Trump’s next chance to undercut Obamacare is almost here

Aug 31, 2017, 8:20 PM UTC

Dylan Scott covers health for Vox, guiding readers through the emerging opportunities and challenges in improving our health. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo, and STAT before joining Vox in 2017.

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“I don’t think we can force people to sign up for a program.”

I attended a briefing yesterday with a Trump administration official (one condition was we had to quote the person this way), and the big topic of discussion was what the administration was willing to do to help people sign up for health coverage under Obamacare in 2018.

That answer stuck out to me. Even as the nation’s uninsured rate hits an all-time low, the administration still portrays the law as failing and waves away accusations that it is helping foster uncertainty by, for example, refusing to commit to making key payments to insurers.

“We want people to have health care,” the official said toward the end, answering a basic question about whether they wanted the Obamacare markets to work. “We want the individual marketplace to function, and it’s not functioning today.”

We didn’t get a lot of specifics about open enrollment. But there was little indication that the administration was preparing a robust outreach program. Experts have told me that a muted enrollment campaign could have serious consequences for the law’s markets.

Would the administration advertise Obamacare open enrollment? “You’ll hear more from us soon.”

What about the navigator program, which trains individuals and organizations to provide people with unbiased information and help them sign up? “I’m not a business-as-usual person.”

(Reports from conservative outlets have cast doubt on the value of enrollment outreach programs, and HHS has highlighted those stories to other reporters.)

The official did say they wanted customers to have a good shopping experience. “One of the things people really struggled with in the past is they would call and be on hold for a long time.”

“I look at it as: Our role is good government,” the official said. “Our job is to uphold the law.”

But we didn’t learn what exactly that meant.

So I asked Tim Jost, a Washington and Lee law professor who is generally supportive of Obamacare but also probably knows the legal issues around it better than anyone. What is the administration required by law to do?

Going by the letter of the Affordable Care Act, the administration must:

Perform outreach and education
Have a call center for people to sign up for insurance or ask questions by phone
Have a website for people to shop and enroll in coverage
Run a navigator program

But that’s about it. There aren’t many requirements when it comes to scale: How much money must be spent on outreach, how many navigators must be funded, how many calls the centers can handle, etc.

The administration has done a few things to smooth enrollment for 2018, Jost said. They’ve said they will continue to automatically reenroll people in their existing coverage, unless they choose to shop around. They have held webinars for navigators and promised to spend a percentage of the fees that insurers pay to help fund the marketplaces on outreach.

“I don’t know about President Trump, but as far as the 80,000 employees of HHS are concerned, this is a program that continues to operate,” Jost told me.

But the administration has also taken steps to restrict enrollment, like shortening the open enrollment period. TPM has also reported that Latino groups that had working relationships with the Obama White House to help sign that population up for coverage have been cut off by the new regime.

Then, as we heard Wednesday, the administration isn’t exactly committing to a major outreach campaign.

“The surest way to kill the exchanges is to keep them a secret,” Jost said. “Sick people will find them, but getting younger and healthier people enrolled is the problem.”

Experts believe the Trump administration has already demonstrated it could have a real impact on Obamacare sign-ups.

Enrollment for 2017 was tracking ahead of 2016, Larry Levitt at the Kaiser Family Foundation told me, until President Trump was sworn in with a little more than a week left for sign-ups. Enrollment trailed off at the end, which is doubly strange because there is usually a surge of enrollees around the deadline.

Trump might have complicated issues by signing an executive order on his first day, which, while lacking many details, sent a message that the new administration would look for ways to scale back enforcement of the ACA.

“Something definitely happened,” Levitt said. “It’s hard to say for sure exactly what caused the drop-off, but prime candidates are the scaling back of outreach and confusion among potential enrollees following the president’s executive order.”

“There may have been a sense that the individual mandate was no longer in force following the executive order and that the law was going to end imminently,” he added, “so it didn’t make sense to enroll.”

Obamacare averted one crisis when the last of its bare counties were filled in last week. Open enrollment is the next test. The Trump administration might not love the health care law, but coverage for millions of people will hinge in part on how good of a show they run. We’ll see how they handle it.

Chart of the Day

RWJF/TFAH

Obesity in America in 2016. Obesity remains one of the paramount public health challenges for our country. The Robert Wood Johnson Foundation and Trust for America’s Health have pulled together some new data. While rates remain high, if there is some good news, it appears they are starting to level off. There is a lot of data and info on the new report’s website.

Kliff’s Notes

With research help from Caitlin Davis

Today’s top news

“Trump Administration Wants to Stabilize Health Markets but Won’t Say How”: “A Trump administration official said Wednesday that the administration wanted to stabilize health insurance markets, but refused to say if the government would promote enrollment this fall under the Affordable Care Act or pay for the activities of counselors who help people sign up for coverage.” —Robert Pear, New York Times
“Sen. Kamala Harris announces support for ‘Medicare-for-All’ bill”: ““I intend to co-sponsor the Medicaid-for-All bill,” California’s junior senator told several hundred people at a town hall at Oakland’s Beebe Memorial Cathedral, referring to Vermont Sen. Bernie Sanders’ Medicare-for-All proposal.” —Casey Tolan, San Jose Mercury News
“St. Kitts Launches Probe Of Herpes Vaccine Tests On U.S. Patients”: “The vaccine research has sparked controversy because the lead investigator, a professor with Southern Illinois University, and the U.S. company he co-founded did not rely on traditional U.S. safety oversight while testing the vaccine last year on mostly American participants on the Caribbean island of St. Kitts.” —Marisa Taylor, Kaiser Health News

Analysis and longer reads

“While Congress is away, this bipartisan group of governors is trying to fix Obamacare”: “Written by Govs. John Kasich (R-Ohio) and John Hickenlooper (D-Colo.) with six other governors signing on, the plan makes adjustments to the ACA around the edges, as opposed to the large upheavals that Republican lawmakers have been trying to move through Congress.” —Kim Soffen, Reuben Fischer-Baum, and Kevin Uhrmacher, Washington Post
“Are Short-Term Limited Duration Plans Bad For The Individual Market?”: “With the impasse in the congressional GOP’s attempts to repeal and replace the Affordable Care Act (ACA), the Trump administration has sought regulatory reforms that could improve health care choices and reduce costs for consumers. Among their options is the reversal of a recent regulation that sought to restrict the availability of short-term limited duration plans.“ —Christopher Pope, Health Affairs
“In mega-shelter for Harvey evacuees, telemedicine plans to help doctors keep up”: “Children’s Health has set up a telemedicine station from which ER physicians at the hospital can remotely see children at the shelter, via a computer monitor and specially designed equipment for measuring vital signs. The telemedicine station has been in use since Monday.” —Leah Samuel, STAT