Q&A: The impact of Trump's order to weaken the Affordable Care Act

WASHINGTON — President Donald Trump signed an executive order Friday aimed at defanging the Affordable Care Act, giving heads of federal departments more power to delay or grant exemptions from regulations associated with the law.

Its immediate effect remains unclear. Here are some of the most important questions:

Q: What does the executive order say?

A: The first executive order from Trump reaffirms his administration's dedication to repealing the Affordable Care Act, encouraging heads of federal agencies to "minimize unwarranted economic and regulatory burdens of the act."

It tries to do this by giving the Department of Health and Human Services and other agencies leeway in how to enforce the health care law. It also asks heads of various federal departments to give flexibility to the states in their own health care programs "to the maximum extent permitted by law."

Q: What does the executive order do?

A: Nothing now, said Cynthia Cox, associate director for the program for the study of health reform and private insurance at the Kaiser Family Foundation.


"Any change would have to come from a new guidance that HHS and IRS would issue," Cox said in an interview. "It just signals that the administration will be working with the (Department of Health and Human Services) and other agencies."

The order can't overturn provisions of the law enacted by Congress. But it can give heads of departments that deal with regulations found in it some discretionary leeway when dealing with some of the its regulations.

One example is the individual mandate, which requires Americans who can afford coverage to purchase health insurance or pay a fee. But those who feel they cannot afford either the health insurance or the penalty for lacking it because of a "hardship" can ask for an exemption.

The Trump administration could loosen the requirements to receive a "hardship" exemption, potentially increasing premiums and prompting some to leave the insurance market, Cox said.

Q: How quickly could the executive order affect the law?

A: Not very.

As it was passed by Congress, much of the law can be overturned only if the Republican-controlled Congress passes more legislation.

"Once (Trump's) Cabinet is in place and once they are able to carry out this order, we will see more specifics come out," Cox said.

Many changes through the executive branch would require a public-comment period before they could take effect. Cox said that process can take a few months.

Health insurance companies have already included government regulations in their contracts for the year, so there may not be major changes in premiums this year, Cox said, but the executive order and changes in regulations could affect premiums in 2018.

Insurance companies "will set those premiums in April or May," Cox said. "The administration wants to make these changes before midyear so insurers will know the rules of the game next year."

Q: I still have until Jan. 31 to sign up for health insurance under the law. What happens if I do?

A: Those who are already insured under the law, or plan to sign up before the Jan. 31 deadline, shouldn't expect any major changes in their coverage from the executive order this year. But premiums could rise next year, Cox said.

Q: The executive order enables departments to slow the implementation of a "fiscal burden" on the states or a "regulatory burden" on business. What defines "burden?"

A: Cox said it is very challenging to determine the exact meaning of what a "burden" is until the Trump administration begins to propose policies.

Still, a weekend television interview with a Trump adviser hints at the main target of such language: the act's individual mandate.

Kellyanne Conway, a Trump counselor, suggested that the president "may" stop enforcing the mandate altogether.


"What President Trump is doing is, he wants to get rid of that Obamacare penalty almost immediately, because that is something that is really strangling a lot of Americans, to have to pay a penalty for not buying government-run health insurance," Conway said.

The penalty in 2016 and 2017 is calculated in two ways: either by a percentage of income — 2.5 percent of household income with a maximum of the yearly premium for a bronze plan in the health care marketplace — or per person — $695 per adult and $347.50 per child under 18, with a maximum of $2,085.

An individual pays whichever is higher.

Q: Besides the individual mandate, what are some other aspects of the Affordable Care Act that could be affected by the executive order?

A: Essential health benefits: Cox said one of the quicker changes to the law could be the definition of what is an "essential health benefit," or the minimum requirement for coverage under an insurance plan.

Under the law, services like hospitalization and prescription drugs were considered "essential health benefits" for insurance plans in the marketplace.

This could be one of the first changes to the law because essential health benefits were a regulation enacted under President Barack Obama, allowing the Trump administration to repeal or weaken the policy through the executive branch.

Premiums: Weakening requirements for "essential health benefits" could also decrease the premiums of healthy people, but lead to increased treatment costs for sick people, Cox said.


"It makes it so the costs are incurred by sick people or those who need health care."

Weakening the individual mandate portion of the Affordable Care Act would also likely push the cost of premiums up and lead many to abandon the health care marketplace altogether, Cox said.

Medicaid: The executive order urges agencies to do all they can to "provide greater flexibility to states and cooperate with them in implementing health care programs."

Cox said the goal of changing the rules for Medicaid is to nudge states that have not expanded their Medicaid programs to do so. Thirty-two states and the District of Columbia have opted into the Medicaid expansion. Nineteen have chosen not to.

Conway said Sunday that the pending replacement of the health care law would make Medicaid a "block grant program." That means the states will receive money from the federal government to build their own statewide Medicaid programs as they see fit.