Jayne O'Donnell

USA TODAY

A Monday court hearing offers the Trump administration its best opportunity to prevent significant increases in health care costs for about 7 million lower-income Americans who buy their plans on the Affordable Care Act exchanges.

The administration's next move could prevent these insurance marketplaces from imploding as insurers are deciding which states, if any, to sell insurance in and at what price.

The hearing is part of a lawsuit filed by House Republicans claiming Congress hadn't authorized payment of the subsidies to insurers to help consumers defray their out-of-pocket insurance costs. If they don't know the subsidies are going to be paid next year, insurers will price plans up to 20% higher to cover their costs, the Kaiser Family Foundation estimated.

A lower court ruled that the subsidies were not authorized, and the Obama administration filed an appeal. It's unclear whether the Trump administration will ask for the case to be delayed until August (after insurers have to file their proposed 2018 premiums), allow the case to proceed or withdraw the Obama administration's appeal. None of these outcomes would provide relief to insurers

"The only outcome that is acceptable" is for the Trump administration to announce they are committed to paying the subsidies through 2018, said Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services. That is the certainty insurers need to confidently continue selling on the ACA exchanges, he said.

"If they do that, health plans will rush back," says Slavitt, now with the Bipartisan Policy Center and a USA TODAY editorial page columnist. "If they kick the can down the road, you’re basically sowing more uncertainty."

President Trump has warned that he might withhold the payments to pressure Senate Democrats to support the House-passed Obamacare replacement bill.

As Democrats and Republicans spar over who deserves blame for problems in the Affordable Care Act markets, a bipartisan cross-section of insurance regulators and health industry officials is pressuring the Trump administration to help solve them before the insurance exchanges implode.

The National Association of Insurance Commissioners asked Senate leaders Wednesday to commit to funding the subsidies through 2018. Last month, an unlikely coalition that included the U.S. Chamber of Commerce, the left-leaning American Academy of Family Physicians and trade groups for insurers and hospitals co-signed a similar letter to Trump and administration officials.

Supporters of the law say the Trump administration has weakened the ACA with a series of actions — including Trump's varying statements on the subsidies — that led to much higher premiums and insurers' withdrawals in several states. Critics say the law was doomed before Trump took office.

Health and Human Services spokeswoman Alleigh Marre said in a statement that it would require "impressive mental gymnastics to make the case that Obamacare is working."

"Obamacare has failed," said Marre. "For this reason, Republicans are reforming healthcare so it delivers access to quality, affordable coverage to the American people.”

Some say there's plenty of blame to go around.

“I think it is reasonable to partially blame the Trump administration for the recent premium increases, due in large part to the president’s consistent messaging that the law is imploding and we want to repeal it,” says Christopher Condeluci, a former Republican counsel to the Senate Finance Committee who drafted portions of the ACA.

But Condeluci believes the way the Obama administration implemented the ACA caused most of the current market woes, with fewer healthy people signing up for coverage, which leads to higher premiums. He attributes 30% of the blame to the Trump administration and 70% to the Obama administration.

Insurers have said somewhere between 15% and 40% of their rate increases were due to efforts to undermine the law in D.C., according to ACASignups.net.

A poll out Monday by Democratic pollster Geoff Garin found 46% of voters said Trump has a lot of the responsibility for the ACA's success or failure, while 33% said he has some responsibility. Just 21% said he bore only a little or no responsibility. Among those who voted for Trump, 71% said he gets some or a lot of the responsibility for the future success or failure of the law. More than 1,000 people were polled online May 13 to 15. They were about evenly split between Democrats and Republicans.

As most state deadlines approach for insurers to announce their proposed rates and plans for 2018, if they "still don’t know what the rules will be," many will err on the side of caution, says Pennsylvania insurance commissioner Teresa Miller. "It could cause insurers to exit and individual markets to collapse."

What else affects the market:

• Shorter open enrollment. Center for American Progress senior policy adviser Sam Berger cites the Trump administration's decision to shorten the open enrollment period for 2017 and 2018 as an example of how it is undermining the law. Condeluci points out that it was the Obama administration that first proposed the short enrollment period, and that this administration simply implemented it earlier. The plan was for the enrollment period to be shortened in 2019 — or later — when the exchanges were running smoothly, says Slavitt. Insurers prefer shorter enrollment periods as sicker people are more likely to sign up if it extends into the new year, Slavitt said.

• Enforcement of tax penalty. Trump signed an executive order the day after he was inaugurated that authorized federal agencies to minimize the economic and regulatory burdens of the ACA. The Internal Revenue Service announced soon after that it was going to continue to process tax returns whether or not people checked the box that they had health insurance. That led to continuing speculation that the uninsured won't have to pay the penalty at tax time. But Condeluci says that's the way it had been all along; it just had been slated to change for the 2016 tax year and didn't. He blames the media for blowing the decision out of proportion. Without the requirement that everyone have insurance or pay a penalty, healthy people become less likely to enroll and offset the cost of insuring the sick.

• Advertising — or not. The Obama administration aggressively promoted the open enrollment period deadlines and health care exchanges, while Trump's tweets and Health and Human Services press releases instead emphasize the failure of the law. The Trump administration also cut the marketing budget ahead of the late 2016 open enrollment deadline, so the "very obvious result was fewer people signing up," says Slavitt.

There's both good and bad news in the states and Washington, D.C., where insurers had to file their rates already, says Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms.

"Multiple insurers submitted initial plans, but they are asking for pretty significant rate hikes in most of these states," says Corlette.

In Connecticut, proposed rates increases for 2018 individual plans range from about 15% to nearly 35%.

"The uncertainly about cost sharing subsidies and enforcement of the individual mandate, definitely has had an effect on 2018 rates," says Connecticut real estate broker David Isenstadt, who owns New England Insurance Group.

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