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November 21, 2016

Washington Health Policy Week in Review Archive fc40eda0-ae62-4ebf-92ce-4da2ac975015

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Hill Staff Talks Health Law Repeal as HHS Signs Up Consumers

By Andrew Siddons and Rebecca Adams, CQ Roll Call

November 16, 2016 -- Republican committee staff members say their party is weighing a range of options for repealing and replacing the Affordable Care Act, with an eye toward making sure that people don't lose their insurance coverage.

Speaking at a briefing by the Alliance for Health Reform, staff members who work on health policy said that Democrats can be a productive part of the conversation on replacement. And Democratic aides urged congressional Republicans to listen to President-elect Donald Trump's campaign promises when pursuing a health care overhaul of their own.

"I hope the Republicans will reach out to us. I have a great number of great President-elect Trump quotes that shows clearly we could work with the President-elect," said Wendell Primus, a top adviser on health policy to House Democratic leader Nancy Pelosi, D-Calif. "I think my boss would be willing to work with the President-elect to improve our health care system, improve coverage and improve quality."

During the campaign, Trump embraced certain aspects of the health care law, including its guarantee of coverage for people with preexisting conditions and allowing young adults to remain on their parents health insurance plans until they turn 26. At times, he has even embraced the individual mandate requiring most Americans to buy insurance and said he wants every American to be covered. Democrats hope that Trump follows through on some of his campaign statements.

"We should be embracing President-elect Trump's commitment, stated commitment, to covering every American and not disrupting policies so much," said Chris Jennings, who advised both the Obama and Clinton administrations on health care policy.

Republican aides echoed lawmakers who in recent days said they want to proceed with a replacement in a bipartisan manner.

"There has been bipartisan support for making certain changes to the Affordable Care Act before the election, so I think there are obviously areas where there can be bipartisan agreement," said Emily Murray, a health adviser for House Ways and Means Committee Republicans.

Other observers think that Republicans have a political imperative to quickly craft a repeal that provides time to come up with an adequate replacement that will help people remain insured.

"It will be extremely difficult for Republicans in the Congress to wait until they have a consensus document about legislative language defining what the replacement looks like to have a repeal," said Gail Wilensky, a Republican health consultant who formerly chaired the Medicare Payment Advisory Commission. Doing anything that strips people of their insurance coverage would be risky, she added. "Having a large block of people without any kind of coverage going into the 2018 election would not be regarded as a place that most politicians want to be."

Ongoing Open Enrollment

The discussion came as the Centers for Medicare and Medicaid Services announced that about 1 million people—nearly 250,000 new customers and more than 760,000 returning customers—signed up for coverage during the first 12 days of the enrollment period that runs from Nov. 1 through Jan. 31. That represents about 53,000 more people than over the same timeframe last year.

However, about one-third of customers at the start of last year's sign-up season were new customers during the first two weeks, compared to just under one-fourth in the first 12 days this year.

About 4.5 million people have visited the website, which allows people in 39 states to buy insurance. Other states have their own marketplace websites.

More than 8,000 people contacted the call centers that answer questions about coverage after the Nov. 8 election to explain how much their coverage means to them, CMS Acting Administrator Andy Slavitt told reporters. Consumers are expressing concern by asking about the election's impact and whether they should still buy coverage.

"It puts people very much at ease when they understand this is the law of the land," said Slavitt.

CMS held off on routine outreach efforts until after the election, Slavitt said. Since the election, "each day has seen more enrollments than the previous day."

The administration is ramping up its publicity efforts, including a video from Obama that federal officials emailed to people who have registered with About 2.5 million people who are buying individual coverage outside of the exchanges could get a subsidy if they instead buy through the marketplace, Slavitt noted.

Slavitt promised a "great transition" to the next administration—as soon as Trump administration officials contact the agency.

However, consumers' concerns underscore the fragility of the marketplace as Republicans plan to repeal the law.

Congressional Republicans have discussed a transition period, but the Trump administration could act quickly in 2017 to stop enforcing the law's mandates or drop a defense of litigation against the administration's funding of subsidies.

Health plans have signed contracts for 2017, which Slavitt said he expected insurers to honor. Plans have been in the midst of preparing bids to participate in 2018.

But it's not clear whether the Trump administration would penalize insurers if some were to decide to scale back coverage. The main recourse that federal officials have if a plan withdraws is to ban the insurer from participating in exchange coverage for five years if the plan completely drops all of its individual coverage options both within and outside of the exchanges.

Even as Slavitt sounded reassuring notes and said federal officials had held dozens of conversations with insurance executives since the election, he acknowledged that insurers may drop coverage in 2018.

"Plans are going to continue to adjust their strategy based on what they're hearing and learning," Slavitt said.

A report from the liberal Center for American Progress (CAP) released Tuesday said that a gradual transition is unlikely if Republicans move to repeal the law, regardless of whether the legislation delays the effective date of repeal for two years as the GOP has previously supported. Republicans would be unable to use the reconciliation process to kill a number of insurance protections in the law, such as allowing young adults to stay on parents' plans, preventing insurers from rescinding coverage after their customers get sick, banning annual or lifetime limits on insurance, and banning insurers from denying people coverage because they had been sick.

"If these consumer protections remain without the premium tax credits or individual mandate penalties, it would cause chaos and spiraling costs in what is left of the individual market for health insurance," CAP said.

The center found that "even with a delayed effective date, the reconciliation bill approach would cause massive disruption and chaos in the individual market for health insurance. The complete unraveling of the market would occur by the end of 2017."

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Republicans in Medicaid Expansion States Cautious on Repeal

By Erin Mershon, CQ Roll Call

November 17, 2016 -- Most Republicans are eager to move forward with their long-promised repeal of President Barack Obama's signature health care overhaul, now that they will control Congress and the White House in 2017. But for more than a quarter of GOP lawmakers, repeal could eliminate significant federal funding their states are counting on to support the expansion of the Medicaid program.

There are 20 Republicans in the Senate and 120 more in the House who represent the 32 states, including the District of Columbia, that chose to expand their Medicaid programs under the 2010 health law. Some 15.7 million Americans gained Medicaid or Children's Health Insurance Program coverage since enrollments under the law began in October 2013. In just the first year, expansion states benefited from about $47.2 billion in federal funding, according to the latest data.

That reality complicates repeal deliberations. Republican senators from expansion states danced around the issue in interviews this week, emphasizing more than some of their more conservative colleagues that discussions are preliminary and that any plan to repeal coverage should include a transition period to make sure those with benefits now don't lose them. None of the Republican senators representing those states committed to supporting a repeal of the expansion, but at the same time, none promised to preserve it without changes.

"That to me is critical, that we don't all of a sudden leave people out in the cold, that we work toward a transition and we create a better program that works for everybody and gives better health care options for those people on Medicaid," said Sen. Shelley Moore Capito of West Virginia, a state that expanded in May 2013 to cover almost 100,000 more people.

"We've got to make sure we're looking at what the impacts are in terms of repeal," said Sen. Dan Sullivan, R-Alaska. In that state, Gov. Bill Walker, an independent, broadened eligibility in 2015. "For citizens who have followed the law, abided by the law, we certainly want to minimize any negative impacts."

The reconciliation bill (HR 3762) that Obama vetoed earlier this year included a transition period of almost two years.

"When you go back and look at what we did last year, there was a transition period," emphasized Sen. Rob Portman, R-Ohio. "The idea was to leave time for Congress to come up with an alternative, not to pull the rug out from under people."

Republican leaders haven't yet said whether they plan to repeal the part of the 2010 health law that expanded Medicaid. When Republicans moved earlier this year to repeal the health law through the budget process known as reconciliation, the House initially didn't repeal expansion, but the Senate version did and the House agreed. The vetoed legislation is eyed as an early draft for next year's efforts.

Asked this week about whether a repeal bill would include Medicaid expansion, leaders of several congressional committees with jurisdiction over health care said it was too early to say.

"To be determined," said House Ways and Means Chairman Kevin Brady, R-Texas.

"That's going to be up to the leadership," said Senate Finance Chairman Orrin G. Hatch, R-Utah.

Republicans in both chambers also emphasized that they plan to include Medicaid changes in their promised effort to replace the health law. Republican replacement plans, including an oft-cited proposal from House Speaker Paul D. Ryan, R-Wis., have focused on restructuring the program into so-called block grants or per capita caps, which would reduce federal funding growth for the program.

None of those proposals spelled out details, including whether the funding would be based on the number of people in an expanded Medicaid program or a pre-expansion one.

Shift to the States

Sen. John Barrasso, R-Wyo., who helms the Senate Republican Policy Committee, acknowledged the complicated politics surrounding a repeal of Medicaid expansion—but speculated that the changes could be popular with state officials who might otherwise worry about losing their funding.

"You want to give states more authority. Indiana, with Gov. Mike Pence who's coming in as vice president, expanded Medicaid. He got waivers to do it, and he could have even done a better job with more authority," he said. "What we're trying to do is get the decisions out of Washington and back to the states."

Sen. Cory Gardner, R-Colo., whose state expanded Medicaid in 2013, said overhauling the program is key to ensuring its sustainability.

"Those people who think we can just keep this as it is in Medicaid still haven't answered the question of how it's sustainable long term, how they're going to pay for it long term without breaking this country," he said. "There is a tremendous amount of federal money in the Medicaid program and that's what people haven't explained to millions of people around the nation, is how is that sustainable going forward?"

Rep. Andy Harris, R-Md., a member of the conservative House Freedom Caucus, voiced similar thoughts.

"My philosophy is the states should be helping a whole lot more," he said. "You want expansion, then let's increase the [state matching percentage] on the expansion, then states can choose if they want expansion, that's fine. But the federal government is out of money."

Sen. Lisa Murkowski, R-Alaska, said in an interview that she and others in her state are worried about the costs the state will face, now that it has expanded. Though the 2010 health law initially funded 100 percent of the cost of expansion, next year it will pay just 95 percent of the costs. In 2020 and beyond, the federal government will fund 90 percent of the costs under current law.

"We're just in the first year of expansion and it's actually quite a tough situation for our state, as we realize that the cost for expansion is beyond what they had anticipated," she said. "The legislature's coming in in January, and it's my understanding that this is one of the things that's on deck for them, in terms of how we can deal with expanded Medicaid costs."

Asked about repealing expansion, she added, "I'm not weighing in right now either way."

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Republicans Reconsider Opposition to Medicare Innovation Center

By Andrew Siddons, CQ Roll Call

November 17, 2016 -- Republicans have called for abolishing a center created in the health care law that was designed to test innovative ideas, citing it as an example of federal overreach. But now, with the party set to overhaul the health care system, Republicans might look to that center to implement changes they would like to see.

The Center for Medicare and Medicaid Innovation was established under the 2010 overhaul to support new models of care and payments under Medicare and Medicaid. Getting rid of the center is near the top of the list of President Barack Obama's health care policies that Republicans want to repeal as part of a plan by Republican Speaker Paul D. Ryan of Wisconsin.

Republicans opposed the way that some of the center's demonstration projects required many doctors, hospitals or others to participate. They particularly opposed its March proposal for reimbursing prescription drugs that doctors administer. If finalized, that proposal would affect many doctors and patients around the country, as well as the pharmaceutical industry. For Republicans and many Democrats, it went too far.

The center's proposal to change how hip and knee replacements are paid for also was met with opposition from hospitals.

"They are routinely overstepping their authority and forcing mandates in health care that are termed 'demonstration projects' that have serious long-term implications," House Ways and Means Chairman Kevin Brady, R-Texas, told CQ.

However, Republicans, who are now in control of the White House and both chambers of Congress, could reshape the center to their own ends.

"I think done right, clearly, innovation is key to making health care affordable and saving Medicare for the long term. But that agency needs real scrutiny," Brady said.

The center could be used by Republicans to pursue changes in Medicare and Medicaid that they might not be able to do legislatively. At the very least, Republicans want to see how they might make the innovation center more transparent and keep it from doing anything they wouldn't approve.

"I think the concept, the theory behind it in passing it, is good. But I think this administration went way beyond that," said Rep. Pat Tiberi, R-Ohio, chairman of the Ways and Means Health Subcommittee. "I am open to hear as to why it would be a good thing to keep, but maybe put some guardrails on it in terms of what parameters they have."

The unpredictability of President-elect Donald Trump's policies could also drive Republicans to keep the innovation center on a short leash. "I certainly don't know what this administration might do. They might be the same in terms of using it in a broader way than what we would have envisioned," Tiberi said.

In the meantime, health groups are trying to advocate for changes to the center that could make it more accountable to Congress while still resulting in better outcomes and reduced federal health spending.

On Thursday, the Healthcare Leadership Council, a group representing executives from hospitals, insurers, and pharmaceutical companies, launched a new coalition known as the Healthcare Leaders for Accountable Innovation in Medicare. These groups want Congress to limit the scale of the demonstration projects and ensure that the center establishes quality measurement tools to monitor its proposals. They also want more transparency, in terms of both stricter congressional oversight and more active engagement by the center with outside groups.

Before any of that might happen, Republicans will have to get past their anger over the Part B demonstration project and other far-reaching initiatives. A bill (HR 5122) to repeal the initiative would cost $395 million over a decade, according to a Congressional Budget Office estimate released earlier this fall.

"We have to remember innovation is more than just new payment models," said Tom Valuck, principal at Discern Health and a former Medicare official.

Dan Crippen, a former director of the Congressional Budget Office and the National Governors Association, hopes that Republicans begin to understand the center's value and walk back from the plan to repeal the center. "I think it will be less a target and hopefully more constructive," he said.

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Red State Democrats Open to Working on Obamacare Replacement

By Erin Mershon, CQ Roll Call

November 16, 2016 -- Some vulnerable Senate Democrats are already signaling an openness to working with Republicans in their efforts to replace President Barack Obama's signature health care law.

"Do we need to fix some things with the health care bill? Absolutely. And it's going to take Republicans and Democrats working together to make that happen," said Sen. Jon Tester, D-Mont. "There's going to be areas, there's going to be spaces where we can work together and spaces where we can't. Hopefully if the needle isn't pushed too far to the right, we'll be able to get some things done," Tested added.

"What I've been saying to people about repeal is that I want to see what they're going to replace it with," said Sen. Joe Manchin III of West Virginia. "I'm open to working with everybody but I want to see what they're going to replace it with."

"Absolutely. I've been talking about appropriate amendments," said Sen. Heidi Heitkamp of North Dakota. "Until now it's been all or nothing. Let's see if it's something that can get managed here," Heitkamp added.

The Democrats' open minds may help Republicans, who will likely need to bring along at least eight Democrats to help pass their promised "replacement" for the controversial and mammoth health care law. Republicans can repeal and perhaps even replace some of the law through an arcane process known as reconciliation that requires only 51 votes, but any other legislative efforts will need to clear the Senate's 60-vote threshold. Republicans are expected to have 52 seats in the upper chamber next year.

The new statements reflect the suddenly much-improved political odds for repeal. Democrats in both chambers have remained united against many Republican affronts to the health care law over the last six years. Even after the election, many progressives on and off the Hill have vowed to continue fighting to preserve the law.

The openness to replacement, however, from Tester, Manchin, Heitkamp and other vulnerable Democrats, isn't a complete reversal for many of the more moderate lawmakers in the upper chamber. Many in the caucus have in the past offered or supported legislation to "fix" narrow pieces of the law, several of which became law.

The new statements highlight instead just how vulnerable many Democrats are after last week's election. At least 10 of the 25 Democrats who are up for reelection in 2018 come from states that Donald Trump won on Election Day. Another handful are from states that Trump narrowly lost.

Several said their main concern is providing coverage for the millions of Americans who rely on the law.

"I want to hear about replacement before I start talking about repeal," said Angus King, an independent from Maine who caucuses with the Democrats and faces a 2018 reelection race. "Working with them may be too strong a term. I've been proposing fixes for the ACA for three years. I think there are a number of things that can be fixed. But I'm also deeply worried about 20 million people losing insurance. I'm not going to support anything that would lead to that result."

Tester and Sen. Debbie Stabenow, D-Mich., shared King's sentiment that anything that would take away health insurance for the 20 million Americans who got it under the health law would be very hard to support.

Replacement Process

That will be a challenge for Republicans as they draft their replacement bill. Already many GOP leaders have said they do not want anyone to lose their coverage. Trump has said he wants to minimize disruption to those Americans while a replacement is being worked out. Using the reconciliation process might let senators bypass the 60-vote threshold, but it is not a quick and easy process, several lawmakers warned.

"There are things that you can do with regulations pretty quickly to provide some relief, but even to do reconciliation you have to do a budget, so it takes a little bit longer," said Sen. John Barrasso, R-Wyo., who helms the Senate Republican Policy Committee. Republicans must pass a budget resolution before passing reconciliation legislation, which could take months.

"I think that's the discussion we need to have—do we want a show vote or a real vote? Do we want to make law?" said Rep. Pat Tiberi, R-Ohio, the Ways and Means Committee health subcommittee chair. "You can't get rid of a lot of Obamacare without either going through reconciliation or getting eight more Democrats in the Senate to get to the president's desk."

Finding those eight votes still could require work. Outside of a moderate, vulnerable group of Democrats, many in the Democratic caucus aren't ready to give much room to the Republicans who are trying to repeal Obama's landmark domestic achievement.

"We're going to fight like hell against [repeal]," said Sen. Sherrod Brown of Ohio, who is also up for reelection in a red state. "They didn't expect to win this. They just thought their talking point would go on until the 22nd Century, I guess. . . . How do they explain to the 600,000 Ohioans? We're going to start naming the victims."

Still, it's possible Democrats may not be quite the obstructionists that Republicans have been.

"Unlike them, we're not out to simply deny Trump victories at any cost," said Sen. Sheldon Whitehouse, D-R.I., who is also up for reelection in 2018. "Nobody is going to buy the proverbial pig and a poke, and so until they have proposed a solution to that problem it's hard to know how to react to it. But I think a solution that continues to provide coverage, solves the pre-existing condition problem, maintains the end of the donut hole [lowering seniors' drug costs], particularly if it makes progress in the quality and performance area—I mean we want to do what's right here."

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Lawmakers Working on Legislative Text for Medicare Overhaul

By Erin Mershon, CQ Roll Call

November 17, 2016 -- House Ways and Means Committee Chairman Kevin Brady said he and his staff are currently drafting legislative text to address Medicare changes sometime in the next Congress.

The comments from the Texas Republican came as House Budget Committee Chairman Tom Price, R-Ga., laid out a goal of restructuring Medicare in 2017 in comments to The Hill. An aide to Price confirmed to CQ Roll Call that he hopes to use reconciliation to advance major changes, including Medicare. But the aide said timing and structure will depend on the incoming Congress and administration.

Brady, for his part, did not commit to any specific timeline in an interview with CQ Roll Call.

"I'm not engaging on the procedure and the sequencing or timing of all of that, but we are, as we speak, writing the Medicare reforms to save Medicare that we included in our Better Way plan," he said. "We're working on that legislation. We continue, we have work to do to complete it, but The Better Way laid out our approach to save Medicare for the long term, so we're working to put that into legislative text."

Brady was referencing a House document, finalized earlier this year at the request of Speaker Paul D. Ryan, R-Wis., that lays out the Republican alternative to the 2010 health law. The proposal also lays out changes to Medicaid and Medicare that have long been favored by Republican policymakers, including so-called premium support, which would give seniors a set amount of money to purchase coverage, either from Medicare or a private plan. Critics say that over time, the funding would be lower than under the current entitlement system and seniors could receive fewer benefits.

Though President-elect Donald Trump said on the campaign trail that he did not plan to cut Medicare or Medicaid, a transition website that lists his presidential priorities for health care includes plans to "modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation—and beyond."

Price, who is being considered for the post of Health and Human Services Secretary under the incoming Trump administration, told The Hill he hoped to advance Medicare changes in a so-called reconciliation package later in 2017 that would be drawn from a fiscal 2018 budget resolution. Many Republicans have coalesced around a plan to use the fiscal 2017 budget resolution and its accompanying reconciliation instructions to begin work in January to repeal the controversial health overhaul. Reconciliation allows Republicans, who are expected to hold just 52 Senate seats next year, to get around the upper chamber's 60-vote firewall.

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Trump Administration Poised to Oversee Exchange Plans in 2017

By Erin Mershon, CQ Roll Call

November 15, 2016 -- Republicans eager to repeal President Barack Obama's health overhaul are promising a "smooth transition" for its current enrollees.

However, that could task the Trump administration with completing the ongoing open enrollment period and running the next one—potentially opening it to the same criticisms of increasing premiums and diminishing competition that Republicans have historically lobbed against Democrats.

Even as repeal looms, people are signing up for new or renewed coverage under the health law. New enrollment figures will be released soon. It is the Trump administration that will have to oversee the final days of the 2017 open enrollment period, which ends Jan. 31.

Insurance companies, at least for now, are set to provide coverage under the law through the end of 2017 under contracts with the administration. And the planning process for 2018—in which insurance companies propose rates for review by state and federal officials and commit to participating in the marketplaces—is already underway, said industry spokeswoman Kristine Grow of America's Health Insurance Plans.

In some ways, it's business as usual so far. President-elect Donald Trump said this weekend he does not want disruption in the system as the law is repealed. Republicans' most recent effort to repeal the health law, using the so-called reconciliation process, gave the party two years to come up with a replacement plan before the health law would disappear. Most lawmakers, including House Majority Leader Kevin McCarthy, R-Calif., have similarly said they want to keep the chaos to a minimum.

Though the details are entirely up in the air, a "smooth" transition means there could be some sort of enrollment period for 2018 next fall. According to the latest regulatory schedule, that would mean insurers would have to submit their premiums for 2018 before May 3. That deadline is likely to come before Congress has time to flesh out a replacement, even if it does not build in a two-year transition.

Companies are already planning business strategies, product designs and their premium costs for 2018—and reading the tea leaves as closely as possible, said Ceci Connolly, president of the Alliance of Community Health Plans, which represents smaller nonprofit plans.

"You're hoping that by May, there have at least been some pretty thoughtful, substantive conversations that have taken place to inform that process," she said. "We often find in these situations, when you can't get policymakers to agree on something, they pass a step kind of like a continuing resolution. Sometimes the default is the status quo until the change gets resolved."

But the uncertainty in the market could drive up premiums from insurers concerned about how many people will still sign up for coverage and how sick those people will be. It could also make participating in the marketplaces a riskier business prospect for insurers—which would likely induce more of them to drop out.

This year, Republicans blasted Democrats for months for premium spikes that averaged 25 percent for benchmark silver plans across the country. The GOP spotlighted the massive market withdrawals by companies like UnitedHealth Group Inc. and Aetna Inc., who left, citing millions in financial losses.

Next fall, it will be Republicans overseeing the exchanges--potentially putting them on the receiving end of those headlines and criticisms, if premiums continue to go up or more companies decide to drop out.

"If there's no replacement in effect by the end of 2017, a Trump administration could find themselves operating an open enrollment period with lots of insurers dropping out. And any insurer that stuck around would raise their premiums significantly," said Larry Levitt, senior vice president for special initiatives at the nonpartisan Kaiser Family Foundation. "It's kind of like musical chairs; no one wants to be the one left insuring the sickest people."

"For some period of time, the Trump administration could blame the Obama administration, but at some point they assume the blame themselves," he added.

Calculating the Risks

Annual premium increases are based on several factors, like the expected makeup of the pool of enrollees and the expected annual increase in the cost of care. Insurers also build in a cushion known as the "risk charge," a calculated part of the premium designed to take into account further unknowns.

That part of the charge could fluctuate given the current political situation and the uncertainty of the marketplace's future, according to Cori Uccello, a senior health fellow at the American Academy of Actuaries.

"Actuaries by nature are cautious and conservative about numbers," Connolly agreed. "They're thinking about how they keep their companies afloat."

But insurance companies have had to assess the risk of major threats to the health law in the past—including the 2012 Supreme Court case on the constitutionality of the law's individual mandate, and the 2015 case on the law's central tax credits, both of which would have upended much of the health law had they been decided the other way.

"There were a lot of things over the past few years that [created] uncertainty—did we see premiums go up? No. If the subsidies were taken away, the difference in the risk charge was not going to be enough to compensate for the tremendous upward pressure that would have resulted from the deterioration in the risk pool," Uccello said. "There are potential changes that would dwarf what you would be compensated for in a risk charge."

Insurance companies could also create contingency plans. They could prepare one set of rates if the law's requirements for insurance, such as a ban on lifetime caps or denials based on pre-existing conditions, stay in place during a temporary transition and another ready in case they realize the climate will be more risky for them.
Possibility of Faster Action

It's possible Trump will repeal some of the law immediately—which experts warn could send the markets spiraling. Already some in the conservative House Freedom Caucus and at the right-leaning group Heritage Action are demanding swift action.

Even a relatively simple step, like ceasing to fund the law's cost-sharing reductions for insurance companies, which could be quickly done through administrative action, could upend the market, experts said. It would drain a major source of funding that insurers counted on when they set their rates, dramatically changing their business prospects for the coming year. Some might drop out of the market, kicking their customers off their plans.

And repealing the law's unpopular—but central—individual mandate would be even more devastating, experts said. The individual mandate was the key reason insurance companies agreed to cover people with pre-existing conditions, which they often did not do before the health law passed. The ban on exclusions for pre-existing conditions is among the most popular parts of the law. Even Trump has expressed support.

"If they did that, it would be catastrophic," Uccello said. "If the mandate goes away for 2017, not only are you having the problem of people dropping coverage, but with that, the risk profile is going to deteriorate and now premiums that already have been finalized are too low compared to what insurers need. You're going to have insurer insolvency problems as well as more people being uninsured....That it would be problematic would be an understatement."

The incoming administration is still weighing the options and has not yet even announced who will lead the efforts. Former presidential contender Ben Carson will not oversee the Department of Health and Human Services, a spokesman told news outlets Tuesday. Other names under consideration are former Louisiana GOP Gov. Bobby Jindal and Rep. Tom Price, R-Ga.

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