How Trump could un­der­mine the ACA dur­ing the first week

Modern Healthcare - - THE WEEK AHEAD - —Shan­non Much­more

Pres­i­dent Don­ald Trump could be­gin un­do­ing the Af­ford­able Care Act al­most im­me­di­ately through the use of ex­ec­u­tive or­ders that would weaken the law, and through other meth­ods.

But some in the GOP are get­ting skit­tish about the prospect of tak­ing in­sur­ance away from up to 30 mil­lion peo­ple, and a few sen­a­tors have said they will not sup­port re­peal with­out a re­place­ment plan in place.

Trump and other GOP lead­ers have given con­flict­ing mes­sages about re­peal­ing the ACA. Trump has praised ef­forts to move quickly to re­peal and has made broad prom­ises about a re­place­ment with “in­sur­ance for ev­ery­body” that more cau­tious Re­pub­li­cans are not will­ing to fully stand be­hind.

But Vice Pres­i­dent Mike Pence said early this month that the in­com­ing ad­min­is­tra­tion is “work­ing on a strat­egy, in con­cert with the lead­er­ship of the House and the Se­nate, for both a leg­isla­tive and ex­ec­u­tive ac­tion agenda to en­sure that an or­derly and smooth tran­si­tion to a mar­ket-based health­care re­form sys­tem is achieved.”

Trump ad­min­is­tra­tion of­fi­cials have not yet spec­i­fied what ex­ec­u­tive ac­tions the new pres­i­dent may take with the ACA, but he could di­rect fed­eral agen­cies on dif­fer­ent ways to carry out the law.

He could broaden hard­ship ex­emp­tions to the in­di­vid­ual man­date or di­rect that penal­ties not be im­posed for cer­tain vi­o­la­tions of the law. He could also ex­tend an ad­min­is­tra­tive fix to the law and al­low more plans with skimpy cov­er­age that would oth­er­wise not qual­ify.

Trump could also stop de­fend­ing law­suits like the House Re­pub­li­cans’ case that cost-shar­ing sub­si­dies to in­sur­ers are be­ing im­prop­erly paid or the chal­lenge to the man­date re­quir­ing em­ploy­ers and in­sur­ers to pro­vide free con­tra­cep­tion ser­vices.

An­other op­tion would be for the ad­min­is­tra­tion to ap­prove more state Med­i­caid ex­pan­sion waivers. Pres­i­dent Barack Obama’s ad­min­is­tra­tion had re­fused some of the waivers with more con­ser­va­tive pro­vi­sions such as work re­quire­ments.

Th­ese ac­tions could, how­ever, have a ma­jor desta­bi­liz­ing ef­fect on the mar­ket­place ex­changes and the in­dus­try is likely to push back on big changes. The Amer­i­can Med­i­cal As­so­ci­a­tion, the Amer­i­can Hospi­tal As­so­ci­a­tion and other groups have said there should be no re­peal un­til a re­place­ment plan is put for­ward.

Trump

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