By Peter Sullivan - 03-28-17 06:00 AM EDT
Secretary of Health and Human Services Tom Price came into office last month ready to lead the charge on repealing ObamaCare. Now, that effort has run into a brick wall, leaving him to oversee a law he fiercely opposes.
President Trump last week predicted that ObamaCare "soon will explode," stirring speculation that the administration could seek to undermine the law.
Yet there are also signs that Price and the Department of Health and Human Services (HHS) will take a more pragmatic approach.
In February, HHS proposed some relatively minor regulatory changes aimed at "stabilizing" the Affordable Care Act (ACA) marketplaces. Earlier this month, Price wrote a letter to governors saying one of the administration's top priorities is "bringing stability" to health insurance markets.
"I'm sure he's going to start looking around at every administrative tool he has," said Tom Scully, who was head of the Centers for Medicare and Medicaid Services under former President George W. Bush.
Scully, however, said he expected that Price would seek to move the system in a conservative direction without seeking to sabotage it.
"They'll have a conservative spin on things, but I'd be very surprised if they intentionally tried to destabilize [the law]," Scully said.
One of the main ways the Trump administration could seek to bring about the collapse of ObamaCare marketplaces is by canceling payments known as cost-sharing reductions.
Those payments reimburse insurers for giving discounted deductibles to low-income ObamaCare enrollees. House Republicans sued the Obama administration, arguing the payments were being made illegally without a congressional appropriation.
The Trump administration could simply drop its defense in the lawsuit and cancel the payments, but that could spur insurers to bolt from the marketplaces, creating chaos.
Asked Monday what would happen to the cost-sharing payments, House Ways and Means Committee Chairman Kevin Brady (R-Texas) said, "I don't know."
Scully predicted that Republicans would end the payments, since they have already sued to stop them.
"I do not see any way philosophically they can continue the cost-sharing [reductions]," Scully said. "I don't see how they can spend that money with a straight face."
Rep. Tom Cole (R-Okla.), who chairs the Appropriations health subcommittee, indicated Monday that he thinks the cost-sharing reductions should continue. "You're going to have instability in the market otherwise," he said. But he added that no decision has been made and discussions are going on above his level.
He said the spending would either have to come out of mandatory funds, or the budget allocation for healthcare would have to be increased.
The other major way Price could upend the ACA is by using his authority to ease enforcement of the mandate for people to buy insurance. Without the mandate, young, healthy people could choose not to enroll in ObamaCare, driving up premiums.
However, it is possible that Price, and Republicans in general, might not want to risk the political blowback from destabilizing a health insurance system they now oversee.
Democrats are already warning that they will be watching every move the Trump administration makes on ObamaCare.
"If he, out of anger or vengeance or whatever, starts undermining ACA, it's going to backfire on him, because he's the president, and the American people know he's in charge and they want him to make things better," Senate Democratic Leader Charles Schumer (N.Y.) said Sunday on ABC.
Democrats cried foul in January when the Trump administration canceled some remaining outreach ads aimed at getting people to sign up for ObamaCare.
And Schumer called Monday for Trump to rescind an executive order he signed that called for agencies to ease regulatory burdens under the healthcare law.
Alternatively, there are several steps that Price could take to move ObamaCare in a more conservative direction without causing chaos or destabilizing markets.
ObamaCare's essential health benefits are one Republican target. While Price cannot eliminate the basic benefits insurers must cover, he does have some authority to loosen the definitions of which services are included.
There could even be room for some bipartisanship on the law.
Andy Slavitt, the head of the Centers for Medicare and Medicaid Services under former President Obama, told The Hill on Friday that one way Republicans could improve the ACA is by setting up state-based funding known as "reinsurance" that can help bring premiums down, citing Alaska's system as a model.
Price earlier this month wrote a letter to governors calling on them to submit ideas along those lines and also cited Alaska's system as a model.
More broadly, there are waivers under ObamaCare that allow states to innovate and change rules on their own, which could allow states to move the law in a more conservative direction.
Losing the cost-sharing reduction payments, though, is the main worry for insures. J. Mario Molina, CEO of the insurer Molina Healthcare, said his company might have to drop out of ObamaCare next year without the payments.
"It would certainly play into our decision," he said in an interview. "We'll look at this on a market-by-market basis. We could leave some. We could leave all."
Sen. Lamar Alexander (R-Tenn.), who has taken a more pragmatic approach to ObamaCare, has previously called for temporarily extending the payments to insurers. A spokesman said Monday that Alexander still holds that view.
"I think [Price is] going to do what he can to move it in a conservative direction," said former Rep. Jack Kingston (R-Ga.), who served in the House with Price -- a fellow former Georgia Republican representative - and was a surrogate for the Trump campaign.
But Price will know he is being watched closely.
"He'll have 535 eyes watching him in the legislative branch," Kingston added. "He will have a lot of backseat drivers on all sides of the spectrum."