Axios Vitals

A briefcase with a red cross on the front.

April 25, 2017

Good morning ... Looks like it's going to be a struggle to get those Affordable Care Act insurer payments out of Congress after all, and there's no real movement on that compromise amendment to bring the GOP health care bill back to life. But we like to cheer you up in the mornings, so here's that cute robot that slips on the banana peel.

We're also looking forward to tonight's Axios-HBO event: the D.C. premiere of HBO's new documentary on the opioid addiction crisis, "Warning: This Drug May Kill You." The event is full, but if you've RSVP'ed already, we look forward to seeing you there.

It's not looking good for those insurer payments

President Donald Trump may be backing away from a fight over the border wall funding, but it's looking harder to resolve what to do about those Affordable Care Act insurer payments. It's tough to find a middle ground between Republicans who don't want to pay for them at all and Democrats who really want them. You either pay for them or you don't.

The latest, per Caitlin Owens:

  • Democrats made an offer to Republicans on Sunday on the government funding bill, but hadn't gotten a response.
  • Their offer called for the ACA subsidy payments to be made through "mandatory funding," or spending that happens automatically. That's not a compromise — that's been their position all along.
  • Republicans are concerned that if they include any funding for the payments, it will chase away a pretty big block of GOP votes. A lot of Republicans don't want to do anything that could be seen as supporting the ACA, even if it's to prevent a market collapse.
  • Senate Republicans say they need to figure out by the end of the day today what would be in the funding bill — otherwise they'll need to pass a one-week temporary spending bill to buy more time and avoid a government shutdown.
  • Senate Majority Whip John Cornyn sounded open to at least considering the payments: "I'm not sold on any particular timing and sequence, but we need to attend to the individual marketplace or else people won't have a place to buy health care."
  • But Sen. Roy Blunt, one of the top GOP appropriators, didn't seem to feel a sense of urgency: "From the insurance perspective, they do need to factor this in, but they have some time to do that."

Why it's more expensive not to pay for the ACA subsidies

The Kaiser Family Foundation did the math on those ACA insurer payments, to see what happens if Congress doesn't provide them because of Republican objections. Turns out the federal government would actually have to spend $2.3 billion more in that case, because it would have to pay for bigger tax credits for ACA customers.

Here's why:

  • If insurers don't get paid back for the cost-sharing reduction subsidies they have to give to low-income customers, they'll get the money another way — by raising premiums. (If they don't leave the marketplaces altogether.)
  • Higher premiums = bigger tax credits, because the tax credits are supposed to cushion the blow of the rate hikes.
  • If the tax credits are bigger, the federal government spends more.
  • The government would save $10 billion in 2018 by not making the insurer payments, but it would have to spend $12.3 billion more on the tax credits.
  • Net increase in government spending: $2.3 billion.

And don't forget the health insurer tax

There's also another health insurer issue that some lobbyists are trying to throw into the mix. The Stop The HIT Coalition, an alliance of business groups, is pushing Congress to use the funding bill to delay the ACA's tax on health insurers again. The last time the tax was delayed, in December 2015, it was also done as part of a government funding bill. But it's about to return, and the coalition says the tax would cost insurers $14.3 billion dollars — all of which would get passed on in higher premiums.

But why would Congress want to do insurers yet another favor when they're already asking for those ACA payments? For one thing, some insurance officials consider the tax a bigger issue, because it affects all insurers. But there's another argument they hope will resonate with Republicans: This would be cancelling a tax, which should be hard for the GOP to resist — especially since the tax is already set to be eliminated if the repeal bill ever gets off the ground.

ACA regulation changes still might not survive Senate rules

Even if the new health care compromise allows Republicans to pass their ACA repeal bill, the victory could be short-lived, Caitlin reports. As of yesterday afternoon, the Senate was still scrubbing the latest health care amendment by Rep. Tom MacArthur, a leader of the moderate Tuesday Group, for provisions that could ruin the effort to pass it through the Senate with 51 votes. But it hadn't reached the stage yet of determining whether the amendment violates the Byrd Rule, which, if invoked, could require some non-budgetary pieces to be stripped from the legislation but doesn't tank the entire thing.

Why this matters: This means even if the Senate gives the OK to the amendment for now, the jury is still out on whether the ACA regulation portions of the House replacement bill will survive the Senate. These provisions could still be stripped if the bill makes it out of the House and to the upper chamber.

The dos and don'ts for stable ACA markets

If Congress really wants to know how to stabilize the ACA marketplaces, they could ask some actuaries — the people who know how health insurance really works. The American Academy of Actuaries is normally pretty cautious, but they had some suggestions yesterday. Here are their dos and don'ts:


  • Fund the ACA insurer payments.
  • Enforce the individual mandate.
  • Provide extra funding through a program like an "invisible high-risk pool" (similar to what the House GOP is considering).


  • Let health insurers sell coverage across state lines.
  • Let people buy coverage through association health plans.

A reminder that health startups can fail

ICYMI earlier this month: Venture-backed startup Zoom is exiting the entire health insurance market. Now, it's officially entering voluntary receivership, a spokesman confirmed to Bob Herman. The Oregon-based company began several years ago as a chain of neighborhood clinics, and it expanded into health insurance in 2015 with the hopes of becoming the next iteration of the successful Kaiser Permanente organization. So much for that.

Between the lines: It's a pretty quick flame-out. Zoom bailed on the ACA marketplaces after just one year, and now it is giving up on health insurance altogether after roughly two years. Not exactly the type of experiment you'd expect from a system that said its goal was to "enhance human performance." It's a stark reminder that many new health care companies don't live up to some of their grandiose promises.

HHS sends a message about health data privacy

The Department of Health and Human Services made a big deal yesterday of a $2.5 million settlement it reached with a wireless health services company for not protecting customers' health data. The company, CardioNet, got nailed after an employee's laptop was stolen from a car with the private health information of nearly 1,400 people. That information wasn't protected the way it was supposed to be under a security rule issued under the 1996 privacy law, the Health Insurance Portability and Accountability Act.

The big picture: The HHS Office for Civil Rights said there's a lesson for all health care companies: Mobile devices are vulnerable. Don't get sloppy.

What we're watching today: Universal Health Services earnings call, after markets close.

What we're watching this week: GOP health care negotiations and ACA insurer payments, of course. Drug company earnings calls throughout the week. Anthem earnings call, Wednesday before markets open; Senate HELP Committee vote on FDA commissioner nominee Scott Gottlieb, Wednesday; Trump signs executive order on veterans' health care, Thursday; HHS secretary Tom Price speaks at Health Datapalooza, Thursday.

Thanks for reading, and thanks for staying engaged — it's always a kick to get smart questions and comments. Please keep them coming: [email protected]