Obamacare hasn't collapsed, but Trump and the GOP might just let it

"Nobody knew healthcare could be this complicated," Trump mused during a White House event on February 27.

Three months, two votes, and one hugely unpopular bill later, the Republican Party is still struggling with just how complicated healthcare can be.

Despite advancing the American Health Care Act (AHCA) out of the House, the GOP's attempt to repeal and replace the Affordable Care Act is still, at best, from completion. A series of snags have complicated the top item on the party's agenda.

Between crumbling insurance markets, policy divisions in the party, and public dissatisfaction with their proposals, the GOP's healthcare overhaul is on shaky ground.

Whats the score?

The AHCA took another hit this week when the Congressional Budget Office released its updated projections on the legislation's effects on premiums and coverage.

The CBO found that the bill would bring down premiums in the aggregate and reduce the deficit, but also result in 23 million fewer people having health insurance in 2026 than under the current baseline.

Perhaps most strikingly, the CBO found that a new provision in the AHCA, imposed by the so-called MacArthur amendment, would undermine protections for people with preexisting conditions and leave them subject to sky-high premiums.

(Read a full breakdown of the new CBO score»)

Even before the score, the bill was not popular with Americans.

A poll released by Quinnipiac University on Thursday showed just 20% of Americans support the AHCA, and other polls consistently show that the bill is deeply unpopular.

At the same time, Obamacare has seen a surge in popularity. A recent Gallup poll showed 55% of Americans support the law, its highest level of approval since its passage more than seven years ago.

Its a very awkward process

Republicans in Washington have heard the pushback — at least in the Senate.

Even as House GOP leaders were celebrating the passage of the AHCA in a white House Rose Garden ceremony with Trump earlier this month, Senate GOP members were saying they were prepared to scrap the legislation and write their own version of the bill.

Senate Republicans have worked over the last few weeks in an attempt to come up with their own version of a healthcare bill.

It doesn't appear to be going smoothly.

On Tuesday, GOP Sen. Bob Corker expressed frustration with the Senate process, questioning the working group of roughly 13 lawmakers that are crafting the bill.

While there are plenty of issues to iron out, there are two major disagreements, said Cynthia Cox, associate director at nonpartisan health policy think tank The Kaiser Family Foundation:

Both of these issues, Cox said, do have a common theme: money.

"To make any of those changes, they need one relative to the AHCA," Cox said. "So it would also come down to which taxes they cut, or don't."

They really need clarity

So-called cost sharing reduction (CSR) payments help to offset costs to insurers for providing low-income Americans with affordable plans that reduce out-of-pocket costs. Their future is uncertain.

As Obamacare was signed into law, the Obama administration stipulated that CSR payments would be funded via the executive branch. That authority was contested by the Republican-led House in a lawsuit that has been ongoing for several years. The House argues that only Congress has the authority to appropriate the funds.

A court ruled in 2016 against the Obama administration, endangering the future of the CSR payments. The Obama administration appealed the ruling. Now, the Trump administration must ultimately decide whether to continue with the lawsuit. Trump himself has cast serious doubt as to whether it will.

On Monday, the Trump administration and the House agreed to delay the next step in the case, punting another 90 days to try and come up with a solution outside of the courts.

But the uncertainty over the critical CSR payments have left insurers in limbo as they decide their plans for the exchanges' 2018 plan year. The deadline to submit plans for the exchanges next year is late June, giving insurers little time and clarity on how to price their plans — or whether it's worth participating at all.

Cox said the uncertainty over the payments could end up driving insurers away, or cause the companies to increase their premiums.

"They really need clarity on this now," Cox said. "Without this clarity, they're either going to have to decide to leave the market or raise their premiums substantially, and in most cases I would expect insurers to do one of those two things."

Matthew Fiedler, agreed that the uncertainty could have a negative effect on consumer choices.

"The fact that the administration is a big question mark that needs to be resolved at some point later in the summer can't make them feel particularly good about where the market is," Fiedler told Business Insider. "I think it continues to make them place significant weight on the idea that the payments might ultimately not be there next year and when there's any possibility that they won't be paid it just makes it very hard to plan."

Market wobbles

Already, states where insurers have submitted their 2018 exchange plans have seen significant premium increases.

Republicans have argued that the rates are another sign that Obamacare as it stands is failing and that the need to pass a repeal and replacement is even more urgent.

House Speaker Paul Ryan's website labeled a New York Times editorial attributing some of the insurer exits from insurance exchanges to the AHCA as "disingenuous nonsense."

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One insurer took this a step further and clearly pinned the blame on the AHCA for serious instability in the individual insurance market.

Blue Cross Blue Shield of North Carolina said the company decided to more than double their requested premium increase due to the CSR uncertainty.

The company has requested a 22.9% increase for the average premium in 2018, but said that if the CSR payments were guaranteed, that would only by 8.8%.

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Obamacare hasn't collapsed, but Trump and the GOP might just let it

Whats the score?

Its a very awkward process

They really need clarity

Market wobbles

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