Trump rolls back some health rules

Move sparks de­bate over who will be helped, hurt.

The Atlanta Journal-Constitution - - FRONT PAGE - By Amy Gold­stein

WASH­ING­TON — Pres­i­dent Don­ald Trump signed an ex­ec­u­tive or­der Thurs­day in­tended to cir­cum­vent the Af­ford­able Care Act by mak­ing it eas­ier for in­di­vid­u­als and small busi­nesses to buy al­ter­na­tive types of health in­sur­ance with lower prices, fewer ben­e­fits and weaker gov­ern­ment pro­tec­tions.

The White House and al­lies por­trayed the pres­i­dent’s move as wield­ing ad­min­is­tra­tive pow­ers to ac­com­plish what con­gres­sional Repub­li­cans have failed to achieve: fos­ter­ing more cov­er­age choices while tear­ing down the law’s in­sur­ance mar­ket­places.

The or­der rep­re­sents Trump’s big­gest step to date to re­verse the health-care poli­cies of the Obama ad­min­is­tra­tion, a cen­tral prom­ise since last year’s pres­i­den­tial cam­paign.

Crit­ics, who in­clude state in­sur­ance com­mis­sion­ers, most of the health-in­sur­ance industry and main­stream pol­icy spe­cial­ists, pre­dict that a pro­lif­er­a­tion of these other kinds of cov­er­age will have dam­ag­ing rip­ple ef­fects, driv­ing up costs for con­sumers with se­ri­ous med­i­cal con­di­tions and prompt­ing more in­sur­ers to flee the law’s mar­ket­places. Part of Trump’s ac­tion, they say, will spark court chal­lenges over its le­gal­ity.

The most far-reach­ing el­e­ment of the or­der in­structs a trio of Cab­i­net de­part­ments to re­write fed­eral rules for “as­so­ci­a­tion health plans” — a form of in­sur­ance in which small busi­nesses of a sim­i­lar type band to­gether through an

as­so­ci­a­tion to ne­go­ti­ate health ben­e­fits. These plans have had to meet cov­er­age re­quire­ments and con­sumer pro­tec­tions un­der the 2010 health-care law, but the ad­min­is­tra­tion is likely to ex­empt them from those rules and let such plans be sold from state to state with­out in­sur­ance li­censes in each one.

In ad­di­tion, the or­der is de­signed to ex­pand the avail­abil­ity of short-term in­sur­ance poli­cies, which of­fer lim­ited ben­e­fits as a bridge for peo­ple be­tween jobs or young adults no longer eligi- ble for their par­ents’ health plans. The Obama ad­min­is­tra­tion ruled that short-term in­sur­ance may not last for more than three months; Trump wants to ex­tend that to nearly a year.

Trump’s ac­tion also is in­tended to widen em­ploy­ers’ abil­ity to use pre­tax dol- lars in “health re­im­burse- ment ar­range­ments” to help work­ers pay for any med­i­cal ex­penses, not just for health poli­cies that meet ACA rules — an­other re­ver­sal of Obama pol­icy.

In a late-morn­ing sign­ing cer­e­mony in the White House’s Roo­sevelt Room, sur­rounded by sup­port­ive small-busi­ness own­ers, Cab­i­net mem­bers and a few Repub­li­cans from Capi­tol Hill, the pres­i­dent spoke about the ef­fects of his ac­tion and what he called “the Obamacare nightmare.”

Trump said that Thurs- day’s move, which will trig­ger months of reg­u­la­tory work by fed­eral agen­cies, “is only the be­gin­ning.” He prom- ised “even more re­lief and more free­dom” from ACA rules. And al­though lead­ing GOP law­mak­ers are ea­ger to move on from their un­suc- cess­ful at­tempts this year to abol­ish cen­tral facets of the 2010 law, Trump said that “we are go­ing to pres­sure Congress very strongly to fin­ish the re­peal and re­place of Obamacare.”

The ex­ec­u­tive or­der will ful­fill a quest by con­ser­va­tive Repub­li­can law­mak­ers, es­pe­cially in the House, who have tried for more than two decades to ex­pand the avail­abil­ity of as­so­ci­a­tion health plans by al­low­ing them to be sold, un­reg­u­lated, across state lines. On the other hand, Trump’s ap­proach con­flicts with what he and GOP lead- ers in Congress have held out as a main health-pol­icy goal — giv­ing each state more dis­cre­tion over mat­ters of in­sur­ance.

Health pol­icy ex­perts in think tanks, academia and the health-care industry pointed out that the or­der’s lan­guage is fairly broad, so the en­su­ing fine print in agen­cies’ rules will de­ter­mine whether the im­pact will be as sweep­ing or quick as Trump boasted — his di­rec­tive will pro­vide “mil­lions of peo­ple with Obamacare re­lief,” he said.

Sig­nif­i­cant ques­tions that re­main in­clude whether in­di­vid­u­als will be able to join as­so­ci­a­tions, an is­sue that could raise le­gal is­sues; whether the ad­min­is­tra­tion will start to let as­so­ci­a­tion health plans count to­ward the ACA’s re­quire­ment that most Amer­i­cans carry in­sur­ance; and whether such plans can charge higher prices to small busi­nesses with sicker work- ers — or refuse to in­sure them.

The pres­i­dent is­sued the di­rec­tive less than three weeks be­fore the Nov. 1 start of the fifth open-en­roll­ment sea­son in ACA mar­ket­places for peo­ple who do not have ac­cess to af­ford­able health ben­e­fits through a job. Trump noted that about half of the na­tion’s coun­ties will have just one in­surer in their ex­change, and he claimed that “many will have none.” How­ever, the most re­cent can­vass shows that there will be no “bare” coun­ties in 2018.

A se­nior ad­min­is­tra­tion of­fi­cial, speak­ing to re­porters on the con­di­tion of ano- nymity shortly be­fore Trump signed the or­der, said that the pol­icy changes it sets in mo­tion will re­quire agen­cies to fol­low cus­tom­ary pro­ce­dures to write new rules and so­licit pub­lic com­ment. That means new in­sur­ance op­tions will not be avail­able in time for cov­er­age be­gin­ning in Jan­uary, he said.

Even so, with a short­ened sign-up pe­riod and large cuts in fed­eral funds for ad­ver­tis­ing and en­roll­ment help al­ready hob­bling the mar­ket­places, “if there’s a lot of hoopla around new op­tions that may be avail­able soon, it could be one more thing that dis­cour­ages en­roll­ment,” said Larry Le­vitt, the Kaiser Fam­ily Foun­da­tion’s se­nior vice pres­i­dent.

Other as­pects of the ex­ec­u­tive or­der in­clude com­mis­sion­ing a six-month study, to be led by fed­eral health of­fi­cials, of ways to limit con­sol­i­da­tion within the in­sur­ance and hos­pi­tal in­dus­tries. Trump also di­rected agen­cies to find ad­di­tional means to in­crease com­pe­ti­tion and choice in health care to im­prove its qual­ity and lower its cost.

The or­der pro­duced pre­dictable re­ac­tions in Congress, with Repub­li­can lead­ers prais­ing the move and Democrats ac­cus­ing the White House of sab­o­tag­ing the law.

Among pol­icy ex­perts, crit­ics warned that young and healthy peo­ple who use rel­a­tively lit­tle in­sur­ance will grav­i­tate to as­so­ci­a­tion health plans be­cause of their lower price tags. That would con­cen­trate older and sicker cus­tomers in ACA mar­ket­places with spik­ing rates.

Mike Conse­dine, chief ex­ec­u­tive of the Na­tional As­so­ci­a­tion of In­sur­ance Com­mis­sion­ers (NAIC) said Thurs­day that the group has long op­posed such plans and is con­cerned that the ad­min­is­tra­tion will al­low ones that can by­pass state li­censes and have such weak fi­nan­cial un­der­pin­nings that some will col­lapse, leav­ing cus­tomers stranded and state in­sur­ance reg­u­la­tors “pick­ing up the pieces.”

DOUG MILLS / THE NEW YORK TIMES

Pres­i­dent Don­ald Trump shakes hands with Sen. Rand Paul, R-Ky., at the White House as Vice Pres­i­dent Mike Pence looks on dur­ing an event where Trump signed an ex­ec­u­tive or­der that clears the way for po­ten­tially sweep­ing changes in health in­sur­ance.

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