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Trump hates Obamacare. He’s also in charge of running it.

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The Trump administration will, in the coming weeks and months, need to make a decision: Does it want to force Obamacare's collapse?

President Trump for months now has predicted Obamacare's implosion. His most recent forecast came Monday night, as Senate Republicans' repeal effort began to falter.

Trump often talks about Obamacare's "failure" like a predetermined, fixed event on the horizon. That is hardly the case: Much of Obamacare's success or failure rests on the decisions the Trump administration will make.

"There is little question in my mind that through active mismanagement, you could do a lot of damage," says Andy Slavitt, who previously served as Medicare administrator under President Obama. "There are an untold number of ways you could mismanage this thing."

Obamacare is not a program that runs on autopilot. It requires active management and policy decisions about how to allocate resources, and how to communicate with the health plans that sell coverage. These decisions will need to be made in the coming months, and they'll determine whether Trump's predictions come true.

Slavitt, an advocate for the Affordable Care Act, demurred when I asked him about what opportunities for mismanagement exist — he didn't want to hand the White House a playbook for sabotage. Still, it's not hard to come up with a list of key decision points that sit in front of the Trump administration right now:

  • Do they commit to paying cost-sharing reduction subsidies or continue to stoke uncertainty? The Trump administration has been aggressively ambiguous when asked about whether it will continue making these payments to cover the bills of low-income Obamacare enrollees. Not making these payments or stoking uncertainty about their future is an easy way to encourage insurance plans to raise premiums or quit the marketplaces altogether.
  • Do they actively recruit health plans to join the marketplaces? About this time last year, Obama administration officials were crisscrossing the country, ensuring that each county would have at least one health plan selling coverage in the next open enrollment. There is no indication that the Trump administration — which sends out press releases highlighting how few insurers want to sell Obamacare — is taking similar steps. That would be an easy way to depress health plan competition under the health law.
  • Do they advertise the Affordable Care Act's open enrollment period? One of the Trump administration's first actions on health care was to attempt to pull Affordable Care Act advertisements that let people know they could sign up for coverage. Whether the Trump administration publicizes enrollment opportunities or does little in public education will make a big difference for the marketplaces' stability.

So far, we've generally seen the Trump administration make policy decisions that hurt Obamacare. It won't commit to paying the law's cost-sharing reduction subsidies.

Office of Management and Budget Director Mick Mulvaney reportedly told health insurance officials this week that "we are looking at the cost-sharing payments on a month-to-month basis. We made them today. We'll make them tomorrow. But I don't think we'll see a long-term commitment from this administration."

At the same time, the Trump administration doesn't seem quite ready to press the explode button yet. This was made apparent last week when Health and Human Services approved funding for a program that would make Obamacare work better in Alaska. It was the rare Trump administration action that Slavitt praised.

"It was a really good decision, and I applaud it," he says.

Myriad decisions face the Trump administration in the coming weeks and months. It will be these decisions that determine whether Trump's prediction ultimately comes true.

Quote of the Day

“The best way to stop bogus health claims from taking off is to teach people how to think critically about the information they receive from a very early age.” - Julia Belluz, Senior Health Reporter Julia Belluz/Vox

The rise of pseudoscience — and how to stop it. I very much enjoyed taking a break from health policy news to read Julia Belluz's excellent piece on the rise of Goop, the lifestyle brand owned by Gwyneth Paltrow, and what it says about our vulnerability to false health claims. Read the story here.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

Analysis and longer reads

  • “How the Senate Health Care Bill Failed: G.O.P. Divisions and a Fed-Up President”: “The Senate bill, which faced a near-impossible path forward after the House passed its version of the legislation in May, was ultimately defeated by deep divisions within the party, a lack of a viable health care alternative and a president who, one staff member said, was growing bored in selling the bill and often undermined the best-laid plans of his aides with a quip or a tweet.” —Jennifer Steinhauer, Glenn Thrush, and Robert Pear, New York Times
  • "Are Republicans Finally Ready to Fix Obamacare?": “The Senate’s old guard, after watching the party’s leaders leadership flail their way toward legislative disaster over the past few weeks, may be moving to reassert its institutional authority. But one key ally who isn’t on board yet is President Trump, who on Tuesday called on Republicans in a tweet to 'let Obamacare fail.'” —Rob Garver, Fiscal Times
  • "Health experts puzzled by HHS analysis of Cruz amendment": “Sen. Ted Cruz got some good news to take into today's White House lunch with President Trump and the other Republican senators: a Department of Health and Human Services analysis that says his insurance deregulation provision in the Senate health care bill would lower premiums, both for people in traditional Affordable Care Act plans and in less regulated plans that wouldn't meet its standards. But that's almost the exact opposite of what most experts, as well as actuaries and the main health insurance trade groups, say would happen.” —David Nather, Axios

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