WASHINGTON — Repeal and replace "Obamacare." Just repeal. Or let it fail — maybe with a little nudge. President Donald Trump has sent a flurry of mixed messages, raising questions about the White House strategy on health care.
Democrats say Trump's confusing signals are part of a strategy to destabilize the Affordable Care Act, as a way to force recalcitrant Republicans in Congress to repeal former President Barack Obama's signature law.
White House officials say they remain focused on trying to get a bill passed and have declined to delve deeply into their health care options if legislation fails.
"The White House does not have a strategy," said health industry consultant Robert Laszewski, an "Obamacare" critic who believes the administration is at a loss.
Another theory: Trump may have to cut his losses and take modest steps to sustain subsidized insurance markets if the GOP's legislative drive fails. A Senate vote is planned Tuesday.
Ironically, insurance markets don't appear to be on the verge of collapse as Trump and other Republicans keep saying. About 10 million people have individual policies under that part of "Obamacare."
"Improving but fragile," is how Standard & Poor's analyst Deep Banerjee describes the insurance exchanges. "We expect on average for insurers to hit break even" in 2017.
And Obama's Medicaid expansion —which provides coverage to another 11 million— is unaffected by problems on the exchanges.
Sen. Ron Wyden, D-Ore., who has previously worked with Republicans on health care, sees a White House bent on mischief.
"They are doing everything they can to stoke the fires of uncertainty, which is what really damages this law," Wyden said. "You can say 'I'd like to change the law,' but you don't just say 'We're going to do everything in our power to undermine a law that is on the books.' This is about being willing to hurt people in order to get a political advantage, and I've never seen a president doing it in such a brazen way."
The Trump administration says what's really hurting people is higher premiums and dwindling choice under "Obamacare." Some major insurers have bailed out or scaled back their offerings on the exchanges, leaving many consumers with limited options.
But Democrats cite the administration's pullback of open enrollment ads early this year as evidence of "sabotage," along with the recently disclosed termination of federal contracts for sign-up assistance in 18 cities. Also the 2018 enrollment season has been shortened to 45 days, about half the time previously provided.
And the Health and Human Services Department has posted internet videos of small business owners blaming high insurance costs on "Obamacare." Those videos are "important and educational testimonials" that show the ACA has made affordable insurance "impossible for millions of Americans," said agency spokeswoman Alleigh Marre.
It definitely looks like a hostile takeover, said economist Joe Antos of the business-oriented American Enterprise Institute, "but usually with a hostile takeover there is a business objective that is relatively clear." In this case, he said, objectives seem to shift.
Laszewski, the consultant, put it this way: "First, it was the Democrats will come begging (Trump) to fix it. Then it was repeal and replace, then it was just repeal, and now it is repeal and replace again."
The most immediate question is whether the Trump administration will continue monthly payments to insurers on subsidies that reduce deductibles and copayments for consumers with modest incomes. "Cost-sharing reductions" total $7 billion a year.
The payments are embroiled in a lawsuit brought by House Republicans over whether the ACA specifically included a congressional appropriation for the money, as required under the U.S. Constitution. Elsewhere, the ACA text plainly says the government "shall" make the payments. But Trump recently suggested to GOP senators he might just stop.
"We pay hundreds of millions of dollars a month in subsidy, that the courts don't even want us to pay," the president said. "And when those payments stop, it (Obamacare) stops immediately. It doesn't take two years, three years, one year — it stops immediately."
With key 2018 decision deadlines nearing, insurers want a guarantee that the administration will keep making the payments, as it has since Trump took office. State insurance commissioners and congressional leaders of both parties are seeking a similar acknowledgement. White House officials say the issue remains under review from month to month.
Rohit Kumar, a former top aide to Senate Majority Leader Mitch McConnell now with accounting firm PwC, said that while the administration has engaged in "saber rattling," it would likely take steps to shore up the individual market if the legislative push fails.
It would be difficult for Trump to avoid the backlash if the health care markets collapsed during his watch. "Whatever political fallout results from the destabilization of the exchange and rising costs, I don't think they're going to be able to successfully put that on the previous administration," Kumar said.
Republican Mike Leavitt, who served as health secretary for President George W. Bush, has some advice for the administration: "First, remain patient but keep the pressure on Congress," he said. "It's going to take more time, but they can still produce a health care bill."