While a full repeal of the Affordable Care Act (ACA) in Congress failed last year, the Trump administration, in the courts and through regulation, has managed to get closer and closer to its goal as a matter of practicality. As health policy watchers wait for an impending decision to drop in Texas v Azar, the case about the constitutionality of the ACA, here is a look back at the healthcare actions taken during the first 2 years of the Trump administration.
When Donald Trump became president, he did so after campaigning on specific ways he intended to shake up healthcare, starting with a repeal of the Affordable Care Act (ACA). While a full repeal in Congress failed last year, the administration, in the courts and through regulation, has managed to get closer and closer to its goal as a matter of practicality.
As health policy watchers wait for an impending decision to drop in Texas v Azar, the case about the constitutionality of the ACA, which the Department of Justice decided not to defend, here is a look back at the healthcare actions taken during the first 2 years of the Trump administration.
1. Chipping away at protections for pre-existing conditions
Even without the decision in the Texas case—which could come at any time—the administration has been trimming the protections for pre-existing conditions, which are a key part of the ACA, even while the president and health officials say they are still supported. The administration allowed short-term, limited-duration health plans (STLDHPs) to expand their duration to 12 months, with renewals that last up to 3 years; previously, the limit was 3 months. That previous limit was set to prevent consumers from winding up with huge medical bills from an unexpected crisis. The administration is pitching these plans, as well as association health plans (AHPs), as less expensive alternatives to individual health insurance purchased through the exchanges created by the ACA. Neither are required to cover people with pre-existing conditions, like ACA-compliant plans, or offer the ACA’s 10 essential health benefits.
If District Court Judge Reed O’Connor, the federal judge in the Texas v Azar case, rules in favor of the 20 Republican-led states that sued the federal government over the constitutionality of the ACA, it would create a huge cloud over the notion of pre-existing conditions, which played a key role in the outcome of midterm elections this month.
But if the judge rules against the ACA, Democrats, who will retake the House of Representatives in January, have pledged to protect the law. A showdown in the Supreme Court, with newly appointed Justice Brett Kavanaugh, is also likely.
2. Promoting and treating STLDHPs and AHPs like ACA-type health insurance
This week, CMS put forth a proposed policy which would allow public subsidies, intended to help people afford insurance purchased through the ACA exchange, to be used for the purchase of STLDHPs. Democrats sought additional information about the substantive changes to the Section 1332 waiver process and called it illegal because it subverts the legislative intent of the ACA.
In addition, during the current open enrollment for the individual insurance purchased on the exchanges, CMS is promoting STLDHPs and AHPs as equivalent to the more robust exchange plans. Open enrollment began November 1 and ends on December 15.
Administration changes also allow AHPs to be sold across state lines, another Trump campaign issue. Under the new rule, AHPs can serve employers in a state or employers in the same industry across state lines. According to the DOL, the new rule provides more choice and will make health insurance more affordable.
3. Expanding use of health savings accounts
In the same announcement this week about the changes to the Section 1332 waiver process, CMS also said it would allow the subsidies to be used in plans that include health savings accounts (HSAs). HSAs allow pretax income to be saved to help pay for medical costs, and in this case, states could seek a waiver to allow subsidies to be used for HSAs instead, where consumers can add funds from an employer. HSAs are a favorite of conservatives, but advocates for the poor and those with low incomes say they are not useful for those who struggle with basic necessities. Studies have found that they are more likely to be used by those with higher incomes and higher education.
4. Removing the individual mandate
A year ago at this time, the White House was pushing forward with a plan to kill the ACA’s individual mandate, which required tax penalties on individuals if they lacked health coverage. While CMS began expanding exemptions to the individual mandate this year, it is next year that the full effect of removing the tax penalty, or individual mandate under the ACA, will be seen. While the number of people enrolling in ACA plans is lower than last year, some people think it is the lack of patient navigators that will depress enrollment the most, not the lack of the mandate.
5. Conditioning Medicaid health benefits to work
With CMS’s blessing, states have pursued waivers to include work requirements as a condition for some of their Medicaid beneficiaries to receive health benefits. One of those states, Arkansas, has seen steep numbers of people losing coverage as a result of not reporting work or community engagement activities in order to keep their benefits, prompting the Medicaid and CHIP Payment and Access Commission to express concerns to HHS Secretary Alex Azar. The commission asked that the program be paused while adjustments are made. Conservatives praise the idea of work requirements, noting that it is a feature of cash assistance and that some recipients may be capable of working. Advocates for the poor say there is no evidence that employment boosts health and say it may have negative effects.