As Democrats debate the best way to achieve universal coverage and lower health care costs, the Trump administration has a different approach to the challenges of our current system. It’s working overtime to make the system more fragile for the sick and the poor, even as it misrepresents to Congress and the American public what it’s up to.
Speaking to reporters in late October, President Trump said that “we have a great Republican plan” to replace the Affordable Care Act. “Much less expensive. Deductibles will be much lower.” His statements came on the heels of a congressional hearing in which one of his top health officials, Seema Verma, said that the administration would do “everything we can” for Americans with pre-existing conditions. Under oath, she swore that the administration was aiming to help people find a pathway out of poverty.
None of this is true.
Far from supporting protections for people with pre-existing conditions, the Trump administration has thrown its weight behind a lawsuit seeking to topple the Affordable Care Act. In court filings, if not in its public statements, the administration is clear about what it wants done to the law: “The proper course is to strike it down in its entirety.”
If the lawsuit succeeds, protections for people with pre-existing conditions would be wiped from the books. Overnight, we’d be back in a world where private insurers could discriminate against the sick.
In her testimony, Ms. Verma insisted that “the president has made clear that we will have a plan in action.” But she refused to share any details. And no wonder: Without the Affordable Care Act, the Trump administration doesn’t have the power to force insurers not to discriminate against the sick. You’d need a new law for that.
Good luck getting Congress to pass one. Though Republicans have no shortage of white papers endorsing controversial reform plans — the Republican Study Committee, a group of legislators, recently released another one — they’ve never been able to coalesce around a piece of actual legislation.
And the bills that are most popular among Republicans don’t actually protect sick people. During the repeal-and-replace debate in 2017, for example, the leading replacement bill would have increased the number of uninsured by 23 million over a decade. For the sick, deductibles would have gone up, not down.
The Affordable Care Act exchanges
In the meantime, the Trump administration is trying to sabotage the exchanges. A new rule that took effect last month will exploit a loophole in the law allowing for the sale of “short term” health plans.
Originally meant to serve as a stopgap for those with temporary breaks in coverage, short-term plans discriminate against people with pre-existing conditions and usually exclude vital protections, including prescription drugs and maternity care. They’re cheap — but you get what you pay for.
Now, under the new rule, plans that last for 364 days out of 365 can qualify as “short term.” As relatively healthy people who like the low price tag leave the exchanges to buy short-term coverage, the pool of people left on the exchanges will be relatively sicker. Prices will surge by an average of 18 percent in most states, according to researchers at the Urban Institute.
Already, unscrupulous brokers are using high-pressure tactics to sell short-term plans over the phone. Internet searches for “Obamacare plans” or “ACA enroll” will usually direct people to brokers selling short-term plans, not comprehensive coverage. Many of those people will be in for a rude shock when they get sick and discover how little their insurance actually covers.
There’s more. Earlier this year, a low-profile rule change reduced the subsidies for people who buy health insurance through the exchanges. President Trump’s own health officials recommended against the change because it “would cause coverage losses, further premium increases, and market disruption.” But the White House approved the cut anyway, and 70,000 people are expected to lose coverage as a result.
Insurance for the poor
At the same time, the Trump administration is laboring to tear health care from the poor. In its most galling move, it has been allowing states to add work requirements to Medicaid. To date, 18 states (most Republican controlled) have sought to impose work requirements, though Kentucky is likely to drop the request after Gov. Matt Bevin’s apparent loss last week.
Work requirements poll well: If you’re getting benefits on the government’s dime, shouldn’t you be expected to pull your own weight? But they are a policy nightmare. Fully 60 percent of those who are subject to work requirements already work. Of those who don’t, the overwhelming majority are in school, disabled or caring for dependents. There just aren’t that many people on Medicaid who can work but have chosen not to.
That’s why work requirements can’t stimulate much new employment. Every Medicaid beneficiary who’s subject to the requirements, however, has to jump through the bureaucratic hoops of attesting to their work status. Desperately poor people who lack the bandwidth or the wherewithal to comply will lose health coverage because they can’t manage the paperwork.
Experience in Arkansas bears the point out. More than 18,000 people, or nearly one in four Medicaid beneficiaries subject to work requirements, lost coverage in the first seven months of the program. A careful study in the New England Journal of Medicine found that “lack of awareness and confusion about the reporting requirements were common.” Employment rates didn’t budge.
Losing Medicaid isn’t a pathway out of poverty. It’s a pathway to destitution. A randomized trial out of Oregon, for example, shows that getting Medicaid eliminated catastrophic medical bills and cut in half the rates of people who had to borrow money or skip other bills to pay for health care. Recent research also shows that Medicaid sharply reduces evictions.
Attacks on the poor go beyond work requirements. For decades, Title X has offered grants for family planning services — including contraception and screenings for sexually transmitted diseases — for low-income women and families. In February, however, the Trump administration eliminated funding for any organization that refers patients for abortions.
The change was a deliberate effort to target Planned Parenthood, which, through its large network of clinics, serves about 40 percent of the women receiving help through Title X. Planned Parenthood has since withdrawn from the program, with the predictable result that poor women, especially those in rural areas, will face new barriers to receiving care.
Trump is even using health care as a weapon in his immigration war. Most legal immigrants are eligible for Medicaid once they’ve lived in the United States for more than five years, and millions have enrolled. But in a new “public charge” rule, originally set to take effect this month, the administration said that it would start denying citizenship to immigrants who are on Medicaid.
The courts have enjoined the rule for now; one judge said it was “repugnant to the American dream.” If the rule takes effect, however, millions of poor immigrants — every one of whom is legally present in the United States — will lose coverage.
So ignore what the Trump administration says. Pay attention to what it’s doing. It’s working to eliminate protections for the sick, destabilize the exchanges, and strip insurance from the poor. That’s the ugly truth.
Nicholas Bagley is a professor at the University of Michigan Law School. And a nephew of Salt Lake Tribune editorial cartoonist Pat Bagley. Both of them hope you won’t hold that against either one of them.