President Donald Trump, who promised to repeal and replace “Obamacare” on day one in office — “it will be easy” — suffered humiliating deafeats after several failed attempts by Congress. For a man fixated on erasing any legacy of Barack Obama out of jealousy and spite, he has been stewing about ways he can sabotage “Obamacare,” and with it the health care of millions of Americans, outside of congressional action. It is purposeful, malicious and amoral.

The New York Times reports that, as I predicted, Trump has gone nuclear in House v. Price, ending the Cost Sharing Reduction subsidies (CSRs) to insurers for low income Americans. Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again:

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President Trump will scrap subsidies to health insurance companies that help pay out-of-pocket costs of low-income people, the White House said late Thursday. His plans were disclosed hours after the president ordered potentially sweeping changes in the nation’s insurance system, including sales of cheaper policies with fewer benefits and fewer protections for consumers.

The twin hits to the Affordable Care Act could unravel President Barack Obama’s signature domestic achievement, sending insurance premiums soaring and insurance companies fleeing from the health law’s online marketplaces. After Republicans failed to repeal the health law in Congress, Mr. Trump appears determined to dismantle it on his own.

Without the subsidies, insurance markets could quickly unravel. Insurers have said they will need much higher premiums and may pull out of the insurance exchanges created under the Affordable Care Act if the subsidies were cut off. Known as cost-sharing reduction payments, the subsidies were expected to total $9 billion in the coming year and nearly $100 billion in the coming decade.

“The government cannot lawfully make the cost-sharing reduction payments,” the White House said in a statement.

It concluded that “Congress needs to repeal and replace the disastrous Obamacare law and provide real relief to the American people.”

In a joint statement, the top Democrats in Congress, Senator Chuck Schumer of New York and Representative Nancy Pelosi of California, said Mr. Trump had “apparently decided to punish the American people for his inability to improve our health care system.”

“It is a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America,” they said. “Make no mistake about it, Trump will try to blame the Affordable Care Act, but this will fall on his back and he will pay the price for it.”

Lawmakers from both parties have urged the president to continue the payments. Mr. Trump had raised the possibility of eliminating the subsidies at a White House meeting with Republican senators several months ago. At the time, one senator told him that the Republican Party would effectively “own health care” as a political issue if the president did so.

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The future of the payments has been in doubt because of a lawsuit filed in 2014 by House Republicans, who said the Obama administration was paying the subsidies illegally. Judge Rosemary M. Collyer of the United States District Court in Washington agreed, finding that Congress had never appropriated money for the cost-sharing subsidies.

The Obama administration appealed the ruling. The Trump administration has continued the payments from month to month, even though Mr. Trump has made clear that he detests the payments and sees them as a bailout for insurance companies.

This summer, a group of states, including New York and California, was allowed to intervene in the court case over the subsidies. The New York attorney general, Eric T. Schneiderman, said on Thursday night that the coalition of states “stands ready to sue” if Mr. Trump cut off the subsidies.

Mr. Trump’s decision to stop the subsidy payments puts pressure on Congress to provide money for them in a spending bill.

Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, and Senator Patty Murray of Washington, the senior Democrat on the panel, have been trying to work out a bipartisan deal that would continue the subsidy payments while making it easier for states to obtain waivers from some requirements of the Affordable Care Act. White House officials have sent mixed signals about whether Mr. Trump was open to such a deal.

The decision to end subsidies came on the heels of [another] executive order, which he signed earlier Thursday.

With an 1,100-word directive to federal agencies, the president laid the groundwork for an expanding array of health insurance products, mainly less comprehensive plans offered through associations of small employers and greater use of short-term medical coverage.

Dylan Scott at Vox.com explains. Trump’s executive order to undermine Obamacare, explained:

Trump is asking federal agencies to look for ways to expand the use of association health plans, groups of small businesses that pool together to buy health insurance, and to broaden the definition of short-term insurance, which is exempt from the Affordable Care Act’s rules, administration officials said.

The ultimate impact will depend on any new regulations written as a result of the order, but overall, the Trump administration could make cheaper plans with skimpier benefits more available — and experts worry that will damage the ACA’s marketplaces.

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Policy experts warn that together, these changes could represent a serious threat to Obamacare: Trump wants to open more loopholes for more people to buy insurance outside the health care law’s markets, which experts anticipate would destabilize the market for customers who are left behind with higher premiums and fewer insurers.

The fear is that Trump’s action could lead to many association health plans being exempted from core Obamacare requirements like the coverage of certain essential health benefits. It could also potentially allow some individuals to join these plans too, which could hurt the individual insurance marketplaces by drawing younger and healthier people away from them. In much the same way, short-term insurance could also take healthier people out of the law’s markets.

The effect won’t be immediate: Administration officials said they didn’t expect any new regulations to be implemented before the end of the year. But Trump’s order does present a long-term risk to the ACA.

The Times report also emphasizes this point:

Most of the changes will not occur until federal agencies write and adopt regulations implementing them. The process, which includes a period for public comments, could take months. That means the order will probably not affect insurance coverage next year, but could lead to major changes in 2019.

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[M]any patients, doctors, hospital executives and state insurance regulators were not so happy. They said the changes envisioned by Mr. Trump could raise costs for sick people, increase sales of bare-bones insurance and add uncertainty to wobbly health insurance markets.

Chris Hansen, the president of the lobbying arm of the American Cancer Society, said the order “could leave millions of cancer patients and survivors unable to access meaningful coverage.”

In a statement from six physician groups, including the American Academy of Family Physicians, the doctors predicted that “allowing insurers to sell narrow, low-cost health plans likely will cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options.”

While many health insurers remained silent about the executive order, some voiced concern that it could destabilize the market. The Trump proposal “would draw younger and healthier people away from the exchanges and drive additional plans out of the market,” warned Ceci Connolly, the chief executive of the Alliance of Community Health Plans.

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The executive order’s quickest effect on the marketplaces would be the potential expansion of short-term plans, which are exempt from Affordable Care Act requirements. Many health policy experts worry that if large numbers of healthy people move into such plans, it would drive up premiums for those left in Affordable Care Act plans because the risk pool would have sicker people.

“If the short-term plans are able to siphon off the healthiest people, then the more highly regulated marketplaces may not be sustainable,” said Larry Levitt, a senior vice president for the Kaiser Family Foundation. “These plans follow no rules.”

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Association plans have a troubled history. Because the plans were not subject to state regulations that required insurers to have adequate financial resources, some became insolvent, leaving people with unpaid medical bills. Some insurers were accused of fraud, telling customers that the plans were more comprehensive than they were and leaving them uncovered when consumers became seriously ill.

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Mr. Trump’s order followed the pattern of previous policy shifts that originated with similar directives to agencies to come up with new rules.

Within hours of his inauguration in January, he ordered federal agencies to find ways to waive or defer provisions of the Affordable Care Act that might burden consumers, insurers or health care providers. In May, he directed officials to help employers with religious objections to the federal mandate for insurance coverage of contraception.

Both of those orders were followed up with specific, substantive regulations that rolled back Mr. Obama’s policies.

In battles over the Affordable Care Act this year, Mr. Trump and Senate Republicans said they wanted to give state officials vast new power to regulate insurance because state officials were wiser than federal officials and better understood local needs. But under Thursday’s order, the federal government could pre-empt many state insurance rules, a prospect that alarms state insurance regulators.

The Washington Post editorializes, Trump ramps up the Obamacare sabotage campaign:

PRESIDENT TRUMP on Thursday signed an executive order directing his administration to ramp up its sabotage campaign against the Affordable Care Act, also known as Obamacare, also known as the health-care law without which millions of needy people would lack coverage.

The only good news is that the order merely instructs executive agencies to draw up some new, looser regulations, rather than immediately eroding Obamacare’s protections. The bad news is that those looser regulations may nevertheless come soon, and they could devastate the ACA’s carefully regulated marketplaces. Much depends on how reckless the leaders of agencies such as the Labor Department decide to be.

Obamacare’s underlying logic is that covering people who get sick or are likely to become sick, because of their age or preexisting conditions, requires a big insurance pool with enough healthy people to spread risk evenly. Republicans have argued that this system is unjust to the healthy and young, who pay more into the system than they get out of it, and that they can adjust the system to favor the fortunate without harming the unlucky. They are wrong, as analysis after analysis of their various health-care bills showed. That is one reason GOP lawmakers failed to pass the bills. Not taking the hint, Mr. Trump is now trying to undercut Obamacare’s insurance pool by executive fiat, sidestepping Congress.

The president’s executive order instructs the Labor Department to rewrite rules on health-care plans that small businesses can band together and buy into. Instead of being regulated like other Obamacare insurance plans, these association health-care plans would potentially not have to cover a slate of essential benefits. The plans could be cheaper but also useless for sick people. Also, insurers might be able to charge small employers much more for plans if they have older or sicker employees.

The result is that healthy people would end up covered with cheap and scanty association plans while sick people were left in the normal Obamacare market that guarantees them needed benefits. Premiums for those sick people then would skyrocket. The damage would be profound if the Labor Department concluded that individual insurance customers could buy into plans meant for small associations. Then many healthy individuals would exit Obamacare’s big insurance pool.

The president’s plan to enhance supposedly short-term insurance policies is similarly dangerous. Meant as stopgap insurance for people between jobs, these plans are almost totally unregulated — so they can be cheap, skimpy and fairly useless for sick people — but they can run only for three months. Mr. Trump’s executive order could allow them to run for 364 days in a year, enabling healthy people to use skimpy plans as their primary health-insurance policies. Once again, this would pull healthy people out of the Obamacare pool and into cheap, substandard plans, triggering a disastrous escalation in costs for those left behind in the ACA insurance pool.

Mr. Trump constantly criticizes Obamacare’s rising premiums. If his executive order is fully implemented, those premiums will rise a lot more — especially for some of the Americans who need help the most.

As the Post’s Greg Sargent notes, As Trump implodes, he threatens to hurt millions — out of pure rage and spite. This is a mentally and emotionally unstable man who is unraveling. See, Trump aides scramble to manage the president’s outbursts; “I Hate Everyone in the White House!”: Trump Seethes as Advisers Fear the President Is “Unraveling”. It’s time for Congress to act to stop Trump before he can harm any more Americans out of pure rage and spite.

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