The Administration announces that it will stop planned ads for the final week of open enrollment for marketplace health coverage.
Sabotage Watch: Tracking Efforts to Undermine the ACA
President Trump has said that, politically, the best thing to do would be to let the Affordable Care Act (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.
Last updated August 1
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.
After running ahead of 2016 enrollment totals through mid-January, final 2017 HealthCare.gov plan selections come in slightly below 2016.
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.
Administration’s first health care rule is billed as market stabilization, but would discourage enrollment and undermine market stability by making plans less affordable.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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|
|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%|
Anthem Inc. announces it will exit Ohio's marketplace, pointing to the uncertainty around whether CSRs would be paid and an "increasing lack of overall predictability (that) simply does not provide a sustainable path forward to provide affordable plan choices for consumers." The move leaves at least 18 Ohio counties with no marketplace plans. Little more than a month before, Anthem executives noted the marketplace business was going well and "doing markedly better than it did last year" but that its participation in the marketplaces would hinge on certainty about the CSR payments.
Health and Human Services Secretary Tom Price refuses to say if the Trump Administration will fund CSR payments in 2018 during questioning at a Senate Budget Committee hearing. Senators note that lack of certainty about the payments is causing insurers to submit higher premiums and even to stop offering coverage.
The Trump Administration ends contracts with two private firms to provide in-person assistance in states using HealthCare.gov for marketplace enrollment. Since the first open enrollment period in 2013, Cognosante LLC and CSRA Inc. have provided one-on-one assistance for people enrolling in marketplace plans and applying for subsidies. The loss of this assistance is especially likely to affect enrollment for 2018 coverage because the Administration has already shortened the open enrollment period to six weeks.
The Department of Health and Human Services (HHS) continues its public relations campaign attacking the ACA. HHS has released 23 videos featuring individuals explaining how the ACA has harmed them. HHS has also used its twitter account to amplify anti-ACA messages and removed website content promoting the ACA, including the popular ACA provision enabling young people to stay on their parents’ plans until they turn 26.
After Senate Republicans fail to pass a bill to repeal or replace the ACA, President Trump takes to Twitter to threaten that he will stop making CSR payments to insurers. Trump falsely calls these payments a “bailout.” Actually, the ACA requires the federal government to make these payments to compensate insurers for reducing deductibles and copayments for low- and moderate-income marketplace enrollees. Ending the payments would hike premiums in the individual market for many consumers, raise federal marketplace costs, and likely cause some insurers to withdraw from the marketplaces. The renewed threat comes just two weeks before the deadline for insurers to finalize their premium rates for 2018 marketplace plans.
Beginning in 2013, the Obama Administration successfully engaged a diverse set of partners to spread the word about coverage available in the marketplaces and Medicaid. The Administration enlisted “gig economy” companies like Lyft and Uber, faith-based organizations like the United Methodist Church, and medical groups like the American Congress of Obstetricians and Gynecologists in efforts to raise awareness and boost enrollment. Former HHS officials have described these partnerships as key to advancing enrollment especially among diverse, young, and healthy people. But this year, there’s no sign that the Trump Administration has reached out to these groups. Ending these partnerships will likely depress enrollment in the coming open enrollment period.
Just two months before the start of open enrollment, the Trump Administration announces it will slash funding for marketplace outreach (by at least 90 percent) and consumer enrollment assistance through the navigator programs (by about 40 percent). Without a robust awareness campaign, many people will be unaware of the availability of affordable coverage options and will remain uninsured. Bipartisan efforts to stabilize the marketplaces are developing, but the Administration’s cuts will make that goal far more challenging.
Navigator groups that conduct consumer outreach and provide marketplace enrollment assistance haven’t received federal funding for the next year, even though their budget year started September 1. The lack of clarity about navigator funding continues more than a week after the Trump Administration announced it would slash funding for the organizations. Without funding or assurances that funding — if and when it is finally awarded — can be used retroactively for expenses incurred starting September 1, navigator groups have been forced to make drastic cuts that would severely undermine their outreach efforts for the open enrollment period that starts on November 1. Some groups are already cutting highly trained staff whom they could lose permanently if they find other jobs. And groups have begun canceling outreach activities, which are especially critical in this year’s shortened open enrollment period.
The Trump Administration sends navigator groups their new target budgets for consumer outreach and enrollment assistance. Many groups face steep cuts and are being forced to make difficult decisions such as cutting services to hard-to-reach rural communities. Centers for Medicare & Medicaid Services (CMS) officials continue to point to poor performance in enrollment as justification for the cuts, though relying on enrollment numbers is a flawed measure of navigator effectiveness that doesn’t reflect their full value. Furthermore, as groups received notification of their new award amounts, some groups that met or exceeded enrollment targets for the 2017 coverage year received deep cuts, calling into question how CMS used data sources and methods to make cuts.
Centers for Medicare & Medicaid Services (CMS) informs navigator groups it could take up to 30 days to review and approve their revised proposals and budgets to reflect the major budget cuts it has made, and that the groups’ funding won’t be guaranteed until final CMS approval. The Ohio Association of Foodbanks — which had its award reduced to 71 percent of what it anticipated — announces it will no longer pursue navigator funding due to the limited funding levels and continued uncertainty, leaving a huge gap for Ohioans who need help enrolling in the marketplace.
Consumers won’t be able to complete HealthCare.gov applications on all but one Sunday morning during the upcoming 45-day enrollment period due to system maintenance, CMS announces. While downtimes due to system maintenance have occurred in the past, regularly taking the system off line on Sunday mornings — especially during open enrollment — has never happened. Sunday mornings are popular times for assistance groups to help people enroll at community events, including faith-based gatherings.
The Department of Health and Human Services (HHS) stops staff from its regional offices from participating in marketplace enrollment events. In past years, regional office staff played an important role in outreach and other events promoting enrollment, such as the education sessions the Mississippi Health Advocacy Program conducted throughout the state. HHS staff were scheduled to participate in next week’s sessions as in past years, but with very little notice, they told event organizers they couldn’t attend due to HHS restrictions on regional staff attending open enrollment events.
The Department of Health and Human Services (HHS) responds to criticism of its decision to prohibit HHS regional staff from attending marketplace open enrollment events by lashing out with false claims that the ACA has failed and is harming people.
The Trump Administration announces that it is allowing employers to opt out of covering contraception based on a moral or religious objection. Previous policy ensured that employees had access to birth control even if their employer had a religious objection, giving 62 million women access to birth control without co-payments. The change could threaten many women’s access to essential contraceptive care. Moreover, the Trump Administration is taking an inappropriate short cut to put this change into effect immediately by releasing the change as an “interim final” rule, a process that is typically used when there is a public health crisis or other emergency need for a rule to take effect right away.
President Trump signs an executive order that could destabilize the health insurance markets where millions of individuals and small businesses get their coverage and undermine protections for people with pre-existing health conditions. The order directs relevant agencies to consider ways for more people to buy health coverage that’s exempt from many standards of the Affordable Care Act — such as the requirement that health plans cover a package of “essential health benefits” including maternity care and mental health treatment and the prohibition against charging people different premiums based on their health status.
The Trump Administration announces that it will stop making cost-sharing reduction (CSR) payments to insurers, which help lower deductibles and other out-of-pocket health care costs for roughly 6 million low- and moderate-income people. This action will raise costs for consumers and further disrupt health insurance markets. The Congressional Budget Office has estimated that ending the CSR payments will raise the number of insured people by 1 million in 2018, increase marketplace premiums by 20 percent, and cause insurers to pull out of the marketplace, leaving some consumers with no marketplace plans. And far from saving the federal government money, ending CSR payments will increase the federal deficit by $194 billion over the next ten years.
The Department of Health and Human Services’ Office of Inspector General releases a report explaining how the Trump Administration’s actions terminating marketplace outreach, which we described in our Sabotage Watch entry on January 26, 2017, led to $1.1 million in unrecoverable costs.
STAT News reports that Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma said during an appearance in Cleveland that CMS will give states an “unprecedented level of flexibility” in requesting waivers of federal Medicaid rules. This will likely undermine the intent of Medicaid waivers — namely, to enable states to test new approaches to providing care to beneficiaries — and instead end up harming beneficiaries.
Verma also criticized the Affordable Care Act’s (ACA) expansion of Medicaid to millions of low-income adults, saying that “the policies that are in the Medicaid program are not designed for an able-bodied individual” and that the Trump Administration seeks to keep such individuals in the private insurance market, where they would not be “dependent on public assistance.”
Verma’s statements raise concerns that the Administration may seek to use waivers to do what congressional Republicans’ ACA repeal efforts failed to do: cut health coverage and benefits.
The Trump Administration reduces email outreach for the marketplace open enrollment period. Although the HealthCare.gov database has email addresses for about 20 million consumers — those currently or previously enrolled or who have expressed interest in HealthCare.gov coverage — the Department of Health and Human Services (HHS) will only reach out to current enrollees.
When announcing its plan to slash its outreach budget by 90 percent, the Administration said that it would focus its open enrollment advertising and outreach activities on email, digital media, and text messaging. Yet HHS isn’t emailing millions of people who need information about open enrollment and coverage.
President Trump signs into law major tax legislation that repeals the ACA’s individual mandate beginning in 2019. (The individual mandate requires most people to either have coverage or pay a penalty.) Without the mandate, fewer healthy people will sign up for coverage, increasing average health care costs in the individual market and causing premiums to rise by 10 percent, according to Congressional Budget Office (CBO) estimates.
CBO also estimates that mandate repeal will cause 13 million people to become uninsured, increasing the non-elderly uninsured rate by almost 50 percent. Because of these coverages losses, federal funding for marketplace subsidies and Medicaid will fall substantially, generating savings of $314 billion, according to Joint Committee on Taxation estimates. The tax legislation uses these savings to help pay for making its corporate rate cuts permanent, providing tax cuts averaging nearly $100,000 to the top 0.1 percent of households (those with incomes over $3.1 million in 2017).
The Trump Administration proposes a new rule to dramatically broaden enrollment in association health plans (AHPs), coverage offered by trade and professional associations. If finalized, the rule would likely devastate small-group insurance markets and could hurt the individual insurance market, while putting people who enroll in AHPs at significant risk, particularly those who have a pre-existing medical condition or develop costly health needs.
The rule proposes allowing AHPs that enroll small businesses and self-employed people to be treated as large employers. This would exempt the AHPs from a number of consumer protections that otherwise apply in the small-group and individual insurance markets, including the Affordable Care Act’s (ACA) requirement to cover essential health benefits, the prohibition against charging higher premiums based on factors like people’s gender or occupation, and the limits on charging higher premiums to older people.
Because the rule would subject AHPs to substantially weaker standards than ACA-compliant plans in the small-group and individual markets, they could — and likely would — be structured and marketed to attract younger and healthier people, thus pulling them out of the ACA-compliant small-group market and leaving older, sicker, and costlier risk pools behind. Enrollees who need comprehensive coverage, or those with pre-existing conditions and with incomes too high to qualify for subsidies, would face rising premiums and large gaps in coverage.
In a sharp reversal of long-standing federal policy, the Centers for Medicare & Medicaid Services (CMS) issues guidance allowing states to block some low-income adults from getting Medicaid coverage if they’re not working or participating in work-related activities. CMS attempts to justify its new policy with the spurious claim that tying health insurance coverage to work will improve Medicaid beneficiaries’ health and economic well-being, because people who work are healthier.
The Department of Health and Human Services approves Kentucky’s Medicaid waiver, making Kentucky the first state to require Medicaid beneficiaries to work or participate in work-related activities as a condition of Medicaid eligibility. Kentucky’s waiver includes other harmful provisions that will jeopardize coverage for hundreds of thousands low-income Kentuckians, such as premiums; six-month coverage lock-outs for failing to pay premiums, renew coverage on time, or report changes affecting eligibility; and delays in the effective date of coverage.
The Centers for Medicare & Medicaid Services (CMS) rescinds guidance it issued in April 2016 reaffirming Medicaid’s “free choice of provider” provision, which allows beneficiaries to receive family planning services from all qualified providers of such services. CMS’ reversal raises concerns that states will be allowed to restrict women covered by Medicaid from choosing certain health care providers like Planned Parenthood.
The Department of Health and Human Services (HHS) approves Indiana’s Medicaid waiver, allowing it to impose a work requirement on Medicaid beneficiaries as part of its three-year waiver renewal. HHS extended Indiana’s waiver, known as HIP, even though the state’s own evaluation shows that the waiver, with its premiums and coverage lockouts, has made it harder for eligible Hoosiers to get coverage and care. Adding a work requirement will exacerbate HIP’s shortcomings and cause additional beneficiaries to lose coverage.
The Trump Administration proposes rules to expand the use of short-term health plans as an alternative to plans that meet more stringent standards under the Affordable Care Act. This would let a parallel market for skimpy plans operate alongside the market for comprehensive individual health insurance, exposing consumers to new risks and raising premiums for people seeking comprehensive coverage, especially middle-income consumers with pre-existing conditions. A rise in enrollment in short-term plans would also expose more consumers to coverage gaps and higher costs.
The Centers for Medicare & Medicaid Services (CMS) finalizes health care rule changes for the individual market that will weaken benefit standards, likely harming people with pre-existing conditions; raise new barriers for people who want to enroll in health coverage; and reduce accountability for insurers and transparency for consumers. Among the most significant provisions of the wide-ranging rule: it lets states and insurers scale back benefits, weakens risk adjustment, creates new enrollment barriers, reduces consumer access to assistance with eligibility and enrollment, reduces transparency of insurance premium setting, and weakens the standard that individual market insurers must spend at least 80 percent of premiums on medical care and improving health care quality.
The Department of Justice (DOJ) files a brief declining to defend the constitutionality of the Affordable Care Act (ACA) in an action brought by 20 states’ attorneys general. In Texas v. United States, the states assert that the entire ACA must be struck down because the Supreme Court’s 2012 decision in National Federation of Independent Business v. Sebelius upheld the coverage requirement under Congress’s taxing power and the 2017 tax law zeroed out that tax penalty.
DOJ agrees with their argument but stops short of saying the entire law must be overturned. Rather, the Trump Administration asks the court to strike down two critical consumer protections: the provision that bars insurers from denying coverage to people with pre-existing conditions (guaranteed issue) and the prohibition on charging higher premiums to people because of their health status (community rating). The Administration claims, wrongly, that these provisions are inextricably linked to the mandate and must be thrown out if the mandate is found to be unconstitutional, ignoring Congress’s decision in December to repeal the penalty but not other portions of the law.
Allowing insurers to again use pre-existing condition exclusions puts coverage at risk for 133 million people who could be charged more, denied coverage for certain diagnoses, or blocked from individual market coverage altogether because they have certain health conditions. Eliminating these provisions could also allow insurers to charge higher premiums to women, older people, and people in certain occupations. The attorneys general of 16 states and the District of Columbia have intervened in the case to defend the law.
The Labor Department finalizes rule changes expected to increase enrollment in association health plans (AHPs), coverage offered by trade and professional associations. Under the new rules, these associations could sell coverage to small businesses and self-employed individuals without meeting key Affordable Care Act (ACA) standards that would otherwise apply to plans sold to these customers. These include requirements to cover essential health benefits, prohibitions against charging higher premiums based on factors such as gender or occupation, and limits on charging higher premiums to older people.
Under the new rules, AHPs likely will be structured and marketed to attract younger and healthier people and firms with younger and healthier workforces, pulling them out of the ACA-compliant individual and small-group insurance markets and leaving older, sicker, and costlier risk pools behind. And because the AHP changes take effect starting this fall, the plans could result in 2019 premium increases and confuse consumers if they hit the market at the same time as the ACA open enrollment period.
The Centers for Medicare & Medicaid Services (CMS) announces that Affordable Care Act risk adjustment transfers for 2017 may be delayed. Risk adjustment is a federal program that transfers revenues from insurers that enroll a healthier-than-average group of consumers to those that enroll a sicker-than-average group. By doing so, risk adjustment reduces the incentives for insurers to design plans to avoid attracting people with pre-existing conditions and other serious health needs.
CMS’s announcement has created uncertainty and confusion, with insurers unsure how long transfers might be delayed. This disruption is unnecessary: while CMS linked its decision to an adverse New Mexico federal district court ruling regarding the risk adjustment program, legal experts have concluded that CMS had — and continues to have — options to avoid disrupting or delaying transfers.
CMS’s decision does not implicate the 2019 risk adjustment program: in finalizing 2019 marketplace rules, CMS addressed the legal issues the New Mexico court case raised. Nonetheless, the Administration’s decision has raised concerns about whether it signals an intent to interfere with the risk adjustment program going forward. As such, the announcement adds to insurers’ concerns about future policy actions, concerns that are likely causing them to increase 2019 individual market premiums more than they otherwise would.
The Centers for Medicare & Medicaid Services (CMS) slashes funding for consumer enrollment assistance and outreach through the navigator program to just $10 million for the 34 states whose Affordable Care Act marketplaces are facilitated by the federal government. Combined with the large cut last year, navigator funding has now fallen more than 80 percent from its 2016 level.
In addition, the funding announcement opens the door to other significant changes that may leave consumers in some states without access to in-person, marketplace-funded assistance. In a particularly troubling change, it encourages navigators to promote limited-benefit coverage options, “such as association health plans, short-term, limited-duration insurance, and health reimbursement arrangements.” As we’ve explained, such plans can leave consumers exposed to significant financial risk if they become ill or injured, and the proliferation of such plans will result in higher costs for people needing comprehensive coverage.
Taken together, these actions and dramatic funding cuts will lead to fewer people getting the impartial assistance they need to enroll in and maintain coverage.
The Trump Administration releases rules to expand the use of short-term health plans as an alternative to plans that meet more stringent standards under the Affordable Care Act (ACA). Short-term plans, which have been limited to no more than three months, will now be able to last for up to one year, mimicking regular health insurance even though short-term plans do not have to meet most standards and consumer protections that apply to regular health insurance. For example, short-term plans do not have to cover the ACA’s essential health benefits and frequently do not include maternity services, prescription drugs, mental health care, and substance use disorder treatment. Short-term plans can deny coverage or charge higher prices to people with pre-existing conditions, and they typically do not cover medical services related to a pre-existing condition.
Expanding short-term plans will let a parallel market for skimpy plans operate alongside the market for comprehensive individual health insurance, exposing consumers to new risks and raising premiums for people seeking comprehensive coverage, especially middle-income consumers with pre-existing conditions. The only good news: states have the authority to set their own limits and protections for short-term plans.