ARI SHAPIRO, HOST:
Now that the Republican health care bill is dead, President Trump says his plan is to let Obamacare explode. There are lots of ways his administration can chip away at the Affordable Care Act, which is the official name for Obamacare.
Sarah Kliff covers health policy for vox.com. And she has made a list of things the administration could do by itself to undermine the system.
Welcome to the program.
SARAH KLIFF: Thanks for having me.
SHAPIRO: First, is the Affordable Care Act already exploding, or does it require Republicans taking steps to make the system fail?
KLIFF: I don't think it's exploding. It's not performing as well as Democrats would like. It certainly has its problems. But it is working. It's covering about 20 million people. But there are certainly policy decisions the Trump administration will need to make that will really determine if it goes into explosion mode like Trump is predicting.
SHAPIRO: You've listed more than a dozen policy decisions the administration can or will have to make. In your opinion, what would be the single most consequential one that could undermine the Affordable Care Act?
KLIFF: So right now there is this lawsuit pending over Obamacare's cost-sharing reductions. These are payment to insurance companies to offset the co-pays and deductibles for especially low-income Obamacare enrollees. The...
SHAPIRO: You're talking about people who don't make a lot of money, who get coverage under the insurance exchanges, get basically underwritten by the government.
KLIFF: Exactly. So these are people who earn maybe $20,000 or so a year. And if the co-pay is normally $10, they might pay a $3 co-pay because the government is paying the other $7.
There is a lawsuit right now brought by House Republicans saying that these cost-sharing reductions are illegal. The biggest thing the Trump administration could do right now to undermine the Affordable Care Act is just stop defending the lawsuit, to say, we agree with House Republicans; they're illegal. And that would wipe out a $7 billion fund that provides these cost-sharing reductions to low-income Americans.
SHAPIRO: You write that the Trump administration could stop enforcing the individual mandate, the requirement that everybody have health insurance. Didn't President Trump sign an executive order basically saying this when he first took office?
KLIFF: Not exactly. So he did sign an executive order that told the whole Trump administration to get rid of whatever regulations, whatever mandates you can. Just try and cut them out.
The hard thing about the individual mandate is it's part of the Affordable Care Act. You can't really get rid of it entirely through regulation. But what the Trump administration can do is essentially change the rules around the individual mandate.
They could say, the fine seems to be too onerous, so we are going to scale it back this year, or we're going to create more exemptions from the mandates so fewer people have to pay.
So they do want to get rid of the mandate. But what they need to do next if they're going to do that is write the rules around the mandate and essentially clarify if they're going to enforce it or not.
SHAPIRO: Also on this list of ways the Trump administration could undermine the Affordable Care Act, there has been a lot of debate about essential health benefits. Those are 10 categories of services that insurers must cover under the Affordable Care Act, like maternity or pediatric care. What would it look like if the Trump administration decided to narrow the definition of these services?
KLIFF: So you would have much skimpier health insurance plans. Things like you mentioned, Ari, maternity care, for example, used to not be covered in most individual market plans. The Trump administration is a little bit restricted on how much it can do on the essential health benefits here. They're actually written into law. So in the Affordable Care Act, it says that all insurance plans must cover maternity care, these other sets of 9 benefits.
But we're waiting to see right now, do they think there are things they can do through regulation to narrow that down or narrow down within maternity care - for example, what counts as covering maternity care? - or turn more of a blind eye towards health insurance plans that aren't covering those benefits.
SHAPIRO: Can you give us an example of, for example, if they scaled back maternity care, what that might look like?
KLIFF: Yeah, so they might take out, like, certain prenatal benefits, for example. Or they might try and target certain services related to breastfeeding after birth. So right now we don't really know. We haven't seen a proposal from the Trump administration.
But what they could do is say that fewer services count as coverage, essentially, to say, you know, as long as you're covering the actual delivery, that counts as maternity care. And we won't make you cover all the rest of the things associated with the pregnancy.
SHAPIRO: If we imagine the Trump administration doing everything within its power to undermine the Affordable Care Act, how significant will the likely impact be? Could the administration basically make Obamacare fail by implementing all these changes?
KLIFF: I think so. If they put them all together, if we take together, for example, not defending the cost-sharing subsidies, not advertising the marketplaces, scaling back the essential health benefits however they can through regulation, not trying to get more insurers into the market, I think you would definitely see some marketplaces collapse.
One of the things that's important to remember about Obamacare is it really varies a lot state by state. You have states like California that has a very active board running its marketplace. They'll be fine. They will make this work because they want to make it work. But you have big, rural states, like Alaska and Tennessee and a lot of states in the South, that could teeter into collapse if you make the policy decisions that are generally going to decrease enrollment and make insurance companies less excited to be part of the marketplace.
SHAPIRO: Sarah Kliff is senior policy correspondent at Vox. Thanks for joining us.
KLIFF: Thank you. Transcript provided by NPR, Copyright NPR.
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