By Peter Sullivan - 08-10-17 06:00 AM EDT
The Trump administration is now confronted with the challenge of deciding how to oversee ObamaCare, a law it fiercely opposes but that is still on the books.
With the Senate's failure to repeal the healthcare law last month, the Trump administration now has pressing questions to answer about how it will manage a system that provides insurance to more than 10 million people.
President Trump has threatened to cancel key ObamaCare payments to insurers as part of an effort to make the health law "implode." But he is yet to follow through on that threat, leaving insurers in a state of anxious uncertainty.
The next sign-up period for enrolling in ObamaCare begins Nov. 1. The Obama administration ran advertisements to encourage enrollment, but Trump officials have signaled that promotion effort might come to an end.
Indeed, the Trump administration cancelled some ObamaCare ads upon taking office in January, which was the end of the last sign-up period.
Trump officials also have the power to loosen up on enforcement and regulation, particularly on the mandate under the healthcare law for people to have coverage.
The difficulty for the White House is that Trump and, by extension, congressional Republicans, could be blamed if ObamaCare premiums spike or the marketplaces start to collapse.
The Trump administration has sent mixed signals about whether it will seek to actively undermine ObamaCare.
Trump tweeted after the Senate's failed vote: "As I said from the beginning, let ObamaCare implode, then deal. Watch!"
But his Secretary of Health and Human Services, Tom Price, asked about those comments on ABC's "This Week," declined to reiterate the goal of letting the law implode.
Price said Trump's "implode" remark simply "punctuates the concern that he has about getting this moved in the right direction."
On NBC, Price added that he had a duty to uphold ObamaCare. "Our responsibility is to follow the law," Price said. "And again, we take that responsibility seriously and we will continue to do so. But remember that the current law right now is failing the American people."
For those involved in providing ObamaCare coverage, the conflicting messages from the administration are a source of frustration.
"The biggest challenge that we have right now is the unknown, because this is the first enrollment season with the new administration," said Shelli Quenga, director of programs at the Palmetto Project in South Carolina, one of the "navigator" organizations across the country that help people enroll in Affordable Care Act coverage.
Quenga said she is worried there will not be advertising from the administration to make people aware of the sign-up period.
Despite the uncertainty, much of the routine work on ObamaCare at the Department of Health and Human Services (HHS) is proceeding as normal.
Career officials traveled to a conference of navigators in Baltimore in June to coordinate on strategy for signing people up. And HHS recently issued its yearly online training for navigators, which Quenga said is "better than it has been in previous years," because there are now more enrollment periods under the belt.
But there are limits to what career officials can do without the sign-off of the political leadership.
The Obama administration, for example, pushed last year to recruit an insurer to offer coverage in an Arizona county that was at risk of having no choices for coverage.
This year, the risk of "bare counties" with no insurers is spreading to more places, with several states facing the possibility of having rural counties without any ObamaCare options next year.
Washington state averted that risk in June by finding insurers to fill in its empty counties.
But the state insurance commissioner, Mike Kreidler, said that the Trump administration was "pretty much absent" from that effort to fill the counties.
Kreidler said career officials at HHS "help cheer you on but there's very little they can wind up doing" without the support of the political appointees opposed to ObamaCare.
Insurers and many healthcare experts say that the biggest source of instability is Trump's threat to end the payments to insurers, known as cost-sharing reductions (CSRs). Those payments reimburse insurers for giving discounted deductibles to low-income ObamaCare enrollees.
Insurers would need to spike premiums to make up for the lost money if the payments were cancelled, and the uncertainty about receiving the payments has already caused premium increases for 2018.
Blue Cross Blue Shield of North Carolina, for example, has proposed a 22.9 percent premium increase for next year, but it says it only would have proposed an 8.8 percent increase if it knew the CSR payments would continue.
Price also left the door open to waiving enforcement of the mandate to have coverage, which is another worry for insurers who fear that only sick people would then remain in the market, causing premium increases.
"All things are on the table to try to help patients," Price told ABC when asked about waiving the mandate.
The conservative group Freedom Partners is pushing Price to make it easier for states to apply for waivers for ObamaCare regulations, though it did not echo calls for letting the law implode.
"The Secretary has within his abilities to do a bunch of things that ultimately won't get rid of ObamaCare but will start to provide some of the relief that people expect," said Nathan Nascimento, the vice president of policy at Freedom Partners.
Yet administrative actions to increase flexibility under ObamaCare would be a significant step down from Congress repealing the law. In fact, some in Congress are now discussing a bipartisan fix to shore up the stability of ObamaCare markets, in part by guaranteeing CSR payments.
Price himself used the word "fix" in an appearance on Fox News on Wednesday.
"Both folks in the House and the Senate, on both sides of the aisle frankly, have said that ObamaCare doesn't work and it needs to be either repealed or fixed," he said.