The Trump Administration’s Health Care Sabotage

President Trump bookended his Administration with efforts to repeal the entire Affordable Care Act (ACA) — first through legislation and, after that failed, through the courts. Late in 2020 the Trump Administration and Texas attorney general’s office, with the support of 17 other Republican state attorneys general, argued before the Supreme Court that it should strike down the entire ACA as unconstitutional. If it does, some 21 million people would become uninsured, and millions more could be charged more or denied coverage altogether because they have a pre-existing condition or would lose other important protections.

Along with pushing for full ACA repeal, President Trump also took administrative actions throughout his time in office that caused people to lose coverage or made coverage less comprehensive or less affordable. Despite strong economic growth and falling unemployment between 2016 and 2019, the number of people without health insurance coverage rose by 2.3 million, including over 700,000 children. This is likely due in large part to the following and other Trump Administration actions to undermine the ACA and Medicaid.[1] The Trump Administration:

Made It Harder for Eligible People to Get Coverage

  • Slashed consumer outreach and enrollment assistance. The Centers for Medicare & Medicaid Services (CMS) slashed funding for outreach by 90 percent and for the navigator program’s enrollment assistance and outreach by more than 80 percent. These cuts alone caused an estimated 500,000 to 1 million people to lose coverage.
  • Discouraged immigrants and their family members from enrolling in coverage. The Trump Administration issued immigration rules in 2019 that severely restricted family-based immigration to the United States and created a climate of fear among immigrants and their family members. This led many people to forgo Medicaid or marketplace coverage and other assistance programs for which they were eligible, likely contributing to uninsured rate increases among Hispanic adults, Hispanic children, and children who were not born in the United States.
  • Encouraged over-verification in Medicaid and the marketplaces. The Trump Administration pressed states to add burdensome paperwork requirements and other complexity to their systems for verifying Medicaid coverage. This likely caused low-income people — among them eligible children with complex health care needs — to lose coverage and forgo needed medical care, with some states seeing large Medicaid enrollment declines for both children and adults. Likewise, the Administration added new paperwork and verification requirements in the marketplaces, for example making it harder for people to enroll mid-year through special enrollment periods and harder for some very low-income people to enroll at any time.

Encouraged States to Cut Coverage

  • Took coverage away from people who didn’t meet work requirements. The Administration released guidance in January 2018 that encouraged states to take Medicaid coverage away from people who weren’t working or engaged in work-related activities for a specified number of hours each month. Where implemented, these policies terminated or threatened health coverage for 20 to 40 percent of those subject to them; meanwhile, studies of Arkansas’ policy found it increased uninsured rates, worsened access to care, and did not increase employment. Federal courts struck down CMS’ approval of demonstrations that included work requirements in several states. The Supreme Court has agreed to hear the Trump Administration’s appeal of the courts’ decisions.
  • Imposed premiums on people in poverty. The Trump Administration gave states unprecedented authority to require people in poverty to pay premiums for their Medicaid coverage, in spite of extensive research showing that premiums significantly reduce coverage for low-income people. For example, in October 2018, it approved a Wisconsin demonstration requiring some people with incomes as low as $500 per month to pay premiums to keep their coverage.
  • Threatened coverage for HealthCare.gov enrollees. In November 2020, the Trump Administration approved an unprecedented ACA waiver under which Georgia plans to exit HealthCare.gov without creating an alternative state marketplace, requiring its residents to enroll in marketplace coverage exclusively through private brokers and insurers. Tens of thousands of Georgians could lose comprehensive coverage under this fragmented and confusing system. On January 14 the Administration finalized a rule that lets other states make the same harmful change without even requiring a waiver.
  • Invited state “block grant” demonstrations. The Trump Administration issued guidance in January 2020 inviting states to apply for demonstrations that would convert their Medicaid programs for adults into a form of block grant, with capped federal funding and new authorities to cut coverage and benefits. This guidance could have led to state policy changes resulting in large coverage losses and reduced access to care. In its final days in office, the Trump Administration approved an unprecedented Tennessee demonstration project that incorporates several policies from the guidance. It creates a financial incentive for Tennessee to restrict access to care for Medicaid enrollees, while offering the state a federal “slush fund” that it can use to supplant state spending with no benefit to Tennesseans needing Medicaid coverage.

Cut Financial Assistance

  • Raised costs for millions with marketplace or employer plans by changing insurance payment formulas. In April 2019, the Administration finalized a rule changing the formula for how premium tax credits are updated each year. In 2022, the formula change will raise premiums, after tax credits, by almost 5 percent for millions of marketplace consumers by cutting their premium tax credits. Based on the Administration’s own estimates, the rule change will likely reduce coverage by over 100,000 people in 2022.
  • Other cuts to premium tax credits. In April 2017, the Trump Administration finalized a regulation letting marketplace insurers reduce the value of coverage provided in marketplace silver plans, on which premium tax credits are based. This likely reduced the value of premium tax credits for millions of people.

Weakened Consumer Protections

  • Expanded subpar health plans. In October 2018, the Trump Administration finalized a regulation expanding the availability of so-called short-term health plans, which are exempt from benefit standards and protections for people with pre-existing conditions. The new rules define short-term plans as those lasting less than a year, up from three months under the previous rules, and let insurers extend them for longer. The Administration also changed rules to expand the availability of association health plans, which are also exempt from many ACA standards. Expanded availability of these subpar plans exposes consumers to new risks and raises premiums for those seeking comprehensive coverage — especially middle-income consumers with pre-existing conditions.
  • Weakened standards for access to care in Medicaid. The Trump Administration significantly weakened standards for access to care for Medicaid enrollees who receive care through both the managed care and fee-for-service systems. In November 2020, the Administration finalized a rule undermining key sections of the managed care rule. In July 2019, it proposed to rescind the access rule entirely (though this change was not finalized).
  • Restricted access to qualified family planning providers. The Trump Administration rescinded guidance in January 2018 that affirmed Medicaid’s “free choice of provider” provision, which allows beneficiaries to receive family planning services from all qualified providers of such services. It then approved state proposals preventing qualified family planning providers, in particular Planned Parenthood, from participating in Medicaid’s family planning program if they also provide abortions. This policy significantly limits access to care in many places.
  • Attempted to gut anti-discrimination policies. In June 2020, the Trump Administration finalized a rule gutting anti-discrimination protections for LGBTQ+ people, women, people with limited English proficiency, and people with disabilities. Among other things, the rule eliminated specific non-discrimination protections based on sex, gender identity, and association and removes requirements ensuring that people with limited English proficiency can get important information about their health care and coverage. Within days, the Supreme Court issued a historic decision that undercuts the Trump Administration’s changes, yet they are likely to create confusion and fear, causing people to delay or avoid seeking medical attention or health coverage.

End Notes

[1] For a complete timetable of Trump Administration actions undermining health coverage, see https://www.cbpp.org/sabotage-watch-tracking-efforts-to-undermine-the-aca.