Although the GOP repeal-and-replace mantra seems to have quieted, some Republican lawmakers continue efforts to get around the sweeping federal health law's requirements.
Sometimes that happens in surprising places. Like the farm bill.
Tucked deep inside the House version of the massive bill — amid crop subsidies and food assistance programs — is a provision that supporters say could help provide farmers with cheaper (and likely less comprehensive) health insurance than plans offered through the Affordable Care Act.
It calls for $65 million in loans and grants administered by the Department of Agriculture to help organizations establish agricultural-related policies modeled on "association health plans."
But the idea is not without skeptics.
"I don't know that anyone at the Department of Agriculture, with all due respect, knows a darn thing about starting and maintaining a successful insurance company," said Sabrina Corlette, a professor and project director at the Georgetown University Health Policy Institute.
Association health plans are offered through organizations whose members usually share a professional, employment, trade or other relationship, although the Trump administration is soon to finalize new rules widely expected to broaden eligibility while loosening the rules on benefits these plans must include.
Under Trump's proposal, association plans would not have to offer coverage across 10 broad "essential" categories of care, including hospitalization, prescription drugs and emergency care. They could also spend less of the revenue from premiums on medical care.
Under the farm bill, starting next year, the secretary of Agriculture could grant up to 10 loans of no more than $15 million each to existing associations whose members are ranchers, farmers or other agribusinesses.
The language is strikingly similar to a bill introduced April 12 by Rep. Jeff Fortenberry (R-Neb.), a supporter of association health plans. He did not respond to calls for comment.
Although the farm bill is usually considered "must-pass" legislation by many lawmakers, this year's version is currently facing pushback because of controversy surrounding other parts of the measure — mainly language that would add additional work requirements to the food stamp program.
Still, no matter what happens there, the focus on association health plans won't go away.
The plans — coupled with another Trump administration move to make short-term insurance more widely available — could draw healthier people out of the ACA markets, leaving the pool of beneficiaries with higher percentages of people who need medical care. And that, some say, could drive up premiums for those who remain in marketplace plans.
The National Association of Insurance Commissioners, for example, has warned that association plans "threaten the stability of the small group market" and "provide inadequate benefits and insufficient protection to consumers."
Actuaries have made similar arguments.
Others are concerned about the idea of the government providing funding for such plans.
"We have reams of experience with AHPs that have gone belly up ... and the notion that we should put taxpayer money into them is irresponsible," says Georgetown University's Corlette.
She's referring to the industry's mixed track record with plans. Some have served members well, but other plans have been marked by solvency problems that left consumers on the hook with unpaid medical bills, or were investigated for providing little or no coverage for such things as chemotherapy or doctor office visits.
It's not fair to simply focus on the failures, counters attorney Christopher Condeluci, who in the past has served as tax and benefits counsel to the Senate Finance Committee and now advises private clients, some of whom are interested in association plans.
"Some AHPs were not successful," he agrees. "But there are arguably more examples of AHPs that work. The trouble is, everyone focuses on the negative."
Although the GOP generally supports association plans, using taxpayer funds to help start them could prove problematic for some conservatives in Congress.
Many Republican lawmakers have expressed concern about the use of tens of millions of taxpayer dollars to start insurance co-ops that were part of the ACA; most of them failed.
"The hard-earned tax dollars collected from working Americans, sitting at Treasury right now, are not venture capital, Rep. Kevin Brady (R-Texas) said at a subcommittee hearing in November 2015. Currently, Brady is chairman of the powerful House Ways and Means Committee.
But the provision could be popular in rural areas.
"We think it's a good idea," says Rob Robertson, chief administrator for the Nebraska Farm Bureau Federation, whose group is considering sponsoring an association plan.
About half of his members, Robertson says, have a spouse working a non-farm job, mainly to get the health insurance coverage the job entails. And of other members who buy their own health insurance, some are facing astronomical premiums and are looking for relief.
"I can't think of any sector that is affected more by the huge premium increases under Obamacare than farmers and ranchers," Robertson says.
The farm bill — including the AHP provision — was approved by the House Committee on Agriculture in mid-April, and is currently awaiting floor consideration. Meanwhile, a final rule on the Trump AHP rule, which has drawn more than 900 comments from supporters and opponents, could be issued as early as this summer.
Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.
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