President Donald Trump’s attempt to transform American health insurance is almost complete.

Twenty months ago, frustrated after attempts to repeal Obamacare fell apart in the Republican-controlled Senate, Trump pledged to use executive power to do what Congress failed to legislate. An executive order set in motion regulations to promote “healthcare choice and competition across the United States.”

On Thursday, the administration finished the last of three rules to do just that -- advancing conservative policies without undoing the central framework established by the ACA.

Together, the changes have loosened Obama-era restrictions on short-term health plans that don’t meet the Affordable Care Act’s standards. They’ve permitted small employers to join together to buy lightly regulated coverage called association health plans. And the rule published Thursday gives employers, particularly small businesses, more flexibility to steer tax-exempt dollars to employees for health care.

The administrative actions are far short of repealing or replacing the Affordable Care Act, the law that expanded coverage to about 20 million people. Many of the ACA’s elements remain largely intact, including billions of dollars in subsidies, strict standards for insurance plan design, and rules that protect people with pre-existing medical conditions.

But Trump’s agencies have “taken administrative steps to shift the health law quite significantly,” said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation, a health research group.

Spreading Risk
The cumulative effect could erode a core principle of the ACA: ensuring that people can rely on their health insurance if they get sick, and to spread the costs of illness widely.

“It opens up an opportunity for healthy people to land with coverage that may be cheaper, but not necessarily as comprehensive,” said Kevin Lucia, research professor at Center on Health Insurance Reforms at Georgetown University.

The rule completed Thursday expands the use of health reimbursement arrangements, or HRAs, which let employers use tax-exempt funds to help workers pay for medical expenses, like a co-pay at a doctor’s office. In the past, HRAs could be used only in combination with group health plans sponsored by the employers. Starting in 2020, companies can use HRAs to subsidize workers buying entire health plans on the individual market, instead of offering them a company plan.

The Trump administration estimates that the rule will have far-reaching effects in the long-run. It projects that 800,000 employers, most with fewer than 20 workers, will eventually offer HRAs to help 11 million workers purchase individual insurance coverage by 2029.

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