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Trump just ended in Georgia

On election eve, the Trump administration is still working to roll back Obamacare.

President Trump’s Medicare administrator, Seema Verma, has approved Georgia’s plan to end the use of in the state.
AP Photo/Alex Brandon
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017. is the face of Obamacare, the online marketplace where millions of Americans sign up for health insurance — and now, two days before the 2020 election, the Trump administration has approved a plan to scrap the website in the swing state of Georgia.

In a Sunday announcement, which is highly unusual timing, as several health care experts noted, the US Department of Health and Human Services announced it had approved a plan from Georgia Gov. Brian Kemp to close to his state’s residents. They will instead be asked to shop for health insurance through brokers or on private websites.

“The Obamacare Exchanges have not worked for Georgians, leaving them with fewer options and skyrocketing premiums,” CMS Administrator Seema Verma said in a Sunday statement. “Today’s approval of the state’s waiver will usher in a groundswell of healthcare innovation that will deliver lower costs, better care, and more choice to Georgians in the individual market.”

That statement is untrue on both counts. Georgia’s uninsured rate today is 5 points lower today (13.7 percent) than it was before Obamacare took full effect (18.8 percent in 2013). More than 430,000 Georgians buy their health insurance through, and almost all of them receive premium subsidies created by the health care law. The reason the state’s uninsured rate isn’t even lower is its Republican leaders had refused to expand Medicaid through Obamacare, leaving 240,000 people without coverage. (We’ll come back to this in a moment.)

So, contrary to Verma’s claims, the ACA provided a lot of people in Georgia with health coverage. Moreover, experts expect thousands of people in the state could lose coverage as a result of this new waiver.

The Center on Budget Policy and Priorities laid out the ways people could lose coverage or face higher medical costs as a result of eliminating in Georgia. Consumers may be confused about where to buy coverage after seven years of using the federal website. Insurer brokers have incentives to steer people to non-ACA coverage that doesn’t cover preexisting conditions. Many private insurance exchanges sell noncompliant coverage alongside ACA plans.

“Evidence from past, far simpler transitions between federal and state marketplaces suggests that tens of thousands of Georgians might lose coverage simply because of the disruption from the state’s transition away from,” the center’s analyst, Tara Straw, wrote.

The Trump administration is approving health care proposals that could lead to thousands of people losing health coverage

For that reason alone, the Georgia waiver is arguably illegal. The waiver program under which the plan has been approved specifically stipulates that a state waiver cannot lead to people losing coverage or costs increasing.

Georgia and Trump’s health department say the state’s plan won’t lead to coverage losses. But outside experts disagree.

Christen Linke Young and Jason Levitis at the Brookings Institution pointed out in their analysis that 25 percent of Obamacare enrollees in Georgia don’t actively shop for their insurance; they are simply reenrolled in the same plan or a similar one year after year. The state assumes 90 percent of them would actively pick a new plan under this waiver, an assumption that Young and Levitis call “unreasonably optimistic.”

Instead, if you assume 95 percent of previously active shoppers find new coverage and 50 percent of the previously passive consumers also pick a new plan but the other 50 percent do not, that means about 50,000 people would become uninsured. That would be a blatant violation of the ACA’s waiver requirements.

“Despite the state’s claims to the contrary, the waiver proposal would likely cause tens of thousands of Georgia residents to lose their health insurance coverage, especially in the first year, and therefore fails to satisfy the statutory requirement that a 1332 waiver may not decrease the number of people with health insurance coverage,” they wrote.

But the Trump administration has repeatedly stretched its administrative authority to roll back Obamacare as far as it can go — and arguably beyond its legal bounds. That was also the case of Medicaid work requirements, which Verma also recently approved in Georgia, a plan specifically designed to circumvent the previous court rulings blocking Medicaid work requirements.

Georgia’s Medicaid plan would only partially cover the population meant to be covered by Medicaid expansion (up to 100 percent of the federal poverty level instead of 133 percent), and it would impose work requirements for many of the newly eligible people. So while the state estimates 64,000 people would gain coverage under the plan, that is a small fraction of the number of people who would gain coverage under regular expansion: just 11 percent, according to Georgetown University’s Center for Children and Families.

The state is also forgoing Obamacare’s 90 percent federal Medicaid expansion match under this plan, instead receiving its traditional 67 percent Medicaid match with the state on the hook for the other 33 percent.

“Georgia’s approach severely limits access to health insurance during a pandemic, conditions it on having work hours during a recession with high unemployment (especially in certain industries), and asks state taxpayers to pick up more of the tab at a time when state budgets are under considerable strain,” Georgetown’s Joan Alker and Allexa Gardner wrote.

The US uninsured rate was already increasing under Trump, and it could still get worse if he’s reelected. Even if Trump’s bid to get the Supreme Court to overturn Obamacare fails, he would have four more years to approve proposals like this. The only limitations would be whether states would want to take up the administration’s preferred policies — and clearly some, like Georgia, are — and whether the increasingly conservative judiciary would stop them.

To put it another way: These are the health care plans that the Trump administration has been approving in a swing state, on the eve of Election Day. If Trump is reelected, his health officials will be unbound by any electoral concerns. Georgia provides a preview of what the president could do if he wins a second term without having to pass a bill through Congress.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.