President Donald Trump and his fellow Republicans have failed, at least for now, in their bid to repeal Obamacare entirely, but they still have plenty of ways to cripple the law without pulling it off the books.
By blocking funding for subsidies or refusing to enforce the individual mandate, the administration and congressional Republicans could undermine the law's insurance exchanges — government-established marketplaces where individuals can buy health insurance from private companies, often with the help of federal subsidies. The exchanges and an expanded Medicaid program are the main programs in Obamacare, officially known as the Affordable Care Act, aimed at expanding coverage to the uninsured.
While Republicans can attack the exchanges, the marketplaces' health is ultimately in the hands of the health insurance companies that have to decide whether to participate in them by selling insurance plans and consumers who have to decide whether to buy that insurance.
When Trump promised Friday that the law would "explode" on its own, he appeared to be referencing an argument shared among many Republicans that the exchanges would falter because people wouldn't sign up for coverage and insurers would pull out, deciding that participating would be a bad investment.
The current health of the exchanges is hotly debated. Some insurers have curtailed their participation, leaving nearly a third of counties with only one insurer. But the Congressional Budget Office noted in its recent analysis that the market would "probably be stable in most areas" under current law. Republicans are vowing they aren't finished with health care yet, which could prolong the uncertainty for insurers trying to make plans about what to do next year.
For now, Republicans haven't announced any specific changes, and — given their plan was to repeal the law entirely — they're likely still mulling what to do now. Insurers are largely keeping quiet about their next steps, in large part because they want to see if the White House and Congress will make policy changes to help address some of the problems in the exchanges.
But policymakers and insurers each have a deadline coming up that will force decisions, whether they're ready for them or not. Here are two key dates to watch.
May 22: The ACA's day in court
One key to insurers selling plans in the marketplace are reimbursements they receive called cost-sharing reductions. These aren't the same as the tax credits that people receive to help pay their premiums; it is financial assistance to help low-income people pay their out-of-pocket costs, such as deductibles. The Congressional Budget Office projected those payments would add up to $7 billion this year and $10 billion in 2018.
But for insurers, there's a question over how long that money will be delivered, due to an ongoing political and legal dispute about whether the cost-sharing money should be distributed at all.
In 2014, House Republicans sued the Obama administration over the constitutionality of the cost-sharing reduction payments, which had not been appropriated by Congress. The lawmakers won the lawsuit, and the Obama administration appealed it. Late last year, with a new administration on the other end of the suit, the House sought to pause the proceedings — with a deadline for a status update in late May.
The Trump administration and House lawmakers have to report to the judge this spring. If the Trump administration drops the appeal, it would mean the subsidies would stop being paid — a huge blow to the marketplaces and millions of people. If lawmakers wanted the payments to continue, they would have to find a way to fund them. One opportunity for that is coming up fast, the continuing resolution that must be passed by April 28. If the Trump administration continues the lawsuit, it will be in the odd position of fighting its own party.
"We're working with the Trump administration and evaluating the options in front of us," AshLee Strong, a spokeswoman for House Speaker Paul Ryan, R-Wis., said in an email.
In the interim, it has been the status quo: The cost-sharing reduction payments are being made each month. Lobbyists for the insurance industry are meeting with lawmakers to pressure them to continue funding cost-sharing reductions.
"Our hope is that there is a mechanism for continued funding for cost-sharing reductions, that happens regardless of the lawsuit, because this is what makes sense for the Americans we're serving, for the American people," said Kristine Grow, a spokeswoman for America's Health Insurance Plans. "But that is a deadline that we are keeping in mind as we're having conversations with policymakers."
Mario Molina, chief executive of Molina Healthcare, predicted that if the cost-sharing reductions are not funded, it could result in premium increases on the order of 10 to 12 percent.
"They could stop funding those as early as May this year," Molina said.
June 21: Decision day for insurers
While all this uncertainty swirls, health insurers must decide — soon — whether to make rate filings to sell insurance in 2018. The deadline varies by state, but for those that have marketplaces run by the federal government, it is June 21. Filing doesn't mean that insurers will participate; they'll have months more to negotiate and could still drop out. But it's the first step toward offering plans in 2018 and should provide a signal about what the marketplaces are likely to look like.
That's putting insurance commissioners on alert. John Doak, the insurance commissioner for Oklahoma, which has only a single insurer offering plans in its marketplace this year, says he's watching the calendar closely — about a month and a half from deadline.
"We know the playing field is not changing; it's going to remain the same. We're going to be anticipating and watching those releases and dates," Doak said.
Some insurers have already made up their minds: Humana announced earlier this year that it would exit the marketplaces where it sold individual plans for 2018. Most have been more cagey. Aetna already exited all but four of the states where it offered plans on the exchanges, and its chief executive described the marketplaces as being in a "death spiral" at a Wall Street Journal event in February, without specifying whether his company would remain in the business for 2018. Molina, which has about a million members in the state exchanges, has said it will evaluate its participation, depending on what actions the administration and Congress take.
Ironically, while the GOP health-care bill was criticized by many health-care industries, it contained provisions that would have helped insurers, including a repeal of the health insurer tax and a risk stabilization fund that could have been used to help buoy insurers.
"We expect [marketplace] health insurers will continue to flee the marketplaces in 2018 or raise premiums significantly as they will no longer enjoy the substantial risk stabilization fund proposed by the American Health Care Act, destabilizing and shrinking the marketplaces," Leerink Partners analyst Ana Gupte wrote in a research note.