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Terry H. Schwadron

March 27, 2019

The Trump administration is on the march once again to kill health care.

The Department of Justice has reversed its earlier opinion in a court challenge to the whole of Obamacare,using a Texas case in the Court of Appeals to say the entire law should be invalidated.

And, moving on its own, without consulting Congress, the administration is encouraging states, red states in particular, to limit Medicaid, making changes to the program while avoiding congressional approval.

So much for upholding the law.

Together, of course, the moves highlight access to health care as one of the preeminent issues for the 2020 presidential campaign. The future of a legal system of access to health are is quickly moving from confused toward critical.

· After dozens of votes and adverse court decisions, Republicans continue to insist that Obamacare is the wrong answer, in part simply because it came about under the previous president. Still, all these years later, we know what Republicans do not want, but not what they do want

· Meanwhile among Democrats, we know that there is a strong undercurrent moving Democrats towards expansion of the Medicare-Medicaid single-payer approach, even as Speaker Nancy Pelosi is moving ahead with a more incremental approach to improving Obamacare.

· Meanwhile, the Trump administration seems to have a mind of its own, moving in anything but orderly ways to knock out various supports for Obamacare before restoring some of them before knocking them out again. And among all of these changes, still more than 11 million signed up for health care under the Affordable Care Act.

· And yet, in its new budget, the White House has proposed cutting billions of dollars from Medicare and Medicaid, the one set of policies that they had promised to leave alone.

All of the court challenges and administrative moves feel yet more insidious as each reflects some partial answer that just confuses the present health insurance marketplace.

In the Texas court case, the government, which previously had said only that the law’s protections for people with pre-existing conditions should be outlawed, now want the entire Affordable Care Act removed — over an argument about whether there is a “tax” in play because of Obamacare, even if set at zero. That kind of move would not only leave millions without health insurance, but also completely undercut all of the insurance companies, hospitals, health providers and others who have built systems around the law.

Success at overturning Obamacare would also heighten that the Trump administration, which says it wants to protect those with pre-existing conditions, is eliminating any legal basis for getting such coverage.

In the new budget, the Trump administration has proposed big cuts to the Medicaid and Medicare programs. At the same time, Democratic candidates for president have generally coalesced around a message that would protect the current programs and explore the idea of expanding Medicare for All.

And, according to The,administration officials are granting approvals to states seeking to impose work requirements on Medicaid recipients, even in the face of legal challenges and large-scale losses in the number of people covered. Last week, for example, the Centers for Medicare and Medicaid Services (CMS) granted Ohio’s request for work requirements, the ninth such approval since President Trump took office. Lawyers for the government were in federal court defending the work requirements for two other states, Arkansas and Kentucky.

Clearly, the actions are prompting a reaction among critics of the administration. The Kentucky court action in particular has irked critics, since a federal court there in 2018 blocked Kentucky’s work requirements from taking effect.

The administration sought more comments on the policy. CMS Administrator Seema Verma ultimately granted approval to Kentucky to move ahead with work requirements even though the state made few changes to their plan. The administration was sued again over Kentucky’s rules, and last week the case landed back in front of the same federal judge.

The administration has staunchly defended its bold moves.

Verma has been outspoken in her support of work requirements and has made approving state requests one of her top priorities. Last month, after reports that 18,000 people lost their coverage under work rules in Arkansas, top Democrats urged officials to reverse course.

“The Medicaid program was designed to serve our most vulnerable populations like children and people with disabilities,” Verma wrote in a blog post last week. She said the changes were a “logical” step, considering “the unprecedented expansion of [Medicaid] eligibility to childless, working-age adults that occurred under Obamacare.”

The administration’s efforts are much broader than work requirements. Secretary of Health and Human Services Alexander Azar has also been quietly trying to sell states on the merits of imposing block grants, or a per-person spending cap, without congressional approval.

Imposing block grants in Medicaid has long been a major conservative goal. Republicans say policies like block grants and payment caps allow for more state flexibility and are more fiscally sustainable. Azar’s admission raised hackles among Democrats, who fiercely oppose the idea, which would limit the amount of money going to Medicaid and require harmful cuts in the program.

But it also is a defense of congressional oversight. The administration policy seems equally devoted to avoiding congressional input.

Along with continuing attacks on Obamacare and general support for freeing institutions and employers from guaranteeing health care, it is more difficult than ever to determine what exactly President Trump means by a better health insurance policy.


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