With the failure by Republicans in Congress to repeal Obamacare this year, President Trump took matters into his own hands this fall, signing an executive order in October that targets the health care law.
Trump asked federal agencies to look for ways to expand the use of association health plans, groups of small businesses that pool together to buy health insurance, and to broaden the definition of short-term insurance, which is exempt from the Affordable Care Act's rules, administration officials said.
The ultimate impact will depend on any new regulations written as a result of the order, but overall, the Trump administration could make cheaper plans with skimpier benefits more available — and experts worry that will damage the ACA's marketplaces.
"The president still firmly believes that Congress must act to repeal and replace Obamacare, but before that can be done, this administration must act to provide relief," Andrew Bremberg, who oversees domestic policy at the White House, told reporters earlier this year. "We expect these policy changes to potentially benefit tens of millions of Americans over time."
During an impromptu end-of-the-year interview with the New York Times, Trump touted the expanasion of these association health plans and the repeal of Obamacare's individual mandate in the Republican tax bill as his big wins against the health care law in 2017.
"We've created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn't have insurance. Or didn't have health care. Millions of people," he told the Times. "That's gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that's a big thing."
The president is surely overstating the impact of his executive order, which hasn't actually changed anything yet. But policy experts warn that together, these changes could represent a serious threat to Obamacare: Trump wants to open more loopholes for more people to buy insurance outside the health care law's markets, which experts anticipate would destabilize the market for customers who are left behind with higher premiums and fewer insurers.
The fear is that Trump's action could lead to many association health plans being exempted from core Obamacare requirements like the coverage of certain essential health benefits. It could also potentially allow some individuals to join these plans too, which could hurt the individual insurance marketplaces by drawing younger and healthier people away from them. In much the same way, short-term insurance could also take healthier people out of the law's markets.
The effect won't be immediate: Administration officials said they didn't expect any new regulations to be implemented before the end of the year. But Trump's order does present a long-term risk to the ACA.
"The clear intent of the executive order is to create a parallel insurance market exempt from many of the consumer protections in the Affordable Care Act," Larry Levitt at the Kaiser Family Foundation told me. "This has the potential to siphon off healthy people with skinnier benefits and cheaper premiums, leaving behind a sicker pool of people under ACA plans."