Health insurers are signaling they'll go along with Republicans' plans to repeal most of the Affordable Care Act—but only if new legislation includes a strong substitute for the ACA provision encouraging younger and healthier people to buy coverage.
It's highly uncertain, both procedurally and politically, that GOP leaders can quickly pass such a provision. That is widely viewed as necessary to avoid a chaotic meltdown in the individual insurance market where nearly 20 million Americans get coverage.
In spite of the uncertain future of the exchanges, sign-ups in the open enrollment period that started Nov. 1 are outpacing last year's numbers, according to the Obama administration. More than 1.6 million Americans had renewed their coverage by the end of November, and another half million consumers who are new to the marketplaces selected plans.
GOP leaders have announced plans to abolish most of the ACA as early as next month through an expedited budget reconciliation bill requiring just 51 votes in the Senate. The legislation would delay much of the impact for two or three years to allow Congress to craft and pass a replacement plan, but Republicans have signaled they are inclined to nix the mandate immediately.
Some of the ACA replacement proposals floated by Republicans outline measures that would require people to maintain unbroken coverage to avoid higher premiums and loss of coverage for pre-existing conditions.
America's Health Insurance Plans, the industry's largest lobbying group, said one of its key conditions for accepting the elimination of the ACA's so-called individual mandate is the creation of strong incentives for people to maintain continuous coverage. Otherwise, they warn, healthier consumers will drop insurance; sicker people will stay in; costs and premiums will shoot up; and insurers will abandon the individual market in 2018.
As examples of policies that could compensate for the loss of the mandate, AHIP pointed to Medicare rules imposing higher premiums on seniors who wait to sign up for Part B, Part D and Medigap coverage. AHIP also mentioned waiting periods or penalties for people who have had a break in private coverage.
But it's not clear that Senate rules would allow new requirements for continuous coverage as part of a budget reconciliation bill, which can only include provisions with a direct impact on the federal budget and that do not raise spending.
If Republicans can't get the coverage rules into a reconciliation bill, they would have to pass them in separate legislation requiring 60 votes to overcome a likely Senate Democratic filibuster. That means they would have to get Democratic support, and Senate Democratic leader Chuck Schumer has said his caucus will not take part in any GOP effort to repeal the ACA without replacing it.