How Trump’s White House can still undermine Obamacare

Obamacare may have survived another Republican repeal effort, but the Trump administration can still take steps to weaken it.

The administration for months has taken steps to undercut the Affordable Care Act independent from Congress. Friday’s collapse of Senate Republicans’ slimmed-down repeal bill could push President Donald Trump to escalate those efforts, possibly by taking aim at the law’s individual mandate.

“As I said from the beginning, let Obamacare implode, then deal. Watch!” Trump tweeted after the GOP’s so-called “skinny” repeal bill went down in flames.

Among Trump’s options is unilaterally cutting off billions of dollars in crucial subsidy payments to insurers — funding seen as necessary to keep the law’s insurance markets afloat. The administration so far has paid the subsidies, which total about $7 billion this year, on a month-to-month basis. But insurers fear that Trump could make good on past threats to cut them off, possibly to force Democrats to negotiate on health care.

Here are some of Trump’s other options:

Nixing the individual mandate

The mandate requiring most Americans to have health insurance or pay a tax penalty is easily the most unpopular piece of the 2010 health law.

Only Congress can strike the mandate, but many viewed the executive order Trump issued on his first day in office instructing agencies to weaken Obamacare as a sign to stop enforcing the penalties. The mandate hasn’t convinced enough young and healthy people to buy insurance, but health plans see it as a crucial tool to keep markets stable. Without it, premiums could unexpectedly spike or carriers could exit markets altogether, accelerating a trend that began this year.

Cutting enrollment outreach

Weeks after taking power, the Trump administration canceled $5 million in HealthCare.gov ads at the end of the previous enrollment season, a move the law’s supporters said prevented enrollment gains, especially among younger Americans.

That trend could continue for the upcoming enrollment season that begins Nov. 1 and further hamper sign-ups.

The Department of Health and Human Services has already decided to terminate at the end of August two contracts for programs aimed at signing up people for insurance across the country. The administration could also pare millions in federal funding for other outreach. The Obama administration awarded $63 million in grants to nonprofits last September to help states bolster enrollment efforts, and another tranche of funding is supposed to be released by this fall. To date, the Trump administration hasn’t signaled whether it would continue it.

Letting red states enact coverage limits

Conservative activists incensed with the Senate’s doomed repeal vote are already prodding the administration to loosen Obamacare’s coverage mandates and give states more flexibility to skirt federal regulations.

“There are several actions the Trump administration and Congress should take right now to help ease Obamacare’s burden on millions of hardworking Americans, increase access to health care, especially for those most in need, and give patients more control,” Freedom Partners’ Nathan Nascimento said in a statement Friday.

HHS is expected to give Republican states much wider latitude to limit who can sign up for Medicaid, especially in those states that expanded their programs under Obamacare. Arizona, Arkansas, Indiana, Kentucky, Maine and Wisconsin are among the states with Republican governors seeking federal permission to add work requirements or make able-bodied adult beneficiaries pay more out of pocket for care. The Obama administration largely shunned similar requests, arguing they would discourage people from enrolling.

At least one state is seeking the Trump administration’s permission to significantly overhaul Obamacare’s rules for private insurance in order to attract insurers back to its struggling marketplace. Iowa, which is at risk of having no insurer sell coverage statewide next year, wants to scrap Obamacare’s subsidies helping customers pay for premiums and medical bills and replace them with a limited tax credit. That could make lower-income and sick enrollees pay a lot more for coverage.

Making it harder to sign up

Obamacare saw one of its worst moments in the fall of 2013 when the HealthCare.gov enrollment website crashed, making it impossible to sign up for insurance.

The website now functions virtually glitch-free, but only after the Obama administration put years of effort into triaging problems and making it more customer-friendly. Obama officials added online capacity during key enrollment deadlines when traffic swelled, boosted customer service staff to help people in queues and even left the enrollment windows open past deadlines if people hadn’t finished. The Trump administration could opt out of any such efforts, further tamping down on enrollment.

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