We have to stand up to Trump’s health insurance bullying

 We have to stand up to Trump’s health insurance bullying
© Greg Nash

Donald TrumpDonald John TrumpAlaska Republican Party cancels 2020 primary Ukrainian official denies Trump pressured president Trump goes after New York Times, Washington Post: 'They have gone totally CRAZY!!!!' MORE doesn’t want you to have health insurance. At least, that’s what all his policy decisions about the Affordable Care Act (ACA) suggest.

Open enrollment for marketplace health insurance begins today, Nov. 1 This year, it only lasts until Dec. 15 making it the shortest enrollment period in the history of the ACA. The administration will also pull the website down every Sunday for maintenance, effectively further shortening open enrollment.m

Trump gutted funding for advertising and enrollment navigators, which used to help individuals learn about their options, choose plans carefully, and maximize subsidies when eligible. Making matters worse, he has issued a series of executive orders and policy statements to further sabotage the system with uncertainty.


These moves are those of a classic bully: through intimidation and confusion, suppress any behavior that threatens the bully’s position. Trump has used his platform to try to destabilize the Affordable Care Act and thereby diminish Obama’s legacy. But discouraging marketplace enrollment most acutely hurts middle-class and working-poor families, the very supporters to whom Trump claims to be dedicated.

For example, last month, Trump eliminated funding for cost sharing reductions (CSRs), the ACA mechanism that subsidizes co-payments and deductibles for people earning between 100 percent and 250 percent of the Federal Poverty Level (FPL). Everyone had something to say about Trump’s decision, and the mixed messages may have left people confused. Are CSRs insurance company bailouts or handouts to the poor? Would doing away with them stick it to insurers or kill the most vulnerable among us?

In fact, marketplace insurers are contractually obligated to continue offering CSRs to those making less than $30,150 a year, with or without government funding. Thus, lower-income people are protected and ought not let Trump’s action deter them from enrolling in a marketplace plan. Silver-level plans with CSRs offer significantly lower consumer cost-sharing. (For instance, a deductible in a CSR plan is $246 compared to $3,063 to $7,150 for a non-CSR silver plan).

Insurers will compensate for the loss of CSR subsidies by raising premiums across the board. People earning between 100 percent and 400 percent of the FPL (or $12,060 and $48,240 per year) will still get premium subsidies — another ACA mechanism to help make health plans more affordable — to offset premium increases. But anyone making over $48,240 a year is not eligible for premium subsidies and will face those premium increases without financial support.

CSRs are essentially market stabilizers to keep costs down. Let’s be clear: By failing to fund them, the Trump administration is punishing the middle class, and the middle class alone.

Those in the unsubsidized middle class will face tough choices: pay more, leave the exchanges to buy skinnier plans that leave them exposed, or potentially go without coverage altogether. With a drop in marketplace enrollment, the ACA is more likely to implode. Prices will go up. Millions will be uninsured. Trump can claim political victory, but it will be on the backs of hard-working Americans.

But, what would happen if everyone signs up? And for the right plan? Last year, at least two million exchange enrollees missed out on cost-sharing reductions by not choosing the silver-level plans on the marketplace, the only plans to which CSR reductions are applied.

That figure doesn’t count the two and a half million people with incomes under 400 percent FPL who bought health plans off the exchanges, forgoing both premium and CSR support for which they are eligible. Just as Donald Trump wouldn’t leave money on the table, neither should low- and modest-income Americans.

The insurance industry is governed by the law of large numbers. When they cover more enrollees, there are more people across whom to spread financial risk. And, the more data they have about their membership, the more accurately they can price risk. With more people enrolled, insurers will have less room to justify wild price increases due to uncertainty.

Of the 28 million still uninsured Americans, 80 percent would qualify for subsidies based on their income and would benefit from signing up. Additionally, 75 percent of the uninsured work full time, many of whom are likely middle-class Americans sitting on the sidelines, put off by the swirl of negative political discourse. Not only does opting out hurt those individuals by leaving them uncovered, it contributes to Trump’s desired dismantling of the ACA and hands victory to the bully.

Isn’t a better approach to sign up during open enrollment, get the individual benefits, and help strengthen the market and lower costs for everyone? Getting covered is the middle class’ best recourse against political bullying.  

Deborah Gordon is a senior fellow and Anna Ford is a research assistant at the Mossavar-Rahmani Center for Business and Government at the Harvard Kennedy School. Follow Deb on Twitter @gordondeb.