This story was updated in October 2020.
During his time in the White House, Barack Obama made healthcare reform a priority. The Affordable Care Act (ACA), passed in 2010, could go down as the 44th president’s signature legislative achievement. Upon taking office in 2017, Donald Trump promised to “repeal and replace” the ACA, a goal buoyed by congressional Republicans who’d been trying to defeat the law since its passage. While efforts to kill the ACA in its entirety haven’t been successful, key measures of the law have changed.
On November 10, the Supreme Court will hear California v. Texas, the case challenging the constitutionality of the ACA. If the Court strikes down the whole ACA, more than 30 million Americans could be left without healthcare coverage; 133 million other Americans with pre-existing conditions would be vulnerable to losing their coverage. An extensive set of policies affecting Medicare, Medicaid, prescription drugs and other parts of the healthcare system may also be affected.
In general, Trump-era healthcare changes have emphasized individual agency in obtaining both coverage and care. With help from healthcare policy experts and public health researchers, we put together a primer on the most significant ways healthcare has changed since Trump became president.
Repeal of the individual mandate
In effect? Yes, as of January 2019
The gist: In 2018, Congress voted to get rid of the individual mandate, which imposed a financial penalty on anyone who sidestepped the ACA requirement to obtain basic health insurance. The individual mandate was designed as a cost-control measure: It incentivized healthy people to buy into the insurance marketplace, thus lowering premiums for everyone. The $0 penalty for not having health insurance went into effect in 2019.
The impact: “The absence of the individual mandate has contributed to a modest meltdown in the individual healthcare market for unsubsidized low-risks who mostly use the off-exchange market — which is disappearing,” says Mark Pauly, a professor of healthcare management at the Wharton School of the University of Pennsylvania. “But the impact is limited. There may not be great concern about reasonably well-off low-risk people who choose to be without insurance, compared to equally well-off high-risk people who might otherwise pay a lot more for their insurance.”
Still, the individual mandate repeal combined with slashed HealthCare.gov sign-up advertising budgets has resulted in fewer insured Americans. From 2016 to 2019, the number of uninsured Americans increased by 2.3 million, to 29.2 million (that’s 10.8 percent of the population), including 726,000 children, according to the US Census Bureau.
One consequence of more uninsured people is crowded emergency rooms. When uninsured people need medical care, they’re more likely to rely on the ER instead of primary care providers, says Ruth Linden, an independent patient advocate and president of Tree of Life Health Advocates in San Francisco. “Emergency rooms are overburdened by people who show up and need to manage their predictable, if not manageable, concerns, and it burdens our already-crumbling infrastructure,” says Linden.
Not buying into the marketplace, Linden believes, “is an example of ‘me first; I’m not going to pay my share because it doesn’t benefit my family.’”
Expansion of loosely regulated “skinny” healthcare plans
In effect? Yes, as of August 2018
The gist: In the summer of 2018, the departments of Health and Human Services, Labor and Treasury jointly announced that Americans would have more leeway to enroll in short-term, limited-duration insurance plans, also known as nonqualified short-term plans.
Nonqualified short-term plans aren’t subject to the ACA’s essential health benefits requirement. That means these plans don’t need to provide free contraception, insure people with pre-existing conditions or include coverage for services such as prescription drugs, maternity care, mental healthcare and substance abuse treatment. Given their limited benefits, these skimpy plans tend to be cheaper than ACA-compliant plans. But they’re also not supposed to compete with ACA plans. Insurance companies intended for nonqualified short-term plans to be used as just-in-case safety nets during transitional periods. Enrollees were only allowed to stay on them for up to three months. But the Trump administration extended that limit; people can now keep these plans for up to three years.
The impact: Healthy people can buy these typically lower-priced skeletal plans, though Pauly notes that the number of individuals choosing these plans is minimal. “It’s not a big deal in terms of the proportion of the population,” Pauly says.
Still, the costs of healthcare coverage are rising — employer-sponsored family health coverage, for instance, is up 4 percent in 2020 following years of similar increases.
“If people in sizable numbers, the young and healthy, are purchasing plans outside of the general insurance market, the risk pool will be concentrated with heavier users of health insurance,” says Linden. “This means the cost of healthcare will increase.”
Also, she says, some people are buying them without realizing just how limited they are and then seeking out services like emergency care without knowing it’s not covered.
The Right to Try Act
In effect? Yes, as of May 2018
The gist: The Right to Try Act lets people with terminal diseases try experimental drugs that have passed through early-stage clinical trials but have not secured approval from the Food and Drug Administration for use by the general public. The idea is to give people who have exhausted all other treatment options access to potentially life-saving- or -prolonging drugs. But unlike in FDA clinical trials, no one is keeping records of Right to Try treatment outcomes. That means patients can try promising new drugs at their discretion, but no one is systematically collecting data about their experiences.
The impact: “I think Right to Try is a good thing, but it’s a mixed bag,” says Harry Nelson, founder and co-partner of healthcare law firm Nelson Hardiman, based in Los Angeles. “It opens up experimental treatment to bypass the FDA, and the FDA and state medical boards have been negative on innovative treatments. But when you are dealing with people fighting for their lives, late in the game, people have the right to make choices and decisions in pursuit of their care.”
Linden, the patient advocate, says the law doesn’t help determine who might benefit from trying unapproved drugs; it only ensures the drugs are available to desperately ill patients.
Work requirements for Medicaid
In effect? Not currently. The Centers for Medicare and Medicaid Services (CMS) has approved waivers for 10 states to implement work requirements for Medicaid, but no states are currently running a work requirement program. Arkansas, Indiana, Michigan and New Hampshire all started work requirement programs, but court rulings struck them down. Utah implemented its work requirement program in January, but it was suspended in April due to COVID-19.
The gist: Medicaid, a program jointly funded by the federal and state governments and overseen by states, provides health insurance to low-income and disabled individuals, as well as select health services to the elderly. In early 2018, the CMS announced that different states would require Medicaid recipients to either work or enroll in school or job-training programs for a certain number of hours each week to keep or apply for Medicaid coverage.
The idea came from a federal initiative and had been embraced by states with Republican leaders who support Trump. But work requirements have been linked to federal benefits in the past; a 1996 federal welfare law under President Bill Clinton stipulated that recipients work while receiving welfare, per the New York Times.
The impact: Between June and December 2018, more than 18,000 people lost healthcare coverage in Arkansas, the first state to impose these work requirements, according to the Arkansas Department of Human Services. This happened for various reasons: Some recipients didn’t know about the requirements due to relocation or lack of a permanent address; others were unable to work on account of disability, chronic illness or logistical barriers like transportation or childcare.
A recent report also determined that the work requirement did not increase employment over 18 months of follow-up.
Medicaid work requirements or other barriers “could scare away or disqualify Medicaid-eligible individuals in their state,” says Nadereh Pourat, a professor of health policy and management at the University of California Los Angeles Fielding School of Public Health and the associate director of the UCLA Center for Health Policy Research.
Hospital pricing transparency
In effect? Yes, as of January 2019
The gist: Hospitals are now required by CMS to post an annually updated list of charges for all of their services, known as a chargemaster. While hospitals have been complying, chargemasters aren’t necessarily helpful to patients. The prices are often inflated and fail to reflect discounts negotiated by health insurers, so the numbers don’t give patients a simple way to know how much they will pay for a given procedure or doctor’s visit.
The impact: “This sounds good on paper, and it’s my right as a consumer to know what I am responsible for when I go to the hospital for an emergency appendectomy or a brain lesion,” says Linden, adding that the rates patients are charged “have little to do with the chargemaster. Instead, patients are charged based on rates negotiated by the hospital and the insurance provider, whether it is public, like Medicare or Medicaid, or private like Blue Cross/Blue Shield, Anthem or Cigna. And making one’s way through the list is impossible; nobody can understand that data, not even the smartest health policy wonk. It’s impenetrable.”
“[Chargemasters] are the right idea, but they have been spectacularly ineffective, because there are no requirements for how the data has to be shared,” says Nelson, the healthcare attorney. “Health systems ended up vomiting out the information in deliberately overwhelming and confusing ways. Until there are some regulations to make the numbers fit into an apples to apples comparison, it’s completely unhelpful to patients.”
In addition to these five healthcare policy changes, Trump, congressional Republicans and federal agencies have either announced or already introduced several initiatives that affect healthcare access for different groups of Americans. Here are some of them:
- In 2019, the Trump Administration and the Department of Health and Human Services implemented the “Protect Life” rule affecting health clinics receiving “Title X” federal funding. The rule restricts clinics from providing, or even counseling patients about, abortion services. The affected clinics typically serve about 4 million low-income people each year. Last summer, Planned Parenthood withdrew from Title X rather than abide by the new requirements. The American Medical Association, Planned Parenthood and others are petitioning the Supreme Court to review the rule.
- Trump pledged to curb the opioid crisis. The October 2018 bill he signed included measures to increase access to addiction treatment, open more opioid recovery centers and reduce opiate prescriptions. The legislation received bipartisan support, but some experts say it didn’t provide enough money to curtail the epidemic.
- Trump proposed privatizing Veterans Administration hospitals in 2018, but it’s still unclear how funding will be handled.
- The ban on transgender troops went into effect in April 2019. Trump cited the high costs of transgender healthcare as one of the main reasons for the ban. But according to Defense Department data, the military was spending less than 1 percent of its health budget on trans care between July 2016 and February 2019. This past summer, the Democrat-led House adopted an amendment to the fiscal 2021 Defense appropriations bill that would end the Trump administration’s severe restrictions on transgender people serving openly in the military.