President Trump faces a slew of critical decisions in 2018 about how far he wants to go to undermine ObamaCare.
There are increasing doubts about the ability of Congress to repeal the law, which will put even more focus on administrative actions to chip away at the Affordable Care Act.
It is unlikely, though, that Trump can deal a death blow to the law.
“There are all kinds of opportunities to operate in good faith or try to undermine it,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation.
“I think we mostly saw an effort to undermine the ACA from the administration this year and the question is, are they ready to move on to other things?”
Here are five ways Trump could undermine ObamaCare in the year ahead.
The ObamaCare executive order
Trump issued an executive order aimed at easing ObamaCare rules in October, but the major implications are still to come.
Agencies need to issue regulations to bring the order into effect, which has not yet happened. There are questions about how far those regulations will go and how they will impact the stability of ObamaCare.
Democrats fear the order will undermine the law by opening up skimpier, cheaper plans that will siphon healthy people away from ObamaCare plans. That could lead to spiking premiums or other problems in the ObamaCare marketplaces. Adding to that instability is the repeal of the individual mandate in the Trump tax bill.
There are two avenues for a shake-up in the order: an expansion of short-term health insurance plans, and an expansion of association health plans, which allow small businesses and other groups to band together to purchase health coverage. Both of these kinds of plans do not have to follow the same pre-existing condition protections as ObamaCare plans.
Trump on Thursday touted the association health plans, as well as mandate repeal, for their ability to do damage to ObamaCare and spur Democrats to negotiate with him.
“I believe that because of the individual mandate and the associations, the Democrats will and certainly should come to me and see if they can do a really great health-care plan for the remaining people,” Trump told The New York Times.
Cuts to outreach
The Trump administration poked a hornet’s nest in 2017 by cutting back on outreach that encourages people to sign up for ObamaCare, fueling Democratic cries of “sabotage.”
Officials cut advertising by 90 percent and reduced the length of the sign-up period by half.
Some functions still went on, though, like maintaining staffing levels at the ObamaCare call center and email reminders sent out to consumers.
Advocates will be on the watch for any further cuts next year.
Democrats argued that the unexpectedly high 2017 enrollment numbers, 8.7 million, down just slightly from the 9.2 million last year, show the law’s resilience even in the face of these cutbacks.
“Enrollment defied expectations and the Trump administration’s efforts to undermine it by cutting Open Enrollment in half and outreach and advertising by 90%,” Lori Lodes, a former Obama administration official now working to sign people up, wrote in an email.
Targeting essential health benefits
ObamaCare’s essential health benefits emerged as one of the main rallying cries for defenders of the law during the repeal effort this year. Patient groups and others rose to defend the rules, which mandate that insurance plans cover a range of services, such as mental health care and prescription drugs.
While Trump cannot repeal the rules without action from Congress, he can take steps on his own to loosen definitions and give states more flexibility to change the requirements.
The administration started to do just that in October, with a proposed regulation aimed at giving states more ability to ease the essential health benefit requirements. That change has yet to be finalized.
“I’m not sure how many states will do that and how quickly they’ll do it, but I think that has the possibility of undermining the protections the Affordable Care Act offers to people with pre-existing conditions,” said Tim Jost, a law professor at Washington and Lee University.
Allowing counties to lose insurers
In 2016 and 2017, officials had to scramble to prevent certain counties from going without an insurer offering ObamaCare coverage at all. The Obama administration helped pressure insurers to step in, and this year, state insurance commissioners worked to prevent any gaps.
But there could be more need for the Trump administration to step in next year as more areas could be faced with losing their insurance options after the repeal of the individual mandate.
It is unclear what the Trump administration would do if faced with an outbreak of counties lacking insurers. Officials earlier this year declined to comment on a press call about whether they would encourage insurers to participate.
Support for stabilizing ObamaCare markets
Trump will face an important test early in the year on two bipartisan bills aimed at stabilizing ObamaCare.
Sens. Lamar Alexander (R-Tenn.) and Susan Collins (R-Maine) are pushing for the measures to be included in a government funding bill that must pass by Jan. 19. But the measures face resistance in the House, where conservatives say they are just throwing more money at ObamaCare.
Pressure from Trump on the House could be needed to get the measure through that chamber, but it is unclear whether Trump will go that far.
The measures provide funding to reimburse insurers for discounts to low-income enrollees and to pick up the cost of some especially sick patients, which is aimed at bringing down premiums.
Alexander said last week before Congress left for break that he had seen encouraging signs from Trump and Speaker Paul Ryan (R-Wis.).
“We have the president’s renewed interest, more interest from the House, [Senate Majority Leader Mitch] McConnell [R-Ky.] has renewed his commitment to schedule it and support it,” Alexander said. “So I think it’s just a matter of when we come back putting our ideas together and finding a way to get a result.”