As the Friday deadline to sign up for Affordable Care Act insurance approaches, thousands of Mainers are enrolling in individual health plans even as the law is under threat by the Trump administration. A tax reform bill that repeals a key part of the law is moving quickly through Congress.

As of Saturday, 40,608 Mainers had signed up for a 2018 ACA plan on the individual marketplace, according to numbers released by the U.S. Centers for Medicare and Medicaid Services on Wednesday. Nationally, 4.7 million had signed up for 2018 plans. About 10 million Americans — and 80,000 Mainers — have marketplace plans in 2017.

Last year, there were 33,500 enrollees through Dec. 10, but that was roughly halfway through the 2017 enrollment period, which was 12 weeks long compared with six weeks this year.

The individual marketplace is where people can purchase subsidized coverage, which typically appeals to those who don’t have access to employer-based insurance, such as the self-employed, part-time workers or those employed by small businesses.

Experts expect total enrollments to be down from 2017 because of the compressed sign-up period. 

Steve Butterfield, policy director for Consumers for Affordable Health Care, an Augusta-based health advocacy nonprofit, said that auto-enrollments — people who choose to keep their current plans and are automatically renewed — haven’t been counted yet and will substantially boost final enrollment numbers. So Maine’s final numbers may be closer to 80,000, he said.

Butterfield said the high enrollment numbers show that the ACA remains popular despite the Trump administration’s attempts to sabotage the law. 

“It seems pretty robust,” Butterfield said. “These enrollment numbers show that people, not just in Maine but also nationally, want the ACA to stay in place.”

Butterfield also said that the approval of Medicaid expansion by 59 percent of Maine voters on Nov. 7 is another sign of the law’s popularity. Medicaid expansion is another major component of the ACA that reduces the uninsured rate.  

A new wrinkle this year that could be helping sign-ups is the availability of zero-premium bronze plans, which Mainers are selecting in increasing numbers, according to Community Health Options, a Maine-based insurer on the marketplace.

When the Trump administration ended cost-sharing reduction payments to insurers, many states, including Maine, used a workaround that resulted in more people becoming eligible for zero-premium plans. Those earning between 100 and 225 percent of the federal poverty limit, or about $27,000 for a single person, can pick up a zero-premium plan.

“We’ve seen a definite shift toward bronze plans, with nearly 60 percent picking up bronze plans, as compared to 20 percent in 2017,” said Kevin Lewis, president and CEO of Community Health Options. 

About 18 percent of CHO enrollees so far are selecting the zero-premium plans, Lewis said, up from 2 percent in 2017.

In Maine, insurers filed a set of rates that anticipated the payments ending. The rates offset the loss of insurer payments by increasing the premiums for “silver” plans, the middle tier in the three-tiered system of bronze, silver and gold plans. Bronze plans have the lowest premiums and highest deductibles, while gold plans have the highest premiums, lowest deductibles and most benefits. Silver plans are in the middle.

Health policy advocates say the Trump administration has tried to undermine the ACA in numerous ways, including shortening the enrollment period, ending the cost-sharing reduction payments, and slashing funding for outreach and advertising.

President Donald Trump has supported efforts to repeal the ACA, which was thwarted by one vote in Congress this past summer. Maine Sen. Susan Collins, a moderate Republican, was one of three Republicans voting no, bucking the party and preserving the ACA. But the tax reform bill making its way through Congress would eliminate the ACA’s individual mandate, which studies predict would result in a 10 percent premium increase and, eventually, about 50,000 fewer Mainers with health insurance. Nationally, 13 million fewer Americans would have health coverage by 2027 with the individual mandate repeal.

The individual mandate requires that people who can’t obtain employer-based coverage sign up for marketplace insurance or pay a penalty. The mandate is a way to ensure that young, healthy people are in the insurance pool, helping to keep premiums down. 

While Collins was against ACA repeal, she voted for the tax reform bill — which slashes taxes for corporations and balloons the deficit by $1 trillion over the next 10 years, according to an analysis by the Joint Committee for Taxation, which analyzes bills for Congress. 

Critics say the bill is skewed to benefit the wealthy, while proponents argue it will boost businesses and generate jobs.

But one of the conditions for Collins’ support of the tax reform bill, she has said, would be to mitigate the harm caused by the loss of the individual mandate by having Congress approve ACA stabilization bills. Different versions of tax reform have passed the House and Senate, and the two legislative branches are working to craft one bill in a conference committee. That bill would have to be voted on again by the Senate and House and be signed by Trump to become law.

On Wednesday, Republican leaders announced they had a deal on tax reform, and a final version of the bill will be voted on in the next week. 

While Senate Majority Leader Mitch McConnell made public remarks supporting both ACA stabilization bills, Republican House Speaker Paul Ryan has not made such commitments, and House conservatives have called the Collins-Nelson reinsurance bill a “bailout” for insurance companies.

The Collins-Nelson bill would fund ACA reinsurance programs for two years, $5 billion per year. Avalere, a Washington-based health policy consulting firm, has estimated that passing the Collins-Nelson bill would reduce the 10 percent premium increases from repealing the individual mandate by 4 percent.

Collins told the Press Herald that McConnell’s promise implies that, in the end, Ryan would move the bills through the House.

“Now, I’m not minimizing the difficulty of this, but neither am I minimizing the importance of (the ACA bills),” Collins said Tuesday. She said she would be “much more comfortable” if the two ACA bills were voted on before the final vote on tax reform.

During a Christian Science Monitor breakfast on Nov. 30, Collins was quoted as saying she expected that the ACA bills would be approved by Congress before the final vote on tax reform. Collins was quoted in the Hill newspaper on Nov. 30 from the same breakfast saying that it “matters hugely to me” to know whether the ACA bills were approved.

Because of the speed with which tax reform is going through Congress, it appears that the tax reform bill will be voted on before the ACA bills. 

Collins has not ruled out changing her vote on the final bill to come out of the conference committee, depending on the details of the final bill.

But Kathleen Sebelius, former U.S. secretary of health and human services in the Obama administration, said in a phone interview with the Press Herald this week that while she appreciated Collins’ stance against ACA repeal, she doesn’t believe the House and Senate will follow through on the ACA stabilization bills touted by Maine’s senior senator. Sebelius said Ryan was not part of any deal between McConnell and Collins, and especially if tax reform is approved first, there’s not much motivation for Ryan to pass the bills. 

“It seems unlikely any of that is going to happen,” Sebelius said.

Sebelius said she’s also concerned that Medicare would be cut by $25 billion per year if the tax reform bill were to be approved, because the tax cuts would trigger automatic cuts to Medicare and other spending under a 2010 “pay-as-you-go” law that attempts to limit deficit spending. 

“Medicare would take a pretty big hit,” Sebelius said. “It would run counter to public sentiment that people want more health care and not less.”

But Collins has said she has an “ironclad” agreement that the Medicare cuts won’t happen, and that Congress has routinely waived the triggered spending cuts. 

McConnell and Ryan issued a joint statement on Dec. 1 promising that the “pay-as-you-go” cuts triggered by tax reform would be waived. However, Ryan has also said that one of the goals for 2018 is to do “entitlement reform” which would include subsequent cuts to Medicare and Medicaid.

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