How Has Trump Changed Healthcare In America?

At a rally against the effort to repeal the Affordable Care Act last July in New York City

When Senate Democrats managed to block the Republicans’ “skinny repeal” of the Affordable Care Act last year, it was a much-needed win in an otherwise grim political moment for the party out of power. “This bill,” Senator Chris Murphy of Connecticut warned, at the time “will light the American health-care system on fire, with intentionality.”

“We are not celebrating,” Senate Minority Leader Charles Schumer said after the close call, “We are relieved.”

Though the Republicans have largely stopped campaigning on health care, President Donald Trump remains adamant in persuing Obamacare's demise, and his administration has found ways to unravel parts of the Affordable Care Act without permission from Congress. This summer, in West Virginia, Trump assured the crowd that the Affordable Care Act "is being chipped away."

Has Trump succeeded?

This week on 30 Issues In 30 Days, The Brian Lehrer Show looks at ten ways Trump and his Republican Congress have changed America through policy, with a series of debates asking - for better or for worse?

Here’s some of how the Trump administration has changed the healthcare market since he’s been in office.

Trump killed the individual mandate

As part of the Republican tax overhaul bill passed in late 2017, Congress did effectively end the individual mandate, which required nearly all Americans to have health insurance or pay a penalty. Trump called the mandate “cruel” and criticized the provision for targeting poor people who couldn’t afford to pay for “government ordered health plans.”

The individual mandate never performed its intended effect, argues Robert Moffit, senior fellow in The Heritage Foundation's Center for Health Policy Studies. "It was never a really serious driver of expanded health insurance coverage,” Moffit told Brian Lehrer on Monday. “Subsidies drive enrollment. The Mandate was a laughably weak tax penalty that neither political party would ever enforce, and when it was imposed, as was reported, it was imposed on lower income individuals.”

Moffit added, “If the mandate was really consequential, how do you explain the decline of enrollment, when the penalty was at its highest in 2016?”

“The individual mandate was an important part of the Affordable Care Act,” counters Heather Howard, a Lecturer at Princeton University’s Woodrow Wilson School of Public and International Affairs and former New Jersey Commissioner of Health and Senior Services. “It’s important to bring young and healthy people in the insurance market because health insurance is about spreading risk broadly. We don't know what impact the repeal will have, but the Congressional Budget Office did estimate that they thought it would both add to the number of people who are uninsured and increase prices for the people who are still buying health insurance.”

Trump extended short term policies’ allowable length to three years

Under the Obama administration, consumers could buy short-term policies—that did not have to comply with Affordable Care Act standards—as a stopgap measure until they found longer lasting insurance. In August the Trump Administration issued a final rule, allowing agencies to expand the availability of short-term health insurance policies beyond the Obama-era three month limit to three years. Trump says plans will provide “much less expensive health care at a much lower price.”

“Expanding these plans will end up luring young and healthy people because they're cheaper because—guess why?—they’re not covering a lot of conditions,” said Howard. “The majority of short-term plans don't cover things like hospitalization and maternity care. Young people end up opting into these policies because they're attractive but they don't end up meeting their needs, and protecting them. Older and sicker people are left remaining in the Obamacare-compliant plans and those plans will get more and more expensive.”

Moffit’s response: “The standard progressive line is: we know what is best for people rather than what they think is best for themselves. These plans provide a perfectly legal off ramp for lots of Americans who do not want or do not like, or simply cannot afford The Affordable Care Act.”

Trump allowed states to impose work requirements on Medicaid recipients

President Trump gave states more control over their Medicaid programs by authorizing states to impose "work requirements" to qualify for benefits. In June, Arkansas became the first state to impose these rules. Now Arkansas residents must work, go to school or volunteer for at least 80 hours a month, in order to receive healthcare. CNN reports that since the change went into effect as many as 4,600 recipients have lost their benefits.

Three consumer groups are suing the Trump administration in an effort to halt the Arkansas program, arguing that it runs counter to Medicaid’s objective of providing the poor with access to health care.

Arkansas Governor, Republican Asa Hutchinson, approves: "Personal responsibility is important. We will continue to do everything we can to ensure those who qualify for the program keep their coverage, but we will also make sure those who no longer qualify are removed." The Trump administration has also approved requests to implement work requirements in Indiana and New Hampshire, though the new rules have yet to take effect in those states.

Trump’s “American Patients First Plan”

The Trump Administration has a set of proposals called the American Patients First Plan, that includes putting pressure on companies known as “pharmacy benefits managers” that take a “middleman” profit for themselves between the pharmaceutical company, health insurance company, and the patient. The biggest point of contention isn’t what’s in the plan, but what it leaves out: allowing Medicare to negotiate with drug companies.

“This plan is just nibbling around the edges,” says Howard. “Allowing Medicare to negotiate would be fundamental” to lowering drug costs. Medicare has tens of millions of patients, meaning really good clout in the marketplace with the drug companies. Other countries do it with their public health care systems, resulting in lower prices.

Edmund Haislmaier, a health care policy expert at the Heritage Foundation, argues that some of those countries that drive a hard bargain wind up with some good medications being unavailable altogether because the drug companies won’t agree to the price demands and the government walks away.

The Trump Administration says it likes state-level experimentation more than federal government mandates. But while they’re allowing states to experiment now with requiring work for Medicaid benefits, they have turned down a request by Massachusetts to allow just that one state to allow Medicare to negotiate prices with Big Pharma.

Coming up in 30 Issues, Brian hosts debates on how Trump has affected trade, taxes, immigration, the environment and more.