Orlando Harmon
During his 2016 campaign, President Donald Trump promised insurance for everybody and that he would “take care of everybody”. However, between 2016 and 2019, the number of uninsured Americans rose by 2.3 million, including 726,000 children. Trump's administration attempted to repeal the Affordable Care Act (ACA) and took actions to undermine it, such as slashing funding for outreach and enrollment assistance, and discouraging immigrants and their families from enrolling. These actions caused people to lose coverage and made it harder for eligible people to get insurance. Trump's promotion of junk plans and failure to address rising Obamacare premiums also contributed to the problem.
What You'll Learn
Trump's efforts to repeal the Affordable Care Act (ACA)
On his first day in office, President Trump signed an executive order to turn back the ACA's implementation. Throughout his presidency, he made efforts to destabilize the ACA and undermine insurance markets.
Reducing Outreach and Education
The Trump administration scaled back ACA outreach and education programs, including funding for the navigators who help consumers find coverage. This made it harder for people to learn about their health insurance options and get help enrolling.
Terminating Reimbursement Payments to Insurers
The Trump administration ended reimbursement payments to insurers for reducing costs for low-income enrollees. This threatened to destabilize the ACA markets, but state regulators reacted swiftly to prevent chaos.
Short-Term Limited Duration Coverage Rule
The Trump administration allowed the marketing of more plans completely free from all ACA insurance reforms. These short-term plans are typically cheaper but can turn down people with pre-existing conditions or charge them higher premiums.
Enhancing Direct Enrollment Program
The Trump administration transferred responsibility for marketplace enrollment from the federal marketplace to private web brokers through its enhanced direct enrollment program. This increased reliance on the private sector to implement the ACA, risking uneven and ineffective enforcement and consumer protection.
Ending Cost-Sharing Reduction Payments
The Trump administration ended cost-sharing reduction payments to insurers, which help lower deductibles and out-of-pocket health care costs for low- and moderate-income people. This resulted in higher premiums and federal costs, as well as potential insurer withdrawals from the marketplaces.
Supporting a Major Court Challenge
The Trump administration supported a major court challenge to the Affordable Care Act's constitutionality. This put the law at risk of being invalidated, but a coalition of Democratic attorneys general successfully stepped in to defend it.
Eliminating the Individual Mandate
Trump signed a bill effectively eliminating the individual mandate, which required most Americans to have health insurance or face a penalty. This was achieved by reducing the basis of individual mandate taxation to zero percent.
Requiring Work for Medicaid Coverage
Under Trump's administration, the Centers for Medicare and Medicaid Services allowed states to require certain Medicaid enrollees to work to continue their coverage. This policy was implemented in Arkansas before being halted by the courts, resulting in over 18,000 residents losing their Medicaid benefits.
Other Rule Changes
The Trump administration made various other rule changes that critics claimed undermined the ACA:
- Tightening income verification
- Limiting the ability of people to sign up during special enrollment
- Requiring consumers to pay back premiums before enrolling again
- Cutting the open enrollment period in half
- Slashing the advertising budget and funding for enrollment assistance
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Cuts to funding for outreach and enrollment assistance
The Trump administration's cuts to funding for outreach and enrollment assistance have been described as ""sabotage" and a "slashing" of funds. The Centers for Medicare & Medicaid Services (CMS) cut funding for outreach by 90% and for the navigator program's enrollment assistance and outreach by more than 40% (one source states over 80%).
These cuts are thought to have caused an estimated 500,000 to 1 million people to lose coverage. The large consumer outreach cuts have had major negative effects, with nearly half of uninsured adults unaware of the financial assistance available to help pay for health insurance. This means that fewer people will take advantage of the coverage and financial assistance available to them, and more will go uninsured.
The cuts to funding for outreach and enrollment assistance are part of a broader pattern of the Trump administration's actions to undermine the ACA and Medicaid. The administration also made it harder for eligible people to get coverage, discouraged immigrants and their family members from enrolling in coverage, and encouraged states to cut coverage.
The Trump administration's public charge rule created a "chilling effect", discouraging immigrants and their family members from seeking coverage and care for which they were eligible. This likely contributed to uninsured rate increases among Hispanic adults, Hispanic children, and children who were not born in the United States.
At the Trump administration's urging, some states implemented work requirements for Medicaid. A study of Arkansas' program found that these requirements resulted in coverage losses without increasing employment. Where implemented, these policies terminated or threatened health coverage for 20-40% of those subject to them.
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Discouraging immigrants and their families from enrolling
In 2019, the Trump administration issued immigration rules that severely restricted family-based immigration to the United States. This move created a climate of fear among immigrants and their families, leading many to forgo Medicaid or marketplace coverage and other assistance programs for which they were eligible. This likely contributed to the increase in uninsured rates among Hispanic adults and children, as well as children who were not born in the United States.
The Trump administration's public charge rule has been criticised for creating a "chilling effect" on immigrants and their families seeking healthcare coverage and care. This rule expands the definition of a "public charge", meaning someone likely to become dependent on government assistance. Noncitizens identified as likely public charges would become ineligible for permanent resident status and family reunification visas. This change would likely strip low-income households of access to a wide range of health-related benefits. While noncitizens who are legal residents would remain eligible for these benefits, enrolling in them could jeopardise their immigration status.
The Migration Policy Institute's analysis of the draft rule indicates that the expanded definition of public charge is likely to include the use of Medicaid, publicly subsidised health insurance, the Children's Health Insurance Program (CHIP), and other health-related benefits. By making it risky for immigrants to apply for and use publicly funded benefits, the public charge policy would especially disadvantage certain immigrant populations. For example, it would become more difficult for children, the elderly, persons with lower levels of education, limited English proficiency, and those with incomes below the federal poverty line to enter and remain in the United States.
The Trump administration's policies have also been criticised for undermining trust between immigrants and the systems that aim to support their health. While federal immigration authorities have long had the power to limit noncitizens' access to publicly funded programs, earlier restrictions excluded the use of medical and nutrition programs as grounds for denying permanent residency or citizenship. If a medical professional cannot encourage an immigrant parent to enrol her US-born child in health insurance or other subsidized programs for which they are eligible, health and social systems will be blocked from strengthening public health and immigrant integration in the communities they serve.
In conclusion, the Trump administration's immigration policies have contributed to a climate of fear and uncertainty among immigrants and their families, leading to a decline in healthcare coverage and access to critical health-related services. These policies have disproportionately impacted vulnerable populations, including children, the elderly, and those with limited resources.
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Encouraging states to implement work requirements for Medicaid
In January 2018, the Centers for Medicare & Medicaid Services (CMS) issued a new policy allowing states to implement work and community engagement requirements for certain Medicaid enrollees. States must seek federal approval to require non-elderly, non-pregnant, and non-disabled adults to meet these requirements to qualify for full or partial Medicaid coverage.
During the Trump administration, 13 states received approval for work rules, and several others sought permission. However, some of these approvals were struck down by courts on procedural grounds.
The Trump administration's encouragement of states to implement work requirements for Medicaid was part of a broader effort to undermine the Affordable Care Act (ACA) and reduce the number of people with health insurance coverage. This policy, along with other actions taken by the administration, contributed to an increase in the number of uninsured Americans, including children.
The impact of work requirements on Medicaid enrollees varied across states. In Arkansas, which became the first state to implement work requirements in 2018, about 18,000 adults temporarily lost Medicaid coverage before a judge halted the program. A study on Arkansas' program demonstrated that these requirements resulted in coverage losses without increasing employment.
Georgia is currently the only state with a Medicaid work requirement after a federal judge allowed a Trump-approved waiver to move forward. However, only 1,800 people have enrolled in the program, indicating limited uptake.
Overall, the encouragement of states to implement work requirements for Medicaid was one factor contributing to the loss of health insurance coverage for many Americans during the Trump administration.
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Changes to insurance payment formulas
During his 2016 campaign, President Donald Trump promised "insurance for everybody" and pledged to "take care of everybody" and lower costs. However, his administration's actions have led to the opposite outcome, with millions of Americans losing their health insurance coverage. One of the reasons for this is the changes made to insurance payment formulas, which have raised costs for those with marketplace or employer plans.
In April 2019, the Trump administration finalised a rule that altered the formula for updating premium tax credits annually. This change will result in a nearly 5% increase in premiums after tax credits for millions of marketplace consumers, leading to an estimated reduction in coverage of over 100,000 people in 2022. The administration's own analysis acknowledged that these premium increases would cause 70,000 people to drop their marketplace coverage each year.
Additionally, in April 2017, the Trump administration approved a regulation allowing marketplace insurers to reduce the value of coverage provided in marketplace silver plans, which are the basis for premium tax credits. This decision likely diminished the value of premium tax credits for millions of people.
The cumulative effect of these changes to insurance payment formulas has been to increase costs for those with marketplace or employer plans, causing some individuals to forgo coverage altogether. These actions contradict President Trump's campaign promises to provide insurance and lower costs for all Americans.
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Frequently asked questions
Trumpcare, or the American Health Care Act, would have caused people to lose insurance by repealing the Affordable Care Act (ACA), also known as Obamacare. The ACA was passed in 2010 after over a year of debate, whereas Trump's plan to replace it only lasted 63 days. The Congressional Budget Office estimated that the bill would cut $880 billion from Medicaid over a decade and would eventually cost 53 million Americans their health insurance, including 14 million in the first year.
During his time in office, Trump's policies caused a rise in the number of uninsured Americans. Between 2016 and 2019, the number of uninsured Americans increased by 2.3 million, including 726,000 children. This was due to a combination of factors, including cuts to funding for Obamacare enrollment and outreach, the promotion of short-term health insurance plans, and the addition of work requirements for Medicaid.
Trump's attempts to repeal the ACA, or Obamacare, caused significant uncertainty and contributed to the rise in the number of uninsured Americans. If the ACA had been repealed, it would have ended coverage for more than 20 million Americans, driven up costs for those seeking to buy coverage, and eliminated consumer protections for millions of people with pre-existing conditions.
