Trumpcare, defined as the current administration's effort to undo every achievement of the Affordable Care Act it can get its paws on, is going from strength to strength.
The latest readings of its accomplishments come from the Commonwealth Fund, a healthcare advocacy think tank, and Tom Price, who was drummed out of his job as Trump's first secretary of Health and Human Services over his predilection for luxury charter flights when commercial flights would do just as well.
The Commonwealth Fund reported Tuesday that the administration's concerted attack on the ACA has driven the uninsured rate among working-age people (those aged 19 to 64) to 15.5%, up from 12.7% in 2016. That translates into lost coverage for 4 million Americans.
The fund's analytical team, led by Sara R. Collins, also projected that the zeroing out of the individual mandate penalty, a charge levied on those who fail to carry health coverage, will prompt 5% of currently insured individuals to drop their coverage. The penalty was eliminated as of 2019 by the Republican tax cut bill enacted in December.
That projection matches the expectations of Price. Eliminating the penalty "actually will harm the pool in the exchange market," he told a healthcare conference in Washington on Tuesday, according to the Washington Times, "because you'll likely have individuals who are younger and healthier not participating in that market, and consequently that drives up the cost for other folks within that market."
This falls in to the category of saying the quiet parts out loud. Price, who demonstrated unexampled hostility to the ACA while in office, advocated eliminating the individual mandate because he claimed it served no purpose.
During his time as Health and Human Services secretary, Price presided over the initial steps in the Trump attack on the Affordable Care Act and its beneficiaries. These steps included a drastic cutback in advertising and marketing just as the 2017 enrollment period was wrapping up — a time when a is especially effective at getting last-minute holdouts to sign up for coverage — and a contraction in the open enrollment period to six weeks from three months for exchanges managed by the federal government through its healthcare.gov website.
"It's hard to know exactly what is driving the increase" in the uninsured rate, Collins told me, "but those are some likely factors." She also argued that "the nine-month effort last year to repeal and replace the Affordable Care Act also created some confusion about the status of the law."
Collins cautioned that Commonwealth's survey is small, drawn from a sample of 2,403 people including 638 with individual market, marketplace or Medicaid coverage. The margin of error is +/– 2.8 percentage points. But its findings are consistent with other surveys, including a Gallup poll that found the uninsured rate rising to 12.2% in December from 10.9% in November 2016, after Trump's election.
Collins said we should expect "a gradual erosion over time" in ACA enrollment "unless measures are taken by Congress."
The measures that would restore growth in the ranks of the insured aren't a mystery. They include increasing federal premium subsidies for middle- and working-class households and implementing the law's Medicaid expansion, which serves the lowest-income families, in the 18 states that haven't done so yet.
The assault on the Affordable Care Act at the federal level has prompted many states to take matters into their own hands. California, among other states, has taken steps to retain the incentives and consumer protections being eaten away by the administration initiatives.
Those efforts are a mixed bag, however. Voter initiatives aimed at forcing expansion are expected to appear on the ballots of Utah and several other red states this November. But some would create a more limited expansion than the ACA's provision. In Maine, where voters enacted expansion last year, Gov. Paul LePage was sued by healthcare advocates Tuesday for refusing to implement the expansion despite the vote.
Other states have sought federal approval for restrictive versions of Medicaid expansion, including features such as premium charges and work requirements.
Collins believes that despite the Trump administration's attacks, the Affordable Care Act marketplace will remain viable, largely due to the survival of premium subsidies, which immunize most ACA households from the run-up in gross premiums caused by federal policies. "It's not as if we're going to see a collapse of the individual market. But it's likely we'll see the market at a lower equilibrium."