After the Affordable Care Act took effect in 2010, it created a review mechanism intended to prevent exorbitant increases in health insurance rates by shaming companies that sought them.

But this summer, insurers are turning that process on its head, using it to highlight the reasons they are losing money under the health care law and their case for raising premiums in 2017.

That has ignited an election-year fight between insurers and consumers, who are complaining bitterly about the double-digit increases being sought across the country.

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For several years, the Obama administration has urged state insurance regulators to use tools provided by the Affordable Care Act to hold down health care premiums.

Now federal officials will have a chance to practice what they preach as they confront big increases proposed in several states where they are responsible for reviewing rates.

Federal officials defer to the insurance commissioners in 46 states deemed to have “effective rate review” programs. But in Missouri, Oklahoma, Texas and Wyoming, the federal government is in charge of reviewing rates.

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The Republican assertion that the administration is spending on health insurance subsidies without required congressional authority hasn’t gotten much news coverage. Many people dismiss it as yet another time-wasting attempt by Republicans to undermine the president’s signature domestic policy achievement.

But the central issue goes beyond health care to the fundamental division of federal power, particularly in a time of deep fissures between the legislative and executive branches.

Congress is supposed to approve every penny of federal spending. But the institution is in such partisan disarray that the appropriations process barely functions, giving rise to the temptation for presidents to assert greater power over the purse, marginalizing Congress.

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The Obama administration knowingly spent billions in health care dollars without proper congressional authority and went to “great lengths” to impede congressional scrutiny of the money, Republicans on two major House committees said in a report that will be made public on Thursday.

An extensive investigation by the Ways and Means and the Energy and Commerce Committees concluded that the administration plowed ahead with funding for a consumer cost-reduction program that was central to the new health insurance law even though Congress did not provide money for it.

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A federal appeals court has ruled that consumers must be allowed to buy certain types of health insurance that do not meet the stringent standards of the Affordable Care Act, deciding that the administration had gone beyond the terms of federal law.

The court struck down a rule issued by the Obama administration that barred the sale of such insurance as a separate stand-alone product. “Disagreeing with Congress’s expressly codified policy choices isn’t a luxury administrative agencies enjoy,” the United States Court of Appeals for the District of Columbia Circuit said on Friday in a decision that criticized “administrative overreach” by the Department of Health and Human Services.

At issue is a type of insurance that pays consumers a fixed dollar amount, such as $500 a day for hospital care or $50 for a doctor’s visit, regardless of how much is actually owed to the provider.

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Oscar Health was going to be a new kind of insurance company. Started in 2012, just in time to offer plans to people buying insurance under the new federal health care law, the business promised to use technology to push less costly care and more consumer-friendly coverage.

“We’re trying to build something that’s going to turn the industry on its head,” Joshua Kushner, one of the company’s founders, said in 2014, as Oscar began to enroll its first customers.

These days, though, Oscar is more of a case study in how brutally tough it is to keep a business above water in the state marketplaces created under the Affordable Care Act. And its struggles highlight a critical question about the act: Can insurance companies run a viable business in the individual market?

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While it will be months before insurers and regulators agree to final rates for the coming year, a new Kaiser Family Foundation analysis confirms the signals we have seen from industry and government experts — that consumers and the federal government are likely to see much higher prices in many markets. Clearly, insurers are struggling to figure out how much to charge so they can cover their costs but still attract customers.

As health care reporters, we’ve been debating exactly how worried one should be about the fate of the Affordable Care Act, known informally as Obamacare, in the face of steep rate increases next year.

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The Geisinger Health Plan foresees health costs rising 7.5% next year, but requested a 40% rate increase. The plan, which is run by one of the nation’s top-rated health organizations, underestimated the cost of covering the newly insured under ObamaCare. “Our rates for Medicare, Medicaid and employer-sponsored insurance have been relatively stable, but those products have to bear the cost of our losses on exchange business,” Kurt Wrobel, Geisinger’s chief actuary, said. Many insurers are struggling to find the best ways of providing care to their new customers as they prepare for the fourth year of coverage under ObamaCare.

On Jan. 13, 2014, a team of Internal Revenue Service financial managers piled into government vans and headed to the Old Executive Office Building for what would turn out to be a very unusual meeting.

 

The clandestine nature of the session underscores the intense conflict over Obamacare spending, which is the subject of a federal lawsuit in which House Republicans have so far prevailed, as well as a continuing investigation by the Ways and Means and the Energy and Commerce Committees. It also shows that more than six years after President Obama signed the Affordable Care Act into law, Republican opposition has not waned.

After failing to win congressional approval for the funds, the Obama administration spent the money anyway and has now distributed about $7 billion to insurance companies to offset out-of-pocket costs for eligible consumers. The administration asserts that the health care legislation provided permanent, continuing authority to do so, and that no further appropriation was necessary.

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For months during the Democratic presidential nominating contest, Hillary Clinton has resisted calls from Senator Bernie Sanders to back a single-payer health system, arguing that the fight for government-run health care was a wrenching legislative battle that had already been lost.

But as she tries to clinch the nomination, Mrs. Clinton is moving to the left on health care and this week took a significant step in her opponent’s direction, suggesting she would like to give people the option to buy into Medicare.

“I’m also in favor of what’s called the public option, so that people can buy into Medicare at a certain age,” Mrs. Clinton said on Monday at a campaign event in Virginia.

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