Health care reform and the future of the Affordable Care Act are on the ballot in 2020, just as in 2018. This memo contains several comments and links to research on the Trump Administration health care record along with an implicit discussion of implications of the impact a second Trump term.
Comment One: The actual number of people without health insurance has grown under the Trump Administration. According to the Census Department, the number of people without health insurance increased from 25.6 million in 2017 to 27.5 million in 2018. These increases in the number of uninsured occurred during years where the unemployment rate actually fell slightly and prior to the repeal of fines for the individual mandate and the COVID pandemic. The increase in the number of uninsured occurred because of policy actions taken by the Trump Administration and despite a relatively strong economy.
Comment Two: A recent study by the Economic Policy Institute found that around 9.2 million people have lost their health insurance due to the COVID pandemic. A Democratic proposal to provide COBRA subsidiesfor laid off workers has not advanced through Congress. Analysis discussed in this NPR article indicates that strengthening the ACA would be a more effective way to maintain health insurance for the unemployed.
Comment Three: The Trump Administration has moved to make it easier for people to purchase short-term health insurance policies that do not cover many essential services. Shortcomings and coverage gaps from use of short-term health plans are revealed in this paper by Families USA. Often the fine print of short-term health plans excludes specific procedures services and conditions including pregnancies, certain common operations, and prescription drugs. The existence of pre-existing conditions can lead to denial of benefits and even recission of the insurance plan. Often people with short term health plans incur substantial medical debt. The Center for Medicaid Services projects around one million people are projected to purchase short-term health plans by 2022. A substantial portion of the demand for short term health plans is among healthy individuals who are ineligible for the premium tax credit. This shift in demand towards short-term health plans will undermine state exchange markets.
Comment Four: The Trump Administration has consistently supported repeal of the ACA. The CBO estimated that had ACA repeal efforts been successful the number of uninsured would have increased by 17 million in 2018 and by 27 million in 2020.
Comment Five: The Trump Administration supported the successful repeal of fines for violating the Individual Mandate. The CBO estimates the repeal of the individual mandate will increase the number of uninsured by 4 million in 2019 and 13 million in 2027. Surveys of 2019 health insurance coverage rates should be released soon giving us an idea of whether CBO projections were accurate on this point.
Comment Six: The Trump Administration legal brief, in a court case seeking to overturn the ACA, states the entire ACA, including rules establishing community rating, guarantee issue and tax credits, is unconstitutional because of repeal of the individual mandate. (See page 43 of the brief.) At the same time, President Trump has floated the idea of issuing an executive order requiring health insurance companies to cover people with pre-existing conditions. I have a hard time understanding how an executive order preventing health insurance companies from denying benefits to firms with pre-existing conditions can be legal when the law mandating these protections is unconstitutional.
Comment Seven: The Trump Administration and the Republican Congress killed the risk-corridor subsidy designed to help insurance companies in the first years of the ACA. The Supreme Court restored the risk-corridor subsidies.
Comment Eight: This article by Timothy Jost does a good job in analyzing several Republican efforts to replace the ACA. Standard features of Republican ACA replacement bills include — limits on Medicaid spending, repeal of cost sharing reduction payments, replacement of the individual mandate with a continuous coverage mandate, removing penalties with both the employer and individual mandate provisions, repeal of some revenue provisions and several changes to the premium tax credit. Many of these changes would reduce coverage or increase costs for low-income households.
Comment Nine: This discussion of the use of the continuous coverage mandate by researchers at Randindicates many households will lose coverage because of payment problems. Analysis by the New York Federal Reserve Bank indicating that around 40 percent of U.S. households could not afford a $400 emergency bill bolsters the Rand finding.
Comment Ten: The Trump Administration killed ACA cost sharing subsidies for low-income households. The combination of a continuous coverage mandate without coverage subsidies could result in many lower income people and people experiencing job losses losing health coverage.
Comment Eleven: One Republican bill would have repealed the ACA means tested premium tax credit and replaced it with a new tax credit. An analysis of these proposed changes by Cutler and coauthors find the GOP plans would result in a substantial increase in costs for average state exchange participants.
Comment Twelve: The Trump Administration allowed states to impose work requirements for people receiving Medicaid. The Center for Budget and Policy Priorities wrote a number of articles discussing the impact of these requirements on households. The Trump Administration wants to eliminate the Medicaid expansion and replace it with state waivers providing Medicaid block grant. A CBPP article on the impact of block Medicaid grants can be found here.