By Michael Ollove, Stateline

President Donald Trump has spent four years trying to undermine the Affordable Care Act. President-elect Joe Biden has pledged to bolster the law and give states new tools to expand coverage.

Among them: more money and additional guides to help people buy health insurance on the ACA exchanges; support for states that want to allow more people onto Medicaid rather than fewer; and a crackdown on health care plans that don’t offer the minimum benefits required by Obamacare.

Unlike the Biden health care idea that has attracted the most attention—the addition of a Medicare-like public option to the ACA exchanges—Biden could make these changes through executive orders, without congressional approval.

By doing so, advocates hope Biden would reverse the uptick in the rate of Americans without insurance. The percentage of Americans without coverage declined during the Obama administration after implementation of the ACA, but the rate climbed during the Trump administration, even before the economic blowback of the coronavirus pandemic cost 7.7 million Americans their employer-sponsored health insurance.

“It’s critical that we get that turned around,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families, which promotes access to affordable health care. 

The U.S. Supreme Court could extinguish Biden’s efforts to strengthen Obamacare by striking down the law in a case brought by Republican governors and state attorneys general. But after oral arguments earlier this month, most court observers consider that outcome to be highly unlikely. A final ruling isn’t expected before March.

Assuming the law stands, state officials who support the ACA are looking forward to having an ally in the White House.

Pennsylvania Insurance Commissioner Jessica Altman, a strong ACA supporter, said that after four years of federal hostility toward the law, she and other state officials will be grateful “for all of us to be rowing in the same direction.”

Undermining the Exchanges

One of the main issues health policy experts expect Biden to quickly address is Healthcare.gov, the federal health insurance marketplace where people can enroll in ACA-compliant health insurance plans and learn about the federal subsidies they qualify for based on their income. (These plans are distinct from employer-sponsored health plans.)

The ACA gave all the states the option of running their own health exchanges, and so far, 14 states and Washington, D.C., have elected to do so. The rest either use the federal website Healthcare.gov or rely on some aspects of it in a hybrid arrangement.

Initially, Obamacare provided money to nonprofit organizations in states that use the federal exchange to boost enrollment through marketing and outreach. The money also paid for counselors known as navigators to help consumers compare options, understand the federal subsidies available to them and sign up for plans.

The Trump administration cut almost all that funding, which comes from user fees imposed on health insurance carriers. That reduction contributed to an enrollment drop on the federal exchange of 13.5% between 2016 and 2020. Analysts think Biden will quickly restore that funding, a move that would be particularly helpful to low-income people and immigrants. Analysts say he can do that without congressional action.

“If you are unfamiliar with insurance, having someone to help walk you through that is very important, not only in signing up for a plan but in how to use their benefits,” said Amy Behnke, the CEO of the Health Center Association of Nebraska, a state that relies on the federal exchange. “For people who haven’t had access to insurance before, using the marketplace can be overwhelming and confusing.”

Biden’s support for the federal exchange might boost participation in states that operate their own exchanges, officials in some of those states say, because he can use his bully pulpit to spread the word. Unlike Healthcare.gov, state-based exchanges have continued to provide enrollment and outreach services, but they can’t match the full-throated support of a presidential administration.

“A national approach from Washington would shine a big light and help all of us improve our enrollment,” said Mike Kreidler, the insurance commissioner of Washington, which runs its own exchange.

A Kaiser Family Foundation survey published this summer found that fewer than a third of respondents realized that the Affordable Care Act, which established the health exchanges, still exists.

Trump also took other swipes at the federal exchange. Beginning in 2017, the administration shortened the time people had to sign up for insurance on the federal exchange, eventually cutting that window from three months to 45 days. After COVID-19 struck, the Trump administration refused to add special enrollment periods, unlike many states that run their own exchanges. 

Analysts expect Biden to restore the longer open enrollment period and implement special enrollment periods during the pandemic.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, said she also is hopeful that Biden will push for greater subsidies to help low-income Americans pay their health insurance premiums.

In 2017, Trump cut part of that assistance. Eberle would like to see the Biden administration increase subsidies, particularly to entice younger, healthier people to buy insurance, which would help lower premiums for everyone. 

“We do know that younger folks, between 18 and 34, often feel that premiums are out of their cost range or they choose to be uninsured,” Eberle said. Extra help from the federal government, she said, “would attract the younger cohort to come in and get insured.”

Some advocates hope the Biden administration will take steps to encourage states to follow the examples of Minnesota and New York, which have created state-run health care plans for people with incomes too high to qualify for Medicaid but who still can’t afford the premiums on the health exchanges. 

And advocates for the poor want Biden to also allow tax credits for people who have access to an employer-provided plan but would rather purchase an exchange plan. Many employer plans have higher out-of-pocket expenses than plans available on the exchanges. 

That change, which Biden might not be able to make without congressional approval, could benefit more than 12 million people, according to an analysis by the Kaiser Family Foundation.

Reversing Trump on Medicaid

Another broad area where analysts expect Biden to have a major impact is Medicaid, the public health plan for the poor that is jointly financed by the federal and state governments. 

Although Congress and the federal Centers for Medicare and Medicaid Services set many of the policies governing Medicaid, states can apply for waivers to customize their programs. Critics say the Trump administration has used this power to encourage and approve waivers that make it harder for eligible people to enroll in the program or to access the benefits.

For example, the administration has allowed states to impose work requirements, premiums and other fees on Medicaid recipients. It also has approved technical changes making it more difficult for people to join or remain enrolled in the program.

Seema Verma, the administrator of CMS under Trump, has said the waivers give states much-needed flexibility. “I am supportive of states making decisions about their programs and deciding what has worked best,” Verma told the Aspen Institute last month.

Defending work requirements, Verma has cited data suggesting that people who work are healthier. “When we talk about social determinants of health, just giving somebody a Medicaid card isn’t going to solve their problems,” she said.

Verma’s CMS has approved work requirements in 10 states, but they have not taken effect in any of them. Federal courts struck down the requirements in Arkansas, Indiana, Michigan and New Hampshire. The U.S. Supreme Court is expected to announce Friday whether to take up appeals of those cases.

Most people on Medicaid already work, according to researchers. And a New England Journal of Medicine study of Arkansas’s program found that before the work requirement was suspended, it led to 17,000 people losing Medicaid coverage but no significant gain in employment.

Judy Solomon, a health policy analyst with the progressive Washington, D.C., think tank the Center on Budget and Policy Priorities, said many of the Trump Medicaid waivers were intended to create obstacles for people wanting coverage, and are not consistent with the law creating the program.

“My feeling is that these restrictions were not contemplated in Medicaid, and there’s no evidence that they work,” she said. 

Solomon and other analysts predict that Biden will withdraw federal approval of many of the waivers or allow them to expire when they come up for renewal.

Some conservative-leaning states expanded Medicaid based partly on federal approval of work requirements. But even without those requirements, it seems unlikely that the states would pull back, given the federal money that expansion triggers and the strong public support for Medicaid. Voters in five states, Idaho, Missouri, Nebraska, Oklahoma and Utah, have approved expansion since 2018. 

Instead of approving waivers that curb Medicaid coverage, the Biden administration is likely to approve states’ ideas for expanding it, such as covering substance use treatment and making it easier to enroll recently released inmates. Advocates also expect the new administration to explore enticements that could lure the final 12 states to expand their Medicaid programs to cover all low-income adults.

Aside from the health exchanges and Medicaid, advocates and analysts expect Biden to overturn other Trump actions, including one adopted in June that removed a prohibition against discriminating against transgender people in health care and health insurance.

They also expect Biden to crack down on the ability of insurers to offer cheaper policies that don’t comply with minimum standards set by the ACA. Trump removed those barriers, though 10 states have maintained prohibitions against such policies.

If, contrary to most expectations, the Supreme Court were to abolish the ACA, Biden would face a Herculean task in trying to pass a new health plan, even if Democrats attain control of the Senate. 

States would be hard-pressed to launch their own versions of Obamacare without federal funding. Gone would be subsidies for exchange health plans, the Medicaid expansion and popular features such as protections for people with pre-existing conditions­.

“It’s difficult to imagine states could come up with that funding, especially in the midst of COVID when state budgets have taken significant hits,” said Altman, Pennsylvania’s insurance commissioner.