Republicans, Aiming to Kill Health Law, Also Work to Shore It Up


That requirement, known as the individual mandate, is one of the more unpopular features of the law, signed in 2010 by President Barack Obama. But insurance companies like it because it requires people to buy their product, bringing in healthy people who pay premiums and do not use much care.

Analyzing the Republican strategy, Joel L. Michaels, a health lawyer at the firm McDermott Will & Emery, said there was “a tension” between efforts to repeal the health law and shore up its insurance marketplaces, where more than 10 million people obtained coverage last year.

“A political agenda premised on the Affordable Care Act being unworkable could conflict with efforts to support the A.C.A. exchanges, even on an interim basis,” Mr. Michaels said. “How far do you go with short-term fixes, which could make the law work better in the long term? It’s a delicate political dance.”

Insurers are seeking immediate governmental action because they must decide by early May what kinds of health plans they will offer on the exchanges in 2018.

The proposed rule drafted by the Trump administration and one of the bills drafted by House Republicans would make it more difficult for consumers to obtain insurance outside the annual open enrollment period. Consumers would have to provide documents to show they were eligible for a special enrollment period. Under existing rules, people can sign up after the deadline if they experience certain “life changes” like having a baby, getting married, losing employer-sponsored insurance or moving to a new state.

But insurers say that some consumers have misused these special enrollment periods, signing up when they became sick and dropping coverage after they received the care they needed.

Insurers say people who sign up in a special enrollment period use up to 50 percent more services than those who sign up in the standard enrollment season.

In documents provided to the White House at a meeting last week, Blue Cross and Blue Shield executives said federal officials should limit the number of special enrollment periods and “require all individuals to show proof of eligibility before coverage starts” — an idea endorsed by several governors.

Gov. Bill Haslam of Tennessee, a Republican, said that “special enrollment periods are an absolute necessity for individuals who experience a change in life circumstance.” But, he said, they have been “so broadly defined that they are almost akin to a permanent open enrollment period, allowing individuals to access health insurance benefits only when health care is an immediate necessity.”

Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said she had not seen convincing evidence of abuse.

Moreover, she said, the documentation requirements “will decrease enrollment, for sure, and will disproportionately deter younger and healthier people” from trying to sign up.

Under another Republican proposal, it would be easier for insurers to terminate coverage for people who fail to pay their premiums. The Affordable Care Act says insurers generally must allow a three-month grace period before ending coverage for people who receive federal subsidies to help pay premiums.

About 85 percent of people who obtain insurance through the Affordable Care Act’s marketplaces receive such subsidies, and the three-month grace period is longer than that typically required by state laws.

Under a bill introduced last month by Representative Bill Flores, Republican of Texas, the federal government would recognize any grace period set by state law, and if a state did not have a law, the grace period would be one month.

Several governors, including Brian Sandoval of Nevada and Gary R. Herbert of Utah, both Republicans, endorsed this change. “Reducing the grace period from 90 days to 30 days, which is standard industry practice for most other insurance products, would assist in stabilizing the individual market,” Mr. Herbert said.

Republicans in Congress are also warming to the idea of continuing payments to insurance companies to help cover the out-of-pocket costs for people with low incomes.

House Republicans filed suit against the Obama administration to stop these payments, saying Congress never appropriated money for them, and a federal district judge ruled for the lawmakers in May.

The payments reimburse insurers for certain discounts they are required to provide to low-income people, and without the payments, which are expected to total $9 billion this year, insurers say they would drop out of the market or sharply increase premiums.

Representative Mark Meadows, a conservative Republican from North Carolina and a fierce critic of the health care law, said he wanted to avoid disrupting coverage for consumers while Republicans repeal the law and devise a replacement.

“As long as we have a real repeal and replacement strategy,” Mr. Meadows said, he might accept a temporary continuation of the cost-sharing subsidies.

“I would be more flexible and could swallow some short-term heartburn for longer-term fiscal responsibility and lower health care costs for the people I represent,” he said.

Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, said he, too, was willing to allow a “temporary continuation of cost-sharing subsidies for deductibles and co-payments.”

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