Trump faces risky ObamaCare choice

President Trump is facing a risky choice over whether to follow through on his promise to let ObamaCare collapse.

Trump has predicted that Democrats will own ObamaCare if it falls apart, which he said would happen after legislation repealing the law was pulled from a House vote because of opposition from Republicans.

But a recent poll from the Kaiser Family Foundation shows a majority of voters would blame Trump and Republicans for any “future problems” with the healthcare law.

Asked if Democrats or Republicans would be responsible for any future problems with the law, 61 percent said that since the GOP is in control of the government “they are responsible for any problems with it moving forward.”

Trump’s administration faces several difficult decisions in the coming months that could contribute toward helping the healthcare law or harming it.

In the coming weeks, the Trump administration will need to say clearly whether they plan to fund cost-sharing reductions — payments that reimburse insurers for providing discounted deductibles to low-income ObamaCare enrollees. 

In an interview with The Wall Street Journal Wednesday, Trump said he was considering withholding the payments to force Democrats to work with him on healthcare. 

"I don't want people to get hurt. What I think should happen — and will happen — is the Democrats will start calling me and negotiating." 
But he seemed to acknowledge that he and Republicans could face the blame if the law collapsed. 
"That's part of the reason that I may go the other way" on making the insurer payments, he said. 
"The longer I'm behind this desk and you have ObamaCare, the more I would own it." 

The administration also must finalize a regulation proposed by the Department of Health and Human Services in February that is intended to help prevent insurers from leaving the market or raising premiums. Insurers have called it a good first step toward stabilizing the markets. 

Taking steps to help insurers and bolster ObamaCare could lead to heat from conservatives, who argue a Republican administration should do nothing to help the law.

If he does nothing, and insurers leave the market, Trump would also be taking a risk — if voters blame Trump and Republicans, and not Democrats, for rising premiums and fewer healthcare choices.

Rural voters could especially feel the impact if insurers leave the marketplace, and many of them are Trump voters.

“It’s a calculation they’re going to consider — whether or not the American people will hold them accountable for making sure they enforce the law and have access to coverage,” said Andy Slavitt, who was acting director of the Centers for Medicare and Medicaid under former President Obama for two years.

“I think they will be facing some pretty forceful judgment if they chose not to.”

There is tremendous uncertainty right now in ObamaCare’s insurance markets — in part because of the GOP’s on-again, off-again repeal effort and questions over whether Trump will continue insurer payments that have been made under the law.

Some insurers have already announced that they won't sell plans on the exchanges next year, and more could follow if they don’t get promises from Congress or Trump that they will fund the cost-sharing reductions through all of next year.

That could leave ObamaCare enrollees with no way to use their subsidies and no options on the exchanges.

The Obama administration stepped in to work with insurance companies to make sure all counties have at least one insurer. A primary example came in the summer of 2016 in Pinal County, Ariz., when the administration pressured other insurers to fill that gap. Blue Cross Blue Shield eventually did.

It’s unclear if Trump will take the same steps.

The administration has sent mixed signals to insurers, said Cynthia Cox, a health policy expert with the Kaiser Family Foundation.

“On one hand there were a few new regulations that signaled a willingness to stabilize the market, and they were very favorable to insurance companies,” she said.

“On the other hand, President Trump has made comments about the market exploding and letting that happen. They’re very mixed signals for insurance companies that needed answers yesterday on what the rules for the game are going to be next year.”

Insurers have until June to file rates and plans for 2018, though they could still decide later to make changes to their plans, or event to leave the market altogether.

So far, Humana is the only insurer to say it won’t participate next year in ObamaCare's exchanges, though other insurers are pulling out in Iowa.

Tennessee's insurance commissioner has been in talks with the state's remaining insurers — Blue Cross Blue Shield and Cigna — to fill gaps in that state but doesn't yet have any commitments, a spokesman told The Hill.

“At this time, we have no commitments from other carriers willing to cover that area in 2018,” said Kevin Walters, spokesman for Tennessee’s Department of Commerce and Insurance.

They also don't have any assurances that the insurers already in Tennessee will stay there.

“The Department agrees with Sen. Lamar AlexanderAndrew (Lamar) Lamar AlexanderOvernight Health Care: Trump health chief backs CDC research on gun violence | GOP negotiators meet on ObamaCare market fix | Groups sue over cuts to teen pregnancy program GOP negotiators meet on ObamaCare market fix 30 million people will experience eating disorders — the CDC needs to help MORE’s position that, absent any national direction, there could be Tennesseans who currently buy insurance who may not have any choice for insurance on the exchange in 2018,” Walter said.

Alexander (R-Tenn.) has been supportive of stabilization measures to encourage insures to stay in the market.

He and Sen. Bob CorkerRobert (Bob) Phillips CorkerCongress punts fight over Dreamers to March Drama surrounding Shulkin — what is the future of VA health care? Blackburn pushes back on potential Corker bid: 'I'm going to win' MORE (R-Tenn.) also proposed a bill that would allow people who live in counties without an ObamaCare insurer to use their subsidies for other plans on the individual market.

In Iowa, two of the state's four insurers announced they would not participate in 2018 — Wellmark Blue Cross Blue Shield and Aetna.

That leaves 94 of the state’s 99 counties with only one insurer, Medica, which said it needs to “carefully consider its options” in light of Wellmark's announcement.

A spokesman with Medica told The Hill there is no update on Medica’s plans.

But Anthem, which operates in 14 states, also appears to be eyeing the door.

Analysts at Jeffries, an investment bank, concluded that Anthem is “leaning toward exiting a high percentage” of the areas it currently covers. 

Anthem's departure would be devastating for the exchanges. 

According to an analysis by Katherine Hempstead at the Robert Wood Johnson Foundation, an Anthem exit would leave nearly 300 counties with no carrier, including large parts of Missouri, Kentucky and Georgia.

An additional 227 counties would only have one carrier, the analysis found.

Slavitt, the former CMS director, said if the Trump administration added clarity then he thinks every county would have at least one insurer next year.

“I’ve had enough experience and conversations to believe if they put in the amount of effort and enforce the law and pay cost sharing reductions, there will be insurers in every county, including Knoxville.”