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Sabotage Watch: Tracking Efforts to Undermine the ACA

Following the failed Republican attempt to repeal the Affordable Care Act (ACA), President Trump said that, politically, the best thing to do would be to let the ACA “explode.” This timeline tracks Administration actions that would sabotage the ACA by destabilizing private insurance markets or reversing the law’s historic gains in health coverage.

January 20th, 2017
Trump issues anti-ACA executive order

Shortly after President Trump’s inauguration, he issues an executive order directing federal agencies to use their administrative powers begin dismantling the Affordable Care Act “to the maximum extent permitted by law.” The order instructs agencies, for example, to do what they can to grant exemptions or delay implementation of ACA provisions that impose a tax, fee, or other costs and to encourage development of a “free and open market” in health care services among states, while Congress works to pass repeal legislation.

January 26th, 2017

The Administration announces that it will stop planned ads for the final week of open enrollment for marketplace health coverage.

January 31st, 2017

After running ahead of 2016 enrollment totals through mid-January, final 2017 plan selections come in slightly below 2016.

February 14th, 2017
IRS scraps its plan to tighten reporting for the individual mandate

Building on the confusion created by the President’s January 20th executive order, the Administration announces a new step to undermine stability in the marketplace by preventing the IRS from using new tools to enforce the individual responsibility provision of the ACA – a crucial part of keeping a healthier pool and keeping premiums affordable. While having coverage is still the law – and the IRS will continue enforcing the provision in the same way it did the previous two years – the announcement creates added uncertainty that could damage the marketplaces going forward.

February 15th, 2017

Administration’s first health care rule is billed as market stabilization, but would discourage enrollment and undermine market stability by making plans less affordable.

March 14, 2017

The Trump Administration sends a letter to governors signaling it is open to considering precedent-setting Medicaid waiver proposals that would make it harder for Medicaid beneficiaries to get affordable care and would potentially increase the number of people who are uninsured.

March 28, 2017

After House Republicans fail to advance a bill repealing the Affordable Care Act, Administration officials and congressional Republican leaders continue to discuss bringing that or a similar bill to the floor.

Ongoing talk about the possibility of legislative action only fans insurers’ uncertainty and could cause them to increase premiums or pull back their participation in states’ individual markets in 2018 — even if the House Republican bill never becomes law.

April 12, 2017
Trump threatens to withhold ACA cost-sharing reduction payments to insurers

President Trump threatens to withhold ACA cost-sharing reduction payments to insurers. His comments could on their own cause insurers to balk at offering marketplace plans or to raise their premiums. If he actually followed through, the fallout would be even worse.

Trump’s remarks heighten uncertainty for insurers at the very moment they’re making premium and participation decisions for next year. The cost-sharing reduction payments, which reduce deductibles and other cost-sharing charges for low-income people enrolled in silver-level marketplace plans, have been the subject of a lawsuit by House Republicans since 2014.   If the federal government stopped these payments, the average premium for a silver plan would have to rise 19 percent to compensate, the Kaiser Family Foundation estimates. Equally important, a decision to stop the payments – or even prolonged uncertainty around these payments – could convince insurers that the Administration will keep taking actions that sabotage the individual market and lead them to stop offering plans altogether.

The President suggested that withholding the payments would force Democrats to negotiate with him on health care legislation, after House Republicans failed to advance their health care bill in March. That amounts to holding millions of people’s health care hostage in an attempt to push through legislation that would take away health coverage from millions more people.

April 13, 2017

The Trump Administration finalizes its rule for the individual health insurance market that will raise consumers' deductibles and other out-of-pocket costs, reduce premium tax credits that help millions of people buy insurance, and make it harder for people to enroll in coverage. While the Administration claims the changes are needed to stabilize the insurance market, many of them will reduce market stability by shrinking enrollment and making the pool of people with coverage sicker, on average. What's more, the changes do nothing to address the latest threats roiling insurance markets: comments from President Trump that he may withhold cost-sharing reduction payments and ongoing efforts by Republicans to repeal the ACA.

May 1, 2017

The Trump Administration and congressional Republican leaders fail to include a measure guaranteeing the continued payment of the ACA’s cost-sharing reductions (CSRs) in the fiscal year 2017 spending bill, endangering coverage for millions of people and risking premium increases and marketplace disruption.

May 2, 2017

Just weeks before CSR payments are due to insurers for May and as insurers are beginning to submit preliminary individual market rate filings, Office of Management and Budget (OMB) Director Mick Mulvaney says the Administration hasn’t decided whether to pay them.

May 4, 2017

House Republicans vote to add more than 20 million to the ranks of the uninsured, eliminate the individual mandate, slash subsidies in the marketplaces, and end federal standards for benefits and cost-sharing in the private insurance market. The bill faces an uncertain future in the Senate. But the mere possibility of enactment is likely to cause insurers to propose higher premiums than they otherwise would or discourage them from offering plans in the individual market at all, because the House bill would sharply increase per-enrollee costs and reduce individual market enrollment for 2018.

May 12, 2017

As the 2018 rate-filing season gets underway, initial filings – along with statements from insurers and state regulators — show that sabotage is taking a toll. Premiums are higher than they would otherwise be, and insurers cite uncertainty about the individual mandate, whether they will receive cost-sharing reduction payments, and potential changes to federal rules as contributing factors. “Uncertainty breeds higher costs,” said Martin Hickey, CEO of New Mexico Health Connections. See here for more comments from insurers and state officials on the challenges they are facing.

Meanwhile, fresh threats that President Trump may stop CSR payments to insurers surface upon publication of this interview with The Economist. Trump says, “Plus we’re subsidizing it and we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will.” He indicates that whether Congress passes health care legislation would impact his decision, saying, “if the bill didn’t pass the Republicans would have let me down. And then I’d have to decide what to do because I want people to have health care.”

May 22, 2017

The Trump Administration asks for another 90-day delay in the CSR court case, which would allow the payments to continue temporarily but means insurers will have to finalize marketplace rates in August without any guarantee that these payments will continue to be made.  The request comes days after an Oval Office meeting in which President Trump reportedly told aides he wants to end the CSR payments. The Administration has committed to making the payments only through May; later in the week, OMB Director Mulvaney reiterated that the Administration has not decided whether to make the June CSR payments. 

May 23, 2017
Trump budget proposes large cuts in marketplace funding, hitting consumer outreach and assistance hard.

President Trump’s budget requests 21 percent less funding to administer the marketplace in 2018 than President Obama requested for 2017. More than half the Trump budget’s proposed cuts fall in two categories of marketplace funding: “consumer information and outreach” and “eligibility and enrollment.” These budget items fund the marketplace call center that helps consumers enroll in marketplace coverage, in-person assistance by navigators and assisters, and outreach and marketing to make sure consumers know about the health insurance options available to them. They also fund eligibility determination activities to make sure that eligible consumers get subsidies (and the appropriate subsidy amounts) and ineligible consumers do not. Moreover, the Trump budget would cut “payment and financial management” — the spending category that covers basic program operations, like advance payment of subsidies and work with insurers — by more than half relative to the 2017 budget request. (While actual marketplace funding levels for 2017 are not available, the Obama budget request appears to have been largely or entirely funded in 2017 appropriations legislation.) Were these cuts to be enacted as part of 2018 annual appropriations, they would likely result in significantly lower enrollment during the upcoming open enrollment period for next year.

Marketplace Budget Request, $Millions
(Obama Budget)
(Trump Budget)
Health Plan Benefit, Rate Review, Management, and Oversight 51 31 -20 -39%
Payment and Financial Management 71 33 -38 -54%
Eligibility and Enrollment 456 322 -134 -29%
Consumer Information and Outreach 744 574 -171 -23%
Information Technology 657 636 -21 -3%
Other 166 99 -67 -41%
Total 2,145 1,694 -451 -21%