Early Friday morning, the Senate voted 49–51 against the Health Care Freedom Act. The bill, known as “skinny repeal,” was a last-ditch effort to repeal the Affordable Care Act after months without Republican consensus on how to do so.
Activists and Congressional Democrats are celebrating the bill’s failure, which represents a major political setback for the GOP and means former President Barack Obama’s signature achievement lives to see another day.
But be warned: it’s not over ’til it’s over. The fight against the ACA will rage on, as President Donald Trump can and likely will undermine the law from inside the White House in several major ways.
Cutting off payments
The president has the ability to cut off cost-sharing reduction payments, which are reimbursements for insurers for providing discounted out-of-pocket costs to low-income individuals under Obamacare.
The executive branch currently pays about $7 billion a year in CSRs, but that could stop at any time because of an ongoing lawsuit filed by House Republicans during the Obama years that claimed the CSRs were unconstitutional. A judge ruled in favor of the House Republicans, but the Obama administration appealed the decision, and the payments have continued in the meantime.
If Trump drops the appeal, the CSRs can stop. Insurers have said they will have to pull out of the market or be forced to raise premiums if the government stops providing the payments.
Trump has repeatedly threatened to pull the payments. “[T]here is no Obamacare, it’s dead,” Trump said in an interview with The Economist in May. “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… Anytime I want.”
Fostering uncertainty and discouraging enrollment
Trump can also undermine the ACA simply by discouraging enrollment and fostering uncertainty about the law’s future, moves that threaten to destabilize the insurance markets.
“As I said from the beginning, let ObamaCare implode, then deal,” Trump tweeted early Friday morning.
3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!
— Donald J. Trump (@realDonaldTrump) July 28, 2017
Trump has not always said that Obamacare should just be left to implode. Earlier this month, he changed his position on the health care debate three times in 36 hours.
Without a clear position from the president on the future of the ACA, insurers don’t know how to plan for the future, and the uncertainty alone may cause them to pull out of the markets.
Trump can and likely will discourage enrollment. In January, the administration canceled a round of federally-sponsored ads encouraging people to sign up for the ACA during the open enrollment period. Discouraging widespread buy-in could mean younger, healthier people who are important for subsidizing older, sicker people don’t sign up for insurance, which would ultimately undermine the whole system.
Not enforcing the individual mandate
One of the central tenants of the ACA is the individual mandate, which says people must have health insurance or pay a penalty — and which the White House has already taken steps to undermine.
Soon after his inauguration, Trump signed an executive order that instructed federal agencies to delay implementing provisions that “impose a fiscal burden on any State, or a cost, fee, tax penalty, or regulatory burden.” The executive order also instructed agencies to encourage a “free and open market” in health care services.
The IRS has also announced that it will stop its plan to reject tax returns from individuals who do not say whether they have coverage, a tool that would help enforce the mandate.
The loss of the individual mandate would create a death spiral, as healthy people dropping out of the markets would drive up premiums for sicker people with the greatest need for coverage.
Not taking steps to stabilize the market
Democrats and Republicans agree the ACA needs fixes that would help stabilize the market. A number of insurers have pulled out of the market, and one out of every three counties faces the prospect of having just one insurer next year.
In June, Centers for Medicare and Medicaid Services predicted that 49 counties across the country may not have any insurers at all by next year.
Some Republicans have floated allowing people to use their government subsidies to purchase private plans (though Democrats say this could encourage more insurers to drop out of the markets), while Claire McCaskill (D-MO) has proposed allowing people in counties without an insurer to purchase a plan on the D.C. exchange.
In any case, the legislators need to take steps to stabilize the market or the very people the law is intended to be help will be strapped with increasingly expensive premiums or no coverage at all.
I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead – the Republicans will do much better!
— Donald J. Trump (@realDonaldTrump) May 28, 2017
Trump has often said Obamacare is “dead.” It’s not, but without steps to stabilize the market, death is distinct possibility.