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Trump’s ACA Replacement Would Do Much the Same Damage as His Effort to Repeal the Law Through the Courts

In calling for higher courts to uphold U.S. District Judge Reed O’Connor’s ruling striking down the Affordable Care Act (ACA), President Trump promised to replace the ACA with legislation that supposedly will lower costs while protecting people with pre-existing conditions, although he now says he won’t seek to pass legislation until 2021. Fortunately, O’Connor’s ruling does not alter health care for now; the ACA remains the law of the land as higher courts consider the issue. Moreover, as legal experts have explained, the legal reasoning behind the decision is extraordinarily weak, leading even committed ACA opponents to predict it will be overturned. But regardless of whether the decision is upheld, the Administration has already promoted its ACA replacement – a plan that would have much the same devastating consequences as the court decision itself.

In the President’s 2020 budget, released just last month, the Administration once again called on Congress to enact legislation modeled on the bill that Senators Bill Cassidy, Lindsey Graham, Ron Johnson, and Dean Heller (“Cassidy-Graham”) introduced in 2017. Senate Republicans have also pointed to the Cassidy-Graham bill as the basis for any future Republican health care legislation. Like the Administration’s push for ACA repeal through the courts, that proposal would:

  • Cause millions to lose coverage. If O’Connor’s ruling took effect, the number of non-elderly Americans without health insurance would rise from about 30 million under current law to 50 million, the Urban Institute estimates. The Cassidy-Graham bill would also leave an estimated 50 million Americans uninsured. And the President’s budget proposes over $700 billion in additional cuts to federal coverage programs, compared to the Cassidy-Graham bill.
  • End nationwide pre-existing conditions protections. The Cassidy-Graham bill would let insurers return to charging higher premiums based on pre-existing conditions, ending the ACA’s nationwide ban on that practice. That’s why patient groups, physicians, hospitals, insurers, experts, and independent fact checkers (for example, here and here) concluded that the bill would restore discrimination based on pre-existing conditions.
  • End other critical consumer protections. The Cassidy-Graham bill would also let health plans return to excluding essential health benefits — such as maternity coverage, mental health care, and substance use treatment — as many plans did before the ACA.
  • End the ACA’s Medicaid expansion. The Cassidy-Graham bill would end the Medicaid expansion to low-income adults outright, replacing it with a temporary, underfunded, and structurally flawed block grant to states.
  • End or sharply cut financial assistance for individual market consumers. The Cassidy-Graham bill would end federal financial assistance (premium tax credits and cost-sharing subsidies) altogether, replacing it, too, with a temporary, underfunded, and structurally flawed block grant to states.
  • Destabilize health care markets. If implemented, O’Connor’s ruling would throw much of the health care system into chaos. Similarly, the Cassidy-Graham legislation would “severely disrupt states’ individual insurance markets, with sharp premium increases and insurer exits likely to occur in the short term and over time,” according to 36 current and former insurance commissioners of both parties.