Obamacare premiums are once again poised to spike by double digits in 2019, causing heartburn for politicians as voters will head to the polls within days of learning about the looming hit to their pocketbooks.

But unlike recent campaign cycles, when Republicans capitalized on Obamacare sticker shock to help propel them to control of Congress and the White House, they’re now likely to be the ones feeling the wrath of voters.


That’s because Republicans are now in total control of the federal government and therefore on the hook for the health care system’s chronic shortcomings. Polling data has consistently suggested that more voters will blame Republicans for future problems with Obamacare. In addition, the GOP’s repeated failures to repeal Obamacare after eight years of campaign promises will make it difficult to galvanize the base on health care.

Democrats and their allies have been hammering President Donald Trump and congressional Republicans for “sabotaging” the health care markets and driving up premiums. Protect Our Care has been running digital ads in 13 states featuring news coverage of big rate hikes and concluding with a sound bite from Trump: “Let Obamacare implode.”

They hope that message will stick with voters come November.

“The political implications go only as far as people understand that they are a direct consequence of the administration’s actions,” said Rep. Raul Ruiz (D-Calif.), a medical doctor who sits on a key committee that oversees health care. “If they realize that, then they will be very, very upset with them.”

In particular, Democrats blame Republicans for eliminating the mandate penalty for failing to obtain health insurance, which was designed to be a cudgel to compel people who might otherwise go uninsured to buy coverage. They also point to the Trump administration’s efforts to make it easier to buy skinnier, cheaper plans that don’t meet the Affordable Care Act’s coverage requirements and patient protections as an exacerbating factor.

“Once they fractured the mandate, that changed the insurance pool,” said Rep. Richard Neal (D-Mass.), ranking member on the Ways and Means Committee. “Insurance is based upon shared risk, meaning fewer people contributing, the premiums escalate.”

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Republicans scoff at the notion that they’re to blame for Obamacare’s failings. They point out that big rate hikes were a chronic condition of the exchange markets long before they took full control of the government.

“The Affordable Care Act has been a total failure,” said Rep. Buddy Carter (R-Ga.), a pharmacist who serves on one of the key House committees dealing with health care. “It’s been a train wreck since Day One. What we’re trying to do is to fix it.”

Republicans further argue that Democrats sabotaged a bipartisan effort to pass legislation designed to stabilize the markets and reduce rate hikes. They contend that Democratic concerns over abortion language that ultimately derailed the deal were a smokescreen.

“They are the reason why we didn’t pass the legislation that would have solved the issue,” said Sen. Bill Cassidy (R-La.), who has been closely involved in efforts to come up with a Republican plan to replace the ACA. “I can only guess that it’s politics.”

Democrats counter that the GOP added the abortion restrictions knowing that would be the deal-breaker.

Insurance experts generally agree that the rate hikes will be more severe because of actions taken by the Republican-led Congress and the Trump administration.

“If it hadn’t been for the individual mandate being repealed, and the threat of short-term and other loosely regulated plans proliferating, I think we would have seen single-digit premiums increases,” said Cynthia Cox, an insurance expert at the Kaiser Family Foundation. “Insurers are performing much better on the exchange markets than they had in the early years.”

However, that strong financial performance of the markets is also complicating Democratic talking points about sabotage. In many states, competition is increasing as insurers see opportunities to move into markets with little competition. Most notably, Oscar Health — the tech-friendly startup that’s lost hundreds of millions in the Obamacare markets — is entering or expanding its footprint in six states.

That’s a stark contrast from last summer, when dozens of counties across the country were at risk of having no competing insurers due to market exits.

But double-digit premium increases are still likely in many states, as evidenced by the rate filings that have been trickling out in recent weeks. Premiums for the most popular Obamacare plans are going up by 15 percent on average — about $100 per month — according to an analysis of rate filings in 10 states by Avalere Health. While rates won’t be finalized until the fall, it’s already clear that there will be wide discrepancies across the country that could affect the political salience of the issue.

Insurers in Maryland want to raise rates on the most popular plans by an eye-popping 53 percent, while New York insurers are seeking average premium increases of 24 percent. By contrast, insurers in Pennsylvania want to raise premiums by only 5 percent on average. All four insurers selling Obamacare plans in Minnesota want to decrease premiums.

One big factor affecting the severity of the rate hikes is how insurers account for the removal of the individual mandate. The Congressional Budget Office has projected it will increase premiums by 10 percent, mainly because fewer healthy people will opt to enroll, but Republicans have scoffed at that as an unrealistic assessment of the mandate’s significance.

“It’s really kind of a crapshoot for the actuaries to say, well, it is or it isn’t going to have an effect,” said John Baackes, CEO of L.A. Care Health Plan, which has 70,000 Obamacare customers. “We will make a decision with our gut.”

Highmark Health, which sells Obamacare plans in Pennsylvania, West Virginia and Delaware, plans to raise premiums by 5 percent next year to account for the repeal of the mandate. The insurer made money on its Obamacare customers last year after piling up big losses on that book of business in prior years.

“The rates are catching up to the risks,” said David Holmberg, Highmark Health’s CEO. “Every time you change the rules you disrupt that.”

The other major wild card is the Trump administration’s efforts to increase the availability of cheaper plans that don’t meet the ACA’s coverage requirements. On Tuesday, the Labor Department finalized rules making it easier for small businesses and self-employed workers to band together to purchase association health plans. Still in the pipeline are regulations that will expand the availability of short-term plans.

What it all comes down to for insurers is trying to gauge how many people will drop coverage entirely or seek options outside of the Obamacare markets due to the changes, said Jim Whisler, who leads Deloitte Consulting’s health actuarial practice.

“That’s the real wild card,” Whisler said. “It really dramatically increases the range of reasonable assumptions.”

Republicans are unimpressed by assertions that insurers will be forced to raise rates because of changes they’ve made to Obamacare.

“Insurers are going to cite anything as factors to increase their premiums,” said Carter. “I can assure you that this is a direct result of the Affordable Care Act.”

Democrats note that Republicans are hoping to at least partially insulate themselves from health care attacks by passing a barrage of bills designed to address the opioid crisis. But Ruiz points out that many individuals who enter rehab to treat opioid addiction are enrolled in Medicaid, which Republicans sought to dramatically scale back as part of their Obamacare repeal efforts.

“You realize that this is a small step forward, but 10 steps back if they get their way,” Ruiz said.