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The Trump administration is still unhappy it couldn't get Congress to repeal the Affordable Care Act last year. So -- always working! -- it took another whack at the program this weekend! This time, the Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS) announced the suspension of payments to insurers under one of the ACA's cost containment programs. Boring, right? What does it mean? Just more of that good old "market uncertainty" that's been driving up premiums for plans in the individual markets, just when insurers are setting their premiums for 2019. Since the ACA keeps refusing to collapse under its own weight, Trump's people keep pounding away at it with million-pound shithammers.


The new Trumpfuckery involves Obamacare's risk adjustment program, which doesn't involve any taxpayer funds -- instead, the government takes some money from insurers that have mostly healthier, less-costly enrollees, to transfer to insurers that have sicker customers who generate higher costs. It's a bit like insurance for insurance companies, spreading out the costs of insurance to keep premiums lower overall. As Jordan Weissmann 'splainers at Slate:

The payments, worth billions of dollars a year, are designed to discourage carriers from cherry-picking low-risk insurance shoppers, while keeping health plans afloat if they get unlucky and end up stuck paying the medical costs of an unusually ill group of patients.

The CMS decision stems from a couple of federal lawsuits brought by small insurance companies over the formula used to determine how those payments would be made. The formula was upheld in a case in Massachusetts, but struck down in a New Mexico case in which the judge said the formula might be valid, but the government hadn't explained why it constructed the formula as it did. Because we love you, the reader, we will not go into the weeds on the details here, but what it comes down to is that while the government continues to litigate the New Mexico case, CMS administrator Seema Verma says the ruling means the government has no choice but to halt the payments for the 2017 plan year (about $10.4 billion) -- which a lot of your healthcare policy experts say is just plain not true. Here's Weissmann again:

This is an extremely strange decision by the administration. When a single trial court judge strikes down a regulation, the government typically doesn't just stop enforcing it. "I haven't heard of such a thing happening before," University of Maryland law professor Frank Pasquale told me. Instead, the Justice Department can appeal the decision to a higher court and ask for a stay stopping the lower court's decision from going into effect. It can choose to interpret the ruling narrowly, so that it doesn't apply to the entire country. If it wants to, the administration can also issue a new, "interim" version of a regulation that goes into effect while the litigation rolls on. That would be a triflingly easy thing to do in this instance, since the administration has already tweaked the risk-adjustment rule for next year to address the court's concerns

Translation: The New Mexico ruling looks a hell of a lot like an excuse to throw the ACA's individual markets into more chaos, at a particularly sensitive time of year, as insurance companies set their rates for 2019. Some companies are going to jack up premiums, and some may decide to pull out of the markets, and some smaller insurers may just go belly up if they aren't reimbursed for services they already covered. Why yes, that is the Trump Way: Stiff businesses for compensation that was due to them.

There are plenty of steps the government could take to prevent this instead of just stopping the payments. Burt why wouldn't they just choose chaos? That's their damn mandate.

"They're doing this because they want to," Georgetown University Law Center professor David Super said. "They're doing this because they don't like these payments."

One result of this decision will be higher premiums for plans on the exchanges; for people who qualify for premium subsidies, that price increase will be borne by taxpayers, but for individuals whose income is too high to qualify for subsidies, and for small businesses, it will mean much pricier insurance. It also means companies dropping out of the market altogether, which is what Trump hoped for last year when he eliminated payments for "cost-sharing reduction" payments to insurers -- also with the excuse that a lawsuit forced him to, although that suit hadn't actually been completed, either. The GOP's tax bill also killed the individual mandate, further driving up premiums. Because the ACA was designed to protect most customers from premium hikes, the real effects of those actions was to reduce the availability of plans, price middle-class people out of the market, and raise costs to taxpayers without making the ACA vanish. But hey, Trump gets to brag that he killed Obamacare, and that's all that really matters.

One rightwing website was perfectly happy to brag about the real motive for the administration's action:


Hurr hurr! Making it harder for sick people to get medical care! Gonna cry about it, libs? GONNA CRY?

Fuck that. We're gonna vote.

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[AP/Minneapolis Star-Tribune / Slate / Andy Slavitt on Twitter]

Doktor Zoom

Doktor Zoom's real name is Marty Kelley, and he lives in the wilds of Boise, Idaho. He is not a medical doctor, but does have a real PhD in Rhetoric. You should definitely donate some money to this little mommyblog where he has finally found acceptance and cat pictures. He is on maternity leave until 2033. Here is his Twitter, also. His quest to avoid prolixity is not going so great.

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