On Friday, amid reports that (deep breath) Donald Trump told Russian officials that he fired FBI director James Comey because he was "a real nut job" and that a probe into potential collaboration between Russia and the Trump campaign was scrutinizing a current White House official (phew) came another piece of alarming news: The president is thinking about a unilateral move that would essentially dismantle the exchanges set up by the Affordable Care Act by taking away a set of controversial subsidies.
Under the ACA, people who don't get insurance through their jobs or through Medicaid or Medicare can buy plans from private insurers on marketplaces known as "exchanges." Insurers are required by law to give discounts on costs like copayments to people who buy some plans; to make this work the federal government gives money to the insurance companies—a cost of an estimated $7 billion this year.
Some conservatives in the House think the federal government can't make those payments because Congress didn't specifically authorize them; the House is currently suing the executive branch over the issue, but in the meantime, the payments are continuing. But Trump could simply stop making those payments, which on Friday Politico reported he wanted to do.
Even without those subsidies insurers would still have to give discounts to their customers—but more likely, they would simply withdraw from the marketplaces, making it hard or impossible for some people to get insurance.
Some of Trump's advisers reportedly don't want him to do this because depriving people of insurance will obviously be politically unpopular. Trump keeps talking about "insurance for all," but also supports policies that will result in people losing insurance. The bill passed this month by the Republican-controlled House, for instance, would likely force millions of poor people off Medicaid.
Trump reportedly wants to use this subsidy cut to force Democrats to negotiate with him over healthcare reform but why exactly they would negotiate is a complete mystery—Democrats generally want to preserve the ACA and strengthen various parts of it, and conservative Republicans want to tear it down. The House bill passed after negotiations between factions of Republicans, without a single Democratic vote.
"Several polls show that the public would blame the administration and the Republican-controlled Congress if the markets collapsed," Politico noted. That's probably because it would be entirely Republicans' fault.
Already insurers are skittish about the future of the exchanges thanks to the Trump administration's mismanagement—but any uncertainty or doubt about the system inevitably gets used by Republicans as a reason the ACA needs to be repealed and replaced with a much less generous system. In this context, Trump's threat to the subsidies, whether he goes through with it or not, is just one more thing to worry about.
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