It's death by a thousand cuts.
Two weeks before the start of open enrollment—aka the time when the millions of people who buy their own health insurance under the Affordable Care Act can sign up for coverage or renew their existing plans—President Trump had some thoughts to share about Obamacare. Trump told reporters on October 16: "It's dead. It's gone. It's no longer...you shouldn't even mention. It's gone."
Despite Republicans' multiple, well-publicized failures to repeal or replace the Affordable Care Act, a Morning Consult/Politico survey of about 2,000 American voters conducted in the days after Trump's comments found that 15 percent of people thought Obamacare was indeed fully repealed or replaced with some other law while 24 percent thought it had been partially repealed.
The Trump administration doesn't need to repeal the law to destroy it, they've done plenty of damage by attacking it with a mix of rule changes and executive orders that seem designed to make insurance companies raise prices and make fewer people sign up, which, in turn, will raise prices. That would really be the death spiral that Trump keeps shouting about.
Super quick health insurance lesson: The costs of healthcare are spread throughout what's known as a risk pool. Insurers need healthy people to buy coverage to help offset the costs of less-healthy people who use more services. One of the requirements of Obamacare is that every American has to buy health insurance in order to spread the costs evenly among people in the pool. (Well, it was a requirement until Republicans killed it in their tax bill.) Instead of trying to bring costs down for everyone, the Trump administration is shitting in the pool and then posting Yelp reviews about finding shit in the pool, all while dangling cheaper pool memberships for young, healthy people, which would fuck over people in the other pool, where there's shit piling up.
Let's count all the insurance-sabotaging turds they've dropped so far, shall we?
Cut the sign-up period by half...and then some
Previously, the window to sign up for insurance (aka open enrollment) ran for 90 days, from November 1 to January 31. The Trump administration ended it on December 15 after just 45 days. (Several states run their own insurance exchanges and extended their deadlines, but most states use Healthcare.gov.) If that weren't bad enough, the administration shut down healthcare.gov for 12 hours every Sunday during the sign-up window except for the final Sunday, December 10. The administration says the site was down for maintenance. When the initial changes were announced in April, the Associated Press reported that "some insurers say a tighter sign-up schedule will allow for more focused marketing." But the Trump administration will not help with said marketing—see below.
Why this matters: Giving people less time to sign up could result in fewer people signing up, which goes against rule #1 of health insurance: You need as many people to enroll as possible. Shitty move.
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Slashed 90 percent of the advertising budget
The Department of Health and Human Services (HHS) spent $100 million on advertising for 2017 Obamacare plans. HHS announced in August that funding for 2018 signups would be just $10 million, a reduction of 90 percent. (You may also recall that once the Trump administration assumed control in January 2017, HHS pulled Obamacare ads in the crucial last week of enrollment.)
Why this matters: Advertising for Obamacare is mostly meant to help reach young, healthy people, as those who need insurance for pre-existing conditions are almost certainly going to seek it out without any nudges. Just like having a shorter sign-up window, less advertising could mean fewer healthy people in the pool. That stinks.
Cut funding for outreach programs
Not only is HHS cutting advertising, it's also cutting funding for in-person outreach programs that help people actually sign up for their insurance and help spread the word about Obamacare enrollment more generally. The budget for these so-called "navigators" at health clinics and nonprofits is being cut 41 percent from $62.5 million to $36.8 million. But their budgets ran out on September 1 and grants weren't released until two weeks later at midnight September 13. Vox reports that some groups laid off workers or shut down entirely.
Why this matters: As with the first two turds, this move could affect enrollment numbers. It's also particularly cruel, as a third of the people who seek in-person help don't have internet at home and one in ten don't speak English.
Let people buy garbage insurance
Trump signed an executive order on October 12 that would allow small businesses (and possibly individuals) to band together to buy less comprehensive insurance through what are known as Association Health Plans (AHPs). Per the order, these AHPs would be exempt from current requirements that all insurers must offer a minimum set of so-called essential health benefits, or EHBs, which include things like maternity care, prescription drugs, and mental health services. Basically, it would be garbage health insurance, but hey, it might cost less! Since Obamacare banned annual and lifetime limits for EHBs, striking them could mean the return of coverage caps for those services. The order also calls for expanding access to short-term insurance, aka low-cost plans with fewer benefits which people can only have for three months under Obamacare; the Trump administration wants to extend that limit to one year. The administration issued rules in January 2018 to move forward with association health plans and a rule for short-term plans in February 2018.
Why this matters: It could split the insurance market into healthier people with fewer medical needs getting skimpy AHPs or short-term plans, and less-healthy people with more needs buying Obamacare plans. The former group would be gambling on its own mortality while the latter group would likely face much higher prices. As industry consultant Robert Laszewski told Kaiser Health News in February 2018: "If consumers think Obamacare premiums are high today, wait until people flood into these short-term and association health plans." A shit sandwich.
Cut off key payments to insurers
The Trump administration has been playing chicken with what's known as cost-sharing reduction payments (CSRs) since day one. The CSRs reimburse insurance companies for offering reduced out-of-pocket costs to lower-income people and Trump has been renewing them on a month-to-month basis, often waiting until the last second to do so. On October 13, the White House finally put the nail in the coffin and announced that it would no longer pay the CSRs. Trump at first seemed to support a bipartisan deal to fund the payments for two years, which he called a "short-term solution" on October 17, then backtracked the next morning tweeting that he could never support a "bailout" for insurers. And he's continued to flip-flop.
Why this matters: The uncertainty about whether the White House would continue to pay CSRs led many insurers to increase their rates for 2018. This move doesn't hit lower-income people who qualify for subsidies because those tax credits rise alongside the costs of health plans, but it DOES increase costs for people who don't qualify for help and pay full price. And since tax credits would rise, that means ending CSRs would increase the deficit. Plus, insurers might exit the Obamacare market in 2019 as a result. A turd cocktail with a shit garnish.
Smeared Obamacare all over Twitter
Trump's Twitter screeds are obviously included here but so are those of the official HHS account and of former HHS secretary and private jet aficionado Tom Price. @HHSGov has been openly hostile to the law and retweeted Price's account when he used the hashtag #RepealandReplace.
Why this matters: The president and federal agencies and appointees are actively undermining the law by hyping Obamacare's price increases but absolving themselves of blame when independent experts say they're to blame. They're gaslighting and using feces for the fuel.
Ended the individual mandate
As part of the $1.5 trillion tax cut passed by Congress in December, Republicans effectively ended the requirement that every American have health insurance or pay a tax penalty. This is known as the individual mandate and, again, it's a way to make sure there are enough healthy people in the insurance pool to offset the costs of the less-healthy people. But Republicans were like, "nah, individual freedom is more important than sick people being able to afford healthcare." The tax bill repealed the mandate as of 2019; meaning in 2019 people who don't have insurance won't have to pay the penalty. (Trump had reportedly drafted an executive order to end the mandate if the tax bill didn't include a provision to do so.)
Why this matters: The nonpartisan Congressional Budget Office estimated that repealing the mandate will lead to 4 million fewer people with insurance in 2019 and 13 million fewer by 2027 and, crucially, that premiums would increase by about 10 percent in most years. The CBO analysis said that healthier people would be less likely to obtain insurance and, as costs increase for those who remain (the people more likely to need health insurance in the first place), even more people would drop out. Which, you guessed it, will raise prices even more. The report said: "The resulting increases in premiums would cause more people to not purchase insurance." It's a snake eating its own tail, except its tail is also excreting shit.
Update 2/21/18: This post has been updated to include the repeal of the individual mandate to purchase health insurance and proposed rules that would allow people to band together in association health plans and allow insurance companies to sell short-term health plans for 12 months instead of three.
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