During his time in the White House, Barack Obama made healthcare reform a priority. The Affordable Care Act, passed in 2010, could go down as the 44th president’s signature legislative achievement. While Donald Trump hasn’t focused on reforming our healthcare system to the same degree, he and congressional Republicans have rolled out a number of new policies, regulations and government initiatives related to insurance coverage, medical treatment options and health information.
So far, Trump-era healthcare changes tend to emphasize individual agency in obtaining both coverage and care. The other main theme might be described most accurately as “undoing Obama’s work.” In late March 2019, the Department of Justice announced that despite an earlier affirmative Supreme Court ruling, the Trump administration believes the whole Affordable Care Act is unconstitutional and should be overturned. Getting rid of the ACA would leave more than 30 million Americans without healthcare coverage and make 133 million other Americans with pre-existing conditions vulnerable to losing their coverage. In the meantime, the ACA remains the law of the land in the United States.
With help from 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: Immediately upon taking office, Trump promised to “repeal and replace” the Affordable Care Act, a goal buoyed by congressional Republicans who’d been trying to defeat the law since its passage. Their 2017 repeal-and-replace effort died when Arizona Sen. John McCain famously voted it “thumbs down.” But according to Trump, Republicans are cooking up a new replacement plan — something “far better than Obamacare” — to be unveiled after the 2020 election.
While the ACA hasn’t been replaced in full, key measures of the law have been dismantled. In late 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 impact: In addition to making some 2019 premiums higher, the individual mandate repeal means fewer insured Americans; the uninsured population has grown by about 7 million people since early 2017, according to a January Gallup report. When those uninsured people need medical care, they’re more likely to rely on emergency departments instead of primary care physicians, 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] is an example of ‘me first; I’m not going to pay my share because it doesn’t benefit my family.’”
The end result, Linden believes, is behavior that undermines what it means to live together in a shared community. “You incur [civic] responsibility by living in a society, and there are certain things we have to do because of that, whether we want to or not.”
Expansion of loosely regulated healthcare plans
In effect? Yes, as of August 2018
The gist: In another move to weaken Obama-era healthcare reforms, the departments of Health and Human Services, Labor and Treasury jointly announced last summer that Americans would have more leeway to enroll in short-term, limited-duration insurance plans, also called 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 restrictive 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 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. But in doing so, Linden says, they drive up the cost of ACA-compliant coverage. 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 availability of these plans not only adversely affects those who buy them, but also the whole insurance pool,” Linden says. “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. This means the cost of healthcare will increase.”
Work requirements for Medicaid
In effect? Sort of. As of early March, the Trump administration has permitted eight states to begin imposing Medicaid work requirements, and seven other states are awaiting approval to start the process. But in late March, a federal judge ruled against the policy in Kentucky and Arkansas, where it first went into effect in June 2018.
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 Centers for Medicaid and Medicare Services (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 in order to keep or apply for Medicaid coverage.
The idea comes from a federal initiative and has been embraced by states with Republican leadership 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 a variety of reasons: Some recipients didn’t know about the requirements due to relocation or lack of a permanent address; others are unable to work on account of disability, chronic illness or logistical barriers like transportation or childcare.
Such 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.
Expect work requirements to remain a hot-button issue.
The Right to Try Act
In effect? Yes, as of May 2018
The gist: The Right to Try Act lets people living with terminal diseases try experimental drugs that have passed through early-stage clinical trials and 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. “That being said, to bypass the FDA is to throw a bomb at the regulatory process, and that is what Trump and the current Republican legislators in the Senate and the House wish to do,” she says. “It’s intended to shatter the regulatory mechanisms that protect consumers and create a framework for prescribing safe and effective therapies. Furthermore, Right to Try runs the risk of exploiting patients at their sickest and most vulnerable.”
Hospital price transparency
In effect? Yes, as of January 2019
The gist: Hospitals are now required by CMS to post an annually updated list of the charges for all of their services, known as a chargemaster. While hospitals have been complying, chargemasters aren’t necessarily helpful to patients. Often the prices are 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 actually pay for a given procedure or doctor’s visit.
The impact: The policy is more gestural than meaningful, so far. “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 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 a number of initiatives that affect healthcare access for a few different groups of Americans. Here are some of them:
- Trump has 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 unclear how funding will be handled.
- The ban on transgender troops, which the Supreme Court voted to approve in early 2019, was denounced by the House in March 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 has spent less than 1 percent of its health budget on trans care since 2016.
- In February 2019, the Trump Administration said it would change the rules for health clinics to receive “Title X” federal funding. The Title X gag rule, as it’s become known, restricts clinics from providing, or even counseling patients about, abortion services. The affected clinics typically serve about 4 million low-income people each year.
If you have strong feelings about any of these proposals, it’s worth contacting your elected representatives to voice your opinion.