Following the failure of the latest Republican health care bill, which couldn’t muster enough votes to pass, President Donald Trump took to Twitter on Wednesday to promise, yet again, to kill Obamacare.
With one Yes vote in hospital & very positive signs from Alaska and two others (McCain is out), we have the HCare Vote, but not for Friday!
— Donald J. Trump (@realDonaldTrump) September 27, 2017
That’s a good reminder that the push to repeal Obamacare isn’t dead yet. Even if it hasn’t gained traction in Congress (for now), there are still several ways the White House can sabotage the Affordable Care Act (ACA) without Congress’ help. That includes weakening the individual mandate, failing to provide necessary information to insurance companies, cutting back on open enrollment outreach, and poor maintenance of the federal exchange website.
Lack of clarity around cost-sharing reduction payments
The deadline for health insurance companies to indicate their participation in the ACA marketplaces is Wednesday, but the Trump administration hasn’t announced whether the federal government plans to continue making cost-sharing reduction (CSR) payments — reimbursements provided to insurers to help offset costs and help make co-payments and deductibles affordable for low-income Americans.
Anthem, the second largest insurer in the country, announced Wednesday that it will leave Maine’s insurance marketplace, citing concerns about the “shrinking and deteriorating individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including… continued uncertainty around the future of cost-sharing reduction subsidies.”
There are now only two Maine exchange insurers left.
Early this month, UnitedHealthcare and Aetna both also decided to leave Virginia’s Obamacare exchange. Optima Health announced it would dramatically scale back its coverage in the state.
Virginia Gov. Terry McAuliffe (D) said the decisions of insurance companies to pull out and limit coverage are “being driven by instability and uncertainty that the President and Congress are creating through their inaction.”
Trump has continuously threatened to stop making the CSR payments, and if insurance companies are to take his word for it, they could respond by increasing premiums. According to the Congressional Budget Office, if the government discontinues the CSR subsidies, insurers would likely increase premiums for the mid-level health plan by 20 percent, knowing that the government is responsible for helping low-income people pay for those premiums.
What’s more — individuals may not hear about these premium changes before the open enrollment period.
While stopping the CSR payments won’t actually sabotage Obamacare, the move would end up costing the government about $200 billion and leave one million people without health insurance.
Weakening the individual mandate
Health and Human Services (HHS) Secretary Tom Price announced in July that the department may expand waivers from the ACA’s individual mandate, which requires individuals to purchase health insurance — a move that would cause fewer people to sign up.
The mandate is an important check on the health insurance system, bringing healthy people into the market to balance costs. Without the mandate, insurance companies would have to raise premiums to continue covering individuals with pre-existing conditions.
In a July letter to Congress, America’s Health Insurance Plans (AHIP) — a national health association — criticized getting rid of the individual mandate, citing increasing premiums and deteriorating risk pools.
“[P]olicies that do not stabilize the market and simply drop incentives for people to buy coverage will repeat what we have seen in the past: premiums will rise rapidly, few or no affordable coverage options will be available, and more people will be uninsured,” the letter reads.
Hampering open enrollment
The Obama administration spent years promoting the open enrollment period and doing outreach to educate Americans on their options in various state exchanges.
But shortly after he took office, Trump announced a dramatic reduction in advertising to promote open enrollment, withdrawing about $5 million in ads aimed at this cause. HHS has also cut funding to Obamacare navigator groups, tasked with helping individuals enroll in health insurance coverage, by 41 percent, claiming that it is a waste of taxpayer dollars.
Instead, Trump has been using those same marketing funds to advertise against Obamacare, producing more than 20 testimonial videos about people claiming that Obamacare has hurt them.
With the enrollment period just over a month away, health advocacy groups are struggling to fill the marketing void.
“We can’t really take the place of a government outreach effort,” Cheryl Fish-Parcham, Families USA’s director of access initiatives, told ThinkProgress.
Fish-Parcham said the Trump administration has failed to partner with organizations like Families USA, in providing guidance and messaging for consumer outreach.
On Monday, HHS suddenly withdrew from an ACA education tour in Mississippi, where the department was supposed to partner with the Mississippi Health Advocacy Program to help prepare individuals for open enrollment.
“HHS bailing out was the last straw for us,” Roy Mitchell, executive director of the program, told Vox, which first reported the drop out. “It’s clearly sabotage.”
The one-and-a-half month open enrollment period under the Trump administration is also significantly shorter than the three-month period under the Obama administration, which does not bode well for consumers. According to a HealthAffairs analysis of previous enrollment periods, most consumers and enrollees waited until the final few weeks of the period to sign up.
The shorter enrollment window presents the “very large looming problem” of fewer potential enrollees, Fish-Parcham said. This is especially problematic because individuals who wait to enroll and risk missing the deadline tend to be young and healthy. Without their participation in the health insurance market, premiums could skyrocket.
Shutting down HealthCare.gov
The Trump administration announced last week its plans to shut down the federal exchange website, HealthCare.gov, for maintenance 12 hours every Sunday, beginning overnight on the first day of open enrollment November 1.
Similar blackouts occurred during the Obama administration, but not as often.
Fish-Parcham expressed concern that the outages will cut into consumer efforts to sign up, adding that Sundays, when most individuals have time to enroll, are a “terrible time for websites to be shutting down.”
“It’s really important that people in this country get health care that is good and affordable,” said Fish-Parcham. “I hope our government sees the light.”
This story was updated to include a Vox report that was released after this story was published.