Donald Trump’s first executive order as president appears to be aimed at fulfilling his promise of weakening the Affordable Care Act (ACA). The order is confusing, though, because it doesn’t really do anything immediately. It emphasizes that the next Health and Human Services (HHS) secretary will be in charge of implementing the law as s/he sees fit, which is that job description anyway. The primary content of the order is the framing of the ACA as a burden on many groups of people and the intent is to reduce that burden. Okaaay, but…
The emphasis on giving more control to the states and reducing the financial burden on states is striking. This appears to show belief in disinformation about the law rather than the reality that the ACA has a been a boon to some states. The role of the states in ACA centers around Medicaid expansion. The reality is that the ACA for states that expanded Medicaid has been a windfall. In fact, governors are worried about ACA repeal because of the huge hole repeal will put in their budgets. Giving an order that the ACA must be implemented to reduce the burden on states could be interpreted as encouraging states that haven’t done so already to expand Medicaid. No?
A constant refrain about the ACA is that it is oppressive federal intrusion on the states, but calling it oppressive has always been disingenuous because the federal government has shown great willingness to grant wavers and flexibility to the states in how to implement Medicaid expansion. Trump’s first executive order seems to be encouraging efforts already underway to help craft expansion in a way that the states agree to.
Similarly, the ACA has provided subsidies to reduce the burden of the law on individuals, and the order could be interpreted to make sure these subsidies are maintained. Others have interpreted the order as an attack on the individual mandate. But the mandate is intended to reduce the burden of health costs on more people.
This order does nothing to repeal the law. That is up to congress. Tom Price, or whoever is chosen to lead HHS, will have huge discretion in how to implement the law as it stands now – just as Sylvia Burwell did. To my eyes, the order says, “Obamacare is dead! Long live Obamacare!” It underscores that the title of the law is despised, but the content is not. If I were a Democrat right now, I would see this as an opening for a win-win effort to improve upon the ACA by emphasizing the intent to reduce hardships. Yes, maintaining the framework of the ACA is at odds with the substance of plans GOP lawmakers have floated, but this order seems to suggest that Trump is not yet on their page.