That means that even if there's a last minute change to the bill, at this point, CSR payments are virtually certain notbe guaranteed next year.

If I've figured this out, I'm sure the insurance carriers have as well...which explains why, for instance, Health Alliance Plan here in Michigan just dropped out on Friday.

I wouldn't be at all surprised to see more 11th-hour drop-outs next week. Donald Trump and the Republican Party's open sabotage of the ACA will likely bear even more fruit.

Sidenote: Unfortunately, I was right: Anthem did indeed pull out of Maine at the last minute, although to my knowledge they're the only ones who did so yesterday.

Here's the irony: In this scenario, given the timing of it all, you could see:

  • Carriers dropping out due to CSRs not being paid...because the CSR appropriation came after they dropped out
  • Carriers jacking up their rates an extra 14 points due to CSRs not being paid...because the CSR appropriation came after their rates were locked in.

Congratulations, GOP: You managed to raise premiums 14 points, decimate the market and dole out a good $10 billion designed to avoid both of those outcomes all at once.

At the time, of course, I was focusing primarily on the Graham-Cassidy bill and the fact that CSR appropriation wasn't included in the bill (unlike the 2 earlier GOP bills which included a 2-year CSR appropriation before killing off the program entirely). The fact that Graham-Cassidy went kaput in the end doesn't change the rest of my point.

Cut to just moments ago, via Twitter:

NEW: Senate Health Chair Lamar Alexander says a bipartisan deal to stabilize Obamacare’s insurance exchanges could come as early as tonight

— Laura Litvan (@LauraLitvan) September 28, 2017

Schumer says on floor just now Alexander/Murray "on verge of agreement" for bipartisan health care deal

— Heather Caygle (@heatherscope) September 28, 2017

This could be a big deal, although I'm gonna be pretty muted in my reaction for now. In addition to the timing problem laid out above (no, the 9/27 contract deadline wasn't bumped out in the end), here's what would have to happen for any such stability bill to have an impact in time for 2018 at this point:

  • 1. It'll have to pass the Senate
  • 2. It'll have to pass the House
  • 3. It'll have to be signed into law by Donald Trump

Would Trump sign the bill or veto it? On the one hand, it doesn't repeal the ACA, it strengthens/improves it, which goes completely against what he supposedly wants. On the other hand, he's so clueless about what any healthcare bill does anyway that "Chuck & Nancy" might be able to somehow convince him that it does "repeal Obamacare" (while rolling their eyes the moment Trump turns away from them) as long as it gets him to sign the damned thing. If not, of course, it would have to be re-voted on and pass both the House and Senate again...by a 2/3 majority in each.

  • 4. It would have to have some sort of "backsies" retroactive provision which somehow results in the insurance carriers lowering their 2018 premiums to CSR-funded levels after they already have the higher rates locked in
  • 5. And all of this would have to happen and be entered into the various databases at the insurance carriers, the state insurance departments and the federal and state exchange websites within the next couple of weeks.

Possible? Perhaps. Likely? Probably not. Then again, who the hell knows?

UPDATE: False alarm?

Alexander's remarks about a deal tonight were misconstrued. was giving a hypothetical. Still, he and Murray met last night, more optimistic

— Peter Sullivan (@PeterSullivan4) September 28, 2017

UPDATE: (sigh) Gimme a break...

Ivanka Trump just walked through the Senate side of Capitol with @SenAlexander

— Jennifer Haberkorn (@jenhab) September 28, 2017

Hmm...Alexander earlier said a bipartisan ACA stabilization deal is close... https://t.co/WX0Xce5XMm

— Topher Spiro (@TopherSpiro) September 28, 2017

UPDATE: Here's some actual details on what may (or may not) be happening, courtesy of Inside Health Policy...although it pretty much just reiterates everything I said above:

Senate health committee Chair Lamar Alexander (R-TN) and ranking Democrat Patty Murray (WA) are close to a deal on a market stabilization package, key senators said Thursday (Sept. 28), although Republican leaders continue to signal caution on whether the House and Senate will pass the measure.

...Alexander cautioned that though he and Murray could come up with a deal “tonight,” they still face the challenging of getting enough Democrats and Republicans on board, before passing it along to Schumer and McConnell.

“Then we’ve got the matter of eventually persuading the Senate, the House of Representatives and the president to sign it,” Alexander said. “We’re taking it a step at a time.”

...“I think from a timing standpoint it’s going to have to do with when the next CSR payments are due and whether the president decides to make them or not,” Thune said, noting that Alexander and Murray had pretty much picked up where they had left off before the effort was halted when GOP leaders instead focused their efforts on trying to secure a vote on the Graham-Cassidy plan by Sept. 30. “But I think it’s a pretty short time frame,” Thune added.

Murray told reporters the legislation needed to be passed soon because insurers' Sept. 27 contract deadline had passed and people will now feel the squeeze of higher prices because the deal didn’t get done before then.

As for what such a deal would actually include, that’s unknown, but based on everything I was hearing a couple of weeks ago (before Graham-Cassidy muscled it aside), the most likely components would probably include:


  • CSR reimbursement payments formally appropriated for 2 years
  • Some sort of national, federal reinsurance fund (probably also for 2 years)


  • Streamlining/loosening of some of the state waiver rules (hopefully nothing which would allow weakening of Guaranteed Issue, Community Rating or Essential Health Benefit protections, however)
  • Killing the Medical Device Tax (and/or possibly the Carrier Tax?)
  • Possibly raising the Employer Mandate threshold from companies with 50 employees to 100 or 200??

UPDATE: OK, here's the latest on the likely contents of the deal:

Lobbyists said that elements of the deal being discussed include allowing ObamaCare enrollees to buy “copper plans,” which are cheaper, less generous insurance plans that currently only people under age 30 can buy.

An expansion of waivers currently in ObamaCare that allow states to innovate and change regulations are also said to be part of the potential deal, though it is not clear how far those waiver changes will go.

Those provisions are both Republican requests.

The main provision for Democrats would be funding for key ObamaCare payments known as cost-sharing reductions, which President Trump has threatened to cancel in a bid to make the health-care law “implode.”

Lobbyists say that two years of funding for the payments is possible under the deal, which would be more than Alexander’s initial offer of one year.

My take: If that's the whole deal, I'd say pass. 2 years of CSRs plus solid, multi-year reinsurance might make sense, assuming the waivers don't touch guaranteed issue, community rating or essential health benefits...but 2 years of CSRs by themselves wouldn't be worth it.