How Trump surprised his own team by ruling out Obamacare

12-15 minutes

President Donald Trump at a daily White House coronavirus briefing. | Win McNamee/Getty Images

As coronavirus ran rampant and record jobless numbers piled up, the nation’s health insurers last week readied for a major announcement: The Trump administration was reopening Obamacare to millions of newly uninsured Americans.
It was an announcement that never came.
The White House instead rejected the prospect of allowing new sign-ups across the 38 Affordable Care Act marketplaces it controls – a decision that shocked the health care industry, triggered widespread criticism and prompted a scramble within the administration to find a new way to care for the growing population left exposed to the pandemic.

It's also one that allowed Trump to sidestep an awkward reckoning with the Affordable Care Act that he’s long vowed to kill, and the health care program bearing the name of his Democratic predecessor. The president personally opposed reopening the Obamacare marketplaces when presented with the option, one person familiar with the decision said – prompting the creation of a new initiative that federal officials are now rushing to construct.
“You have a perfectly good answer in front of you, and instead you’re going to make another one up,” said one Republican close to the administration. “It’s purely ideological.”
On Friday, Trump touted his administration’s plan to cover uninsured patients’ coronavirus treatments by paying hospitals for their costs, on the condition that providers also not stick those people with separate charges.
“This should alleviate any concern uninsured Americans may have about seeking the coronavirus treatment,” Trump said during a press briefing. “So that, I think, answers the question pretty well and very much in favor of our great people.”
The rollout of the new hospital pay program capped a frenetic several days within the administration, prompted by a White House official’s confirmation Tuesday that there would be no reopening of the Obamacare markets.
That declaration surprised even some officials in the Health and Human Services Department, who believed the concept was still under consideration. And amid a crush of criticism from Democrats led by 2020 front runner Joe Biden, it worried officials who viewed the verdict as an unforced error in the middle of a historic pandemic.

“It’s a bad decision optics-wise,” one administration official said in the immediate aftermath. “It politicizes people’s access to health services during a serious national health emergency.”

Over the prior weeks, health officials charged with overseeing Obamacare had debated offering special access to those caught without insurance as the coronavirus spread, officials told POLITICO.

Several states with control over their own health exchanges had already flung their doors open in the last month, in an acknowledgment of the deepening crisis that’s already killed thousands and threatens to persist well into the summer.

“We are in a unique situation,” Michele Eberle, the executive director in charge of Maryland’s Obamacare market, said Wednesday, as the state led by GOP Gov. Larry Hogan announced it would enroll people through June 15. “The decision to extend the enrollment deadline was made to ensure as many people as possible get the coverage they need.”

Health insurers that would be on the hook for covering the new population, including the Blue Cross Blue Shield Association, had also thrown their vocal support behind the idea.

"A Special Enrollment Period would offer much needed coverage to millions of Americans and mitigate the potential impact on providers and hospitals which will be forced to rely on emergency funding," the Association of Community Health Plans wrote in a March letter to Centers for Medicare and Medicaid Services Administrator Seema Verma.

The move made sense to many in both the industry and Trump’s own administration, because Americans who lose their health insurance as a result of losing their job are already eligible to sign up for Obamacare outside of the traditional month-long enrollment period. With the coronavirus pandemic straining hospitals and the administration’s projections growing increasingly dire, health officials began signaling to insurers that it was preparing to give the broader pool of uninsured Americans a fresh shot at getting coverage, three people with knowledge of the discussions said.

And by late March, administration officials sent word to insurers that the call would soon be official: They were reopening Obamacare, in an unprecedented move that recognized the depth of the public health emergency.

Major health insurance groups prepped press releases in anticipation of a formal announcement as soon as March 28, two people with knowledge of the arrangements said.

But that Saturday passed quietly, as inside the White House, senior aides to Trump balked at giving the proposal a final sign-off. Among the concerns: That the insurers calling loudly for reopening the markets would return weeks later seeking a bailout, as their new enrollees started to rack up medical expenses, a former senior administration official familiar with the decision said.
White House aides largely agreed it was far better to instead spend that money on hospitals, said two senior administration officials, even after officials at HHS and CMS had signaled plans to reopen the exchanges.
The aides also worried that Obamacare coverage would remain unaffordable for many Americans even if the administration did reopen the markets – introducing a host of new political risks, another former senior administration official added.
By Tuesday, HealthCare.gov's grand reopening was off, with a White House official telling POLITICO that the administration was exploring alternative options.

HHS spokespeople declined to address a series of questions about the decision-making process.

“We do not comment on internal deliberations," an HHS spokesperson said. "This has been publicly addressed during White House press briefings and we would point you to those comments.”

The White House declined comment.

Health and Human Services Secretary Alex Azar on Friday insisted that paying providers directly for coronavirus treatment represented a faster and more targeted solution.

The uninsured will be able to seek treatment immediately, without worrying about first purchasing insurance coverage, Azar said. And hospitals will be reimbursed swiftly for their expenses, on the additional condition that they not stick their patients with surprise bills.

“In many respects it’s better for those uninsured individuals,” Azar said. “What President Trump is doing here with this money is an unprecedented disease-specific support of care for individuals to make sure that people get treatment.”

Yet the announcement comes with fresh questions about how smoothly the administration can run the payment process in the middle of an all-consuming crisis, how much of the $100 billion fund already earmarked for hospitals it will consume and how expansive the coverage for the uninsured will be.

If Trump had chosen instead to reopen the HealthCare.gov website – as 11 largely blue states that control their own markets have already done – people without insurance could buy more comprehensive policies that not only would cover coronavirus but any follow-up treatment, mental-health care, and future check-ups.

Trump, however, has long opposed Obamacare, pledging on the campaign trail to eliminate it and making the law’s repeal and replacement a top priority of his presidency. That aspiration ended in failure in 2017, though the administration has successfully rolled back a central requirement that all Americans purchase health insurance.

The White House has since sought to limit Obamacare’s reach, while backing a lawsuit by GOP-led states to wipe out the law altogether – a position it’s continued to hold as coronavirus cases mount.

The decision not to reopen Obamacare enrollment prompted an immediate rebuke from Democrats and insurers.

"This callous decision will cost lives. Period," former Vice President Joe Biden tweeted on Wednesday.
The White House decision also caught the hospital industry off guard, frustrating executives who spent the past week awaiting guidance for how strained front-line facilities could access the new funding.

“We’re going to provide care to everyone, and we particularly want the uninsured to feel secure that the financing’s not going to get in the way of their care. At the same time, though, the purpose of the $100 billion fund was to keep the doors of hospitals open,” said Chip Kahn, CEO of the Federation of American Hospitals, which represents for-profit hospital systems. “I was a little disappointed that the first thing we hear about the fund is that it’s going to be used for some other purpose.”

Hospital groups are still scrambling for clarity on how much money would be taken from the fund and what the process would look like – warning that creating a whole new system for covering the uninsured might further delay payouts.

“You know what that’s called? That’s called single payer,” one Republican lobbyist said of the plan to directly cover expenses for the uninsured.

Trump administration health officials are still trying to answer those key questions, too – a sign of how hastily the proposal was assembled, with the White House only granting final approval hours before it was formally announced on Friday.

Still, administration officials maintain that the program represents a better solution than asking people to get their own coverage under Obamacare.
“People who lose their jobs and insurance can buy ACA insurance if they want, but we’re covering Covid testing for free and banning balance billing," said one senior administration official. "What is better than that? People want care, not coverage."
And hospitals could end up warming to the program, depending on whether the government reimburses according to a provision in Congress’s rescue package that mandates higher-than-normal pay rates for treating coronavirus patients.
“Medicare is a mediocre payer,” one lobbyist said, "but they’re a fast mediocre payer.”
Yet it’s not likely to quell criticism from consumer advocates and Democrats, who contend that it will force millions of Americans to remain uninsured – with little assurance so far that the government will similarly cover follow-up doctor visits or treatments for other medical conditions like pneumonia that are linked to coronavirus.
For Democrats in particular, the episode has energized a party that’s struggled in recent weeks to balance attacking Trump over a response they view as catastrophic with wariness over appearing overly political in the midst of a pandemic.
With attention shifting back to Obamacare – which has grown increasingly popular since the GOP’s failed 2017 bid to repeal the law – Democrats have appeared to find stable footing, pillorying the administration over its policy making.
“We have a health crisis, and it looks like we’re going to have a health insurance crisis,” Sen. Elizabeth Warren (D-Mass.) said in a lengthy Twitter video attacking the White House’s stance. “It’s time for the federal government to just step up and say, ‘We’re going to cover everyone who doesn’t have health insurance.’”

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