In North Dakota, where about 10% of people get insurance through the Obamacare exchange, officials are looking to pre-Affordable Care Act rules to keep that marketplace working.
About half of the state's tiny individual market is unsubsidized, made up of small farmers, ranchers and business owners for whom spiking premiums aren't a good option. State Insurance Commissioner Jon Godfread has issued a request for proposals on a 1332 waiver that would revive the state's dwindled high-risk pool—established in 1989 for high-cost patients who were being denied insurance coverage and rendered mostly obsolete by the ACA's guaranteed-issue rules. He is also eying Idaho's push for state-based plans that don't follow all the ACA mandates but still offer broad coverage as another way to attract younger and healthier people.
Mostly, Godfread wants the government to let him do more.
"We are ripe for some pilot projects and ideas, but frankly we're not going to get that through a 1332 waiver, or through the ACA framework as it exists now," Godfread said. "We want the control turned over the state. The federal government hasn't gotten it right."
The policy work on the individual market has shifted to states while Congress has largely moved on to the Trump administration's priority list, such as drug pricing, broader transparency issues and rural healthcare access, but lawmakers on both sides of the aisle still pay lip service to their positions on Obamacare.
With the individual mandate effectively gone and the Trump administration pushing short-term plans, Democrats are blasting Republicans for this year's wave of rate hikes. Polling is in their favor: 50% approve of the ACA compared to 43% disapproving, according to a Kaiser Family Foundation poll this month.
As Sen. Chris Murphy (D-Conn.) puts it, Democrats ought to be "talking about healthcare 50% of the time. We ought to be talking about sabotage 80% of the time." However, he noted, decisions about how exactly to unwind the GOP effect on the exchanges will likely have to wait until the Democrats win back both the House and the Senate.
"It could take a while to get to that next step," Murphy said.
Joseph Antos of the right-leaning American Enterprise Institute predicted that timeline will likely drag out until the next presidential cycle at least. For Republicans, the individual market that covers a small slice of America has become a political albatross. Both parties balked at restoring the cost-sharing reduction payments halted by President Donald Trump in October. While Democrats decried Trump's move, they ultimately accepted it as the majority of insurance commissioners piled the payments into silver plans, thereby increasing subsidies for lower-income enrollees. A push by Sens. Lamar Alexander (R-Tenn.) and Susan Collins (R-Maine) to restore these payments and establish a federal reinsurance fund to help bring premiums down fell apart in March as political will failed.
"We're stuck exactly where we are," Antos said. "It's not a question of an unstable market. Insurers know what they should do; insurance commissioners know what they can accept; and here we are. It means more money out of the general federal revenues, but that's the price of political gridlock."
Sen. Claire McCaskill (D-Mo.), considered one of the most vulnerable incumbent senators up for November re-election, said she sees the country at a "breaking point" when it comes to healthcare prices and is looking for opportunities to push through gridlock with smaller efforts that get at wider anxiety.
"I don't know and don't care how quote-unquote Democrats should be addressing healthcare," McCaskill said. "I know how I'm going to address healthcare as the most important issue facing Missourians in terms of their anxiety and their worry about their copays, their deductibles and the cost of medicine particularly."
McCaskill noted that when it comes to anxiety, she is not only talking about the exchanges.
"It's really, frankly, also for people getting insurance at work," she said. "It's for people who are on Medicare. I don't think enough people (in Washington) realize how worried and stressed people in this country are about this."
She wants to talk about drug prices but her ideas go further than the White House and push for volume discount negotiating within Medicare, as Trump promised on the campaign trail.
Sen. Bill Cassidy (R-La.), who authored the last Republican attempt to repeal-and-replace the ACA—a proposal would have turned over substantial federal regulatory authority to the states along with a capped allotment of funding—also has his sights aimed at cost, specifically through transparency measures.
"I think there is tremendous political will to try to lower healthcare costs," Cassidy said. "The president's message about lowering healthcare costs is exactly about that."
McCaskill and Cassidy both touted their co-sponsored bill that would forbid carriers and pharmacy benefit managers from adding so-called "gag clauses" to contracts. These contracts block pharmacists from telling plan enrollees if they would pay less for a drug if they buy it without insurance.
Alexander, who chairs the Senate health committee—which has steered health work in the upper chamber this year from opioids to the 340B drug discount program—also has healthcare costs on his list, as well as other HHS-led priorities like cutting regulations on electronic health records.
But when it comes to the ACA, he doesn't see the point of more talk.
"The Democrats won't agree to change even a sentence of Obamacare, so there doesn't seem much prospect of doing that," Alexander said.
For others like Sen. Doug Jones, the freshman Democrat from Alabama, problems like rural access are key. He is homing in on matters like the Medicaid wage index—Alabama has the lowest in the country—and rural broadband expansion so hospitals and doctors can use telehealth to reach patients.
Rep. Cheri Bustos (D-Ill.), who hails from a purple, rural district that went for Trump, didn't shy away from talking about the ACA—it's more popular than ever, she said, but current policies are pointing the law in the wrong direction. Even if Democrats take the House she wants to work on policies that both sides can rally around, particularly drug prices and expansion of telehealth.
"Prescription drugs seem to be the top issue that we can work on together," Bustos said, noting she wants to push for negotiating prices through Medicare.
In North Dakota, Godfread said people are facing the problems endemic everywhere: rising costs as hospitals buy up physician's practices, high drug costs and more. There is little he can do about that, but he wants to make sure people can still afford insurance.
A 1332 waiver, if approved, would bring new problems to solve. The state would have to pay for it, and Godfread isn't sure whether North Dakota can afford it. The old reinsurance pool from 1989, which at its peak covered about 5,000 people and now covers around 300, was funded through a tax on carriers.
North Dakota and other states are watching whether Idaho's talks with HHS about offering state-based plans will translate into states being able to opt out of some of the mandate rules to lower rates. An Idaho Statehouse lobbyist told Modern Healthcare that talks continue to move forward.
"I would imagine if the Idaho plan is approved, you'll see a few other states jump on board," Godfread said.
Depending on how that contingency plays out, the ACA conversation may look very different when Congress is ready to take it up again.
An edited version of this story can also be found in Modern Healthcare's May 28 print edition.
