Health care system a bipartisan problem in Congress

Dozens of U.S. counties might not have any plans to choose from on Obamacare’s insurance exchanges next year while consumers with options face double-digit rate increases in many places — putting Congress to choose among bipartisan fixes to the program, doubling down on repeal or following President Trump’s advice to “let it implode.”

The stunning collapse of Republican efforts to scrap President Obama’s signature health care overhaul left its linchpin exchanges intact but limping toward an uncertain future, the result of problems with the 2010 law itself and the White House’s wavering commitment to the law’s core mechanisms.

For now, the Trump administration is on the warpath, hinting again Sunday that it might pull back on enforcing Obamacare’s linchpin: the individual mandate that people buy health insurance or pay a fine.

Mr. Trump said that if Senate Republicans can’t cobble together 51 votes for a plan, then he might withdraw critical funds for insurers and the subsidies that blunt premium costs for Capitol Hill lawmakers and their staff members.

“If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” he said on Twitter less than 48 hours after every Senate Democrat and three Republicans sank a pared-down bill on a 49-51 vote that would have scrapped or delayed some of Obamacare’s mandates and taxes in order to prolong repeal talks.

On Sunday’s political talk shows, White House Budget Director Mick Mulvaney repeated the message, saying that “in the White House’s view, they can’t move on in the Senate” before voting again on some sort of health care bill.

“They need to stay. They need to work. They need to pass something,” he said. “And I think that’s not only official White House position on this right now; it’s sort of the national attitude towards it.”

Senate Democrats were relieved but refused to celebrate. Instead, they pleaded with Republicans to shore up the markets and “sit down and trade ideas” over reforms to U.S. health care — a frank acknowledgment of weaknesses in their law after a seven-year Republican repeal pledge was tattered.

Sen. John McCain, the Arizona Republican dealing with a shocking brain cancer diagnosis, cast the deciding vote against the “skinny repeal” bill in the wee hours Friday alongside Republican Sens. Susan M. Collins of Maine and Lisa Murkowski of Alaska, who resisted leadership’s push to debate health care at all.

While some Republicans fumed over the Senate’s failure, saying their party’s holdouts pulled a fast one on voters, others faulted the secretive process that led to the failure or rallied both sides of the debate to focus on the daunting challenge before them.

“I think you could see this was a very somber vote on both sides,” said Sen. David Perdue, a Georgia Republican who backed the leadership’s repeal-and-replace efforts. “I think even Democrats realize, ’OK, you didn’t fix it this way; now it’s on all of us.’”

It’s unclear what form that cooperation might take. Democrats have shown little interest in working toward the Republicans’ idea of a total overhaul of Obamacare and instead are calling for boosting the government control and taxpayer spending at the heart of their law.

Senate Majority Leader Mitch McConnell, Kentucky Republican, called on Democrats to offer ideas but said, “Bailing out insurance companies with no thought of any kind of reform is not something I want to be part of.”

Some liberals are pushing for the sort of government-run “Medicare for all” health care system advocated by Sen. Bernard Sanders, Vermont independent.

Sen. Tim Kaine, Virginia Democrat, said Americans should be able to choose a government-run insurance plan that competes with private companies on the Obamacare exchanges — a proposal that had to be removed from the bill in 2009 to win the votes of centrist Democrats opposed to socialized medicine.

“We ought to have a public option. Why not give people more options?” Mr. Kaine said on MSNBC. “If they want to choose private insurance over a public option, that doesn’t bother me.”

But Republicans control both chambers of Congress. Sen. Lamar Alexander, Tennessee Republican and chairman of the Senate Committee on Health, Education, Labor and Pensions, said he is focused on patching up the program as it exists. He said an individual insurance market in his state is “very near collapse.”

Ms. Collins and Sen. Bill Nelson, Florida Democrat, said a small group of bipartisan senators is discussing a path forward after Obamacare failed to attract enough healthy enrollees in the early round to keep costs in check, particularly harming those who earn too much money to qualify for taxpayer-funded subsidies that absorb rising costs.

“Nobody said Obamacare is perfect,” said Senate Minority Charles E. Schumer, New York Democrat, though he accused Republicans of undermining it. “The problem is when they tried to just pull the rug out from the existing system.”

House conservatives, though, are bent on proving their commitment to repeal.

The House Freedom Caucus will try to gather 218 signatures for a petition that would force a clean repeal bill to the House floor. The same bill made it through Congress in 2015 but failed in the Senate last week, so the effort would likely amount to political messaging.

“I think the voters want to see at least some members, at least one body able to show we can do what we said,” said Rep. Jim Jordan, Ohio Republican. “Maybe that gives a little incentive and pressure and motivation on the Senate to keep working and try to come up with a plan.”

The wild card going forward will be Mr. Trump, who blamed the repeal effort’s failure on Senate filibuster rules. He said Republicans were forced to craft a narrow bill that met arcane budget rules, even though rifts within the party were the main sticking point.

He said senators should waive the 60-vote threshold for regular legislation — something Republican leaders have resisted — so it can beef up its plan and let insurers sell plans across state lines.

A seething Mr. Trump also said he might fiddle with the coverage that members of Congress use for themselves and their families. Obamacare shifted members of Congress and many staffers out of the normal health benefits plan for federal employees and into the Obamacare insurance exchanges.

Yet the Office of Personnel Management under Mr. Obama decided that the employer contribution portion of premiums could be provided through the exchange in the District. Some conservative groups have been calling for that policy to be revoked.

Also under Mr. Obama, the Health and Human Services Department raced to fill counties where insurers had pulled out of the exchanges, potentially leaving them without any options.

Mr. Trump’s HHS says 40 counties spanning Nevada, Indiana and Ohio are projected to have zero carriers next year, yet it’s unclear if the department will be as proactive as it was in the previous administration to lobby other insurers to step in.

Sen. Claire McCaskill, a Missouri Democrat facing re-election next year, wants to let anyone stuck without an option on their Obamacare exchange to shop for insurance on the D.C. small-business exchange — the portal that members of Congress use. It’s part of a reform package Mr. Schumer is touting that would also extend Obamacare’s “reinsurance” program to backstop insurers that take on costly customers.

The most pressing decision facing Mr. Trump is whether to continue funding “cost sharing” payments that reimburse insurers for helping low-income customers.

House Republicans won a ruling last year that Mr. Obama was breaking the law by making payments to insurance companies even though Congress had specifically canceled that funding.

The Trump administration could easily drop the appeal to kill the payments, or the White House and congressional Republicans must decide whether to appropriate the money or let the payments continue on autopilot.

White House counselor Kellyanne Conway on Sunday said Mr. Trump will decide this week whether to cut off the payments. “That’s a decision that only he can make,” she said.

Health and Human Services Secretary Thomas Price said Sunday on ABC’s “This Week” that no decision has been made on the so-called cost-sharing reductions and that he didn’t want to comment further because the issue is the subject of ongoing litigation.

Pro-Obamacare lawmakers have said even the threat of withholding the payments sows uncertainty in the insurance markets, would simply result in hefty premium increases for consumers and was a way for the administration to undermine the law.

“It’s incomprehensible that we have a president of the United States who wants to sabotage health care in America,” Mr. Sanders, whose progressive coalition almost denied Hillary Clinton the Democratic presidential nomination, said on CNN’s “State of the Union.”

Millions of Obamacare customers with incomes from 100 percent to 250 percent of the poverty rate rely on the payments. With repeal off the table, health care plans are still required to reduce their out-of-pocket costs whether they are reimbursed or not.

Insurers say a decision to retain those payments should be coupled with a clear signal that Mr. Trump intends to enforce the individual mandate designed to herd healthy people into the markets and keep premiums low.

But the IRS, citing an executive order from Mr. Trump, has weakened its enforcement of the mandate, and conservatives say they aren’t willing to front the money for cost-sharing reductions.

Mr. Price said Sunday that waiving Obamacare’s individual mandate is possible.

“All things are on the table to try to help patients,” Mr. Price said on ABC’s “This Week.” “What we’re trying to do is to make it so we have a health care system that responds to the needs of the American people.”

He added: “When the federal government gets in the way of responding to those needs,” it needs to start “allowing the American people to actually provide coverage and care for them themselves across this land.”

House Freedom Caucus Chairman Mark Meadows, North Carolina Republican, said House Republicans extended the cost-sharing payments as part of its repeal-and-replace package, recognizing that the insurance markets needed stability during the transition to a new system, yet there is little appetite to fund them under the status quo.

“They’re at risk,” he said.

• Dave Boyer and David Sherfinski contributed to this report.