Senate Republicans face increasing pressure to rescue health insurance markets and protect coverage for millions of Americans amid growing fears the Trump administration is going let the markets collapse.
In recent days, leading hospitals, physician groups, health insurers and the U.S. Chamber of Commerce have pleaded with the Senate to step in, effectively going around the White House.
"Congress must take action now," the groups warned in a letter to Republican and Democratic Senate leaders. "At this point, only congressional action can help consumers."
It remains to be seen whether the GOP-controlled majority — which has been considering more sweeping legislation to roll back the Affordable Care Act — will be willing to shift gears and coalesce around a more short-term fix.
Senate Majority Leader Mitch McConnell (R-Ky.) is laboring to unite GOP senators around a broader bill.
But Senate Republicans may be forced to turn to a more urgent task as growing numbers of insurers threaten to raise premiums or exit markets around the country, including Blue Cross Blue Shield of Tennessee; Molina Healthcare, which sells plans in California, Washington and other states; and CareFirst, the largest insurer in Maryland's market.
Polls suggest that the majority of Americans now hold Republicans responsible for the fate of the nation's healthcare markets, potentially imperiling GOP lawmakers who are up for reelection next year.
"There clearly has to be sort of a short-term solution," Sen. John Thune of South Dakota, the No. 3 Republican, said Tuesday. "We have to do that. There's got to be certainty in the marketplace. There has to be some certainty with the insurers."
According to several lawmakers, Senate Republicans have begun to discuss a "transition plan" to stabilize markets over the next several years.
Trump and many GOP lawmakers, including McConnell, have blamed the proposed premium hikes and market exits on weaknesses in the Affordable Care Act.
But a growing number of health insurers and state regulators, while noting problems with the current law, say the Trump administration is the primary cause of the current turmoil.
The president has sent mixed signals about enforcing penalties on people who don't buy health insurance. The penalty is seen as critical to inducing younger, healthier people to get coverage.
And Trump has repeatedly threatened to withhold federal aid that helps millions of low-income Americans afford their deductibles and co-pays.
The aid, which reimburses insurers for lowering out-of-pocket costs for low-income consumers, was paid by the Obama administration. But it is now the subject of a lawsuit by congressional Republicans, who argue Congress must approve the payments.
The Trump administration still hasn't taken an official position in the lawsuit. On Monday, the administration sought to delay the lawsuit again, effectively prolonging uncertainty over the fate of the payments.
That prompted a new round of urgent warnings from across the healthcare system.
On Monday, America's Health Insurance Plans, the industry's Washington-based lobbying arm, called the Trump administration's refusal to commit to paying the aid "the single most destabilizing factor in the individual market."
"Millions of Americans could soon feel the impact of fewer choices, higher costs and reduced access to care," the group warned.
The warnings have been echoed by leading hospitals and physicians, who increasingly worry about the erosion of insurance coverage.
"Patients who don't have insurance live sicker and die younger," said Dr. Andrew Gurman, president of the American Medical Assn., which signed on to the recent letter to Senate leaders. "We have to provide for these people to have insurance."
Without the aid, insurers almost certainly will raise rates, which, ironically, would most affect middle- and upper-income consumers who have been most critical of the current law and have fueled the GOP repeal campaign.
Lower-income Americans, by contrast, likely would be more insulated from the premium hikes because they get other assistance through Obamacare.
With the White House unwilling to act, many are now turning to Congress, which could vote to appropriate the aid, thus bypassing the Trump administration.
In addition to the healthcare groups and the U.S. Chamber of Commerce, state insurance regulators — Republicans and Democrats — also are pleading with the Senate to step in.
"Your immediate action is critical to the viability of the individual insurance markets in a significant number of states across the country," the National Assn. of Insurance Commissioners wrote in a letter to Senate leaders last week.
Regulators, health insurers and other independent experts say stabilizing insurance markets actually would be relatively straightforward.
In addition to paying the aid — known as Cost Sharing Reductions, or CSRs — for this year and next, Congress also could provide additional funding to protect insurers from costly and unexpected medical claims.
Such funding, which is common in other insurance markets such as Medicare's Part D prescription drug program, helps to lower risk for insurers and thereby decrease pressure on them to raise premiums.
The National Assn. of Insurance Commissioners noted in its letter that the CSR payments and the stabilization funding "alone would go a long way toward stabilizing the individual markets in our states while legislative replacement and reform options are debated."
Whether Senate Republicans will be able to come up with a legislative package that would do this remains unclear, however.
Several senators have indicated they would support a short-term bill to shore up the markets. "We need to stabilize premiums," said Sen. Bill Cassidy (R-La.), who is among a small bipartisan group of lawmakers seeking compromise on healthcare legislation.
"We've got to find a way to help Americans pay for their health insurance premiums," said Sen. Mike Rounds (R-S.D.).
Earlier this year, Senate Health Committee Chairman Lamar Alexander (R-Tenn.) also suggested Republicans should pursue a more incremental approach to reshaping the current law.
But McConnell and other senior GOP leaders have thus far indicated no public interest in such a move. And conservative groups that drive much of the congressional Republican agenda continue to push hard for a sweeping repeal.
"Keeping in place the worst of Obamacare makes it all but impossible to improve our healthcare system," Freedom Partners and Americans for Prosperity warned in a joint letter to Senate Republican leaders Monday.
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2:10 p.m.: This article was updated with a quote from Sen. Mike Rounds.