Dive Brief:

  • While Congress debated repealing and replacing the Affordable Care Act (ACA) last year, the Trump administration had its own plan to cripple the law.

  • Politico published the document, dated March 23, this week. It outlines a plan to use executive orders and policy changes to take apart the ACA. Sen. Bob Casey (D-Pa.) shared the document with Politico after requesting it from the HHS.

  • Many of the 10 steps in the plan have already been implemented or threatened. They aim to give states more control over plan benefit requirements and reduce participation in the ACA exchanges.

Dive Insight:

Casey requested the document after then-HHS Secretary Tom Price reportedly used it during a March meeting with House members.

The plan included 10 executive order plans and policy changes that took aim at the ACA, which the administration said could “improve the individual and small group markets most harmed by (the ACA).”

The plan included:

  • Cut the ACA exchanges’ open enrollment in half, which the Trump administration implemented.
  • Remove the three-month grace period for members in the exchanges to pay outstanding premiums.
  • Tighten verification for people who sign up outside of open enrollment.
  • Allow states to decide whether payers must provide the 10 essential health benefits in the ACA. The CMS released a proposed rule in October on that topic.

On Twitter this week, Larry Levitt, senior vice president of the Kaiser Family Foundation, remarked that the plan doesn’t include “some of the more extreme things the Trump administration could do administratively (and in some cases have done) to undermine the ACA.”

One piece of the ACA not on the list is the individual mandate. Trump has criticized the mandate, which requires most Americans to have health insurance. The president reportedly prepared an executive order to end the mandate last fall, but Congress was able to repeal the individual mandate penalty as part of its tax bill at the end of the year. The individual mandate penalty goes away in 2019. 

The overall plan isn’t really a surprise, but it does show a concerted and organized effort by the Trump administration to harm the ACA. Trump and other Republicans have been working to dismantle the ACA through legislation, proposed rules and executive order since Trump took office. One of his first executive orders was to minimize the ACA’s “economic burden.” It asked the HHS to use “all authority and discretion” to delay ACA provisions that impact members and states financially.

That first ACA executive order led to a later executive order that called for expanding short-term catastrophic plans and association health plans (AHPs). The administration said opening catastrophic plans to more people and removing barriers for AHPs would allow people and businesses to get cheaper health insurance coverage. Critics say expanding those plans would provide limited coverage and could lead to people leaving the exchanges, which would destabilize the market and cause higher premiums.

One of the most public ways the Trump administration worked to derail the ACA was cutting the open enrollment period in half. This change meant that the weekly enrollment needed to double to reach 2017 figures. The final number from the 39 states that use the federal exchange rather than their own state sites was 8.8 million, which was below the 2017 numbers, but not as bad as feared.


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