House Republicans don't want to fund cost-sharing reduction payments in spite of a deal Sen. Susan Collins struck with Senate GOP leadership.
To get the Maine Republican's vote on tax reform, Senate leaders agreed to address market stabilization in a short-term government funding package.
For their part, House Republicans hinted they could go along with CSR funding so long as some conservative policies are attached, including controversial language restricting funding for abortions. However, that would stymie attempts to get a package included in the end-of-the-year spending bill that must pass by Friday to avert government shutdown.
"There's more pushback to CSRs than anything else being added to the spending bill," Rep. Mark Meadows (R-N.C.), chair of the ultra-conservative House Freedom Caucus, told reporters Tuesday. He doesn't see CSR funding moving before Dec. 22.
Already, one healthcare lobbyist said, the House is considering a punt to January to sort these issues out even though Collins secured Senate Majority Leader Mitch McConnell's pledge to move CSR funding—through a compromise bill by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.)—and reinsurance. It still isn't clear whether the Senate would attach Alexander-Murray's bill and Collins' reinsurance bill, which she co-authored with Sen. Ben Nelson (D-Neb.), to the continuing budget resolution which the Senate has to send back to the House.
House Republicans could be even more reluctant to follow the Senate's lead should the upper chamber decide to fund CSRs for 2018, because the government will be paying out higher premium tax credits next year no matter what.
This is because insurers baked CSRs into their 2018 rates. Most states directed their carriers to pile the CSR costs into the benchmark silver plans so that subsidized enrollees wouldn't see their rates climb. The premium tax credits for subsidized enrollees are calculated based on those silver plans.
It's too late now for those premium tax credits to change, said Kris Haltmeyer, vice president of health policy and analysis at the Blue Cross and Blue Shield Association.
Meanwhile, some Republicans are still grappling with how CSRs—payments the government makes to insurers so insurers can help low-income enrollees with co-pays and other cost-sharing—affect premiums and thus premium tax credits.
"The issue is, the whole Obamacare issue, a lot of it is counterintuitive" about the CSRs, said Rep. Brett Guthrie (R-Ky.), vice chair of the House Energy and Commerce health subcommittee. "Those are things we have to work through."
Skepticism about CSRs is widespread among House Republicans.
Rep. Chris Collins, a New York Republican who belongs to the moderate Tuesday Group caucus, said he would "hold his nose" and vote to fund them only if he had to.
House Ways and Means Committee Chair Kevin Brady (R-Texas) said most House Republicans consider CSR funding as leverage for other health reforms. For instance, he would advocate for including provisions that broaden consumer choice of plans.
Adding to the drama, House Democrats—who have their own policy demands for the continuing resolution—aren't a lock to support CSR funding, either. House leadership would need those votes if they lose Meadows' Freedom Caucus block.
"If it came as free-standing bill, we would support it," House Minority Whip Steny Hoyer (D-Md.) said. "On the other hand, if it's attached to things we think are harmful, either to healthcare or to the budget, we'll have to make a judgment call."
Hoyer also noted that Democrats don't think it will affect rates much, if at all, in 2018.
The Alexander-Murray bill would let states decide how to pass rebates on to exchange enrollees.
Matt McColm, a health insurance broker with Suzie Health Solutions in Washington state, said if CSRs are funded before June people would see their premiums lowered.
But the process could be confusing and difficult, said Sean Mullin of Leavitt Partners, particularly since some people might want to change plans once the CSRs alter pricing tiers.
"Administratively, you can figure out how to price the changes in. It's hard, but doable," Mullin said. "But do you let people switch plans? It's very tricky."
