Donald Trump spent much of its first year in office attempting to undermine recent progress to provide more Americans with health insurance coverage.
Republicans’ repeated attempts to repeal the Affordable Care Act, though unsuccessful, injected destabilizing uncertainty into the insurance marketplace. Their decision to attach a repeal of the law’s individual mandate to its tax cut bill late last year won’t help provide more people with coverage or stabilize markets, either. Trump’s decision to cease cost-sharing reduction payments to insurers who cover low-income customers in the individual marketplace forced a number of those insurers to raise premiums.
And then there was the Trump administration’s approach late last year to enrollment in individual plans offered through the HealthCare.gov marketplace. The open enrollment window shrank to 45 days, about the half the length of the 2016 open enrollment period. It sliced outreach and marketing budgets by 90 percent, meaning less money to get the word out. And the Centers for Medicare and Medicaid Services, the federal agency in charge of HealthCare.gov, shut down the online exchange for 12 hours on all but one Sunday during the already compressed open enrollment period.
There’s evidence the administration’s efforts to undermine the Affordable Care Act are working. In the first year of the Trump administration, the number of people lacking health insurance nationwide rose by 3.2 million, to 12.2 percent of the population from 10.9 percent a year earlier, according to Gallup’s ongoing survey on the subject.
The efforts by the Trump administration have also produced some unexpected irony.
HealthCare.gov insurance signups didn’t lag so badly despite the administration making it as inconvenient as possible to sign up for individual market coverage. Open enrollment figures for coverage in 2018 were at 96 percent of their 2017 levels — 8.8 million sign-ups for 2018, compared with 9.2 million in the final year of the Obama administration.
Another bit of irony? Following the release of the relatively strong enrollment figures, the Trump administration tried to take credit for “the smoothest experience for consumers to date” when it attempted to make the experience anything but.
The latest irony has to do with another Trump strategy to limit the reach of Medicaid. The administration’s invitation to states to impose work requirements on Medicaid recipients is likely to lead to fewer people covered by Medicaid in the first states to impose the work requirements. That’s the likely outcome in Maine if the LePage administration gets the greenlight on its request with the federal government to impose work requirements.
The ironic twist is that the ability to impose work requirements as a condition of receiving Medicaid coverage is generating interest in some Republican-controlled states in participating in the Affordable Care Act’s Medicaid expansion. The Washington Post and the Associated Press reported recently that Republicans in Utah, Idaho, North Carolina, Virginia, Wyoming and Kansas are showing renewed interest in the expansion now that the Trump administration has opened the door to work requirements.
Unwittingly, Trump could open the door to more states expanding their Medicaid programs as a result of the work requirement policy.
We believe imposing work requirements as a condition for receiving life-saving health coverage that low-income people need represents bad policy that runs counter to Medicaid’s purpose. (By the way, a majority of adult Medicaid recipients — a percentage similar to the nation’s overall workforce participation rates — already do work; those who don’t tend to have good reasons for not working, such as caring for children or elderly relatives.) It’s disappointing that so many Republicans aren’t open to coverage for low-income residents without tying it to a work requirement.
But the resulting ironies as Trump tries to undermine the Affordable Care Act show that the law can’t simply be wished away.
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