Time is already running out to save Obamacare 2019

• The Obamacare marketplaces aren't slated to open again until November, but signs already point to trouble ahead.

Saul Loeb | AFP | Getty Images

Protesters against the US Senate Republicans' healthcare bill hold a rally outside the US Capitol in Washington, DC, June 28, 2017.

The Obamacare marketplaces aren't slated to open again until November, but signs already point to trouble ahead.

A recent independent analysis confirmed what industry experts and consumer advocacy groups have already argued: Republican changes to key provisions of former President Barack Obama's health care law will do more harm to the already struggling system.

Per the Urban Institute, Congress' repeal of the tax penalty for foregoing health insurance and President Donald Trump's expansion of short-term health care plans, specifically, will cause about 9 million more Americans to have no-to-subpar coverage next year.

As healthy people drop out of the market or opt for cheaper, barebones plans, marketplace premiums will increase an average of 18.2 percent, according to the Urban Institute report. That spike is significant on its own, but more troubling when you consider 2018 plans were already prohibitively expensive for people who didn't qualify for federal subsidies.

Meanwhile, another Obamacare lawsuit emerged. Twenty state attorneys general have filed a complaint in a Texas district court, alleging the law is unconstitutional now that the individual mandate is gone. Congressional efforts to stabilize the federal and state health insurance exchanges stalled behind a series of short-term funding bills. And proposals for long-term solutions are also losing bipartisan support, due to escalating demands from each party that the other is loath to support. (Democrats want increased federal subsidies, while Republicans are pushing for abortion limitations on said subsidies.)

Can Obamacare survive?

Obamacare 2019 isn't necessarily doomed. There's a chance funding to stabilize its marketplaces will get approved as part of the $1.3 trillion spending bill Congress is expected to vote on this week. Moreover, state legislators can step in to mitigate damages related to other changes.

Trump's proposal allowing short-term health insurance to cover any period of less than 12 months (as opposed to only three) doesn't preempt state laws from limiting these plans. Given the Urban Institute found that states with laws blocking this expansion (Massachusetts, New Jersey, New York, Oregon, Vermont, and Washington) would be largely insulated from related premium increases, other states could consider introducing similar legislation.

Moreover, states can conceivably keep more residents insured by enacting their own version of the individual mandate. At least ten states are already attempting to do just that — lawmakers in California, Connecticut, Maryland, Washington, D.C. and Washington are among those currently examining mandate replacement measures.

A reason to intercede

More states should consider following suit — or enact other stabilization measures independent of unreliable (and counterproductive) federal efforts.

The Urban Institute isn't alone in predicting GOP policies will significantly increase premiums and the ranks of the uninsured. Back in November, the Congressional Budget Office and Joint Committee on Taxation found repealing the individual mandate would increase the number of Americans without health insurance by 4 million in 2019 and cause premiums to rise for people ineligible for subsidies by 10 percent in most years of the next decade. Those figures, of course, exclude the millions of people who would lose coverage as a result of the Trump administration's other efforts to roll back the law without a viable replacement.

As I've written before, high uninsurance rates have been found to directly impact state budgets. A separate report from the Urban Institute and Robert Wood Johnson Foundation found reductions to Medicaid spending (another Trump proposal) would increase state spending by $68.5 billion between 2017 and 2026 due to increases in uncompensated care.

Obamacare's resilience

There's no reason to believe states can't get ahead of spending increases, as their efforts to stabilize Obamacare have worked in the past. States electing to expand Medicaid, despite a Supreme Court decision that made the Obamacare provision optional, have been found to have more robust exchanges.

More pointedly, despite Trump's decision to slash the advertising budget, shorten enrollment and cut cost-sharing reduction payments to insurers last year, over 11.7 million Americans signed up for a 2018 health care plan through the federal and state exchanges, just a 3.7 percent dip from 2017 open enrollment.

In a healthy insurance market, enrollment would increase — and, in fact, 15 states, plus Washington, D.C. (11 of which run their own exchanges) saw 2018 sign-ups best enrollment in 2017. Among the states that improved their numbers: New York, which elected to maintain a $14 million advertising spend in the wake of federal budget cuts; Washington, which instructed insurers to load premium increases caused by the cut of cost-sharing reduction payments onto Silver plans so premium subsidies would increase; and Minnesota, which instituted a state reinsurance program and kept its exchange open until Jan. 14, 2018.

If Congress fails to act, and the Trump administration continues to roll back key ACA provisions under the misguided notion it's improving our health care system, the future of Obamacare will be determined at a state level.

Commentary by Jennifer Fitzgerald, the CEO and co-founder of Policygenius, an independent digital insurance company for consumers. Previously, she was a junior partner at McKinsey & Company where she advised Fortune 100 financial services companies on marketing and strategy. She is a graduate of Columbia Law School and Florida State University. Follow her on Twitter @jenlfitzgerald.

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