The Affordable Care Act stabilization measures that Maine Sen. Susan Collins sought in return for her vote for the Republican tax reform bill appear to be in danger of collapsing. Democrats and conservative Republicans have failed to come to a consensus that can pass Congress.

Collins and several fellow moderate Republicans tried to rally support for the bill — which would be attached to must-pass spending legislation expected to go before Congress this week — in a news conference in Washington on Wednesday.

The Hill, a Washington newspaper, and other national media outlets reported this week that it was unlikely the ACA stabilization efforts would be included in the House version of the omnibus spending bill. The House and Senate must agree on an identical bill for it to be approved and go to President Donald Trump for his signature.

Collins’ goal is to shore up the ACA’s individual marketplace, which has been weakened under Trump. 

The Trump administration is opposed to the ACA and has been attempting to undermine President Barack Obama’s signature domestic achievement. The individual marketplace is where those who can’t obtain insurance through an employer — often part-time or self-employed workers — can buy subsidized insurance. Last summer, Collins was one of three Republicans to buck the party and vote to save the ACA from repeal efforts in Congress.

Collins has repeatedly said that the ACA needs to be fixed, not repealed without a suitable replacement. On Wednesday, she said that it would be “incredibly disappointing” to see efforts to repair the ACA fail.

“Are we going to miss this opportunity?” Collins said at the conference. “Inaction will only exacerbate premium spikes and the market instability we’ve already seen.”

In December, Collins said she would support the controversial Republican-led $1.5 trillion tax-cut bill in exchange for promises by Republican leaders that the ACA stabilization measures she had lobbied for would be approved. The tax-reform bill tries to stimulate the economy by lowering corporate tax rates, but with fewer tax dollars coming in, the bill would increase the national debt by $1 trillion over 10 years, according to official estimates. 

Collins sought the ACA stabilization measures because the tax bill also revoked the ACA’s individual mandate, which health care experts warned would result in more uninsured Americans and a weakening of the health insurance marketplace. The individual mandate required people to buy insurance or pay a penalty. Collins was pushing late last year to have the ACA stabilization votes completed by year’s end, but those votes were delayed.

Collins and the other Republicans at Wednesday’s news conference, including Tennessee Sen. Lamar Alexander and Alaska Sen. Lisa Murkowski, touted the three-year, $10 billion-per-year reinsurance plan and the restoration of cost-sharing reduction payments to insurance companies that the Trump administration ended last year. 

Health care experts have praised the reinsurance portion of the bill, but questioned the effectiveness of restoring cost-sharing reduction payments. Reinsurance programs reduce risk for insurance companies by providing funds to insurers for high-risk enrollees, keeping premium costs lower than they otherwise would be. Collins argued that premiums would decrease if the stabilization measures were approved. 

But the official Congressional Budget Office report on the measure released this week showed that while those earning more than 400 percent of the federal poverty limit — about $81,000 for a family of three — would see their premiums decrease, many earning under that amount who qualify for subsidies under the ACA would see premium increases.

“If an ACA stabilization package funded CSRs and created a new reinsurance program, the net effect would be to increase premiums for low-income people and decrease premiums for middle- and higher-income individual market enrollees,” Larry Levitt, a vice president for health reform at the Kaiser Family Foundation, a nonpartisan Washington think tank, said in a tweet Wednesday.

Premiums for many actually declined this year after most states created a work-around in response to the Trump administration ending the cost-sharing reduction payments. In Maine and many parts of the country, lower-income families could select a zero-premium bronze plan. Those who did saw up to an 85 percent premium decrease for a low-income 40-year-old, according to the Kaiser Family Foundation. The no-premium plan would no longer be available if the cost-sharing payments were restored. Other plans, while not offering zero premiums, also were significantly less in 2018 compared to 2017, and those premium declines would be unwound by the ACA stabilization measure, the CBO said.

Annie Clark, Collins’ spokeswoman, said that the workarounds implemented by many states are not sustainable for the insurance markets, and in many cases, will cost more for patients who have to use their health insurance.

“Free or low-cost bronze plans are only a good deal for low-income Americans if they never get sick or injured. If they do, it could cost them hundreds or even thousands of dollars more out of pocket,” Clark said, pointing to examples in which patients would have zero premiums but $5,500 deductibles, or pay premiums but have only a $500 deductible. “In addition to reducing the cost of health care for low-income Americans, restoring funding for CSRs, combined with reinsurance, would lower premiums for plans across all metal levels by up to 40 percent. This would benefit Americans who do not qualify for subsidies, stabilize the health care markets, and reduce costs to taxpayers.”

Ann Woloson, executive director of Consumers for Affordable Health Care, a Maine-based health advocacy group, said that Collins’ efforts are noteworthy, but the bill ultimately falls short because it fails to maintain low premiums for people who receive subsidies and because it would result in more than 500,000 additional Americans becoming uninsured, according to CBO estimates.

About 75,000 Mainers have ACA marketplace insurance.

“She’s been fighting really hard for a way to stabilize the ACA marketplaces, and that’s greatly appreciated,” Woloson said. “Unfortunately, this bill doesn’t do it.”

Woloson said it would be better to regroup and try again than to approve a measure that helps some ACA customers, hurts others and results in fewer people having health insurance.

That appears to be the calculation Democrats are making, as their support is fading. While Republicans control the House, Senate and the presidency, conservatives, especially in the House, are not likely to vote for the omnibus bill because of the domestic spending increases in it, so some Democratic votes may be necessary to pass the House. The government would shut down this weekend if Congress doesn’t act.

Mitchell Stein, a Maine-based independent health policy consultant, said that the unintended consequence of Trump ending cost-sharing reduction payments was that most people getting marketplace coverage saw a premium decrease, so reversing that decision through a law doesn’t make sense.

One prominent ACA stabilization advocate, Sen. Patty Murray, D-Washington, appeared to be walking away from the deal. Murray argued that conservative House Republicans insisting on provisions limiting access to abortion be inserted into the bill are deep-sixing the effort.

“Unfortunately, Republicans are once again putting politics ahead of patients and families with a bill that would undermine care for people with pre-existing conditions and impose harmful, last-minute restrictions on abortion coverage,” Murray said in a tweet Tuesday.

Planned Parenthood of Northern New England slammed the abortion provisions Monday, saying the proposal is “dangerous and part of a larger strategy to eliminate insurance coverage for abortion services.”

But Collins said the abortion restrictions — called the Hyde amendment, which forbids federal funds to be used on abortion — have been included in every major government health care program, such as Medicare and Medicaid, for more than 40 years. 

“It is a common provision that is always included and it is nothing new,” Collins said in response to questions from reporters. “This is nothing that is radical.”

Sen. Susan Collins, R-Maine center, joined by, from left, Sen. Lindsey Graham, R-S.C., Sen. Lisa Murkowski, R-Alaska, and Rep. Greg Walden, R-Ore., pushes for inclusion in the pending government spending bill of provisions aimed at lowering premiums for people purchasing health insurance in the Affordable Care Act’s individual marketplace, during a news conference on Capitol Hill in Washington, Wednesday, March 21, 2018. (AP Photo/J. Scott Applewhite) ]