The Trump administration is trying to make it easier for states to undermine Obamacare on their own, and it could reshape the US healthcare landscape

The Trump administration is trying to make it easier for states to undermine Obamacare on their own, and it could reshape the US healthcare landscape

Doanld Trump Barack Obama

Win McNamee

Donald Trump and Barack Obama.

  • The Trump administration released new rules around the use of Obamacare's state innovation waivers on Monday.
  • The Department of Health and Human Services and Centers of Medicare and Medicaid Services argued that the regulations would help states create rules that would drive down costs and provide flexibility for consumers.
  • The changes appear to be part of the Trump administration's ongoing campaign to reshape the healthcare system without repealing Obamacare.

The Trump administration on Monday released new rules that could allow states to offer less generous health insurance plans through their Obamacare markets to drive down costs for consumers. But health policy experts warned that the changes could help undermine some of Obamacare's key protections.

The Department of Health and Human Services and Centers for Medicare and Medicare Services issued new guidance on the use of the Affordable Care Act's Section 1332 waivers that would give state governments more flexibility in offering plans that do not comply with the ACA's basic coverage requirements.

According to health policy experts, the guidance would make it easier for states to undermine key parts of Obamacare and weaken protections for sicker Americans.

Since the failure of the GOP's Obamacare repeal and replace efforts in 2017, the waivers have become a key approach in the Trump administration's attempts to roll back parts of the ACA.


"Now, states will have a clearer sense of how they can take the lead on making available more insurance options, within the bounds of the Affordable Care Act, that are fiscally sustainable, private sector-driven, and consumer-friendly," HHS Secretary Alex Azar said in a statement.

Larry Levitt, senior vice president at the nonpartisan Kaiser Family Foundation, said the new waiver guidance is further evidence that the Trump administration is attempting to chip away at the ACA.

"Republicans failed to repeal and replace the ACA last year," Levitt tweeted. "This new guidance from the Trump administration on state waivers continues a theme of trying instead to make end-runs around the ACA's rules."

Here's a rundown of some of the key changes in the waiver guidance:

  • Preference for private plans: The Obama administration designed the waivers with the intention of states attempting their own version of a public option, or government-provided healthcare plan. The new guidance makes it clear that the Trump administration favors plans that use private insurance plans, rather than public plans like Medicaid buy-in.
  • Allows the expanded use of non-ACA compliant plans: Currently, insurance plans offered on the Obamacare exchanges - where people without coverage from a job or a government program like Medicare can get their coverage - must abide by a stringent set of rules. The plans must coverpeople with preexisting conditions, must charge those people the same rate as healthier people, and cover 10 essential health benefits (basic types of care like prescription drugs and maternity care).
    • The new wavier rules would allow states to set up programs that offer plans that don't abide by the ACA rules as long as there is one ACA-compliant option. The non-compliant plans would likely be cheaper, but also would provide fewer protections in the event people enrolled in the plan get sick.
    • Dan Meuse, a health policy expert at Princeton University, tweeted that the guidance "suggests that states will be encouraged to expand plans that don't cover preexisting conditions - even using subsidies to pay for them - as long as one comprehensive plan is offered (regardless of cost)."
  • Would allow people to use subsidies to purchase non-ACA compliant plans: Currently, ACA premium subsidies can only be used on plans that comply with all ACA rules. The new guidance could allow states to let people use subsidies to buy less generous plans like short-term, limited-duration health insurance.
  • States can enact a wavier without legislative approval: Previously, any waiver had to be adopted by the state's legislature for the federal government to approve the waiver. Now, in some circumstances an executive order from the governor can be enough.
  • Changes the name of the waivers: Previously, Section 1332 waivers were known as "State Innovation Waivers." The Trump administration renamed them "State Relief and Empowerment Waivers."

Only eight Section 1332 waivers have been approved by the federal government, and most have focused on supporting the current Obamacare market through reinsurance programs - rather than offering alternative plans. But Levitt said the new rules could change that.


"It's hard to overstate how much flexibility states will have under the Trump administration's new guidance for ACA waivers," he said. "This will likely widen the gap between red states and blue states for access, affordability, regulation, and protections for pre-existing conditions."

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