As it works to roll back the Affordable Care Act, the Trump administration is letting crucial state health initiatives languish, frustrating a growing number of state leaders, including several from solidly Republican states.
Last week, Oklahoma's health secretary sent a blistering letter to senior administration officials, taking them to task for failing to approve a plan state officials drew up to protect their consumers from large rate hikes.
"The lack of timely waiver approval will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums," Terry Cline wrote to Treasury Secretary Steven T. Mnuchin and then-Secretary of Health and Human Services Tom Price.
Health officials in other states say the federal health agency for months provided little help as they tried to plan for the expiration of federal funding for the popular Children's Health Insurance Program, or CHIP. Money for the program, which covers nearly 9 million children, has begun to lapse because Congress failed to hit a deadline of Sept. 30 to renew the program, something lawmakers still hope to accomplish this year.
As the Sept. 30 deadline neared, the Trump administration was working to support Republican attempts in the Senate to roll back the current healthcare law, often called Obamacare.
"It was very hard to get answers to our questions," said Cathy Caldwell, who oversees the CHIP program in Alabama and, like many state officials, is scrambling to figure out when they must begin cutting children from CHIP coverage.
The federal healthcare agency did not respond to a request for explanations of its actions or response to the criticism.
Meanwhile, across the country — in red states and blue alike — there are growing questions about how the administration is running complex government health programs that serve tens of millions of Americans.
"There's a problem here," said Virginia Health and Human Resources Secretary William Hazel. "It may be deliberate sabotage at the very top. … But basic capacity seems to be an issue as well," he said, noting vacancies and competing demands at the federal agency. Hazel, who currently serves a Democratic administration, was appointed by a Republican governor.
Minnesota's human services secretary, Emily Piper, who oversees that state's healthcare programs, said it has been hard to discern whether politics are driving all the problems, but the effect is the same.
"Basic services that we expect the federal government to provide are suffering," she said.
Many healthcare programs that Americans rely on — such as CHIP, Medicaid and, in some cases, state insurance marketplaces created by the 2010 Affordable Care Act — are run by state governments, but funded and overseen by the U.S. Department of Health and Human Services.
That division of power has historically led to disputes between state and federal leaders.
The Trump administration has fueled additional tensions with its enthusiastic advocacy for Republican congressional efforts not only to repeal the current healthcare law but to dramatically cut other federal health programs as well. Senior staff at the Department of Health and Human Services have been working all year to support the repeal campaign.
At the same time, the administration has further aggravated many states with actions that are driving up insurance premiums and destabilizing markets, according to insurers, state regulators and consumer advocates.
For example, President Trump has repeatedly threatened to stop making federal payments to health insurers that offset the cost of covering out-of-pocket medical expenses for low-income consumers.
Insurers across the country have cited uncertainty over these payments as a leading cause for big 2018 premium increases.
Over the summer, the administration also announced plans to dramatically scale back advertising and outreach efforts designed to get people signed up for insurance coverage in 2018, saying much of that work had proved ineffective in the past.
An aggressive enrollment campaign is widely considered key to getting younger, healthier Americans into the insurance market and controlling premiums.
In the face of the Trump administration's retreat, many states have intensified their own efforts to stabilize insurance markets and help consumers.
California, which operates its own insurance marketplace, has committed $100 million to a marketing and outreach campaign and developed a new system to shield some consumers from big rate hikes.
Peter Lee, who heads Covered California, said the Trump administration has generally not interfered in the state's marketplace.
But other states that have looked to the administration for assistance have been disappointed.
Oklahoma, for example, proposed a plan earlier this year to control insurance premiums for its residents, who were facing increases of 30% or more next year.
After months of discussions in which state officials said the Trump administration assured them approval would be coming, the administration took no action, letting a crucial deadline pass and ensuring that health insurers would pass along major rate hikes to consumers next year.
"It was very frustrating," said Julie Cox-Kain, Oklahoma's deputy health and human services secretary.
States looking for guidance over the summer about how to prepare for the expiration of federal funding for CHIP were similarly let down, according to multiple officials.
Several said they felt that their warnings about the need for action well before the Sept. 30 deadline were being ignored by federal officials.
"It's been a budgeting nightmare," said Caldwell, the Alabama CHIP official. "And it is very stressful for families."
Most states have enough money in reserve to continue CHIP coverage for weeks if not months, but all need several months of lead time to plan for freezing enrollment or cutting coverage should that become necessary.
In the past, administrations have helped states prepare for that possibility with written guidance about how to make preparations.
But for months, the Trump administration refused to provide states with anything in writing, Caldwell said.
More recently, as the CHIP deadline passed and state pleas intensified, federal officials began offering more assistance, several state officials said. Caldwell said she finally got critical information about how much federal funding was still available to Alabama.
Minnesota, which has few reserve funds in its CHIP program, this week received additional federal money to help tide it over until Congress reauthorizes the CHIP money.
But Piper, the Minnesota human services secretary, said she's still not convinced that the Trump administration is pushing Congress to quickly renew the program.
"I have never received any assurances that this is a priority for them," she said.