Donald Trump's HHS Dept. proposes simply cutting off the ACA's funding altogether.

A month ago I noted that along with a whole mess of other crap, Congressional Republicans were attempting to effectively starve the ACA out by simply cutting off funding of the law via the recent "must pass" omnibus spending bill:

Republicans also want to use the funding bill to go after Obamacare. They would prohibit funding for administering or enforcing the health care law, prohibit the administration from collecting a fee from insurance companies to run the insurance exchanges and eliminate more than half a billion dollars in funding for managing the program at the Centers for Medicare and Medicaid Services.

(sigh) I'm not quite sure how "prohibiting funding for administration" differs from "eliminating funding for managing the program", but it amounts to the same thing: They're trying to shut down CMS's ability to actually run the ACA.

The good news is that none of that ended up making it into the omnibus bill.

The bad news is that the Trump Administration is still trying every possible way to sabotage, undermine and starve out the Affordable Care Act:

BREAKING: Trump proposes to end funding for ACA insurance exchanges.

— Andy Slavitt (@ASlavitt) April 2, 2018

Slavitt is referring to CMS's Fiscal Year 2019 Justification of Estimates for Appropriations Committees (page 3). Here's the paragraph in text format:

CMS’ FY 2019 budget request for Program Operations is $2.4 billion, a decrease of $403.6 million below the FY 2018 Annualized CR Level. This request will allow CMS to continue operating Medicare, Medicaid, CHIP, and basic CMS support programs. The FY 2019 Budget proposes to wind down the Federal Exchanges for plan year 2020, as states transition to new Market-based health care grants. Additionally, the budget requests funding to reinvent CMS Medicaid and CHIP operations through improving data systems and creating scorecards that will give States an opportunity to demonstrate how they are using new and existing flexibilities to serve the interests of their citizens with appropriate Federal oversight. The request also funds core outreach and education activities that positively impact the beneficiary experience and CMS’ customer service goals. CMS will continue to invest in high priority activities with a focus on high quality service for our beneficiaries and participating providers. CMS is evaluating areas for contract efficiencies to maximize our annual appropriation.

This is detailed on Page 43 of the report (emphasis mine):

Federal Exchanges

The Federal Exchanges allow individuals to compare health plan options, see if financial assistance with premiums and cost-sharing is available, and purchase coverage. The FY 2019 Budget assumes passage of legislation to repeal and replace Obamacare, which would phase down the Federal Exchanges as the new Market-Based Health Care grants become available in plan year 2020.

Remember, Fiscal Year 2019 actually begins on October 1st, 2018 and runs through September 30, 2019. This budget proposal assumes the ACA will be repealed by then. I...don't think that's likely to happen at this point.

States currently have the option to operate a State-Based Exchange (SBE) or elect to use the Federally-facilitated Exchange (FFE). SBEs can partner with CMS to use portions of the federal platform, such as enrollment, and are referred to as State-Based Exchanges on the federal platform (SBE-FP).

CMS will continue to conduct the following core responsibilities on behalf of all individual market Exchanges:

  • Verify consumers’ eligibility data for financial assistance through the Exchange or other health insurance programs, including Medicaid and CHIP;
  • Ensure proper payment of financial assistance in the form of advanced payment of the premium tax credit (APTC) and cost-sharing reduction to issuers where a consumer is determined eligible;
  • Operate a quality rating system for display on Exchange websites; and
  • Conduct certification and oversight of SBEs.

If a state elects to use the FFE, CMS oversees these additional functions:

  • Certifying qualified health plans (QHPs) and stand-alone dental plans (SADPs) after reviewing health plan benefits and rates;
  • Providing consumers the ability to apply for coverage, conducting enrollment reconciliation with issuers, conducting appeals, and assisting with APTC reconciliation; and
  • Educating consumers about the Exchange including the open enrollment period (OEP), coverage options, and providing assistance to consumers.

Beginning in January 2018, CMS will no longer facilitate enrollment in the Federally facilitated Small Business Health Options Program (FF-SHOP). Small employers will continue to use FF-SHOP to obtain eligibility determinations, but will enroll directly through participating issuers or work with a SHOP-registered agent or broker to complete the enrollment process. CMS will continue to support policyholders who purchased plans in 2017 through the end of their plan year. States will continue to have the option of operating a State-Based SHOP Exchange. CMS will continue to conduct oversight and provide technical assistance and analytic support to states.

Sidenote: This paragraph, which notes that the federal version of the ACA's small business exchange (SHOP), has already mostly been shuttered, may seem alarming but it was actually announced last May, and even I didn't make that big a fuss over it at the time, in part because the SHOP program has mostly been a dud since day one, with no more than perhaps 230,000 people enrolled in SHOP-based policies nationwide at most. In some ways SHOP was a solution to a problem which didn't really exist in the first place (or at worst, a problem which had other potential solutions readily available). SHOP is pretty highly regarded in a few states, including California, New York, Rhode Island, Vermont and D.C....but all of those run their own ACA exchanges anyway, so there you go.

The individual market exchange at HealthCare.Gov, however, is an entirely different story:

In FY 2019, CMS proposes to further empower stakeholders by providing greater flexibility and recognizing the traditional regulatory role of States. States will be able to assume more control of their markets and expand enrollment options to include private partners to promote innovation and provide a better consumer experience. This includes a proposal to repeal and replace Obamacare, which would phase down Federal Exchange operations in plan year 2020.

On the one hand, this is basically just a Trump/Verma wish list: "IF the Affordable Care Act was repealed, then we'd phase down HealthCare.Gov by 2020! Woo hoo!"

On the other hand, as Slavitt notes a little later on:

If you want to know what’s going to happen next year if the Democrats don’t win at least the House, this is just the beginning.

— Andy Slavitt (@ASlavitt) April 3, 2018

Indeed.

I should also note that it's rather curious and disconcerting to see the phrase "Obamacare" used 10 times throughout an official federal government funding allocation request. Say it with me once again, everyone: There is no law or program actually called "Obamacare". Obamacare is a nickname for a federal law called "The Patient Protection and Affordable Care Act".