Responding to the uproar over ObamaCare premium hikes, Hillary Clinton on Tuesday promised: “We’re going to make changes to fix problems like that.”

The question is: What changes could actually get through Congress?

{mosads}Both parties agree that ObamaCare has problems. Premiums are rising sharply, and the pool of enrollees is smaller and sicker than expected. 

But the agreement mostly ends there. Republicans say the law should be repealed, a position echoed by their presidential nominee, Donald Trump.

Should Clinton, the Democratic nominee, win the White House, most if not all of her ideas for changing ObamaCare would have virtually no chance of passing Congress, so long as Republicans control the House and/or Senate.

Clinton is calling for adding a public insurance option to increase competition with private carriers, but Republicans and some Democrats fiercely oppose that idea. 

She is urging an increase in the financial assistance available under the law to make premiums more affordable, but Republicans say that would be doubling down on a failed system. 

Less sweeping changes perhaps could be part of a compromise with Republicans. Democrats say it is long past time for the GOP to drop its hard-line opposition to the law and come to the table to make fixes. 

“While weeks before an election is obviously not the time to negotiate the exact best way to proceed, it is time to begin to move beyond the stale debates of old and move forward in a more collaborative fashion,” Chris Jennings, an informal adviser to Clinton on health policy, wrote in an email. “The hope and expectation is that Members of both parties will be open to doing that.”

One relatively straightforward way to stabilize the ObamaCare marketplaces would be to extend a program called reinsurance. That program collects money from insurers and redirects it to insurers with especially sick and costly enrollees, helping to guard against premium hikes and heavy losses. 

The program is expiring after this year, and Republicans have denounced it as a “bailout” of insurers.  

Insurers are expected to seek a renewal of the program.  

“Certainly the insurers are going to be pushing really hard for that,” said Ron Pollack, executive director of Families USA, a liberal healthcare advocacy group that was a major player in getting the healthcare law passed.

Pollack said there could be an alliance between insurers and consumer groups like his to push for an extension of the reinsurance program or for the extension of a similar program known as risk corridors.  

One option that could face less opposition from the GOP would be changing an aspect of ObamaCare known as age rating. 

Under the healthcare law, premiums for older people can be no more than three times as much as they are for younger people. Proponents of a change say loosening the restriction to a 4-to-1 or a 5-to-1 ratio would allow premiums to be lowered for young people, a crucial step for getting more of them to sign up for ObamaCare coverage.  

But changing the ratio would mean charging older people more, something Democrats would be loath to support.

“Democrats would never agree to loosening age rating without mitigating the harm to older people,” said Topher Spiro, vice president for health policy at the Center for American Progress, a liberal think tank with ties to the Clinton campaign.

One solution would be to increase subsidies for older people as part of the deal, to cushion them from higher premiums.   

There have already been some discussions about a deal on changing ObamaCare’s age rating.  

A Democratic health adviser spoke to congressional Republicans recently about changing the age rating ratio, with a subsidy for older people, and said the reaction was “favorable.”

House Republicans have already put forward a bill to change the age ratio to 5 to 1. The House Energy and Commerce Committee held a hearing on the measure in June, in what was seen as a significant break from the push for full repeal. 

However, in the run-up to the election, Republicans are bashing ObamaCare and again stressing their desire to repeal it. 

Democrats say they will have to wait until the dust settles from the election to figure out whether Republicans will be willing to make deals on ObamaCare. 

“It’s going to be very hard to figure out how much bipartisanship there’s going to be until we can see the results of the civil war within the Republican Party,” said Pollack of Families USA.

Even if Democrats and Republicans cannot agree on any changes to be made, many experts say ObamaCare would not collapse; it would simply remain a smaller, sicker and more highly subsidized market than originally imagined. 

“In the event changes are not made, it becomes a subsidized low-income insurance program,” said Dan Mendelson, president of Avalere Health, a consulting firm, and a former White House health adviser for President Bill Clinton. 

“It will be very accessible to anyone who doesn’t have to pay for it,” he added, while the minority of consumers who do not receive federal subsidies would be driven away. 

The Obama administration has already been taking some steps on its own to stabilize the market, including actions to tighten the rules for extra sign up periods that insurers complain sick people are using to game the system. Officials are also seeking to sign up more young people in the coming enrollment season.

While Clinton could continue with such administrative fixes, the onus is on Congress to make major changes.  

“What you’re getting from the administration is a lot of spin about how great things are,” Mendelson said. “And what you’re getting from the Congress is an abdication of responsibility.” 

Tags Bill Clinton Donald Trump Hillary Clinton

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