This story was originally published on July 24.听
About an hour after the Senate鈥檚 dramatic third attempt to repeal Obamacare fell short 鈥� and after almost eight months of repeated congressional attempts to dismantle it 鈥� President Donald Trump 听that it was only a matter of time before the law fell apart on its own.
鈥淎s I said from the beginning, let ObamaCare implode, then deal. Watch!鈥� the president wrote.
Independent analyses have concluded that听such spontaneous disintegration isn鈥檛 happening. But the White House has the power to make it so.听In a number of ways,听the Trump administration鈥檚 policies are already pushing Obamacare into the vortex.
Standard & Poor鈥檚, the Congressional Budget Office and the all suggest that the exchanges 鈥� where people can shop for coverage, often with the help of a government subsidy 鈥� are stabilizing. (Kaiser Health News is an editorially independent program of the foundation.)
But Obamacare faces a difficult political reality: Its marketplaces require active maintenance and federal support.
The White House can take a number of behind-the-scenes steps to sabotage the exchanges and hasten their undoing. It has been deploying some of those tactics for weeks now 鈥� even听prompting a听听to see if听these actions are legal.
Meanwhile, in a statement issued after Friday鈥檚 early-morning vote, Health and Human Services Secretary Tom Price the administration鈥檚 commitment to 鈥減rovide relief to Americans who are reeling from the status quo.鈥�
This will be an area to watch.
鈥淭he administration has a lot of power to undermine the markets and make them dysfunctional,鈥� said Sabrina Corlette, a research professor at Georgetown University鈥檚 Center on Health Insurance Reforms, who specializes in private insurance markets.
Here鈥檚 a look at five ways the White House is working to weaken the health law, and what that means for consumers.
鈥楥ost-Sharing Reductions鈥�
Under the ACA, when someone鈥檚 income falls between 100 and 250 percent of the federal poverty level 鈥� up to about $29,000 for an individual or around $61,000 for a family of four 鈥� marketplace carriers must offer a plan with 鈥渃ost-sharing reductions鈥� (CSRs) that reduce consumers鈥� out-of-pocket expenses.
Reducing cost-sharing 鈥� generally copayments and deductibles 鈥� makes plans more expensive for the insurers. The Obama administration used its rule-making power to set up direct payments to carriers to help offset this burden. The Trump White House has inherited that responsibility but also has the power to end the payment program.
The nonpartisan Congressional Budget Office estimated CSR subsidies in 2017 would total about $7 billion. Without that money, analysts say, more insurers might choose to exit, limiting options for consumers, and letting the insurers who remain charge higher prices.
Trump has been committedly noncommittal, publicly indicating he would like to halt the subsidies, but so far 鈥� on a month-to-month basis 鈥� letting them continue.
The uncertainty makes insurance companies skittish about participating, analysts noted. It鈥檚 also one reason some plans say they have had to increase their rates, noted Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups. For instance: When filing plans for the 2018 marketplace, carriers on average raised premiums by about 34 percent 鈥� with about 20 points stemming from CSR uncertainty, Gaba said, based on an analysis of 21 states鈥� initial rate filings. Dropping the subsidies altogether would be even more damaging.
Weaken The Mandate
The White House has already signaled it does not want to enforce the individual mandate 鈥� the health law鈥檚 requirement that all people have coverage and one of the main targets of the Senate Republican鈥檚 so-called 鈥溾�� plan. And administration officials that position.
Meanwhile, in January, it issued that encouraged U.S. agencies to grant exemptions and waive or defer health law provisions that could put financial strain on companies or individuals 鈥� which could also be applied to the individual mandate.
For 2016 tax returns, though, the Internal Revenue Service continued to impose a financial penalty on people who didn鈥檛 have health insurance and who didn鈥檛 qualify for an exemption.
But enforcement may be waning. This year, the IRS was supposed to reject tax returns if people didn鈥檛 indicate whether they had coverage, flagging them for a potential penalty. Instead, it continued processing them, citing Trump鈥檚 executive order.
If the IRS has already processed any tax refunds for consumers, then they 鈥渄on鈥檛 have much leverage鈥� when attempting to collect the mandate fee, said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform.
Enforcement of the mandate enforcement, economists note, is crucial to ensuring that enough healthy people buy coverage to balance the costs of sicker beneficiaries.
But even with the mandate in effect, the efforts to defang it bring confusion.
鈥淎 lot of people believe the Trump administration is not enforcing it,鈥� Jost said.
As a result, healthy people may become less likely to buy insurance, even as sick ones continue seeking it. That means higher prices, and a shakier pool.
鈥淚f they don鈥檛 think they鈥檙e going to get healthy people in the risk pool, they鈥檙e going to increase their rates further to protect themselves,鈥� Jost said. 鈥淎nd as they raise their rates further to protect themselves, people 鈥� start to drop out.鈥�
Thus, the president鈥檚 position on the mandate is leaving insurance carriers and commissioners 鈥渁pprehensive,鈥� noted Mike Kreidler, Washington state鈥檚 insurance commissioner.
A Bare Market
Skittishness on the part of insurers could lead them to drop out of some marketplaces, leaving consumers in some areas with few or no choices. Those 鈥渂are markets鈥� are possible under even stable circumstances 鈥� and preventing them requires active federal involvement.
Under the Obama administration, high-level officials were 鈥渙n the phone daily with insurance company executives 鈥� trying to get them to participate,鈥� Corlette said. 鈥淚t was very much an all-hands-on-deck, 鈥榳e鈥檙e going to make it work for you guys鈥� kind of communication.鈥�
And so far Trump鈥檚 Department of Health and Human Services doesn鈥檛 appear to be emphasizing this kind of essential outreach, both Corlette and Jost suggested. A few months ago, Kreidler agreed, HHS staffers appeared interested in helping states fill their bare counties 鈥� but that support has since dwindled.
鈥淭his may be sort of under the radar, but it can have real, lasting effects鈥� for consumer choice, Corlette said.
All Quiet On The Enrollment Front
The administration could further undermine the marketplace by dropping outreach to consumers. It鈥檚 already a shorter enrollment period this year 鈥� spanning six weeks instead of three months, from Nov. 1 to Dec. 15 鈥� though that change was already slated to eventually take effect.
That shorter period means people may miss the memo on signing up 鈥� or at least need an extra push, Corlette said. And that鈥檚 another way the administration could undermine the marketplaces: simply choosing not to advertise them.
Last sign-up season, HHS in January, pulling ads a few days before the period ended. Enrollment dropped compared with previous years, Jost and Gaba noted, with young, healthy people being more likely not to buy coverage.
The administration also just federal contractors that supported efforts by community groups and other organizations in some of the nation鈥檚 largest cities to sign up people.
Dropping advertising, shortening open enrollment or simply scaling back on technical maintenance for the marketplace website could all have significant impact, Corlette said. People who are sick and need insurance will likely seek it out, but those who are healthier 鈥� for whom health insurance is a less pressing priority 鈥� could miss the boat.
Again, Jost said, that affects insurer participation.
鈥淚nsurance is a product that need to be sold,鈥� he said. 鈥淚f the insurers believe they鈥檙e not going to get any help at all in marketing their product,鈥� he added, fewer will want to enter the marketplace.
Word of (Bad) Mouth
HHS has taken in criticizing the health law 鈥� pushing press releases and videos that argue it has hurt more than helped. That strategy could do a lot of harm, experts said. These actions are the focus of the GAO .
If consumers keep hearing the law is failing, Jost noted, some will ultimately believe it, buying coverage only if they need it and thereby skewing the insurance risk pool.
Perceived hostility also has an effect on insurers, steering them away from marketplace participation.
鈥淲hen you undermine confidence in the marketplace, you don鈥檛 need a Ph.D. in economics to know it鈥檚 not good long term,鈥� Corlette said.
This story was produced by听, an editorially independent program of the听.