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Surprise! Some new Obamacare enrollment rules are out.

The Trump administration is starting to remake Obamacare as its own.

Photo by Brendan Smialowski/Getty Images
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.

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We just got some brand new rules from the Trump administration on Obamacare enrollment.

These have been expected for a while; the wonks call it the "market stabilization" rule. The point, from the Trump administration's view, is to put some new restrictions on enrollment in order to improve the insurance pool for plans on the exchanges, prevent huge premium increases, and stop more insurers from dropping out. You've heard a lot of talk from President Trump about the exchanges imploding, but this is supposed to help.

Here are the highlights:

  • A shorter open enrollment period. The window to sign up for insurance this year will be from November 1 to December 15, instead of January 31 — cutting the window nearly in half, from 91 days to 44. The Department of Health and Human Services says this will discourage people from signing up only because they get sick toward the end of the enrollment period.
  • More verification of special enrollments. Health plans fret about special enrollment periods, which allow people who didn't sign up during the normal window to get coverage. This rule would beef up the verification process to make sure people who sign up that way really qualify — for reasons like losing your health insurance, moving, or getting married.
  • You gotta pay your premiums. The new rule would also require enrollees to pay any outstanding premiums they owe before their new coverage begins. (I'm told insurers are frustrated that healthy people could stop paying their premiums at the end of the year and then re-enroll for the next year with no penalty.)
  • More wiggle room on benefit levels. Obamacare plans have what's called an actuarial value: A silver plan covers 70 percent of costs, for example. But really, plans had some wiggle room: A silver plan covered 68 to 72 percent of costs. This rule expands that flexibility a little more — now, for example, a silver plan can be a bit skimpier and cover 66 to 72 percent of costs. One other drawback: Because the tax credits people receive are based on the cost of silver plans, this could reduce financial assistance offered through the law.
  • Outreach. The Trump administration is also committing to doing some kind of outreach (it remains to be seen how much) to make sure people know to sign up. You might remember that they cut off outreach at the end of this year's enrollment, and experts blamed that in part for a slight drop in enrollment from last year.

These rules are a double-edged sword: They're going to make it harder to sign up for coverage, but they could also help the market function better. Here's how friend of VoxCare Larry Levitt at the Kaiser Family Foundation put it on Twitter:

If you want to get out of Washington, we have a new Medicaid expansion battleground: North Carolina.

People have started wondering: If Obamacare is here to stay, will more states expand Medicaid? It's a big question. An estimated 2.6 million people haven't been covered because their state hasn't yet expanded the program.

You might remember the brief fight this month in Kansas, where a Republican-led government nearly approved Medicaid expansion but ultimately failed. North Carolina looks like the next stop.

At the end of last week, some prominent Republican legislators there introduced a bill to expand Medicaid. It's worth taking seriously. These aren't just any lawmakers; they include the leader of the state House's health committee.

Their plan features some provisions that the Obama administration likely would have rejected, but that President Trump's team might agree to. Here are the highlights:

  • Enrollees would be required to pay a premium equal to 2 percent of their income. There would be some exceptions, including for the poorest.
  • Enrollees would also be required to pay copays for their health care.
  • With a few exceptions, enrollees would be subject to work requirements. The bill isn't specific, but that usually means they must work, look for work, or be in job training.

The last point is a big one. The Obama administration drew a red line on Medicaid work requirements, but Trump health officials have signaled they're open to them, even if there are good arguments that they don't do much. Republicans had previously rejected Medicaid expansion in 2013, and it seems like the opportunity to implement a more conservative version under Trump is what motivated this new plan.

One thing the plan's proponents have going for them that Kansas didn't is a Democratic governor, Roy Cooper, who wants to expand Medicaid. Cooper even tried to do it on his own earlier this year, but he was blocked by a state court because of the 2013 law rejecting the program.

Some top Republicans are still skeptical, however, so it's not a slam dunk — just more evidence that many of the big Obamacare stories are unfolding outside Washington.

Chart of the Day

Health Affairs

Medicaid recipients don't work for a reason. Work requirements are in vogue, as North Carolina's plan shows. But if you look at why Medicaid enrollees aren't working or looking for work, the policy's limits become clear: Even if they aren't on disability, they have good reason to be out of a job. Read more at Health Affairs.

Kliff's Notes

With research help from Caitlin Davis

  • "Behind closed doors, Trump signs bill allowing states to strip federal family planning funds from abortion providers": “President Trump signed legislation Thursday allowing states to withhold federal family planning dollars from clinics that provide abortion services, a move that effectively deprives Planned Parenthood and several other family groups of a significant source of funding. The move marked the 12th time that Trump has signed a resolution under the 1996 Congressional Review Act (CRA) abolishing a rule issued under President Barack Obama.” —Juliet Eilperin, Washington Post
  • "In Remote Idaho, A Tiny Facility Lights The Way For Stressed Rural Hospitals": “For rural hospitals, telehealth can make otherwise faraway services accessible to people where they live, said Keith Mueller, director of the Center for Rural Health Policy Analysis at the University of Iowa. That can be critical, especially during the winter when snowstorms sometimes cut off access to rural towns." —Anna Gorman, Kaiser Health News
  • "Coffman pummeled at town hall over GOP Obamacare repeal": “Coffman put his political career on the line several weeks ago when he threw his support behind Speaker Paul Ryan’s health care bill, legislation with a 17 percent approval rating. Ryan ultimately pulled the bill from the floor amid a collapse in GOP support — but not before Coffman went on record as a supporter. Now, the five-term centrist, one of the most vulnerable members in the House GOP Conference, is paying for it in his district, which Hillary Clinton last year carried by 9 points.” —Rachael Bade, Politico

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