A bipartisan group of senators and House members has been working since last summer toward measures to keep prices from rising out of control and undermining the individual market—the market that serves people who don’t get insurance through work or through the government. Members hope to attach a package of fixes to what should be the year’s final temporary spending bill, due late this month.

The lawmakers are up against both a legislative clock and the insurance companies’ timeline. Insurers have until summer to decide if they want to continue to sell policies on the ACA marketplaces, but many start making preliminary decisions as early as April. Without action, insurers say premiums will go up in 2019 due to the uncertainty. Consumers and the government would share those costs.

It is by no means clear whether any package could gain the votes needed in the House and Senate. Most Republicans are loath to be seen “fixing” Obamacare, although opinion polls clearly show they will be blamed for problems with the law going forward.

Pressure to improve the situation is being felt beyond Capitol Hill. Last week five governors (three Democrats, one Republican and one Independent) released a blueprint for a health system overhaul that includes several of the stabilization ideas under consideration in Congress.

Lawmakers in D.C. are looking at two primary fixes, although they could be combined.

Reinsurance

One, pushed by Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.), is called reinsurance. This is a fund that would help insurers pay for the sickest patients and would guarantee the insurance companies do not face large losses. The idea is that if insurers don’t have to worry about covering the expenses for their highest-cost patients, they can keep premiums lower for everyone.

The ACA had a temporary reinsurance program from 2014 to 2016. It was intended to help insurers get started in a market where sick people were able to buy their own insurance for the first time. Prior to the law, most insurers did not cover many people with preexisting health conditions. If they did, it was at an extremely high cost.

Since the federal program ended, several states, including Minnesota and Alaska, have adopted, with some success, their own reinsurance programs in an attempt to hold premiums down.

The subsidy fix

The other proposal, negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would guarantee insurers would get money that the Trump administration cut off in October. The senators are advocating reinstating federal reimbursement for so-called cost-sharing reduction subsidies—discounts that the ACA requires insurers to provide to their lower-income enrollees to help reduce their deductibles and other out-of-pocket costs.

Senate Majority Leader Mitch McConnell (R-Ky.) pledged to Collins, in exchange for her vote on the GOP tax plan in December, that he would support bringing both bills to the floor for debate.

That has not happened. Although, in a statement, Collins said she is “continuing to have productive discussions” with Senate and House leaders about both bills.

Meanwhile, a lot has changed, including new questions about whether the fixes would work.

Would the fixes help?

State insurance regulators managed to find a workaround for Trump’s sudden cancellation of the federal cost-sharing payments.

The cancellation made some premiums higher but the subsidies the federal government gave to consumers also increased to cover those higher prices. That’s because most states allowed insurers to offset the loss of these funds by attaching the premium increases to the plans that determine how much in subsidies enrollees get to pay those premiums. The result is that most people who get government help pay the same (or, in some cases, less), while insurers are effectively being paid back.

That means, however, if the cost-sharing reduction payments were reinstated for 2018, as the original legislation called for, insurers would have to give the excess money back to the government.

Analysts agree that would only add to the confusion.

Restoring the federal payments for this year, says Joseph Antos of the conservative American Enterprise Institute, “does not lower premiums this year, so it does absolutely no good to the average person.”

Some advocates have suggested that Congress should guarantee the payments for 2019 and 2020. But Antos says that “also makes no sense because the insurers would then think ‘Are we going to go through this again?’ ” They might raise premiums even further to make up for the uncertainty.

Antos — and many other analysts — agree that instead, restoring or creating a new reinsurance program would likely do more to control premium increases.

Reinsurance “will protect premiums for the people who are actually most subject to them,” says Sherry Glied, a former Obama administration health official now at New York University. She was referring to those in the individual market who do not get government help and have been footing large premium increases for the past several years. That’s because having protection against the largest bills would allow insurers to lower premiums across the board.

Potential partisan roadblocks

Then there are the political considerations.

Many Republicans in Congress have called the cost-sharing reduction payments, in particular, a “bailout” to the insurance industry and are resistant to reinstate the payments.

Instead, they seem more amenable to the idea of reinsurance, because they consider it a type of “high-risk pool,” which they have been pushing for years. House Speaker Paul Ryan said at an event in Wisconsin in January that “I think there might be a bipartisan opportunity there to get risk pools, risk mechanisms.”

But Republicans have made clear they want something in return for what could be considered a “fix” to the health law they despise.

Health and Human Services Secretary Alex Azar was careful to say in a meeting with reporters last week that the Trump administration has no formal position yet on the stabilization efforts. But, he said, “I think it would need to be part of an entire set of reforms there that we would want to see.” That would likely include more flexibility for states to opt out of some of the health law’s coverage requirements.

The delay has made Democrats more demanding, too. The repeal of the ACA’s penalties next year for people who don’t have insurance has changed the situation dramatically, says Sen. Murray.

“As I have made clear, the bipartisan bill I originally agreed on with Chairman Alexander will not make up for this latest round of Republican health care sabotage,” she said in a statement. “In fact, there are changes that now need to be made to our bill to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”

What’s at stake

But while Congress decides if it will take action, insurers are warning that doing nothing will lead to still higher premiums.

Premium rates for a “benchmark” silver plan could rise by 27 percent in 2019, the Blue Cross Blue Shield Association said earlier this month.

Congressional action on reinsurance and cost-sharing, the association predicted, would help push premium rates 17 percent below this year’s levels.

“Health plans are looking for certainty in the market,” said Justine Handelman, senior vice president in the association’s policy arm.

Ideally, Congress would include the funding in measures adopted this month, said Handelman, who spoke with reporters during a briefing at the association’s Washington, D.C., headquarters: “Most plans are filing premium rates by April.”

Kaiser Health Newsis a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

KHN senior correspondent Julie Appleby contributed to this story.

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The insurance broker President Trump nominated to lead the Indian Health Service, Robert Weaver, is firing back at the White House and the media after his nomination was withdrawn last week.

“The allegations raised against me in the media are baseless, irrelevant, and in the most important cases simply incorrect,” Weaver said in a press release Tuesday.

In January, The Wall Street Journalquoted a former colleagues of Weaver alleging that he had exaggerated his prior work experience.

More recently, there were reports that he voluntarily withdrew his nomination to head the IHS. But Weaver said in a letter to tribal leaders and supporters published Feb. 22 that the characterization was inaccurate.

“Regardless of what the press reports may say, I was forced out,” Weaver wrote. “I was involuntarily withdrawn.”

In his letter he said he “received a call giving me two minutes this past Friday afternoon at 4:30pm, on a three day holiday weekend, to decide to withdraw or face the public humiliation of having the White House withdraw my nomination, as demanded by a staff person from HHS.”

Weaver hasn’t replied to an interview request from NPR.

The Trump administration hasn’t named a new nominee to lead IHS, which has been without a permanent leader since 2015.

Democrats and Republicans on the Senate Committee on Indian Affairs are both urging the White House to name a new nominee quickly.

“I’m expecting better, and I hope the administration will send us a highly qualified candidate,” said Montana Republican Sen. Steve Daines. He said he didn’t get a favorable impression of Weaver when they met after he was nominated.

Sen. Jon Tester, a Democrat from Montana who is also on the Indian Affairs Committee, said Senate “due diligence” revealed problems with Weaver’s statements about his education and work history.

But Tester said he doesn’t fault the Trump administration for sending them a candidate who was not properly vetted.

“I think this can happen,” Tester said. “What I think is really important moving forward is that they get us somebody much sooner than later. So we can get them confirmed. … If they dilly-dally on this, and this position’s left open it’s a major problem for Indian Health Service and not good for our Native American folks that are depending upon Indian Health Service for their health care.”

An estimated 3.7 million American Indians and Alaska Natives eligible to receive care from the IHS. In treaties, Tribes were promised health care in return for giving up nearly all of their ancestral lands to the federal government.

This month the National Indian Health Board told Congress that the current IHS budget of $4.8 billion dollars will meet less than 47 percent of the need for Native American health care nationwide. But that group of tribal leaders says that bigger picture, the agency needs far more funding. A report it published last year says the real health care needs in Indian Country require a $32 billion infusion the IHS, phased in over 12 years.

Daines isn’t convinced money is the problem, and wouldn’t commit to whether he thinks IHS can function properly on its current budget. “Throwing more money at it isn’t going to solve the fundamental problem of lack of accountability and lack of leadership,” he said.

“You need to prioritize and look at where we spend the money,” Daines said. “One of the areas we need to address is to insure that the compensation structure for the health professionals that serve, the folks that are right there on the front line, delivering health care in Indian Country, that the wages they’re provided are competitive, so that we can attract and retain good health care professionals. That is an area that needs to be addressed, and that’s what we need to prioritize.”

For his part, Tester said, “It’s well documented that IHS has been underfunded now for decades, and you can’t get blood out of a turnip, you can’t get health care out of an agency that doesn’t have enough money to be able to do the job that they’re required to do.

“Congress also needs to do its job and make sure IHS has the dollars it needs, no more, no less, to do the job that’s required, and that’s to take care of the Indian people,” he said.

This story is part of a reporting partnership with NPR, Montana Public Radio and Kaiser Health News.

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