Estimates of the effect of the concerted attack on the Affordable Care Act by the Trump administration and congressional Republicans have been theoretical — until now.
A survey published Friday by Gallup and Sharecare, a health information firm, finds that the uninsured rate has risen by 1.4 percentage points since Trump took office, reaching 12.3% in the third quarter of this year. That translates to 3.5 million Americans who have joined the ranks of the uninsured since the end of 2016, when the uninsured rate reached a record low of 10.9%. The uninsured rate peaked above 18% just before the ACA exchanges opened for business in January 2014.
The rise through the third quarter is the first significant reversal in the trend toward a lower uninsured rate since the ACA exchange market came into being.
Gallup conjectures that the increase in the number of uninsured Americans could be caused by several factors. One is that a decline in competition among insurers in some regions could be driving up premium costs, forcing more Americans to go without coverage.
Another is "uncertainty about the healthcare law." Gallup reckons that "congressional Republicans' attempts to replace the healthcare law may be causing consumers to question whether the government will enforce the penalty for not having insurance."
Make no mistake: Those are related phenomena, and they place the blame squarely with Trump and his GOP colleagues on Capitol Hill. One reason that insurance companies have been backing away from the exchanges is that Trump has continually threatened to undermine the law in every way possible. For months he threatened to cancel reimbursements due insurers for cost-sharing reductions they are required by law to offer low-income buyers; he finally followed through on that threat Oct. 12, raising the prospect of billions of dollars in losses for insurers this year.
The GOP's efforts to repeal the Affordable Care Act this year have failed in Congress but have left a miasma of confusion among consumers. The confusion is about more than merely whether the government would enforce the individual mandate, which requires all households to carry health coverage or pay a penalty; it's about whether the exchange plans would even continue to exist, and how much they would cost.
All these factors were entirely within the power of the White House and Congress to address; instead, Trump kept up a steady — and uninformed — rhetorical attack on the law, and Congress made no effort to ensure that it functioned. Republican assertions that the law has been collapsing under its own weight have been thoroughly debunked by objective analysts, including those at the Congressional Budget Office, which has found that the marketplace was stabilizing through 2016 and would have been stable this year, if not for the GOP campaign of sabotage.
These efforts to undermine a valid law that has been twice upheld by the Supreme Court are unprecedented in American history and quite likely unconstitutional, says Abbe Gluck of Yale Law School. "The intentional, multi-pronged sabotage of the ACA that we have seen over the past nine months," she wrote this week, "violates both Trump's constitutional obligations and quite possibly the obligations of his Department of Health and Human Services."
The Constitution imposes a legal obligation on the president to "take care that the laws be faithfully executed," Gluck observes. "That means he must make sure that our laws are implemented in good faith and that he uses his executive discretion reasonably toward that end. … Far from using his power to faithfully implement the ACA, the president is actively using his power to destroy it."
The consequences of these actions are laid out in detail in the Gallup-Sharecare index. Since the end of 2016, the index shows, "the uninsured rate has increased at least one point among all key demographic subgroups" except those 65 and older, who are covered by Medicare.
The largest increases showed up in the 35-64 age group (up 1.8 percentage points), black families (up 1.5 points), Hispanics (up 1.6 points) and households with annual income below $36,000 (up 1.7 points). These groups are the prime targets of the Affordable Care Act, as they're least likely to have access to decent employer-sponsored health coverage and most in need of government assistance to pay for insurance.
The trend may be just starting. Gallup warns, "without Congress and President Donald Trump taking steps to stabilize the insurance markets, the number of uninsured Americans likely will continue to rise."
The signs are grim. Although a bipartisan group of senators is supporting a compromise aimed at restoring the cost-sharing reduction reimbursements Trump canceled, his other efforts to undermine the law are almost certain to affect the open enrollment period for 2018 coverage, which starts Nov. 1. The Trump administration unilaterally truncated the open enrollment window from its previous three months to only six weeks, ending Dec. 15. At the same time, Trump cut the government's outreach and marketing budget by 90%, hamstringing efforts to inform buyers of the tighter deadline.
The compromise reached by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would restore most of that budget, but the deal hasn't been voted on in Congress, Trump hasn't stated for certain that he would sign it and it may already be too late for the marketing campaign to recover.
MORE FROM MICHAEL HILTZIK