Obamacare Has Survived, but Health Reform Isn’t Over

Jimmy Kimmel is not talking about health reform every night and Mitch McConnell is not trying to advance legislation through the Senate, but the fight over health reform is far from over. More than eight years after its passage, what the Affordable Care Act (ACA) accomplishes and means in the lives of Americans is still not settled. President Trump has turned to a collapse and repeal strategy, hoping that Democrats will be forced to compromise as the law fails.

The most recent attempt is the legal equivalent of a Hail Mary pass at the end of a football game, in which the Department of Justice is asking the courts to invalidate the entire ACA now that the individual mandate is gone. Nick Bagley has a great summary of why this should not go anywhere. As I recently wrote with colleagues in the Journal of Aging and Social Policy, the Trump administration is using a variety of executive branch powers to subtly but proactively foment an implosion.

3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!

— Donald J. Trump (@realDonaldTrump) July 28, 2017

First, President Trump has signed executive orders directing agencies to disregard the ACA “to the maximum extent permitted by law.” These executive orders are mostly symbolic but have served as a precursor to the second type of action: rulemaking. Many of the technical but highly consequential details governing how the ACA operates were not explicitly spelled out in the law. Rather, they were decided by the Obama administration after enactment. The Trump administration has moved swiftly to undo many of these decisions in ways that makes premiums for some people less expensive but increases out-of-pocket spending for older and sicker people.

There are no policy arguments, however, for many of the steps taken by the Trump administration, which are deliberately aimed at limiting the number of people participating in the exchanges.

Some decisions can be defended as stabilizing the market from the insurer’s point of view and thereby helping those who can afford insurance. There are no policy arguments, however, for many of the steps taken by the Trump administration, which are deliberately aimed at limiting the number of people participating in the exchanges. This includes removing information from government websites, shortening the enrollment period to just six weeks, and slashing the advertising budget by 90% such that few people would be aware of these changes. Analysis by the Kaiser Family Foundation (see figure) suggests that these efforts did in fact diminish enrollment in states that rely on the federal government for their exchange.

These shifts are meaningful but hardly amount to an implosion. In fact, activity at the state level suggests that this may be the biggest year for gains under the ACA since the coverage expansions went into effect in 2014. Virginia just expanded Medicaid after many years of trying. A judge has ordered Governor LePage to respect the result of a statewide referendum by expanding Medicaid in Maine. Voters in the deeply red states of Idaho and Utah may make the same choice this fall.

State legislators have told me they are tired of the chaos in Washington and are hungry for bi-partisanship.

The Trump administration has also shown a surprising degree of restraint in ways that help avoid the implosion the President seems to want. For example, a proposal in Kansas was denied which would have allowed the state to impose a three-year lifetime limit of Medicaid benefits. Similarly, Mississippi was warned that it would not be able to establish a work requirement that resulted in people losing coverage because their new income is higher than the state’s dramatically low eligibility threshold. Scholars and pundits are unsure of what to make of these decisions which do not fit the narrative that the Trump administration’s singular health policy goal is to undermine the ACA.

It will likely be many years before Congress considers legislation with a serious shot at passage, either to expand or repeal the ACA. However, the fight over health reform is far from over, with the biggest decisions being made within the executive branch and in state capitals. State legislators have told me they are tired of the chaos in Washington and are hungry for bi-partisanship. Whether that will be possible will largely depend on what happens in state elections this fall as many states are choosing new governors. Stay tuned.

Feature image: Arizona Department of Transportation, SR 89A Sinkhole Closure, used under CC BY-NC-ND 2.0