It’s Called Trumpcare Now

The author of the middle grade memoir, Ugly, visited my office on Thursday. The memoir chronicles author Robert Hoge’s experiences after he was born with a large tumor between his eyes. Through several groundbreaking surgeries, the tumor was removed and his face was reconstructed to the point where he could see properly but doctors stopped short of complete reconstruction due to risk of blindness. As part of our discussion, someone asked him what questions he gets asked most often by kids who come to his events.

“Well in 2016, one of the questions I got asked most often by American kids was how much my many surgeries cost.”

Hoge went on to point out that because he was born in Australia, where they have universal healthcare, the surgeries didn’t cost his parents a single penny beyond the regular taxes that they pay to their government. Everyone in the room visibly recoiled. We are all well aware of our health system’s failings. And we work in children’s publishing, so we are well aware of what children have the capacity to understand.

But it was a harsh rhetorical blow, especially in a week of harsh practical blows from the Trump administration that threaten to upend parts of the insurance market and raise premiums for millions of Americans.

That’s right — even though we beat back the specter of Trumpcare three times this summer, the administration still has significant power over the insurance markets and has chosen to exercise that power to destabilize the insurance markets across the country.

First things first, if you get your insurance through the individual market, or are planning to for 2018 — click here. The New York Times runs through some of the most important questions about who will be impacted and how. I’m going to run through some of the basics, but if you’re worried about your insurance, start there.

On Thursday, October 12 the Trump administration signed an executive order which directed federal agencies to rewrite certain rules about how the insurance market functions. These rules primarily affect the individual insurance markets and relax regulations on group association plans and short term plans, both of which are functions of the insurance market that young, healthy people use to circumvent the more expensive, well regulated plans in the ACA exchanges.

Group association plans allow a bunch of small businesses to band together to purchase insurance for their employees. Because they are small businesses, these associations are exempt from a lot of the regulations that make up the individual insurance market — like essential health benefits. These plans cost less and cover less. In the past, these associations have been largely unregulated — you don’t have to be a baker to join the bakers’ association plan, for example.

Short term insurance plans, or plans that people purchase when they know that they are going to be unemployed for a short period of time, are similar in that they cost less and cover less. Prior to Obama-era regulations, these plans could last as long as a year and were an easy way again for young, healthy people to “have insurance” without having to pay for the more comprehensive and more expensive plans in the individual market.

Current regulations make group associations more difficult to join and make short term plans actually short term (limited to three months). The Trump administration plans to rescind those regulations. (It’s worth noting that states have tried this in the past and it has been an abject failure.) He also plans to loosen up enforcement of the individual mandate, which penalizes those who don’t have insurance with a tax.

These seem like fairly minor changes. Most people reading this do not have group association plans or short term plans. The rules themselves impact a rather small subset of people. So why should you care?

A couple of reasons…

1) This has the potential to induce a death spiral into the individual insurance market. As catastrophic, short term, and group association plans become easier and cheaper, young healthy people leave the market, leaving behind only those who are sick and who have pre-existing conditions — essentially, those who cost more to insure. This drives up costs, which causes insurers to leave the market reducing competition, which drives up costs even more. Which leads me to…

2) This is part of a concerted effort on the part of the Trump Administration to destabilize the law they are tasked with upholding. The purpose of the executive branch is to, wait for it, execute the laws. And the Trump administration’s deliberate efforts to undermine the Affordable Care Act represent a commitment to undermining the institutions of American government for political gain.

This executive order is going to hurt people — particularly the vulnerable, those for whom life is already much more difficult and expensive due to illness or disability. And while these new regulations likely won’t go into effect until the new year, and their impact is not wholly known, it is important to pay attention to actions like these from the Trump administration specifically because they are unknown, poorly thought out, and cruelly designed to cause pain in an effort to force a political blow out in Congress.

But wait, there’s more! (I know, I know — bear with me. There’s some good news at the end)

The Trump Administration also announced in the middle of the night between Thursday and Friday (they may be learning something about that whole take out the trash day thing) that the administration would stop making the Cost Sharing Reduction payments to insurance companies. These are payments which essentially reimburse insurance companies for the money they lose by keeping premiums lower for poorer enrollees in the individual market.

For the sake of trying to maintain a grip on a facts based reality for as long as possible, it’s worth noting that the CSR payments are controversial. Essentially, laws that cost money must be “appropriated” by the text of the bill. The Affordable Care Act promises to reimburse insurance companies through these payments but doesn’t actually appropriate the funds. When the Obama Administration asked Congress to address this, the Republican controlled legislature refused, and so the administration essentially decided to make the payments anyway. House Republicans, being the craven, soulless assholes that most of them are, sued. And while a federal judge ruled on their behalf, they postponed putting that ruling into effect to give the Obama administration time to appeal.

Of course, then Trump won and all hell broke loose. And even though the administration has been making these payments for the past ten months, they’ve just now come to the conclusion that these payments are unconstitutional and therefore they can’t in good conscious continue to pay them.

Insert eye roll here. If anyone believes that the Trump administration cares one wit about what is or isn’t constitutional, I’ve got a bridge in Brooklyn I’d like to sell you. Great views, great pizza. No trolls.

Here’s the kicker: while stopping these payments is going to have an impact, it’s not quite the impact I imagine the Trump administration was hoping for. It will negatively impact the market. Insurance companies exist to make money, and so the costs of plans will rise to make up for the loss of the federal funds. And the Trump administration does want to see the ACA implode because they have no qualms about hurting people to attempt to force a deal. But here are a couple of things they missed:

First, these payments do not impact the subsidies that individuals receive to help them pay for insurance. They only impact subsidies received by the insurance companies themselves. Please note: if you receive subsidies from the federal government to help cover the cost of your insurance, those subsidies remain in tact. You WILL NOT lose your subsidies.

Second, because the individual subsidies have to rise with the cost of plans, this is likely going cost the federal government almost $200 billion over ten years. That’s right — this is going to cost the government money. Your tax dollars are paying for this stupidity.

Third, according to AP, 70% of those who are going to be impacted by stopping these payments live in states that Trump won. And while we haven’t seen any specific figures to this effect, we do know that people who are going to be impacted by this most are middle class families who are going to see their premiums rise without any commensurate assistance from the federal government. And since the average income of a Trump voter was $72,000 ($11,000 more than the average income of a Hillary voter — take that economic anxiety) it stands to reason, that not only will it be those living in Trump states, but it will also impact many Trump voters.

Whoops.

I did promise you some good news though, and that wasn’t it. Raising the cost of insurance, making healthcare harder and more inaccessible for people is awful no matter who they voted for. We are not in the practice of wishing harm on people for some kind of smug “I told you so” moment. We want to help people. It’s what makes us better.

The good news is this: on November 7, Maine is going to vote on expanding Medicaid, which will help people access insurance. Idaho and Utah have also added similar measures to their upcoming ballots. And more people than ever want the Trump administration to stabilize the Affordable Care Act. Finally, Senators Lamar Alexander and Patty Murray are still engaged in bipartisan talks to appropriate funds for these payments and while the Trump administration wants to see something in return — further deregulation or the border wall — Democrats are standing strong against these absurdities.

So what can you do? Well the shitty part is — not much. You can urge your members of Congress to appropriate funds for the CSR payments. You can keep telling them that a border wall is unacceptable and you can fight for things like Chris Murphy’s public option plan or Bernie Sanders’ Medicare for All plan. Or both, since the Medicare for All bill is admittedly an aspirational one. And you can go to Get America Covered and help do the government’s job. Because the Trump administration refuses to promote the individual markets, help with enrollment or run an effective website, former ACA administrators have banded together to make sure Americans can get insurance.

These are the consequences of elections. This is why we have to show up to vote, and we have to do so practically. Real people are going to be hurt by these actions by the administration, and real people are facing uncertainty they wouldn’t be facing if Hillary Clinton were president. So show up to vote. Especially this year if you live in Virginia and New Jersey.

And then next year, we’ll do it all over again.