Dear MAGA: Mazel Tov; here's what you won!

Eight years ago I posted the following:

ACA Signing Off.

I made a commitment to keep this site up and running through next spring, and I intend on keeping this commitment. Beyond that, I have no idea what my plans for the site are.

After yesterday's atrocity, however...I'm honestly dreading the thought of what most of my charts, graphs, spreadsheets and blog entries are going to look like.

You see those impressive-looking odometer-style numbers at the top of the home page? Yeah, forget about those. They're meaningless now.

A lot of people will still sign up, but I'm guessing many who were planning on doing so once they were certain the ACA would still be around next year are now going to take a pass. And that's simply the beginning.

Beyond that...it's 4:30am. I'm exhausted, my stomach hurts and my hands are shaking.

God help us all.

I've spent the past week trying to decide how to approach the elephant in the room this time around.

Oddly enough, even though there's no longer anything stopping Trump & the GOP from doing so (not even John McCain's thumb), I'm not 100% certain that the ACA will be completely repealed "root & branch" as Mitch McConnell once put it, for a couple of reasons:

• First, the ACA is far more popular than it was in 2016. According to the KFF Tracking Poll, as of November 2016, the ACA was underwater with 45% disapproval vs. just 43% approval. As of April 2024, 62% approved vs. just 37% who disapproved.

• Second (and related to the point above), the ACA has far more Americans enrolled in it today than 8 years ago. In February 2017 only 10.3 million were enrolled in ACA policies, plus another 765K with BHP coverage & 15.7 million with ACA Medicaid expansion coverage (around 26.7 million total). As of this year those numbers are up to 21 million, 1.67 million and 22.4 million respectively, or 44.8 million people nationally.

So...it's possible that a Trump 2.0 Administration would instead follow the best-case scenario laid out in detail by my colleague Andrew Sprung here, which would amount to converting the individual health insurance market into a 2-tier system:

• So-called "Short-Term, Limited Duration" (STLD) plans would be vastly expanded & become the equivalent of pre-ACA "Major Medical" plans...with virtually no protections for those with pre-existing conditions, no guaranteed issue, no community rating, no guarantee of coverage of essential health benefits, etc. (aka "Junk Plans").

• The existing ACA market would continue to exist...except with the enhanced financial subsidies provided by the Inflation Reduction Act (IRA) being allowed to expire at the end of 2025, which would instantly cause net premiums to skyrocket for anyone earning more than 4x the federal poverty level.

By starving the ACA subsidies while opening the floodgates on junk plans, this would presumably cause millions of (relatively) currently-healthy ACA enrollees to drop out of the ACA exchange market and move to STLDs...assuming the insurance carriers don't deny them coverage, which they'd be allowed to do again.

This, in turn, would cause full-price ACA exchange premiums to skyrocket further yet, since the healthy enrollees would no longer be part of the risk pool & those left would be people who have the most expensive ailments.

In other words, the ACA marketplace would become a de facto High Risk Pool...presumably not including most of the ugliness which came with those at the state level in the pre-ACA era, in theory.

Something like the scenario laid out above would be pretty horrible for tens of millions of people, but it would at least be vaguely workable.

A second possibility, of course, is that they simply repeal the entire ACA after all, as they've been trying to do since the moment it was signed into law over 14 years ago.

If that were to happen--without some sort of semi-workable replacement plan in place--here's' what the healthcare coverage losses would look like in every state. (ACA Exchange data is as of February 2024; BHP enrollment is as of October or November; Medicaid expansion data was as of December 2023 and is likely several hundred thousand lower as of today):

And that's just the beginning. As Edwin Park of Georgetown University's Public Policy Center for Children & Families laid out last summer, here's what Trump has planned for Medicaid overall:

• It would convert federal Medicaid funding into BLOCK GRANTS (a set amount of money which would remain the same regardless of increased healthcare cost growth, enrollment growth, unexpected additional costs from recessions, disasters, another global pandemic, etc.

• It would require states to pay a much larger share of Medicaid costs

• It would eliminate states ability to use provider taxes, which states use to pay part of their share

• This in turn would prevent states from being able to access even the already-reduced federal revenue

• It would eliminate many Medicaid protections & requirements, including adding coverage time limits and lifetime benefit caps

• It would allow states to increase premiums & cost sharing for enrollees and add them to children and pregnant women

• It would allow states to drop coverage of nursing home care and long-term services

• States would no longer have to coverage non-elderly non-disabled parents

• It would add more red tape & make it more difficult for people to apply for, enroll in and renew their coverage

• It would let states add work reporting requirements, which have proven to be a disaster in the handful of states that it's been allowed for to date

• It would push for Medicaid vouchers for less affordable & far less comprehensive private coverage

• It would remove most federal oversight of state Medicaid programs...except for abortion & reproductive healthcare, where it would crack down with draconian federal requirements including prohibiting Planned Parenthood from receiving federal funding, prohibiting coverage of travel to get an abortion and eliminating Medicaid funding for states which require abortion coverage in private policies*

Overall, he estimates federal Medicaid funding would be slashed by over 50% over the next decade.

This is what you voted for, America.