Shifting timelines for two Affordable Care Act stabilization bills championed by Sen. Susan Collins are raising alarms that the bills could stall out and die. But Maine’s senior senator is insisting that she has commitments for passage of the bills from President Trump and key Republican leaders.

The bills may be delayed further into 2018 as Congress considers many issues.

Collins, a moderate Republican, had emphasized the passage of the two ACA bills to secure her vote for the $1.5 trillion tax reform package because it included the repeal of the ACA’s individual mandate, which will undermine health insurance markets. Collins was a key vote to save the ACA last summer, but part of the reason her December tax reform vote has been criticized is because the tax reform law weakens the ACA.

The ACA remains popular in Maine, with 76,000 people signing up for 2018 coverage through Dec. 15 despite the Trump administration slashing outreach and advertising budgets and compressing the enrollment period. That nearly matches the 79,000 people who signed up for 2017 coverage. Mainers also approved Medicaid expansion in November, 59 percent to 41 percent. About 20 million Americans have insurance through the ACA, either from the marketplace or from Medicaid expansion.

The ACA marketplace is where those who don’t have access to employer-based coverage – usually the self-employed or part-time workers – can purchase subsidized insurance.

INDIVIDUAL MANDATE SET TO EXPIRE IN 2019

The bills Collins wants passed would help shore up the ACA’s individual marketplace after mandate repeal, which is set to take effect in 2019. The mandate, while politically unpopular because it forces people to buy insurance or pay a penalty, helps insurance markets by keeping young and healthy people in the insurance pools.

Senate Majority Leader Mitch McConnell had promised Collins that the bills would pass “certainly” by the end of 2017.

But Congress took no action on the bills by year’s end, and it’s unclear when they will be taken up. Meanwhile, some Republicans are still calling for ACA repeal, and the Trump administration has issued new rules for short-term health plans that health experts warn could destabilize insurance markets.

In this political environment, Collins is working to keep the ACA viable.

The timelines for action on the bills – Collins-Nelson and Alexander-Murray – have changed from the end of 2017 to early 2018, and now Collins has told InsideHealthPolicy.com that the important thing is they be voted on in time to be implemented in 2019, when the ACA’s individual mandate is set to expire.

“Senator Collins is going to push hard on these bills until we get them over the line,” Annie Clark, Collins’ spokeswoman, said Friday. “Both of these bills have the support of the president, the vice president and Senate Republican leaders.”

Collins told the Press Herald in December that if the commitments on the bills aren’t kept, “there will be consequences.”

Clark confirmed that the bills would not be attached to continuing resolution spending bills that Congress must vote on to keep the government running after Jan. 19. She said Collins is looking for votes as soon as possible after that.

The window to help the 2019 insurance markets is narrowing, said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation.

“The relevant timetable is when insurers start submitting their premiums for 2019,” said Levitt, noting that rate requests are done in late spring, usually in May. “The longer this drags on, the lesser the chance that there would be any premium relief for 2019. Insurers could pull out of markets altogether.”

The Congressional Budget Office has estimated that repeal of the individual mandate would increase premiums by 10 percent and result in 13 million fewer insured Americans.

COLLINS-NELSON BILL OFFSETS PREMIUM HIKES

Levitt said of the two bills, the one that would have the most impact on insurance markets is Collins-Nelson. He said the Collins-Nelson reinsurance bill would substantially offset the premium increases for the two years that it’s funded – $5 billion in each of 2019 and 2020 plus $500 million to help states set up a reinsurance fund. Reinsurance helps insurance companies keep premiums in check when higher claims are submitted by sick people.

Collins had said before the Dec. 19 tax reform vote that the bills would be attached to continuing resolutions that needed to be approved before the end of 2017. But a day after the tax vote, Collins and fellow Republican, Tennessee Sen. Lamar Alexander, issued a joint statement saying that the bills would be delayed and votes would happen early in 2018. Alexander called it an early “Valentine’s Day present.”

Democrats attacked Collins for the changing deadlines for the bills.

“The bottom line here is that, by continually shifting this timeline, Sen. Collins is just not being straightforward with the people of Maine,” said Katie Mae Simpson, the Maine Democratic Party’s executive director. “She’s made at least three different promises, and she’s broken them every time. But what’s worse is that Mainers are now left holding the bag because of her bad judgment, and while she scrambles to see if she can strike another bad deal, we are left to wonder what harm she will bring to us next.”

MCCONNELL HAS MADE PLEDGE, RYAN HASN’T

Brent Andersen, an adjunct political science professor at the University of Maine at Presque Isle, believes Collins will get a vote on the bill in the Senate because McConnell promised her one, but it faces a sketchy future in the House.

Collins said in a December statement that she has spoken with House Speaker Paul Ryan, and that Ryan has made positive comments about the bills. But Ryan has not made any public commitments on the ACA bills.

“She was playing a weak hand,” Andersen said, since the tax reform vote likely would have passed without Collins’ vote, blunting her leverage. “It doesn’t fit the House’s political agenda. They are trying to weaken Obamacare every chance they get.”

Andersen said commitments by politicians for future votes are always perilous because “the future is always contingent” and subject to negotiations. Priorities will change over time, Andersen said. But he said Collins’ clout in the Senate will remain potent, because as a centrist her vote is up for grabs in a 51-49 Senate. Alabama Democrat Doug Jones won a December special election, narrowing the Republican majority in the Senate from 52-48 to 51-49.

“I see her as continuing to position herself as a good-government centrist,” Andersen said. “But a lot of her constituents feel burned by the tax reform vote, so I think she has some fence-mending to do.”

Joe Lawlor can be contacted at 791-6376 or at:

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