Donald Trump has spent much of his first year in office trying to sabotage the American health-care system. These acts of administrative vandalism have been about as subtle as the president’s taste in décor. In interviews with major publications, Trump repeatedly threatened to destabilize the Obamacare marketplaces — by abruptly halting subsidies to insurers — as a means of eroding popular support for the law. His Health Department took taxpayer funds that it was supposed to spend on advertisements encouraging people to enroll in the Affordable Care Act and spent them on ads encouraging the public to support the law’s repeal. His administration signaled that it might not enforce the tax penalty for refusing to sign up for insurance. And, in recent weeks, the White House slashed Obamacare’s advertising budget by 90 percent, while cutting funding for the law’s outreach groups.
Now, that decimated outreach budget seems to have disappeared entirely. As Vox’s Sarah Kliff reports:
The government had previously announced it would cut the budget for Obamacare’s navigator program by 41 percent. But right now, the program has no funding at all. Last year’s grants ran out on September 1, and the administration still has not awarded next year’s money.
The sudden funding halt comes at a critical time for the Affordable Care Act. Navigator groups were just beginning to ramp up outreach for the health law’s open enrollment period, which begins November 1 …
… These groups often work with the most vulnerable populations enrolled under the Affordable Care Act. One-third of those who seek in-person help signing up for coverage do not have internet at home, and one in 10 do not speak English.
Navigator organizations say the administration has not made clear when the 2018 funding will arrive, although it could be as late as September 30. Health and Human Services, which oversees the program, has said that this funding will not be retroactive, meaning there may be no budget for activities this month, according to three navigators who have spoken with officials there.
Even before this latest act of subversion, Trump’s extended campaign of sabotage had already generated a minor crisis.
Under Obamacare, participating insurers are required to keep deductibles and co-payments affordable for low-income people. In practice, this means that insurers must under-price the risk of covering such individuals, and, thus, accept a financial loss. To make that proposition more appealing to these for-profit companies, Obamacare provides them with “cost-sharing reductions” — subsidies that defray the insurers’ losses. These are the subsidies that Trump has threatened to unilaterally withdraw (an act that is within his authority for complicated reasons related to a lawsuit that House Republicans brought against the Obama administration). Insurers sought assurances from the White House that Trump’s threats were mere bluster. The White House provided no such thing.
In response, many insurers have proceeded on the assumption that the subsidies will be canceled, and thus, that the costs of participating in Obamacare will soar. Which is to say: They have pulled out of the law’s exchanges, or else prepared to raise premiums high enough to offset the costs of covering low-income enrollees without Uncle Sam’s help.
Now, if Congress does not make those cost-sharing reductions sabotage-proof by the end of this month, premiums are expected to rise by double digits next year.
And Trump’s other acts of sabotage could drive that price spike even higher. Sick people will seek out health insurance, whether or not they’re exposed to advertising that encourages them to do so. But many healthy people will not. And the fewer healthy people participate in the exchanges, the more expensive it will be for insurers to provide coverage through them — and, thus, the higher they will raise their premiums.
All of which raises the question: What do these saboteurs think they’re accomplishing?
Trying to engineer Obamacare’s collapse — so as to create political momentum for a replacement bill that the public otherwise wouldn’t want — was evil and ill-advised. But that strategy was, at least, logically coherent.
Republicans were struggling to convince the public that their plan to keep all of Obamacare’s bureaucratic complexity — while reducing the generosity of its subsidies and ending Medicaid as we’ve known it — represented an improvement on the status quo. So, they argued that the status quo wasn’t an option. Obamacare was “collapsing,” “on its last legs,” and in “a death spiral.” To the extent that Trump could lend credibility to these claims through sabotage, such betrayals of the public trust made some tactical sense.
But now, Trumpcare is dead. Congressional Republicans know that it is dead — and so does Donald Trump. At this point, sabotaging Obamacare doesn’t create momentum for a legislative victory; it merely increases the likelihood that our health-care system will work conspicuously worse under a Republican president than it did under a Democratic one. All available polling suggests that most voters will blame Trump for any problems with Obamacare, going forward. Which makes sense: Historically, the public holds the president — and his party — accountable for virtually everything bad that happens on his watch. A large spike in premiums at the start of a midterm election year is in no one’s immediate interest — except, perhaps, for Nancy Pelosi’s.
So why don’t the Obamacare navigators have a budget right now?
The most plausible answer is that undermining the ACA remains in the long-term interests of the conservative movement. Obamacare was the largest expansion of the welfare state in decades. And for all its shortcomings and travails, the law has already popularized the idea that the government has a responsibility to guarantee affordable health care for all. Many Republicans (including the president) recognized that there was little electoral gain in rejecting this premise, so they attacked Obamacare for failing to live up to the progressive ideal. This left them ill-equipped to defend legislation that pushed their true agenda — throwing millions of people off of health insurance so as to finance tax cuts for millionaires.
Having failed to discredit the ideal of universal health care on the campaign trail or in Congress, conservatives can still try to undermine its viability by making Obamacare work as poorly as possible. Such an endeavor would do little to advance the political fortunes of Donald Trump and congressional Republicans. But one could say the same for their attempt to replace Obamacare with a more austere program, in the first place. In both instances, the ideological project of the party’s libertarian donor class is given precedence over the party’s near-term electoral incentives.
Many within the Trump administration are invested in that project, including Health Secretary Tom Price and budget director Mick Mulvaney. But Donald Trump most certainly isn’t. This president cares about winning favorable press coverage, not a decades-long struggle against “collectivism.” When his advisers encourage him to undermine Obamacare, they are encouraging him to put their interests ahead of his own — a point Chuck and Nancy would do well to make, the next time they drop by the Oval Office for a chat.
