Obamacare evolves along state lines in the age of Trump

Obamacare is fracturing along state lines. Republicans may have failed to repeal the federal health care law, but steps taken by Congress and the Trump administration will significantly alter how people get covered across the country. And where they live will matter.

The most dramatic change states are confronting is the repeal of the individual mandate, one of the Affordable Care Act’s central elements. But the Trump administration’s regulatory efforts to make it easier to buy skinnier, cheaper plans that don’t meet Obamacare’s coverage requirements could prove more consequential, and it may mean that people have far less “insurance” than they realize if they get sick. Both changes are likely to further sap enrollment in the ACA’s insurance markets, leaving only the poorest and the very sick in the exchanges.

Encouraged by the Trump administration, states are also certain to seek further changes through federal waivers for their ACA markets and Medicaid programs. The chasm between red and blue states will grow wider. Lawmakers and regulators in Republican states will look to push the envelope on unwinding Obamacare, while their counterparts in Democrat-led states will pursue policies that limit the ramifications of federal policy changes and preserve enrollment in government-sponsored coverage.

I’m excited to use the 2018 National Fellowship to take an in-depth look at three states — Washington, Mississippi and Idaho — that are likely to pursue divergent paths under the new ACA landscape. Drawing on my experience reporting in Washington, D.C., and the travel the fellowship will enable, I want to follow along as these states wrestle with what Obamacare will look like in the future, and what it will mean for the health of Americans in the coming years.

Washington: The state is among the most enthusiastic backers of Obamacare. The Democrat-controlled state expanded Medicaid, created its own exchange and spent tens of millions of state dollars to boost enrollment and competition. When two counties were at risk of having no participating insurers this year, Insurance Commissioner Mike Kreidler aggressively recruited companies to fill the gaps.

Now lawmakers and regulators in Washington are implementing an array of measures to protect the state’s coverage gains from what they perceive as wrongheaded policies coming from D.C. Earlier this year, lawmakers passed legislation creating a public-option backstop to ensure that Obamacare customers will never end up with no options for coverage. In addition, Kreidler’s office is drafting regulatory changes to counter the Trump administration’s efforts to loosen the rules around “skinny” plans that don’t meet the ACA’s coverage requirements.

“Allowing short-term medical plans to infiltrate our health insurance markets is not the panacea the Trump Administration promises,” Kreidler said recently. “It’s just one more devastating step in dismantling the consumer protections we’ve come to rely on.”

Mississippi: Like most Republican-controlled states, Mississippi did everything in its power to undermine Obamacare. That included refusing to expand Medicaid, even though the state is arguably the poorest and unhealthiest in the country, and mostly defaulting to the federal government to oversee its ACA marketplace. It’s among 20 red states still trying to fight the ACA through the courts more than eight years after it was passed.

The results haven’t been pretty. The state’s dominant insurer, Blue Cross and Blue Shield of Mississippi, refused to participate in the exchange from the outset. The only company currently selling Obamacare plans in the state jacked up rates by nearly 50 percent this year. The state’s uninsured rate is more than double the national average, with minorities disproportionately affected.

State officials welcome the changes coming from the Trump administration and Congress. Mississippi is seeking permission from the Trump administration to add work requirements to its Medicaid program, which already has some of the strictest eligibility rules in the country. Many Republican-led states are making similar changes, although the new work rules are being challenged in the courts.

“This is not, as some would have you believe, a punitive action aimed at recipients,” Mississippi Gov. Phil Bryant said in his State of the State speech in January. “It will actually help this population reap the rewards of a good job, and one day receive health care coverage from their employer, not the state or federal government.”

Idaho: It’s impossible to pigeonhole Idaho. Unlike most deep-red states, Idaho established its own state-based marketplace to enroll Obamacare customers. While insurance markets in other rural states have struggled, Idaho’s exchange has been relatively successful: At least three insurers are selling plans in every county of the state, and premiums are right around the national average.

But the state also rejected Medicaid expansion, denying coverage to tens of thousands of residents who would have been eligible. That could change this year: expansion supporters are pushing to put a referendum on the November ballot to determine whether the state will pursue the ACA program.

Idaho officials aren’t content with the status quo. They point to big premium spikes and lower enrollment this year as troubling signs that the ACA market needs fixes. That led to the development of a plan that would allow insurers to ignore Obamacare’s coverage rules by selling “state-based plans.” That idea has so far been rejected by the Trump administration, but Idaho officials say they’ll push forward with unorthodox changes to the individual insurance market.

“It is a ticking time bomb if the young and healthy keep leaving,” Lt. Gov. Brad Little, who is spearheading the effort, told me earlier this year.

[Photo by Spencer Platt/Getty Images]