WASHINGTON -- Congress may have talked itself out of trying to kill Obamacare after more than seven years, so the idea of repairing the Affordable Care Act instead is gaining steam.
And Ohio Gov. John Kasich is playing a big role in trying to make that happen.
This became increasingly clear in the nation's capital this week, first with a series of bipartisan Senate hearings on stabilizing insurance markets and then with a Friday appearance by Republican Kasich and Democratic Colorado Gov. John Hickenlooper at a rather unusual gathering. The governors have been preaching a proposal getting broad political and public attention, and their appearance on a panel sponsored jointly by a conservative and a liberal think tank drew a full audience of policymakers and media.
The conversation in Washington has moved from "repeal and replace" to "stabilize," a word Kasich and Hickenlooper like to use, said Joseph Antos, a scholar in health policy at the conservative American Enterprise Institute.
"Well what's 'stabilize' mean?" Antos said, kicking off the morning forum at the American Enterprise Institute, or AEI, in concert with the Center for American Progress, a think tank with broad connections to Bill and Hillary Clinton and other Democrats. "It's the politically correct way of saying, 'Repair the Affordable Care Act.'"
Here are reasons "repair" rather than "repeal" seems increasingly likely, and Kasich's role in making that happen.
The Kasich-Hickenlooper show:
Despite some ideological differences, the governors have worked for months on what they called a practical, bipartisan way to make health insurance coverage more stable and affordable. Their proposal, unveiled last week, includes immediate steps to assuage fears by health insurers.
The top two: Congress should pass a bill guaranteeing federal cost-sharing payments that insurers relied on until now, and the White House should implement a reinsurance program to help insurers deal with their most expensive customers. The Affordable Care Act, or ACA, had a reinsurance program to help carriers with exceptionally high medical claims but it expired after three years.
Both of these ideas, while providing money for insurers, actually can hold down costs for insurance policy buyers without adding much cost, if any, for the government.
That's because while these would require government money at first, they would keep customer premiums from rising as high as they otherwise could -- and therefore hold down the amount of subsidies the government provides to help people pay those premiums. Paying on one end, in other words, saves money on the other.
Fearing President Donald Trump's threats this summer to stop making the cost-sharing payments, insurers have had to raise their proposed 2018 ACA premiums to make up for the possible loss. In Ohio, for example, premiums for the average individual policy bought on the ACA exchange will rise by 34 percent in 2018, with 11 percent of that solely to make up for the loss of cost-sharing payments, the Ohio Department of Insurance said this week.
Enrollment for 2018 starts Nov. 1, so there is still time for Congress to act or for Trump to use his executive power and keep the cost-sharing payments coming. But a delay beyond late September would crash aganst federal deadlines for insurers to agree to either be in the market or get out.
The Senate health committee this week held hearings to discuss ways to stabilize the ACA, and Hickenlooper and several other governors testified. Kasich joked he would have testified, too, but "they didn't invite me."
But the Ohio governor has spread his message through correspondence and meetings with Congress members and with regular appearances on national news programs. He is far from the only public figure to recommend these stability measures, but he is one of the most prominent Republicans to do so.
The changing politics:
This week's hearings were noteworthy because they signaled congressional Republicans appear serious about repair and not just repeal.
The congressional schedule may not allow enough time for repeal, anyway. Without a single Democrat joining the repeal caucus, Republicans need nearly every vote they can muster to repeal or, as they said, repeal and replace the ACA.
Efforts this summer showed they could not even meet a 50-vote threshold among their 52 members. Various Republicans had various reasons for voting no, including the prospect of being linked to the likelihood that, according to the Congressional Budget Office, at least 22 million Americans would lose health coverage.
Senators are discussing trying again with a new repeal-and-replace bill that could be introduced next week. It would give states more power to design their own health insurance rules. But their window is closing; to get a bill through with the bare minimum of 50 votes rather than the normal 60, Republicans must use a legislative procedure known as budget reconciliation. That comes with deadlines, and the deadline for this vote will be Sept. 30, barely three weeks away.
Trump's own priorities could play into this. Although Trump pushed Congress repeatedly for a repeal-and-replace measure in the first half of this year, he used Twitter early Friday to mock congressional Republicans for failing after more than seven years of trying. He suggested they need to move swiftly to tax reform.
The Kasich-Hickenlooper fan club:
Meanwhile, interest groups in Washington, including influential think tanks, are paying attention to the Kasich-Hickenlooper ideas.
Topher Spiro, vice president for health policy at the Center for American Progress and a former Democratic Senate health policy staffer, sang the duo's praises at the forum Friday.
"I want to applaud Govs. Kasich and Hickenlooper for their leadership," Spiro said. "They have put partisan politics aside for the moment and have identified solutiuons and targeted resources" that could lead to solutions.
Hickenlooper said he sensed an unusual level of bipartisan support at a Senate health committee hearing Thursday.
"Usually there are two sides" at Senate hearings, Hickenlooper said, and one side attacks the proposals and witnesses of the other side. But on Thursday, when Hickenlooper and four other senators testified, "pretty much every senator was supportive" of the proposals on cost-sharing payments and reinsurance.
After that hearing, Sen. Lamar Alexander, chairman of the health committee, said he hoped to introduce a bipartisan bill by the end of next week. The bill would address cost-sharing payments but might not include a reinsurance pool, according to Modern Healthcare, because it would take more time to deal with a reinsurance program.
The love isn't universal:
Not everyone speaking to, with or about Kasich and Hickenlooper is enamored of their ideas.
Avik Roy, president of the Foundation for Research on Equal Opportunity and an influential health care blogger for Forbes, said at the Friday forum that Kasich was far more critical of Obamacare when running as a Republican presidential candidate in early 2016.
Out-of-control costs and insurance affordability, driven in part by Obamacare regulations, are the real problems in health care, Roy said, and the Kasich-Hickenlooper plan doesn't address them.
"We've talked a lot about stabilizing insurance markets," he said. "But you know what's funny? We haven't talked about why insurance markets were destablized to begin with."
The ACA imposed regulations and requirements to buy insurance that often didn't meet consumer needs, Roy said -- a point on which Kasich later agreed, though in a different part of the program. The ACA doubled the cost of premiums over the last four years, Roy said, "and that's on average. If you're younger, if you're healthier than the average person, your premiums tripled."
By "stabilizing" markets, Roy said, the Kasich-Hickenlooper plan will nevertheless lock in those higher costs. While the government should fund the cost-sharing payments that insurers assumed they'd get under the ACA, he said, Congress still needs to address the ACA's broader problems.
The Kasich-Hickenlooper proposal, Roy said, merely throws "more money at the problem without addressing the things that actually destablize the market."
The next big thing:
Kasich has made clear that the proposal he and Hickenlooper presented is not their last step. If markets can be stabilized in 2018 and 2019 so rates don't go up as steeply and insurers stop leaving, governors and Congress can work on real reforms.
What would those reforms be?
This is where thing could grow heated again. Kasich on Friday talked of continuing the Medicaid expansion that the ACA facilitated, but rolling it back for healthy participants and getting them to buy private insurance instead -- possibly, as he has said before, with a subsidy.
He also talked of giving states flexibility to define their own array of comprehensive or essential health benefits, and of giving young adults more leeway in the kinds of policies they must buy. If they could buy policies that took care of medical catastrophies, let them put money in health savings accounts and took care of their primary care, that would cut their premiums and, for many, be more suitable than the full suite of coverage they now must buy, Kasich said.
He questioned why a 23-year-old who doesn't want maternity care should be requred to have maternity coverage, as the ACA mandates -- the logic being that if everyone shares in paying, it cuts what otherwise would be higher individuals' costs for this and many other kinds of medical expenses.
"You shouldn't have to comply with every one of those essential health benefits," Kasich said. "I can design a plan that can cover me and take care of all of my anticipated needs without having to go from A to Z."
States could set "commonsense" guidelines, Kasich said. Individuals and families could have a more inclusive plan if they wanted, "but they would pay more for it."
That prompted an audience question: How does Kasich reconcile what someone thinks he or she needs with the unpredictability of diseases such as cancer or a sudden car accident -- and the need for insurance to cover them.
Kasich said states and Congress would have to decide how "comprehensive benefits" are defined. But beyond that, he said, "you get a choice. Now if you're a 23-year-old woman, you might want maternity care." But a 23-year-old man might not.
Kasich said Ohio requires insurers to cover autism, for example. Small businesses opposed the provision, Kasich said, because it could drive up insurance costs. He wanted it anyway and got it. The same went for Medicaid expansion and the state's management of its Medicaid benefits, giving seniors more options for home care while holding down costs by working with private insurers.
The question, he said, is what is a "reasonable package that isn't going to leave them in the lurch? What's reasonable?"
What would be in a Kasich set of comprehensive health benefits, then?
"I can't tell you what that would be," the Ohio governor told the think tank crowd. "I would sit down" with advisers "and say, what do we want to do here?"
That's how he and Hickenlooper got where are today, he said.