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More ACA Sabotage From Trump

Executive order is latest attempt to undermine the ACA
Donald Trump issued an executive order today attacking some of the Affordable Care Act’s (ACA) key consumer protections for people buying health insurance on the small business and individual markets. While the executive order itself doesn’t do much, it directs federal agencies to implement disruptive changes to the ACA designed to push younger, healthier people into unregulated “junk” insurance. The order is part of a much bigger push by Trump to sow chaos in ACA markets and build momentum for full repeal.

This is just the latest step in a long line of steps to sabotage the ACA and drive up the costs of insurance for women, families, and anyone with a pre-existing condition. The Protect Our Care coalition, of which Raising Women’s Voices is a member, released this video earlier today explaining how Trump is actively working to sabotage our health care and fulfill his promise to let the ACA “be a disaster.”
Trump’s Department of Health and Human Services (HHS) is cutting nationwide advertising for the 2018 open enrollment period by 90 percent. In addition, HHS announced it was cutting the amount spent on in-person outreach through the federal navigator program by 41 percent—and abruptly stopped funding navigators altogether for 30 days—saving some of the deepest cuts for the most successful navigators.
For example, one of our RWV regional coordinators, Enroll Michigan, was deeply cut despite praise from federal officials for “years of outstanding work as a navigator grantee and leader of your community.” Executive Director Dizzy L. Warren (pictured at left) was quoted in the New York Timeshighlighting the scope of the problem: “Our funds were drastically reduced, but the government did not reduce our responsibilities.” And “we have not received an explanation of why our funds were cut,” she said.
RWV Regional coordinator Planned Parenthood of the Heartland, the largest navigator group in Iowa, was also quoted in the Times after after their grant was cut by 85 percent: “The government claims this funding is tied to performance measures,” said President Suzanna de Baca. “But we met or exceeded nearly all our goals, so a cut of more than 80 percent appears to be completely arbitrary.”
Trump order allows “junk” insurance 

What is “junk” insurance and why is it bad for us? Under current law, short-term health insurance plans intended to cover very short gaps in coverage don’t have to comply with the ACA’s consumer protections. But, they are limited to three months and they don’t satisfy the ACA’s individual mandate to have health insurance coverage.  By contrast, Trump’s order directs the federal government to re-write the rules to allow year-long “junk” insurance policies to satisfy the mandate.
Much like proposals pushed bycongressional conservatives this summer, these plans would not be required to cover essential health benefits like maternity or mental health care. They could discriminate against people with pre-existing conditions, charge limitless out-of-pocket expenses and reinstate annual and lifetime coverage caps. The ”junk” plans would not be required to spend a minimum percentage of our premiums on actually providing health care, instead of CEO salaries or advertising.
With lower monthly premiums, “junk” plans would appeal to younger, healthier people who don’t expect to get sick, have an accident, or need much insurance throughout the year. Referencing an earlier, similar proposal, insurance companies warned, “This would allow the new plans to ‘cherry pick’ only healthy people from the existing market, making coverage unaffordable for the millions of people who need or want comprehensive coverage, including, for example, coverage for prescription drugs and mental health services. … In fact, it creates two systems of insurance for healthy and sick people.
What else would the Trump order do to disrupt the ACA marketplaces?

In a second part of the executive order, Trump directs federal agencies to dramatically expand association health plans with similarly disruptive results. Pre-ACA, national trade associations like the Farm Bureau or the US Chamber of Commerce could pick a state with the worst coverage and use those rules to offer insurance nationwide. So, for example,they could offer coverage that complies with Mississippi’s consumer protections to small businesses in Massachusettsregardless of Massachusetts state law. Under current rules, small businesses can still band together to form association health plans for their members, but they have operate within states (not across state lines). Mostly importantly, they have to abide by ACA coverage requirements for small businesses. For example, they have to cover essential health benefits like maternity care.  
Under the changes Trump is proposing, association health plans would be exempt from a host of ACA consumer protections and would once again be able to operate under the rules of any state they choose – most likely one with the least coverage protections. The small businesses with the youngest, healthiest people would face strong incentives to exit the ACA’s small business marketplaces and buy a cheaper, skimpier association plan, raising prices for all of the small businesses that remained. 

One under-discussed impact of the pre-ACA small business insurance market was how it depressed employment opportunities for women. A small business looking at a highly qualified female candidate and a less qualified male candidate would face a strong financial incentive to pick the male candidate simply because it would mean lower insurance premiums. In industries dominated by women—like home health care—small businesses simply provided no insurance at all. There is every reason to think that the Trump proposal would reinstate barriers to hiring women, particularly older women or those with pre-existing conditions.
But even for women who end up being covered by an association plan, there’s no guarantee that they’ll actually be covered as promised. As the Washington Post notes, “25 years ago, federal watchdogs concluded that [similar] plans ripped off hundreds of thousands of Americans by refusing to pay their medical claims while violating state insurance laws and even criminal statutes.”
If fully implemented the way the Trump order envisions, these two changes (individually and combined) could destabilize ACA marketplaces by setting up a “death spiral” in comprehensive coverage. Some younger and healthier people would opt for cheaper, junk plans (or have their employer choose it for them) making the market for comprehensive coverage slightly older and sicker. That would drive up premiums which would price out the next tier of healthy people, including those who wanted comprehensive coverage but could no longer afford it. And that, in turn, would leave ACA markets as a de facto high risk pool with only the very sickest still trying to afford comprehensive coverage.


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