- Trump Takes a Final Shot at Obamacare Exchanges
- One-Stop Shopping
- ‘Accurate and Impartial Information’
- Trump wants to drop a neutron bomb on the Affordable Care Act. Over to you, 2020 voters
- Only insurance companies and people who have always been 100% healthy would be left standing if Trump gets his way. He's given America a clear choice
- Democrats roll out new health proposals
- Trump reset 2020 focus to health care
- Six ways Trump has sabotaged the Affordable Care Act
- Related Books
Trump Takes a Final Shot at Obamacare Exchanges
On his way the White House, President Donald Trump is taking one last swipe at the Affordable Care Act, proposing to allow states to opt the Obamacare exchanges where millions of Americans enroll in health insurance plans.
If states choose this potential new option, residents would no longer have access to a one-stop shop for health insurance. Instead, they would have to find their way to private insurance brokers or individual carriers.
They also wouldn’t have access to impartial advisers, so-called navigators, to assist them in making their choices.
The rule, proposed on Thanksgiving Eve, is one of the last attempts by the Trump administration to undo the ACA. Trump failed to kill President Barack Obama’s signature law in Congress, but is still attempting to do so in a case heard by the U.S. Supreme Court last month. Through administrative acts, Trump has been able to chip away at the law.
The federal Centers for Medicare and Medicaid Services (CMS) said the proposed rule, which still must go through a public comment period, would increase enrollment in health insurance and decrease premiums by encouraging competition and innovation. CMS claims that if adopted, the rule “would enable a more curated, customized consumer experience.”
Critics complain the Trump administration is trying to rush the proposed rule before Trump leaves office Jan. 20. By accepting public comments only until Dec.
30, there’s an increased lihood that the administration could adopt a final rule before President-elect Joe Biden is inaugurated.
In the past, the process for rules this one has taken three to four months, according to an analysis by the Center on Budget and Policy Priorities, a liberal think tank in Washington, D.C.
The heart of the proposal is modeled after a Georgia plan CMS approved last month that is almost certain to be challenged in court. The Trump administration wants to give all states the opportunity to follow Georgia’s path.
Stateline Update November 2, 2020 Quick View
Critics insist the new rule would actually do the opposite of what CMS claims, diminishing enrollment and increasing customer costs while raising the lihood that individuals and families end up in substandard plans that leave them with gaps in coverage in the event of illness or injury.
“Allowing states to privatize the ACA by eliminating any public marketplace would ly reduce overall enrollment and would surely lead to massive disruption and consumer confusion,” said Joel Ario, managing director with the consulting firm Manatt Health and former director of the Office of Health Insurance Exchanges in Obama’s Department of Health and Human Services.
The Georgia Department of Community Health, whose plan is the model for CMS’s proposed rule, claimed in an email that the change will lead to “improved access, affordability and quality of healthcare statewide.”
Opponents insist that under the new plan, Georgians will end up losing coverage and find health insurance less affordable and comprehensive.
While analysts say the incoming Biden administration could block the national rule, “It’ll distract from other policies and guidelines” at a time when the administration should be giving full attention to the COVID-19 pandemic, said Yvette Fontenot, a former Obama health adviser.
Fourteen states and Washington, D.C., operate their own health insurance exchanges. The rest of the states use the federal site, Healthcare.gov, customized to the market in each state, or partner with Healthcare.gov. The Trump proposal would give all states the opportunity to choose the new option.
This year, nearly 11.5 million Americans signed up for insurance on the exchanges, which provide a side-by-side comparison of nearly all the ACA-compliant plans offered in each state. Consumers also can find out about federal subsidies they might receive.
Stateline Story November 24, 2020 Quick View
All the exchanges used to provide navigators and engage in marketing to boost enrollment, especially in minority communities. But in 2018 the Trump administration eliminated almost all funding for Healthcare.gov navigators and marketing, so now only state-based exchanges have money for those functions.
The exchanges also determine eligibility for Medicaid, the public health plan for the poor. Consumers who qualify are enrolled or passed on to a state website where they can sign up.
The Trump option would strip down the exchanges to a basic listing of insurance plans and perhaps contact information for private brokers or insurance carriers. There would be no comparison of plans, no enrollment option and no guidance. Under this “direct enrollment” approach, brokers could limit options to the carriers they represent, instead of having to present all ACA-compliant plans.
Direct enrollment is already permitted in states that use Healthcare.gov. According to CMS, one-third of people enrolling in individual commercial plans (as opposed to employer-sponsored health plans) do so through direct enrollment. Most enrollees prefer to use the exchanges.
‘Accurate and Impartial Information’
Jessica Altman, insurance commissioner for Pennsylvania, which launched a state-based exchange this year after using Healthcare.gov since 2014, said she was certain her state would not choose the direct enrollment option.
“One of the core values of the ACA is making sure people are given the opportunity to truly shop and see all the plans with fair, accurate and impartial information,” she said, which would not be the case with direct enrollment entities.
Un the navigators, Altman said, brokers would have an incentive to push consumers toward policies that offer the greatest commissions.
She is particularly concerned that brokers seeking high commissions would point consumers to short-term plans, which usually don’t offer the comprehensive coverage of ACA-compliant plans, such as protections for pre-existing conditions. Such plans, which the Trump administration made legal, often leave patients with huge bills for services.
Stateline Story May 25, 2018 Quick View
Medicaid-eligible people are ly to be especially susceptible to that pressure, Altman said.
“There will be a lot of opportunities and perhaps pitfalls for consumers to be directed to plans that don’t meet QHP-certified standards,” said Christina Cousart, a senior policy associate at the National Academy for State Health Policy. (“QHP” stands for “qualified health plan,” one that an exchange has deemed ACA-compliant.)
But Ed Haislmaier, a health policy researcher at the conservative Heritage Foundation, said that in a few scattered cases around the country, insurance carriers with ACA-compliant policies did not join the exchanges. Direct enrollment would make it easier for consumers to purchase policies from those companies, he said.
Overall, he said he thought the effects of the proposed rule would be “pretty marginal.”
Others disagree. “I think the advantage of an exchange is that it offers [an] apples to apples shopping comparison experience,” said Johanna Fabian-Marks, director of policy and plan management of the Maryland Health Benefit Exchange.
“It’s important to have detailed information impartially offered on all plans offered. When you lose that hub approach it can make it potentially more confusing for consumers to navigate and compare the options.”
She said Maryland would not be interested in a direct enrollment option.
Other aspects of the rule also would be detrimental, critics say. The rule would raise annual out-of-pocket maximums and change other accounting formulas, leading to higher consumer costs for commercial health insurance policyholders, including those with employer-sponsored plans, according to Tara Straw of the Center on Budget and Policy Priorities.
Researchers there estimate that the changes sought by the administration could increase an individual’s average out-of-pocket expenses by $400 in 2022; a family’s average expenses would increase by $800.
The administration also wants to further lower the fees insurance carriers pay to be included on the exchanges. CMS argues the reduction would allow insurers to lower premiums, but those fees also help cover the operating expenses of Healthcare.gov.
Overall, Pennsylvania’s Altman said she sees no logic to the administration’s proposed rule. “What’s the point when the exchanges are already out there with carriers competing for business and without the risks that come from diverting consumers to inferior products and not presenting them with their full options?”
Trump wants to drop a neutron bomb on the Affordable Care Act. Over to you, 2020 voters
President Donald Trump reiterated how great he believes the findings from the Special Counsel Robert Mueller's investigation is and the “Republican party will soon be the party of health care.” (March 26) AP Domestic
Only insurance companies and people who have always been 100% healthy would be left standing if Trump gets his way. He's given America a clear choice
Only 24 hours after what he sees as a vindication of his presidency by Attorney General William Barr, President Donald Trump took the most radical, aggressive and harmful move of his presidency when he filed papers to ask the courts to support the complete elimination of the Affordable Care Act.
And in doing so, Trump just framed the stakes of the 2020 election.
In an administration that has attempted to ban Muslims from entering the country and separated small children from their parents, this stands out in some ways as an even more defining step because the impact reaches to nearly every American family.
Trump’s action would be by far the most far-reaching of his presidency. As many as 129 million Americans who have pre-existing conditions would no longer be assured of insurance coverage as they are today; that would be up to insurance companies.
Twelve million seniors would see significant increases in prescription drug costs at a time when Americans rate this is a top issue. The law's Medicaid expansion, which has covered millions of low-income Americans, would end. Over 2 million young adults would be kicked off their parents' plans.
Nine million people who receive subsidies to buy insurance would lose them. The uninsured rate would jump 65 percent.
Majority Whip James E. Clyburn and House Speaker Nancy Pelosi at the Capitol in Washingtonon March 26, 2019. (Photo: J. Scott Applewhite, AP)
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And those are just some of the easier-to-see effects. So much of how the health care law works for people behind the scenes — from regulations requiring 80 percent of your premiums to be spent on health care, to rules that prevent people over 50 from being massively surcharged, to the outlawing of lifetime limits or higher costs for women — would disappear.
Vital progress in making health care more sustainable and affordable would be lost.
We'd see the end of major national initiatives that focus on prevention, better health and the authority to pay doctors and hospitals for better health and lower costs instead of fee for service.
Hospitals, doctors, and nurses would see their operations flipped on end, almost certainly resulting in the closure of rural hospitals and reduced access for basic services.
It’s a neutron bomb. Only insurance companies and people who haven’t experienced an illness yet would be left standing.
Democrats roll out new health proposals
This radical agenda comes at a time when Republicans had been hoping to frame Trump’s 2020 re-election as a last stand against Medicare for All and full-on socialism.
Democrats seeking the presidential nomination have endorsed a number of ways to expand health coverage and some have signed on to multiple bills that range from modest proposals to the sweeping Bernie Sanders plan that would eliminate private insurance coverage.
While Sanders is most identified with this idea, it was a more uncomfortable spot for many of the candidates..
In contrast to Trump’s neutron bomb and claims of a Democratic socialist agenda, House Democrats introduced a very serious, pragmatic bill Tuesday to fix some of the ACA’s challenges, address affordability, and stop the Trump administration agenda of sabotaging the law and most prominently, pre-existing condition protections. Their proposal would mean that nearly all Americans, including those in the middle class who didn’t qualify for ACA subsidies, would never need to pay more than 10 percent of their income for health coverage.
Most new jobs today and into the future don’t provide insurance. So a proposal the one from House Democrats, making it easier for Americans of all ages, employment levels and health conditions to get affordable health insurance, is important — and not just to the public. It's also important to jobs, the economy, and growth.
Trump reset 2020 focus to health care
What can we learn from Trump’s action here? First, that Trump and Republican claims during the 2018 midterms that they favored pre-existing condition protections were what they appeared, an election-year lie that voters never bought. Republicans are running as the party that favors eliminating protections and putting the power of life and death in the hands of the insurance industry.
Second, we learn how Trump chooses to spend the political capital he thinks he’s earned: with a radical agenda that would leave as broad and lasting and damaging an imprint as anything he could do. This complements proposed cuts of nearly $1 trillion to Medicare and $1.5 trillion to Medicaid in his recent budget.
Third, Trump has reset the 2020 race to once again to be about the central issue of access to affordable health care, especially for people with pre-existing conditions. That's territory most Republicans would have just as soon avoided and on which Democrats are not only favored, they enjoy grassroots passion.
Voters loudly rejected all of this in 2018. They will get to make this choice once again next year, this time for keeps.
Andy Slavitt, a member of USA TODAY's Board of Contributors, is a former health care industry executive who ran the Affordable Care Act and the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on : @ASlavitt
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Six ways Trump has sabotaged the Affordable Care Act
Donald Trump’s first term represents an extraordinary development in what political scientists have called the administrative or unilateral presidency: how presidents seek to transform domestic policy through executive initiatives without congressional approval.
Aggressive, partisan, multifaceted administrative presidencies have been especially evident since Reagan with presidents of both parties participating.
Trump has in multiple ways taken this trend to new levels as his efforts to sabotage the Affordable Care Act (ACA, or Obamacare) vividly illustrate.
For analytic purposes, the term “sabotage,” should not be used lightly. Presidents upon taking office typically have priorities that trigger executive actions strengthening some programs while weakening others.
The losing programs often face resource reductions, pressure to deemphasize certain goals, directives to alter their administrative approaches, and other measures that can undermine their effectiveness.
In doing so, a president often pays lip service to the program, claiming it has been “modernized” or otherwise improved. In contrast, Webster’s defines “sabotage” as efforts to foster “destruction and obstruction” and to “cause the failure of something.
” In the context of the administrative presidency, it reflects a commitment to program emasculation and termination through executive action. As such, it sharply departs from the constitutional requirement that the president “take care that the laws be faithfully executed.”
The Trump administration’s efforts to sabotage the ACA and their consequences receive detailed attention in a recently released Brookings book, Trump, the Administrative Presidency, and Federalism. For present purposes, I highlight six major sabotage initiatives which emerged in the wake of congressional failure to repeal and replace the ACA.
1. Reduce outreach and opportunities for enrollment in the ACA’s insurance exchanges. Established to offer health insurance to individuals and small business, the exchanges have provided coverage to some 10 million people annually.
The Obama administration had vigorously promoted the ACA in part to attract healthy, younger people to the exchanges to help keep premiums down.
The Trump administration sharply reduced support for advertising and exchange navigators while reducing the annual enrollment period to about half the number of days.
2. Cut ACA subsidies to insurance companies offering coverage on the exchanges. ACA proponents saw insurance company participation on the exchanges as central to fostering enrollee choice and to fueling competition that would lower premiums.
The law therefore provided various subsidies to insurance companies to reduce their risks of losing money if they participated on the exchanges. The Trump administration joined congressional Republicans in reneging on these financial commitments.
3. Construct off-ramps to cheaper, lower-quality insurance.
The ACA had sought to bolster the quality of health insurance through such measures as requiring insurers in the individual and small-group markets to cover ten essential benefits, guaranteeing coverage of those with preexisting conditions at premium rates similar to heathier enrollees, and reducing risks of medical bankruptcy by prohibiting insurers from imposing certain spending caps on health care for an enrollee. By promulgating new federal rules related to short-term and also employer association health plans, the Trump administration strove to expand access to cheaper coverage that did not meet these quality standards and would siphon off healthier enrollees from the exchanges.
4. Promote waivers that would decrease ACA enrollments and undermine its regulatory structure.
The Trump administration approved demonstration waivers from several states that imposed work requirements and administrative burdens on non-elderly adults benefitting from the ACA’s Medicaid expansion.
CMS also invited states to use new ACA waiver authority to propose alternatives that departed sharply from the “guardrails” that the Obama administration had established to assure that these waivers did not water down coverage.
5. Discourage legal “aliens” from enrolling in Medicaid. The Department of Homeland Security promulgated a “public charge” rule that authorized officials to treat Medicaid enrollment as a negative factor in reviewing the requests of legal noncitizens to extend their stays or change their status (e.g., from temporary to permanent resident).
These five sabotage initiatives precipitated some erosion in ACA enrollments and benefits; they probably contributed to a slight uptick in the number of uninsured Americans. On balance, however, the ACA proved resilient.
Roughly 20 million individuals remain enrolled in the exchanges and via the Medicaid expansion. The number of states opting to expand Medicaid during Trump’s first term grew from 31 to 38 (plus the District of Columbia).
People with preexisting conditions continue to benefit from the ACA’s quality regulations.
ACA resilience largely reflects the potency of state attorneys general, other state policymakers, and private parties in resisting sabotage. Insurance companies have successfully sued to thwart Republican efforts to eradicate their subsidies.
Even before that, they obtained approval from most state insurance commissioners to do “silver loading”—an arcane premium strategy that allowed them to replace the revenues lost from federal cuts.
In turn, Democratic state attorneys general have used the courts to block certain Trump initiatives to promote lower-quality insurance, and to slow down his public charge initiative.
For their part, private advocacy groups have successfully sued to derail work requirement waivers. Moreover, if Biden wins the election, he could reverse most of the Trump administration’s sabotage initiatives.
The modest accomplishments of Trump’s sabotage strategy could, however, be transformed into a resounding success through a sixth initiative: persuading the Supreme Court to destroy the ACA.
In recent decades, the decision on whether to have the Justice Department defend a law’s constitutionality has become a prominent tool of the administrative presidency. So it is with the most recent legal challenge to the ACA that the Supreme Court will hear just after the election.
The case arose from a suit filed by 18 Republican state attorneys general, two Republican governors, and two Texas residents in a federal district court.
The suit reasoned that, since Congress in 2017 had eliminated the financial penalty for failure to obtain health insurance, the mandate to purchase coverage that remained in the law was unconstitutional and invalidated the entire ACA. Judge Reed O’Connor, a George W. Bush appointee, concurred with this view.
O’Connor’s decision was an epiphany for the White House. The Justice Department had originally argued that the remaining, toothless mandate invalidated only a portion of the ACA, primarily protections for those with preexisting conditions. Now, and against the advice of his attorney general, the president embraced overturning all of the ACA’s core provisions.
Legal scholars and pundits from across the ideological spectrum have panned Judge O’Connor’s ruling. But it poses a genuine threat to the ACA.
Two Republican-appointed judges on the Fifth Circuit Court of Appeals (with a Democratic appointee dissenting) upheld the core of O’Connor’s ruling while remanding the case back to him to consider whether portions of the law could be salvaged. Meanwhile, Democratic state attorneys general persuaded the Supreme Court to hear the case.
The passing of Justice Ginsburg and President Trump’s nomination of circuit court judge, Amy Coney Barrett, to replace her heighten the existential threat to the ACA. Barrett has been sharply critical of earlier Supreme Court decisions sustaining the law’s constitutionality.
Current developments illuminate how the administrative presidency can exploit its control over the Justice Department to coalesce with state officials of the same party to accomplish its policy goals.
They also have relevance for the ongoing debate among political scientists as to whether federal judges are best seen as partisans in robes, whose voting behavior on salient policy matters reflects those of the party of the president who appointed them.
To this point, recent court decisions on the individual mandate have faithfully followed the partisans-in-robes model. It remains to be seen whether the pending Supreme Court decision mirrors that pattern.