The Washington PostDemocracy Dies in Darkness

Trump is trying to decimate Obamacare. But that has proved hard to do.

President Trump's health-care actions could have ripple effects throughout the Affordable Care Act's marketplaces. (Video: Jenny Starrs/The Washington Post, Photo: Jabin Botsford/The Washington Post)

Since Congress ultimately decided to keep Obamacare intact last year, President Trump been trying to dismantle the law himself.

In recent weeks, his administration slashed funding to help people sign up for health insurance this fall and halted billions of dollars of payments that help make insuring sicker people viable for insurance companies. On Wednesday, the Trump administration opened up skimpy health plans that don't meet the Affordable Care Act's coverage standards to more Americans. And those are the actions he's taken just this summer.

“Obamacare is largely gone now,” Trump bragged in June.

But despite all Trump's efforts to destroy Obamacare, health policy experts say he hasn't and probably can't end the law on his own.

That's because although Trump can make life harder for insurers, he doesn't have the tools to unilaterally dismantle a law that the health insurance community has already folded into its practice.

“There are little nips around the edges, but basically the market seems to be doing okay,” said Alice Rivlin, the former head of the nonpartisan Congressional Budget Office and a health policy expert with Brookings Institution.

Let's break down what Trump has done to the law and how it has survived his efforts. His actions are ranked in order of what has been least damaging to the ACA to what could be most damaging.

5. His administration slashed funding to help people sign up for Obamacare: Remember those “navigators”? Every enrollment season, they try to guide uninsured people from a variety of backgrounds to use the online marketplace to directly purchase health insurance. In July, the Trump administration announced it was cutting most of the funding for these outreach coordinators for the fall enrollment season.

That could have been severely detrimental to the ACA a few years ago, Rivlin said. But it's possible navigators are less vital to the law's success five years in, especially since insurance companies now have brokers to help enroll people. Community-based organizations also help out.

4. It has approved plans that fall short of ACA coverage requirements: In chipping away at Obamacare, the Trump administration seems to have a driving principle, said Rivlin: to give people access to cheaper health plans that cover less.

That's the opposite of the primary goal of the ACA, which set essential benefits all insurance plans have to cover, like prenatal care. Over the past year or so, the Trump administration has allowed small businesses and self-employed people to purchase health plans that don't cover all those benefits. On Wednesday, it expanded the temporary plans allowed by the ACA from three to 12 months. That means Americans can go a full year skirting ACA regulations if they want to.

But states still regulate insurance markets, so many states can and have decided not to allow these skinnier health plans to be sold, Rivlin said.

3. It ended subsidies to help insure lower-income people: About 7 million lower-income people get health insurance via the ACA exchanges. And the ACA helped them afford deductibles by subsidizing their cost to insurance companies. Trump ended these payments in October, a blow to Obamacare that “could have sunk the whole thing,” said Paul Ginsburg, a health policy expert with the University of Southern California's Brookings Schaeffer Initiative.

That meant insurance companies will continue to have to insure lower-income people but aren't getting subsidies to do it. Congress even tried to step in with a bipartisan deal to save these payments. (It didn't get traction.)

But many states neutralized this burden to insurers by allowing them to increase rates for other plans. It gets wonky, but the end result, Ginsburg said, is that ending the cost-sharing subsidies has cost the government money but has not destabilized insurance markets as much as people had feared.

2. It recently stopped billions of dollars of payments that help insurance companies afford sicker people: The Trump administration last month halted these payments to insurers, which help cover people who have expensive medical services. Like ending the subsidies for lower-income people, this could be disastrous to the insurance marketplace since insurers rely on this money. The Washington Post's Amy Goldstein reports the health insurance industry doesn't want these payments to end.

What happens next could be determined by a court case in New Mexico, which recently ruled against the payments. That's the justification the Trump administration used to stop them at least temporarily. If these payments don't start back up, it could seriously destabilize insurers that rely on them.

“If this is not resolved very quickly,” Ginsburg said, “it clearly will be disruptive, because there is a lot of money involved.”

1. It has ended the requirement that people have to be insured or face a fine: This is the biggest kick in the knees to Obamacare, and notably, Trump didn't do it alone.

A Republican-controlled Congress passed a tax bill in December that also essentially ended the individual mandate, a central tenet of the ACA. That means that starting next year, people don't have to choose between paying for insurance or paying a fine for going uninsured. They won't be punished in their taxes for being uninsured.

The fear among health insurers is that healthier people will leave their plans, and insurers will be stuck insuring sick people — with less in subsidies from the federal government to cover those sick people.

Ending the individual mandate could be the most damaging thing Trump and Republicans have done to Obamacare, but it's hard to know for sure, Rivlin said. It depends how many people decide not to get health insurance next year because they don't have to.

But at the end of the day, the ACA is still a law guiding insurance marketplaces and people's health insurance decisions. The exchanges it set up for insurance companies to sell insurance directly to consumers are still running. Medicaid expansion — the largest aspect of Obamacare — continues to give millions of people insurance.

“The things that the Trump administration has done or threatened to do are anxiety producing,” Rivlin said, “but they seem not to have discouraged people from enrolling.”