Maine Sen. Susan Collins agreed to vote for the president’s tax reform bill in exchange for a promise that the Senate would vote on her bill to stabilize the ACA marketplaces, but now it looks like the bill won’t pass.

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

Collins and several other 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 – at a news conference Wednesday in Washington.

The Hill, a Washington newspaper, and other national media outlets reported this week that it is unlikely that the ACA stabilization proposals 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 Trump for his signature.

Collins’ goal is to shore up the ACA’s individual marketplace, which has been weakened under Trump. The marketplace is where those who can’t obtain insurance through an employer – often part-time or self-employed workers – can purchase government-subsidized insurance. About 75,000 Mainers have ACA marketplace insurance.

Last summer, Collins was one of three Republicans to buck the party and vote to save the ACA from repeal efforts in Congress. Since then, the Trump administration, which is opposed to the ACA, has worked to undermine President Barack Obama’s signature domestic achievement. For instance, Trump announced in October the end of subsidies to health insurance companies – known as cost-sharing reduction payments, or CSRs – that help pay out-of-pocket medical costs of low-income people.

‘INCREDIBLY’ DISMAYED IF BILL FAILS

Collins has repeatedly said the ACA needs to be fixed, not repealed without a suitable replacement.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

“Are we going to miss this opportunity?” Collins said at the news 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 aims 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 purchase insurance or pay a penalty.

Collins and the other Republicans at Wednesday’s news conference, including Tennessee Sen. Lamar Alexander and Alaska Sen. Lisa Murkowski, touted the stabilization bill’s three-year, $10 billion-per-year reinsurance plan and the restoration of cost-sharing reduction payments.

Health care experts have praised the reinsurance portion of the bill, but questioned the effectiveness of restoring CSR 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 although those earning more than 400 percent of the federal poverty level – 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 workaround in response to the elimination of the CSR payments. In Maine and many parts of the country, lower-income families could select a zero-premium bronze plan. Those that 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 CSR payments are restored. Other plans, while not offering zero premiums, also were significantly less in 2018 compared with 2017, and those premium declines would be unwound by the ACA stabilization measure, the CBO said.

CRACKS IN SUPPORT FOR COLLINS’ BILL

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,” she said. “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 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.

“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 that Democrats are making as their support fades. 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 for the bill 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 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.

ABORTION ISSUE UNDERMINES BILL

One prominent ACA stabilization advocate, Sen. Patty Murray, D-Washington, appeared to be walking away from the deal. Murray argued that conservative House Republicans who are insisting that 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 from being used to pay for abortions – 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.”

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

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