Nation/World

Trump’s choice on Obamacare: Sabotage or co-opt?

President Donald Trump and a Republican-led Congress tried and failed to repeal the Affordable Care Act. Now, they have to decide whether they want to work with it or sabotage it.

Both Trump and congressional leaders acknowledged Friday that they would not bring their repeal bill back for a vote any time soon. That means that, as Speaker Paul Ryan said, "we're going to be living with Obamacare for the foreseeable future."

Ryan and Trump reiterated their criticisms of the law and set the stage for watching it collapse and blaming the Democrats for the aftermath. "I've been saying for the last year and a half that the best thing we can do politically speaking is let Obamacare explode," Trump said from the Oval Office. "It is exploding now."

Ryan said that the ACA's architects would be sad that the bill was allowed to live on, given what he described as its inevitable failure.

In fact, the ACA is not on the verge of "explosion." Enrollment in its insurance marketplaces is steady, and several independent analyses suggest that insurance prices have stabilized after a sharp market correction this year. But the structures it set up to provide health insurance to middle-income Americans are vulnerable. Insurance companies have struggled to make money in the early years of the new markets, and many have backed out. Others remain tentatively committed and skittish.

Trump will need to decide, quickly, whether his goal is to knock over the still-functioning markets, or help prop them up. If he decides to topple them, next year could be very messy.

Insurers are making their decisions right now about whether to enter the markets for next year and about how much to charge their customers. Signals from the administration in the next few weeks about whether he will help or hurt them will almost certainly guide insurers' choices.

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The biggest immediate decision concerns a court dispute between the House and the administration over subsidies to help low-income insurance buyers pay their deductibles and copayments. The House has argued that the money for those subsidies was not properly authorized. The Obama White House fought the case. It is not clear whether Trump's lawyers will do the same. The availability of those subsidies, used by a majority of ACA customers, is critical for insurers in the markets.

Without the subsidies, all the insurers will lose some money, and many smaller carriers will face bankruptcy. If Trump does not fight the court case, the ACA markets in most states will unravel quickly, leaving millions without insurance options on his watch. Many of the beneficiaries are Trump voters.

There are smaller decisions ahead, too, about how to administer programs and whether to recruit insurers to participate in markets where competition is thin. So far, Trump's secretary for health and human services, Tom Price, has taken every opportunity to gloat about the health law's setbacks, even as he is administering its programs.

Price, perhaps more than Trump, has long been committed to the Affordable Care Act's demise. But now he will have to manage the law's many programs. Obama administration officials called insurers, cajoling and reassuring them. If Trump wants the markets to be vigorous, he could use his self-described deal-making skills to woo insurance companies into the stabilizing markets.

If Trump and Price can make peace with the health law, there are opportunities to steer it in a more conservative direction. The law gives broad authority to the executive branch to shape health care policy. So far, the health law has been driven by Obama administration priorities, but that could change.

A few early regulatory changes have begun that process. The Trump administration plans to make it harder for people to sign up for plans midyear. It has given insurers more wiggle room to raise their deductibles. It may be able to make alterations that loosen up benefit requirements — though it won't be able to completely eliminate them, as Republicans sought to do at the last minute in the failed bill.

The administration will also have enormous power to allow states to reshape their Medicaid programs — and even their local insurance markets — through waivers to existing law. Seema Verma, the just-confirmed administrator of the Centers for Medicare and Medicaid Services, was a consultant who helped states write pathbreaking conservative proposals for their Medicaid programs. She is ideally positioned to approve many more such waivers from Republican-led states, allowing them to impose premiums, cost-sharing and even work requirements for Medicaid beneficiaries.

A new ACA waiver program has just gone into effect: It would allow states to overhaul their entire health insurance markets if they can show that their revised plans would cover as many people. That process could allow Verma and Price to approve state plans that hew more closely to the Republican vision for health care.

New powers granted under the Affordable Care Act allow the Department of Health and Human Services to make major changes to the Medicare program, through demonstration projects meant to lower costs and improve patient care. The Obama administration set a precedent of imposing "mandatory" projects on large portions of the country to test policy ideas. So far, Price has looked askance at such efforts. But the provision could give him power to reshape what Medicare pays for and how seniors receive their care.

Nicholas Bagley, a law professor at the University of Michigan, has criticized the Obama administration for stretching its legal authority with some of its ACA choices. But those choices have created a precedent for the Trump administration to stretch the health law in its own direction. "If you think Congress is done, and you don't want to provoke a reaction anymore, then you own this," he said. "You will be judged as an executive on the performance of Obamacare."

For years, opposing the Affordable Care Act has been a rallying cry for Republicans. But if Republicans can't repeal the ACA, they could instead co-opt it. There are opportunities for Trumpcare yet.

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