Trump's next big decision is to save or wreck Obamacare
- The biggest question for the future of the US healthcare system is whether President Donald Trump will undermine or support the Obamacare exchanges.
- Trump could support the bipartisan Alexander-Murray deal and help to shore up the market. Or he could take actions to undermine the system further, like denying state stability waivers.
- Trump appears to be leaning toward destruction.
Since the start of the Trump administration, the future of President Barack Obama's landmark Affordable Care Act (ACA) has been in doubt.
Republicans spent the first eight months of Donald Trump's presidency attempting to repeal and replace the ACA, also known as Obamacare, but have ultimately come up short for now.
Now, as the beginning of the open enrollment period for the law's individual insurance exchanges looms (people can sign up starting November 1) and the legislative attempts to dismantle the law are on ice, what Trump will do about the law has become the key issue for the future of the healthcare system.
On the one hand, most Americans will place any problems with the exchanges and Obamacare going forward on the head of Trump and the GOP, according to polling. This would seem to give Trump a reason to try and fix the law in the short term instead of blowing it up.
On the other hand, Trump long stated his desire to blow up the healthcare exchanges in order to get Democrats to negotiate on a replacement deal.
So the questions remains: Will Trump save Obamacare or destroy it?
Save
The easiest way for Trump to help bolster the Obamacare markets would be to signal support for the bipartisan Alexander-Murray deal.
The bill - crafted by Republican chair of the Senate Health, Education, Labor, and Pensions committee Lamar Alexander and the committee's Democratic ranking member Patty Murray - would help fund the cost sharing reduction (CSR) payments, boost spending on advertising for the upcoming open enrollment period, and provide extra flexibility to states.
As of now, the bill has the support of every Democratic senator and at least 12 Republicans who are co-sponsoring it. Additionally Rep. Mark Meadows, chair of the conservative House Freedom Caucus, called the bill "a good start" while saying that there would still need to be a few adjustments.
If Trump were to come out in favor of the bill, there is a good chance it could pass. Besides the obvious stabilizing the items in the bill itself, support from Trump could help ease some of the worries from insurers about the marketplace going forward.
Destroy
Trump already took significant steps to undermine the health of the markets over the past few weeks.
Perhaps most damaging was the decision to end the CSR payments, which had already led to insurers increasing their premiums for 2018. While most of this cost will eventually fall on the federal government, there is another danger in the decision, according to Matthew Fiedler, a health policy expert at the Brookings Institution.
"Some insurers may conclude that operating under this type of uncertainty is intolerable and decide to simply cut their losses," Fiedler told Business Insider. "That could leave some enrollees without any options at all for purchasing coverage. These types of outcomes are particularly likely in states that did not allow insurers to raise premiums to account for the possibility that CSRs would not be paid in 2018."
In addition to ending the CSR payments, the president signed an executive order allowing the expanded use of association health plans. The order could help undermine the Obamacare exchanges, according to experts.
Taken together, these moves already show a preference toward blowing up the law.
"Not one of the Trump administration's actions is crippling to the ACA's marketplace, but the cumulative effect could be quite damaging," Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank, told Business Insider.
If Trump wanted to further destroy the exchanges, he also has simple options in front of him.
The simplest of steps would be to reject the Alexander-Murray deal. Senate Majority Leader Mitch McConnell said Sunday that he would bring the bill to the floor if Trump supports the deal and would sign it. By coming out against the idea, Trump could prevent the market stabilization package from making it to law.
Additionally, a plan proposed by Rep. Kevin Brady, chair of the House Ways and Means committee, and Sen. Orrin Hatch, chair of the Senate Finance committee, would likely have no hope in the Senate and possibly undermine the exchanges even more. If Trump were to throw his weight behind that plan instead, it would still be unlikely to become law and leave Obamacare with no real support.
Other steps Trump could take are also fairly simple. He could instruct his Department of Health and Human Services to continue denying waivers from states that are attempting to stabilize their markets. Also, the HHS's current budget for enrollment advertising is already significantly lower than previous years', and keeping ad costs low is another way to undermine the exchanges.
Which will he choose?
So far, indications appear to point to Trump continuing to aide the collapse of the healthcare market.
The president withheld direct support for the Alexander-Murray deal, and his legislative aides have suggested changes to the plan in order to win Trump's support that would doom the bill with Democrats. Some of these include eliminating the individual mandate and changing key regulations on insurance plans.
The final decision by Trump, however, is unclear.
Sen. John Cornyn, the second-highest ranking Republican in the Senate, merely shrugged when asked what the president thought of the Alexander-Murray bill. Sen. Shelley Moore Capito, a Republican from West Virginia, told Politico, "It's safe to say the president's been unclear."
Additionally, the Trump administration has yet to approve a waiver from the Republican-controlled Iowa government that would help to shore up that state's exchange.
Even Trump's recent comments that Obamacare is "dead" and "no longer exists" help sow uncertainty and could suppress enrollment for next year.
"Through all of these actions, the Administration is sending a strong signal that it wants the individual market to fail," Fiedler said.