This Is All Far From Over...but for the moment, Trumpcare appears to be Dead (Again)


As you've probably heard fby now, Mitch McConnell has formally/officially pulled the latest incarnation of Trumpcare, aka "Graham-Cassidy" (or "Graham-Cassidy-Heller-Johnson" for those who love hyphens) from being voted on this week before the September 30th reconciliation deadline:

Republican leaders have decided not to vote on Obamacare repeal legislation this week, effectively ending the party’s latest effort to wipe away the 2010 health care law.

When, and whether, they will try again remains to be seen. But for now, a defining cause of the Republican Party, including President Donald Trump, lies in tatters.

And at least for the moment, insurance coverage for many millions of Americans who rely on Medicaid or the Affordable Care Act’s federal subsidies remains intact ― although insurance markets in some states remain unstable, and the Trump administration’s willingness to manage the program remains unclear.

The decision to shelve repeal legislation came during a weekly caucus meeting on Capitol Hill, as leaders acknowledged that the the latest proposal, from Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), lacked the 50 votes it required to pass.

“We don’t have the votes,” Cassidy said afterwards.

Etc, etc. Others can fill in the rest. The point is that, while I will still be keeping a nervous eye on the ticking clock at the top of this site for the next 105 hours, this particular chapter in the healthcare battle appears to be over (for now) (temporarily) (probably) (I hope).

As Abby Baird of ThinkProgress, among others, has noted, even when the clock strikes midnight on Saturday, that doesn't necessarily mean the ACA is out of the woods. There are several ways they can still pass a repeal bill using only 50 Senate votes, ranging from trying to tie it in with a budget/tax reform bill or otherwise resetting the "reconciliaton" clock and giving it another shot next year. That seems highly unlikely (especially in the middle of an election year), but who the hell knows?

In other words, Obamacare repeal seems to be Dead Again...but This Is All Still Far From Over.

So. Assuming it doesn't pop back up again at the last minute between now and January, what's the next Big Thing To Focus On?

Well, I made a big stink about Bernie Sanders and the die-hard Single Payer Now! crowd going full throttle on Medicare for All before October 1st, and while it looks like the current repeal effort failed, I still believe it was poorly timed and unhelpful. Frankly, I would've preferred that the SP crowd wait until the 2018 midterms are over to run a full push, or at the very least wait until after the upcoming Open Enrollment Period ends on January 31st (the official end date is December 15th, but some states are extending it for the full 3-month period).

HOWEVER, what's done is done: The M4A campaign has already been formally launched and Graham-Cassidy appears to be dead (for now)...and I did say we could unclench a bit after either Oct. 1st or as soon as Graham-Cassidy was officially pulled from the voting schedule, so, fine; push away.

As for me, my immediate attention and concerns now turn to the upcoming Open Enrollment Period...which, thanks to a combination of massive current sabotage efforts on the part of the Trump Administration, the aftermath of past sabotage efforts by the GOP and yes, let's be honest, some legitimate flaws in the ACA itself, is shaping up to be pretty ugly and confusing this year:

  • ISSUE #1: CSR reimbursement payments are effectively kaput for 2018.

Even if the GOP does immediately agree to returning to the promising bipartisan HELP Committee meetings which Sen. Lamar Alexander and Sen. Patty Murray were holding a week or so ago, there's simply not enough time--barring a miracle--to squeeze in a formal bill, formal Senate vote and formal House vote before the deadline for insurance carriers to formally sign legally-binding contracts for participation in the 2018 Open Enrollment Period...because that deadline happens to be tomorrow, September 27th.

(For that matter, any such bill would also have to be signed by Trump...or, assuming there was concern he'd veto it, would have to pass with a 2/3 majority in both the House and Senate).

Now, it's been reported by Kimberly Leonard of the Washington Examiner that the administration could delay that deadline if they really wanted to...but the delay would likely be no more than a week or so at most, because there's simply not enough breathing room between now and November 1st for the carriers and the administration and the state insurance departments and so forth to do all the stuff they need to prep before the enrollment period kicks off. I suppose it's theoretically possible that they could delay the start of Open Enrollment until November 15th (that was the start date back in 2014), but that also seems extremely farfetched and, again, would cause even more headaches for all involved.

Now, it's possible that a bipartisan deal will be reached and some sort of stabilization bill will pass after the 2018 rates are locked in...but that would be too late for 2018 rates; they'll already be locked in at the higher levels. This was confirmed by Virginia Insurance Dept. officials just today:

...The rate increases can be attributed to an unstable market, with too few healthy people signing up to balance out the number of sick people who enroll, and the uncertainty of cost-sharing reduction payments, which are meant to go to insurers to cover the cost of offering lower prices to poor members, but which the federal government has refused to guarantee.

Even if the federal government comes forward in the next few months and promises to pay insurers the cost-sharing reductions, the prices for 2018 will be locked and unable to be changed, [VA Bureau of Insurance health actuary Dennis] Shea explained.

“What you’re saying is, because no one has made the decision one way or another ... people who need health care insurance are victims beyond their control,” said Sen. Rosalyn R. Dance, D-Petersburg. “Even if it’s corrected, they’re still held hostage for 2018.”

So, what does that mean in practical terms?

Well, that depends on how the carriers in each state handle their CSR loads. As a reminder, there's 5 different ways they could handle the situation. The first two involve dropping out of the individual market altogether (either on exchange or both on/off exchange), which some carriers have already done and others could possibly still do in the next 24 hours.

Assuming they stick around, however, there's three ways to deal with it: Spread the load across all plans (which is what my 2018 Rate Hike project averages have to assume); they can load the cost onto all Silver plans only (which is what I believe most carriers are doing) or they can go with the Silver Switcharoo Gambit, as I call it, which involves loading the CSR costs onto on-exchange Silver plans ONLY, while creating a separate (but virtually identical) Silver plan for off-exchange enrollees only.

By doing it this way, the fewest number of enrollees are negatively impacted, while those who qualify for tax credits could actually see a significant windfall of additional tax credits.

The downside of the Silver Switcharoo Gambit is that it would be messy as hell and confusing to explain to people, especially since a lot of people currently enrolled in unsubsidized Silver plans would have to "switch" to an off-exchange Silver plan for (seemingly) no good reason.


As noted above, the odds are pretty slim that anything either the bipartisan Alexander/Murray Senate HELP Committee or the bipartisan House "Problem Solvers" caucus come up with would be able to be voted on, passed through both chambers and signed into law in enough time to positively impact the 2018 enrollment period, but anything's possible...and at the very least, it'd be nice if things were at least stabilized in time for 2019 enrollment, anyway. Keep an eye on this.


This isn't directly connected to ACA Open Enrollment, but it's certainly an important and extremely time-sensitive healthcare policy problem. The simple version is that funding for the Children's Health Insurance Program also expires at midnight Saturday unless Congress passes a funding extension...and they haven't done so yet, in large part because of the GOP's insistance on pushing the Godawful Graham-Cassidy bill the past few weeks. Hopefully they can scramble to pass and get Trump to sign into law a multi-year CHIP funding extension, because if they don't, nearly 9 million children are pretty much SOL.

In addition, $3.6 billion in Community Health Center (CHC) funding is set to expire at the end of September as well if not reauthorized:

The report found allowing the CHC Fund to expire would amount to a cut of $3.6 billion in health center funding in fiscal 2018. Such a decrease would result in the loss of 51,000 health center jobs, and as many as 9 million patients—or more than one-third of the current population who use community health centers—would lose access to such services.

  • ISSUE #3: Open Enrollment Advertising/Outreach Sabotage

As was reported last month, the Trump Administration has slashed the Open Enrollment advertising budget for HeatlhCare.Gov by a whopping 90% for this year...while also slashing the individual outreach/navigator budget by about 40%. Much has been written by myself and others about the potentially devastating effect this could have on enrollment numbers for 2018, especially when combined with the period being cut in half from 92 days down to just 45...made even worse by the highly suspicious (if potentally unavoidable) decision by CMS to take offline for 72 hours of that time...meaning #OE5 will effectively only be 42 days this year unless they extend the deadline by several days, which would be an easy and obvious way to resolve this particular issue.

Assuming they don't do so, that means that the 2018 period will only be 46% as long as it was in 2017...with only 10% of the marketing and 60% of the outreach assistance to help people get signed up in time. Not a pretty picture. This, of course, is exactly why I've teamed up with the Indivisible ACA Signups Project to help spread the word. You can help yourself by simply signing up for their Thunderclap social media campaign.

  • ISSUE #4: Other potential sabotage efforts (?)

Back in July, I warned of seven potential sabotage/undermining stunts which HHS Secretary Tom Price might order to be pulled this year, including:

  • Minimal or non-existent advertising/outreach/promotional efforts
  • Understaffing of call centers/support staff, leading to absurdly long hold times
  • Deliberately underthrottled server bandwidth, slowing down or even taking it offline, especially during peak hours
  • "Accidentally" misentered enrollment instructions or policy specifications
  • Confusing or missing confirmation/status notification messages either on the site, via email or both
  • Incorrect APTC/CSR subsidy formulas giving incorrect tax credit/financial assistance details to enrollees
  • Burying/completely removing the "Window Shopping" tool on the site

The first two of these, of course, have already been proven true. The third one may or may not be sabotage, but whether it's legitimate or not, the damage will be done. That leaves the other four which we won't know about until Open Enrollment actually starts (at which point it will be too late to do anything about it if they happen). These are just the obvious ones, of course; there could potentially be any number of other ugly little stunts pulled behind the scenes to gum up the works.

On the other hand, it's important to note that as much of a scuzzball as Tom Price is and as potentially duplicitous as Seema Verma may be, the vast majority of HHS/CMS staff are presumably career employees (who pre-dated Trump) trying to do their jobs properly. I hope and pray that these folks are able to counteract as many nasty undermining efforts by Price as possible to help get us over the 2018 Open Enrollment Period hump.


Thanks to LOLGOP for reminding me that the state of Maine is putting ACA Medicaid Expansion on the ballot this November!

Maine Question 2, the Medicaid Expansion Initiative, is on the ballot in Maine as an indirect initiated state statute on November 7, 2017.[1]

  • A "yes" vote supports this initiative to require the state to provide Medicaid services through MaineCare for persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line.
  • A "no" vote opposes this initiative to require the state to provide Medicaid services through MaineCare for persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line.


Once all of this stuff out of the way, then it's onto the bigger campaign: The Midterms.

Oh...and, of course, the potential for Yet Another Repeal/Replace Effort. But that's for another day.

As always, if anyone would like to help help my efforts on these and other healthcare policy issues, I could always use whatever support you're able to provide, either as a one-time thing or on an ongoing monthly basis.

In the meantime, for the time being...