The Trump administration released limited fixes Thursday for shaky health insurance markets, even as it reaffirmed its goal of dismantling the Obama-era law that created them and now covers millions.
Republicans contend that the Affordable Care Act, or ACA, is beyond repair, but their "repeal and replace" slogan hasn't been easy to put into practice, or politically popular. So the administration is taking steps to keep the existing system going even as it pursues its ambition of a total remake.
Many of the changes announced Thursday follow recommendations from insurers, who wanted the government to address shortcomings with HealthCare.gov markets, including complaints that some people are gaming the system by signing up only when they get sick, and then dropping out after being treated.
But the White House remained mum on the biggest concern. Insurers, doctors, hospitals and the business community have asked President Donald Trump to preserve ACA "cost-sharing" subsidies that pare down high deductibles and copayments for consumers with modest incomes. They're separate from the better-known premium subsidies that most customers receive.
Estimated at $7 billion this year, the future of the cost-sharing subsidies is under a legal cloud. Without them, experts say the government marketplaces that provide subsidized private insurance for about 12 million people will be overwhelmed by premium increases and insurer departures.
In a Wall Street Journal interview this week, Trump raised the possibility of shutting off the money if Democrats won't bargain on health care. But the president also said he hasn't made up his mind yet, and said he doesn't want people to get hurt. House Democratic Leader Nancy Pelosi of California called that an "appalling threat," and said Trump is trying to "manufacture a crisis." The new administration has continued to make cost-sharing payments to insurers as it weighs options.
The changes announced Thursday include:
-- A shortened sign-up window of 45 days, starting with coverage for 2018. That's about half as long as the current open enrollment season. Some insurers say a tighter sign-up schedule will allow for more focused marketing. Consumer advocates are worried uninsured people may be left out.
-- Curbs on "special enrollment periods" that allow consumers to sign up outside the normal open enrollment window. Insurers say these have been too easily granted, allowing some people to sign up only when they need costly treatment.
-- Allowing an insurer to collect past debt for unpaid premiums from the prior 12 months before applying a consumer's payments to a new policy.
-- Giving insurers more flexibility to design low-premium plans that can be tailored to young adults.
"While these steps will help stabilize the individual and small group markets, they are not a long-term cure for the problems that the Affordable Care Act has created in our health care system," Seema Verma, the Trump administration official responsible for the markets, said in a statement.
The changes come as insurers are figuring out their plans for 2018.
Consumers likely won't know for certain what sort of choices they will have until late summer or early fall, a couple months before open enrollment begins.
This year saw premium increases averaging 25 percent for a standard plan in states served by HealthCare.gov. Some insurers say they've lost hundreds of millions of dollars, and many have pulled back or are considering it.
Most communities will have competing insurers on the public marketplace next year, but a growing number will be down to one, and some areas may face having none.
Humana Inc. said it would leave the marketplaces next year, a decision that would leave 16 counties in Tennessee with no insurers selling HealthCare.gov coverage.
Aetna and Wellmark Blue Cross and Blue Shield have announced they'll leave Iowa's individual insurance market.
All eyes are now on Anthem, a big Blue Cross-Blue Shield insurer operating in several states that has yet to announce its intentions. CEO Joseph Swedish has said his company would not commit to participating next year. Swedish and other insurance officials have said the government has to stabilize the marketplaces.
Dave Dillion of the Society of Actuaries says growth in underlying medical expenses could drive coverage prices up another 10 percent or more.
Nonetheless, the nonpartisan Congressional Budget Office says the ACA markets will be stable next year in most areas.
In Washington, Republicans are trying to resolve an impasse between hardliners and moderates that has prevented them from getting their own health care bill through the House.
Meanwhile, the legal issue over the cost-sharing subsidies also remains in limbo. A U.S. District Court judge found that Congress did not specifically authorize the payments, making the expenditure unconstitutional. The case is on hold. Congress could approve the money, but that would be a politically difficult vote for Republicans.