AP Exclusive: Stable costs may shift 'Obamacare' politics

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In this Aug. 22, 2018 photo, April Box uses a roller to work on her hip muscles at her home in Spokane, Wash. Millions of people covered under the Affordable Care Act will see only modest premium increases next year, and some will get a price cut. That’s the conclusion from an exclusive analysis of the besieged but resilient program that still divides voters heading into this year's midterm elections. (AP Photo/Ted S. Warren)

After two years of double-digit premium hikes, millions of people covered under the Affordable Care Act will see only modest increases next year, according to an exclusive analysis that highlights the changing politics of health care heading into the midterm elections.

The consulting firm Avalere Health and The Associated Press crunched available state data, finding that "Obamacare's" health insurance marketplaces seem to be stabilizing. Customers in some states will get price cuts. And the exodus of insurers from the program has halted, even reversed somewhat, with more consumer choices for 2019.

The steady outlook means the health care law won't be an easy target for Republicans this year, an election issue that's worked well for them since 2010. But Democrats may also be looking for new talking points. They can't exactly argue that the Trump administration has wrecked the ACA, so they're saying that popular provisions like protections for people with pre-existing conditions are still threatened.

The analysis found a 3.3 percent average increase in proposed or approved premiums across 47 states and Washington, D.C., for next year. This year the average increase nationally was about 30 percent. The average total premium for an individual covered under the health law is now close to $600 a month before subsidies.

For next year, premiums are expected either to drop or increase by less than 10 percent in 41 states with about 9 million customers. Twelve of those states are expected to see a drop in average premiums, with New Jersey joining that list on Friday. In six other states, plus Washington, D.C., premiums are projected to rise between 10 percent and 18 percent.

Insurers also are starting to come back. Nineteen states will either see new insurers enter or current ones expand into more areas. There are no bare counties lacking a willing insurer.

Even so, Chris Sloan, an Avalere director, says, "This is still a market that's unaffordable for many people who aren't eligible for subsidies."

Nearly 9 in 10 ACA customers get government subsidies based on income, shielding most from premium increases. But people with higher incomes, who don't qualify for financial aid, have dropped out in droves.

It's too early to say if the ACA's turnabout will be fleeting or more permanent. Either way, next year's numbers are at odds with the political rhetoric around the ACA, still heated even after President Donald Trump and congressional Republicans failed to repeal the law last year.

Trump regularly calls "Obamacare" a "disaster" and declares it "dead." The GOP tax-cut bill repealed the ACA requirement that Americans have health insurance or risk fines, effective next year. But other key elements remain, including subsidies and protection for people with pre-existing conditions.

The moderating market "takes the issue away from Republican candidates" in the midterm elections, said Mark Hall, a health law and policy expert at Wake Forest University in North Carolina.

Stability also undercuts Democrats' contention that Trump has "sabotaged" the program. But Democrats say the ACA remains at risk while Republicans control Washington, and that premiums would be even lower but for the administration's hostility.

"Voters won't think that the Trump threat to the ACA has passed at all, unless Democrats get at least the House in 2018," said Bill Carrick, a strategist for Sen. Dianne Feinstein, D-Calif., whose re-election ads emphasize her support for the health law.

As if to add weight to Democratic arguments, the Trump administration has said it won't defend the ACA's protections for pre-existing conditions in a federal case in Texas that could put the law's fate back in the hands of the Supreme Court.

In solidly Republican Arkansas, Democratic state legislator and cancer survivor Clarke Tucker is using the ACA in his campaign to try to flip a U.S. House seat from red to blue. Tucker, 37, says part of what made him want to run is the House vote to repeal the ACA last year and images of Trump and GOP lawmakers celebrating at the White House.

Business analysts say the relatively good news for 2019 is partly the result of previous premium increases, which allowed insurers to return to profitability after losing hundreds of millions of dollars.

"They can price better, and they can manage this population better, which is why they can actually make some money," said Deep Banerjee of Standard & Poor's.

Repeal of the ACA's requirement to carry insurance doesn't seem to have had a major impact yet, but Banerjee said there's "a cloud of uncertainty" around the Trump administration's potential policy shifts. Yet some administration actions have also helped settle the markets, such as continuing a premium stabilization program.

April Box of Spokane Valley, Washington, lives in a state where premiums could rise substantially since insurers have proposed an 18 percent increase. In states expecting double-digit increases, the reasons reflect local market conditions. Proposed increases may ultimately get revised downward.

Box is self-employed as a personal advocate helping patients navigate the health care system. She has an ACA plan, but even with a subsidy her premiums are expensive and a high deductible means she's essentially covered only for catastrophic illness.

"I'm choosing not to go to the doctor, and I'm saying to myself I'm not sick enough to go to the doctors," Box said. "We need to figure out how to make it better and lower the price."

Now in her 50s, Box was born with dislocated hips. She worries she could be uninsurable if insurers are allowed to go back to denying coverage for pre-existing conditions. She might need another hip surgery.

"It needs to be a level playing field for everybody," said Box. "We need to have universal coverage — that is really the only answer."

Tennessee is a prime example of the ACA's flipped fortunes.

Last year, the state struggled to secure at least one insurer in every county. But approved rates for 2019 reflect an 11 percent average decrease. Two new insurers — Bright Health and Celtic— have entered its marketplace, and two others —Cigna and Oscar— will expand into new counties.

Tennessee Republican Sen. Lamar Alexander called that a "welcome step," but argued rates could have been even lower if congressional Democrats had supported a market stabilization bill. Democrats blame Republicans for the failure.

To calculate premium changes, Avalere and The Associated Press used proposed overall individual marketplace rate filings for 33 states and D.C., and final rates for 14 states that have already approved them. Data was not available for Massachusetts, Maryland and Alabama. The average rate change calculations include both on-exchange and off-exchange plans that comply with ACA requirements. The government isn't expected to release final national figures until later this fall.