Trump’s Health Care Vision Still Short on Details

The president’s decision to cut off Obamacare subsidies will increase pressure for Hill Republicans to take action—but Trump hasn’t said what he wants them to do.

President Trump shakes hands with Rep. Greg Walden during an event to sign an executive order on health care in the Roosevelt Room of the White House on Oct. 12.
AP Photo/Evan Vucci
Erin Durkin
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Erin Durkin
Oct. 16, 2017, 8 p.m.

President Trump’s big moves on Obamacare last week have heightened the pressure on Congress to take action to avoid spiked premiums and general market instability. But Trump has given Hill Republicans little direction for what they should do next—the same misstep experts say contributed to the party’s inability to repeal the law.

“He’s left them with a big gamble. … If pieces of the Affordable Care Act start to unravel and fall apart, there is a possibility for a negotiated alternative,” said Robert Blendon, professor of health policy and political analysis at Harvard University.

Republicans largely were ready to pause their broader health care debate and move on to tax reform after their last attempt to repeal the law tanked.

But the administration changed the stakes by announcing it will cease making key payments to insurers. Known as cost-sharing-reduction payments, they offset the costs insurers incur when they reduce out-of-pocket expenses for low-income consumers.

Insurers for months have looked for a clear commitment that the government would make these payments. Cutting off the subsidies could lead to higher premiums and cause some insurers to try to leave the exchanges entirely.

This decision came hours after Trump signed an executive order that would expand access to association health plans, which could potentially be exempt from ACA regulations, and expand the duration of short-term insurance plans, among other changes. “The rules that will follow from the executive order may to a substantial degree achieve the goal Congress refused to accept,” wrote Timothy Jost on the Health Affairs Blog.

Critics have said that Trump from the outset had not outlined his vision for health reform and was unable to bridge divisions within the Republican Party. One conservative policy advocate, though, said these recent moves set a course for Congress to pursue.

“The combination of the two actions, I think, helps focus some of the conversation and provides some sort of guidance as to where they need to go,” said Dan Holler, vice president at Heritage Action for America. “It certainly doesn’t solve all the issues.”

But other experts insist the administration’s decisions, particularly ending the cost-sharing-reduction payments, will likely not lead to a substantial overhaul of Obamacare.

“As best as one can tell, the larger imperative for the president … is to get some kind of tangible accomplishment … whether those votes come from Democrats, Republicans, or anyone else you can round up,” said Thomas Miller, resident fellow at the American Enterprise Institute. Miller said that the announcement ending the cost-sharing payments seemed to hint that Trump would use this as leverage to get Democrats to the negotiating table, but the outcome may still not be in the Republicans’ interests.

“Whatever final deal on this may well have more Democrats in favor of it,” Miller said.

Blendon described the decision as a “political calculation” rather than one based in policy—that instead of being the president who “lost on health care,” Trump wanted to show that he’s in charge. Blendon also does not expect a giant overhaul of Obamacare to result from Trump’s action, but perhaps a smaller measure.

“My view generally is that some other bill emerges that allows the president and Republicans to say they have an alternative. … That’s the best case they can hope for,” he said.

Senate Health, Education, Labor, and Pensions Committee Chairman Lamar Alexander and ranking member Patty Murray have been attempting to find an agreement that would have guaranteed the subsidies while also providing states more flexibility to change ACA regulations in their marketplaces.

“The president is not going to continue to throw good money after bad, give $7 billion to insurance companies, unless something changes about Obamacare that would justify it,” Sen. Lindsey Graham said on CBS’s Face the Nation Sunday. “He did talk to Senator Alexander yesterday. He’s encouraging him to get a bipartisan deal that would have some flexibility … for continuing payment. But it’s got to be a good deal.”

But Trump’s budget director, Mick Mulvaney, bashed Alexander and Murray’s efforts, indicating that the president would not support the bill. “Instead of saying what we might support, I’d say I’m pretty sure what we won’t support, which is just a clean Murray-Alexander bill,” Mulvaney told Politico.

Even if Congress can’t find any movement forward, Trump will likely count any result from these executive decisions as an accomplishment. “For him, either outcome, fixing the problem or leaving the problem in place, he will spin toward a political win,” said Molly Reynolds, a fellow in governance studies at the Brookings Institution.

But allowing the Obamacare marketplace to “implode” could have political consequences for congressional Republicans. A Kaiser Family Foundation poll suggests that most of the public views problems with the ACA as Republicans’ responsibility.

If Republicans are concerned about the backlash they may receive, Holler said they should try once again to repeal Obamacare.

“If they are fearful of premium increases as a result of what is essentially the president abiding by the rule of law, they should redouble their efforts to repeal and replace,” he said.

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