The event Wednesday on an airport tarmac in Cincinnati was just the latest opportunity for the White House to disparage and undercut a law it officially must carry out.
Standing in front of Air Force One along with two small-business owners, President Trump recounted how they “have had their lives completely upended by the disaster known as Obamacare.”
One saw her choice of doctors shrink while her premiums and out-of-pocket costs rose, he said. The other has curtailed new investments in his company to maintain employees’ health benefits.
“The coverage is horrendous,” the president declared, ticking off insurers’ recent decisions to pull out of federal marketplaces in Ohio, Kentucky and elsewhere. “Obamacare is in a total death spiral. The problems will only get worse if Congress fails to act.”
Both the gathering and Trump’s remarks represent officials’ strategy to convince Americans that the collapse of the Affordable Care Act is inevitable and to bolster public and congressional support for a GOP overhaul. Since the day he was inaugurated, Trump has taken steps to erode the law, including instructing his deputies to ease up on ACA regulations and curtailing consumer outreach during the final days of health plan enrollment for 2017.
“The best thing politically is to let Obamacare explode,” he told The Washington Post in March. On Wednesday, he declared it “dead.”
But behind the scenes, the increasing fragility of the law’s insurance marketplaces has created an increasingly difficult predicament for the president’s top advisers.
The issue is whether to take steps to allay the concerns of skittish insurers, some of which are either increasing rates or pulling out altogether, or let things deteriorate further — even at the risk of being blamed. The advisers are split, according to several people briefed on the deliberations: Vice President Pence and Office of Management and Budget Director Mick Mulvaney have argued against intervention, while Health and Human Services Secretary Tom Price backs providing federal support if a conservative health-care bill fails to pass this summer.
For the moment, the administration has defaulted to a position of doing little to try to soothe the health insurance industry, even as many insurers warn that federal action — or inaction — could aggravate the situation. Some suggest that the White House’s relentless naysaying is not reflecting marketplace problems as much as driving them.
“We’re in this very strange situation where the agency in charge of stewarding the law is very openly working to undermine that law,” said Caitlin Morris, director of affordability initiatives at Families USA, a pro-ACA consumer group.
“Sabotage is the operative word,” Sen. Richard Blumenthal (D-Conn.) said last month.
The biggest source of industry anxiety right now is whether the administration and Congress will continue to fund cost-sharing subsidies that help 7 million Americans with ACA plans afford deductibles and copays. House Republicans challenged the legality of the $7 billion in subsidies when Barack Obama was president, and the case is still on appeal.
“Absent that funding, I don’t know if we’re going to have much participation in the exchange market in 2018,” said Tennessee insurance commissioner Julie Mix McPeak, a Republican who also serves as president-elect of the National Association of Insurance Commissioners.
The uncertainty is one of the top reasons insurers have cited when explaining why they are posting higher rates for the next year or withdrawing from markets outright. Two weeks ago, Blue Cross Blue Shield of North Carolina filed a rate increase of 22.9 percent that it said would have been 8.8 percent if the administration had committed to paying cost-sharing subsidies. Last week, Blue Cross Blue Shield of Nebraska announced that it would not offer ACA-compliant bronze and catastrophic plans next year, leaving the state with just one insurer on the exchange there.
And on Tuesday, Anthem Blue Cross Blue Shield announced that it was pulling out of the federal exchange in Ohio, meaning that at least 20 of the state’s 88 counties will lack an insurer.
“We have to take a snapshot in time, which is right now,” Blue Cross Blue Shield of North Carolina chief executive Brad Wilson said in an interview. A “lack of action” by the administration, he added, “yields a result we are currently seeing — higher premiums rather than lower premiums.”
State insurance commissioners, Democrats and Republicans alike, are searching for ways to help companies cope with the unpredictability so that they stay put for 2018. Their anxiety is especially acute this spring, since the administration’s drumbeat coincides with the time frame in which insurers must make their decisions.
While the White House tries to prod the Senate into speedy passage of health-care legislation, it simultaneously is using each new revelation about the law’s marketplaces — through which more than 12 million Americans signed up for health coverage this year — to amplify its negative message.
Late last month, HHS issued a study finding that average individual market premiums have more than doubled since 2013. On Friday, a department news release declared, “Today’s front page of the Omaha World Herald spells out the latest bad news for Obamacare.”
Anthem’s withdrawal announcement was immediately highlighted, with White House press secretary Sean Spicer saying it would leave “19,000 Ohioans without any options” — though the state said the move would affect 10,500 consumers.
A short time later, HHS spokeswoman Alleigh Marré called the insurer’s decision “a stark reminder that Obamacare is collapsing.” Less than an hour later, HHS sent a news release touting the request by Minuteman Health in New Hampshire to raise premiums 30 percent next year for its ACA customers.
The vice president has held at least three events since the weekend to spotlight the law’s flaws. On Wednesday, he met on Air Force Two with cancer survivor Traci Lewis, a Houston resident who said that her out-of-pocket costs had become unaffordable under Obamacare.
Administrative actions have been weakening the law for months. Trump signed an executive order within hours of taking office that directed federal agencies to ease regulatory burdens created by the ACA; later, the Internal Revenue Service said it was going to send taxpayers their refunds even if they failed to send proof that they were insured.
Such diminished enforcement, predicted CareFirst BlueCross BlueShield as it filed its rates in Maryland last month, “will have the same impact as repeal” and lead to fewer healthier people enrolling in coverage. “Based on industry and government estimates as well as actuarial judgment, we have projected that this will cause morbidity to increase by an additional 20 percent,” the insurer said.
Washington state’s insurance commissioner, Mike Kreidler, a Democrat and former state legislator, called the move “the shot across the bow.”
Experts note that many consumers on the independent insurance market had struggled to find affordable plans long before Trump took office.
Robert Laszewski, president and chief executive of the consulting firm Health Policy and Strategy Associates, said that even the cheapest unsubsidized plan on North Carolina’s exchange costs a family of four in Charlotte $1,414 a month, plus a $14,300 annual deductible.
“The question is, was Obamacare unstable in the first place and is Trump in the process of wrecking it?” Laszewski asked. “And the answer is yes.”
White House legislative affairs director Marc Short said in an interview that while no final decision has been made on the cost-sharing subsidies, the president “has been clear that in many cases, he views this as a bailout to insurers.”
Some Republicans are urging caution. Rep. Tom Cole (R-Okla.), who chairs the House Appropriations Committee’s subcommittee on labor, health and human services, education and related agencies, said Monday that the administration should continue to provide the subsidies until a new law is in place and there has been sufficient time for a transition.
“I don’t see how you justify making things worse for people in the system, based on some philosophical argument,” said Cole, who has talked with officials on both sides of the debate. Cutting off the cost-sharing subsidies “would totally destroy the market.”
A recent Washington Post-ABC News poll found that more than three-quarters of Americans say Trump should try to make the existing law work as well as possible. Just 13 percent, by contrast, say the president should try to make it fail as soon as possible.
Though Trump has been vocal in his support for the House GOP’s American Health Care Act, which would rewrite key parts of the ACA, his recent tweets have been more difficult to decipher.
In one, he claimed to have suggested “that we add more dollars to Healthcare” to make it “the best anywhere,” a statement at odds with his administration’s budget proposal for big spending cuts.
A health policy expert close to the administration, who spoke on the condition of anonymity to discuss internal deliberations, said the president and his aides were still working out how to proceed.
“There isn’t even a strategy that they’re failing to follow up on,” the expert said. “There just isn’t a strategy.”
Amy Goldstein contributed to this report.