Executive Order 13813

Executive Order 13813[1][2][3]
	Executive Order Promoting Healthcare Choice and Competition
Type	Executive order
Executive Order number	13813
Signed by	Donald Trump on October 12, 2017
Federal Register details
Federal Register document number	2017-22677
Publication date	October 17, 2017
Document citation	82-48385
Summary
	Allows insurance companies to sell low-cost short-term plans with lesser coverage;; Enables small business to collectively purchase association health plans;; Expands health savings accounts;

The Executive Order Promoting Healthcare Choice and Competition, also known as the Trumpcare Executive Order, or Trumpcare,[4][5] is an Executive Order signed by Donald Trump on October 12, 2017, which directs federal agencies to modify how the Patient Protection and Affordable Care Act of the Obama Administration is implemented. The order included a directive to federal agencies to end rules forbidding employers from using health reimbursement arrangements (HRAs) to pay individual insurance premiums.[6]

President Trump signing the Executive Order, October 12, 2017.

In a separate announcement made shortly after the order was signed, Trump announced that he would end subsidies to health insurance companies that sell to low-income consumers through the state health insurance marketplaces.[7][8]

Some sources have described the effect of these executive actions as replacing Obamacare with a new healthcare regime; several days after signing the order, Donald Trump himself stated in a press conference that reporters should no longer refer to "Obamacare" because "it's gone, there is no such thing as Obamacare anymore".[9]

History

Legislative efforts to repeal the Affordable Care Act

The first executive order signed by U.S. President Donald Trump, executed just hours after he was sworn into office on January 20, 2017, was Executive Order 13765, titled Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal. The order set out interim procedures in anticipation of repeal of the Patient Protection and Affordable Care Act (popularly known as the ACA, or Obamacare).[10] The order came on Trump's campaign pledges to repeal the Patient Protection and Affordable Care Act,[11] which Trump stated would take a long time, with a replacement possibly not being ready until 2018.[12]

On May 4, 2017, the United States House of Representatives voted to pass the American Health Care Act of 2017 (ACHA) by a narrow margin of 217–213, sending the bill to the Senate for deliberation.[13][14][15][16][17] It would repeal the parts of the Affordable Care Act within the scope of the federal budget, including provisions contained within the Internal Revenue Code such as the "individual mandates" (in IRC § 205), employer mandates (in IRC § 206) and various taxes (IRC § 201 et. seq.), and also modifications to the federal Medicaid program (in Sections 111-116 and 121).[18]

The nonpartisan Congressional Budget Office projected that the AHCA would increase the number of uninsured people by 23 million over 10 years, but would decrease the federal budget deficit by $119 billion over the same period (about 1%), mainly by cutting Medicaid coverage for lower income Americans. Both the House AHCA bill and Senate BCRA bill would cut taxes largely for wealthy Americans. Insurance premiums were projected to decrease for younger, healthier, and wealthier people, while older and poorer people would likely see their premiums increase.[19]

Senate Republicans initially approached the AHCA with an unprecedented level of secrecy; a group of 13 Republican Senators drafted the Senate's substitute version in private, raising bipartisan concerns about a lack of transparency[20][21][22] and about the all-male composition of the committee.[23][24][25] On June 22, 2017, Republicans released the first discussion draft for an amendment to the bill.[26] On July 25, 2017, although no amendment proposal had yet garnered majority support, Senate Republicans voted to advance the bill to the floor and begin formal consideration of amendments.

On July 28, 2017, the bill was returned to the calendar[27] after the Senate rejected several amendments, including S.Amdt. 667, the "Skinny Repeal" package offered by Sen. Mitch McConnell, which failed on a 49–51 vote. Sens. John McCain, Susan Collins, and Lisa Murkowski were the only Republicans to vote against the measure.[28] On September 13, 2017, Senators Graham, Cassidy, Heller, and Johnson released a draft amendment to the bill[29] that "repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states".[30] However, it was not voted upon due to lack of support. The deadline for Congressional Republicans to end the ACA as part of the Congressional budget reconciliation process (which would enable Senate Republicans to pass new legislation with 51 votes, rather than 60) then expired on September 30, 2017.[31]

Execution of the Executive Order

Following the failure of Congress to repeal the ACA through legislation, Trump issued the new order. Both supporters and critics asserted that the provisions of the order were intended to redefine the American health care market and effectively replace Obamacare with a new health care regime.[4][32] Trump briefly forgot to sign the order before leaving the signing ceremony, but was ushered back to the table by Vice President Mike Pence to complete this step.[33] Senator Rand Paul, who attended the signing, described the order as "the biggest free market reform of health care in a generation".[32]

Provisions

The order reverses a number of aspects of Obamacare upon which that regime had relied.

Section 1, title "Policy", lays out the policies supporting the provisions of the order, noting that the order directs that the government "facilitate the purchase of insurance across State lines" and prioritizes "association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs)". Whereas Obamacare had prohibited insurance companies from selling low-cost short term health insurance plans "that can circumvent some of the mandates created under Obamacare",[4] such as requiring coverage for persons with preexisting conditions, and requiring coverage for various medical services. The order reversed this prohibition, and also directs the Departments of Health and Human Services, Labor, and Treasury to ease access to "association health plans", which also need not provide the coverage that had been mandated by Obamacare, and expands health savings accounts.[4]

Section 2, titled "Expanded Access to Association Health Plans", directs the Secretary of Labor to take steps to "expand access to health coverage by allowing more employers to form AHPs".

Section 3, titled "Expanded Availability of Short-Term, Limited‑Duration Insurance", directs the Secretaries of the Treasury, Labor, and Health and Human Services to take steps to "expand the availability of STLDI".

Section 4, titled "Expanded Availability and Permitted Use of Health Reimbursement Arrangements", directs the Secretaries of the Treasury, Labor, and Health and Human Services to take steps to "increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage".

Impact

A separate decision on the same day commonly associated with the executive order resulted in no longer paying the cost sharing reduction (CSR) subsidies, which are payments to insurers to keep premiums down for low-income persons. The Congressional Budget Office reported in August 2017 that not making the CSR payments could increase health insurance premiums on the ACA exchanges by as much as 20% and add nearly $200 billion to the budget deficit over a decade. The deficit increase is because the premium tax credit subsidy (the largest Affordable Care Act subsidy) increases to offset increases in health insurance premium amounts, far outweighing savings from not paying the smaller CSR subsidy.[34]

Reception

Critical response

Critics described the Executive Order as another part of an ongoing strategy to sabotage the ACA by enabling insurance companies to circumvent ACA mandates and sell insurance that does not cover mandated conditions, and excludes individuals with pre-existing conditions. Other elements alleged to be part of the sabotage strategy include denying funding not mandated by law for cost sharing reduction (CSR) subsidies, significantly reducing funding for enrollment advertising and support efforts, asserting that the ACA exchanges are in a "death spiral" (contrary to CBO conclusions), and conducting negative advertising campaigns, among other measures.[35][36]

For example, President Trump tweeted on October 13, 2017 that: "The Democrats ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!". Journalist Ezra Klein wrote that: "Trump has long held the view that if he can inflict sufficient damage to the Affordable Care Act, Democrats will have no choice but to cut a deal — on Trump’s terms — to save it".[37]

Journalist Sarah Kliff wrote that: "Trump announced last week he would stop making [CSR] payments. But let's be clear: That decision will cause the federal government to spend billions more subsidizing insurance companies, not less." That is because the savings from reducing CSR payments is less than increases in the insurance premium tax credits, which rise along with sizable (20%+) premium increases for 2018 caused by Trump's threats to the CSR payments during 2017. Kliff used the CBO estimate of $194 billion in higher budget deficits from stopping CSR payments as an estimate of the net impact over a decade.[38]

Journalist David Leonhardt wrote on October 15, 2017: "Last week, the administration took several steps to deprive people of health insurance. In doing so, it has both a short-term goal (have the federal government do less to help vulnerable citizens) and a long-term goal (sabotage Obamacare, so that Congress can more easily repeal the law)". He continued: "When [the executive order] takes full effect, it will most likely allow a variety of cheap insurance plans that don’t cover many treatments. These plans will siphon healthy families from the normal markets, raising prices on the sick. It will work nicely for healthy families, until it doesn’t. If they get sick and want insurance that pays for their treatments, they will be out of luck".[39]

According to The Economist, Trump’s plans "are likely to end up inflicting the most pain on self-employed, middle- to upper-income folk—in other words, on a Republican constituency".[40]

Murray—Alexander Individual Market Stabilization Bill

Senator Lamar Alexander and Senator Patty Murray reached a compromise to amend the Affordable Care Act to fund cost cost-sharing reductions.[41] President Trump had stopped paying the cost sharing subsidies and the Congressional Budget Office estimated his action would cost $200 billion, cause insurance sold on the exchange to cost 20% more and cause one million people to lose insurance.[42] The plan will also provide more flexibility for state waivers, allow a new "Copper Plan" or catastrophic coverage for all, allow interstate insurance compacts, and redirect consumer fees to states for outreach.

Although Trump initially expressed support for the compromise, he later reversed course by tweeting a dismissive tweet about it.[43]

gollark: Well, maybe not "deliberately", but they do.

gollark: This is usually quite helpful in case a word is partly misheard.

gollark: Languages deliberately encode some information redundantly.

gollark: newspeak be doubleplusgood.

gollark: We should use Newspeak.

References

"EXECUTIVE ORDER 13813" (PDF). Amazon S3. United States: Amazon.com. October 12, 2017. Retrieved October 17, 2017.
Office of the Press Secretary (October 12, 2017). "Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States". whitehouse.gov. Washington, D.C.: White House. Retrieved October 17, 2017.
"Promoting Healthcare Choice and Competition Across the United States". Federal Register. Washington, D.C.: National Archives and Records Administration. October 12, 2017. Archived (PDF) from the original on October 17, 2017. Retrieved October 17, 2017.
Klein, Philip; King, Robert; Leonard, Kimberly (October 9, 2017). "Daily on Healthcare: Trumpcare is coming to an association health plan near you". The Washington Examiner. Washington, D.C.: Clarity Media Group. Archived from the original on October 9, 2017. Retrieved October 12, 2017.
Gleckman, Howard (October 13, 2017). "Middle Income 50-Somethings Will Be Big Losers In Trumpcare". Forbes. New York City: Forbes, Inc. Retrieved October 13, 2017.
Luhby, Tami (October 13, 2017). "What's in Trump's health care executive order?". CNN. Atlanta: Turner Broadcasting System. Retrieved October 14, 2017.
Liptak, Kevin (October 12, 2017). "Trump will end health care cost-sharing subsidies". CNN. Atlanta: Turner Broadcasting System. Retrieved October 12, 2017.
Robert Pear, Maggie Haberman and Reed Abelson (October 12, 2017). "Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again". New York Times. Retrieved October 14, 2017.
"Trump: No such thing as Obamacare anymore". CNN. Atlanta: Turner Broadcasting System. October 16, 2017. Retrieved October 18, 2017.
Knox, Olivier (January 20, 2017). "Trump signs first executive order, targeting Obamacare with few specifics". Yahoo! News. Sunnyvale, California: Yahoo!. Retrieved October 13, 2017.
Davis, Julie Hirschfeld; Pear, Robert (January 20, 2017). "Trump Issues Executive Order Scaling Back Parts of Obamacare". The New York Times. New York City: The New York Times Company. Retrieved January 23, 2017.
Leonard, Kimberly (February 6, 2017). "Trump Appears to Push Back Obamacare Replacement". U.S. News & World Report. Washington, D.C.: U.S. News & World Report, L.P. Retrieved October 13, 2017.
Kaplan, Thomas; Pear, Robert (May 4, 2017). "House Passes Measure to Repeal and Replace the Affordable Care Act". The New York Times. New York City: The New York Times Company. Archived from the original on May 4, 2017. Retrieved October 12, 2017.
Sanger-Katz, Margot (May 4, 2017). "Who Wins and Who Loses in the Latest G.O.P. Health Care Bill". The New York Times. New York City: The New York Times Company. Archived from the original on May 4, 2017. Retrieved October 12, 2017.
Clerk of the United States House of Representatives (May 4, 2017). "Final Vote Results for Roll Call 256". United States House of Representatives. Washington, D.C.: United States Congress. Archived from the original on October 12, 2017.
Lee, MJ (May 4, 2017). "House Republicans pass bill to repeal and replace Obamacare". CNN. Atlanta: Turner Broadcasting System. Archived from the original on May 5, 2017. Retrieved May 4, 2017.
Associated Press. "Republican health care bill: What's in it?". Fox News. New York City: Fox Entertainment Group. Archived from the original on May 4, 2017. Retrieved October 12, 2017.
Clerk of the United States House of Representatives (May 4, 2017). "All Bill Information (Except Text) for H.R.1628 – American Health Care Act of 2017". United States House of Representatives. Washington, D.C.: United States Congress. Archived from the original on April 19, 2017. Retrieved October 12, 2017.
Kurtzleben, Danielle (May 24, 2017). "GOP Health Plan Would Leave 23 Million More Uninsured, Budget Office Says". NPR. Washington, D.C.: National Public Radio, Inc. Archived from the original on June 21, 2017. Retrieved October 13, 2017.
Kaplan, Thomas; Pear, Robert (June 15, 2017). "Secrecy Surrounding Senate Health Bill Raises Alarms in Both Parties". The New York Times. New York City: The New York Times Company. Archived from the original on June 18, 2017.
Bump, Philip (June 13, 2017). "The remarkable steps Republicans are taking to obscure what's in their health-care bill". The Washington Post. Washington, D.C.: Nash Holdings LLC. Archived from the original on June 20, 2017. Retrieved October 13, 2017.
Sarlin, Benjy; Caldwell, Leigh Ann (June 15, 2017). "The Senate's Health Care Bill Remains Shrouded in Secrecy". NBC News. New York City: NBC. Archived from the original on June 19, 2017.
Kasana, Mehreen (May 7, 2017). ""The 13 Senators Working on the Health Care Bill Are All Men"". Bustle. New York City: Bustle Digital Group. Retrieved October 13, 2017.
Pear, Robert (May 8, 2017). "13 Men, and No Women, Are Writing New G.O.P. Health Bill in Senate". The New York Times. New York City: The New York Times Company. Retrieved October 13, 2017.
Cohen, Michael A. (June 7, 2017). ""Why are 13 men — behind closed doors — writing the health care bill?"". The Boston Globe. Boston: Boston Globe Media Partners, LLC. Retrieved October 13, 2017.
Black, Diane (June 22, 2017). "H.R. 1628, Better Care Reconciliation Act of 2017, discussion draft ERN17282" (PDF). Senate Budget Committee. Washington, D.C.: United States Senate. Retrieved October 13, 2017.
"Congressional Record p. S4415" (PDF). United States Senate. Washington, D.C.: United States Congress. July 27, 2017. Retrieved October 13, 2017.
Black, Diane (July 28, 2017). "On the Amendment S.Amdt. 667". United States Senate. Washington, D.C.: United States Congress. Retrieved October 13, 2017.
Graham, Lindsey (September 13, 2017). "Amendment in the nature of a substitute to H.R. 1628, discussion draft LYN17709". United States Senate. Washington, D.C.: United States Congress. Retrieved October 13, 2017.
Graham, Lindsey (September 13, 2017). "Press Release: Graham-Cassidy-Heller-Johnson Background and Endorsements". United States Senate. Washington, D.C.: United States Congress. Retrieved October 13, 2017.
King, Robert (September 1, 2017). "Deadline for fast track Obamacare repeal bill expires Sept. 30". Washington Examiner.
Schallhorn, Kaitlyn; Gomez, Serafin (October 12, 2017). "Trump clears way for ObamaCare 'alternatives' in new executive order, goes around stalled Congress". Fox News. New York City: Fox Entertainment Group. Retrieved October 12, 2017.
Wilts, Alexandra (October 12, 2017). "Donald Trump almost forgets to sign executive order before reminder from Mike Pence". The Independent. London: Independent Print Limited. Retrieved October 12, 2017.
"The Effects of Terminating Payments for Cost-Sharing Reduction" (PDF). Congressional Budget Office. Washington, D.C.: United States Government. August 15, 2017. Archived from the original on October 17, 2017. Retrieved October 17, 2017.
Scott, Dylan (October 12, 2017). "Trump will pull Obamacare subsidies in another attack on health law". Vox. United States: Vox Media. Retrieved October 13, 2017.
Editorial Board (October 12, 2017). "Congress Shouldn't Let Mr. Trump Kill Obamacare on His Own". The New York Times. New York City: The New York Times Company. Retrieved October 13, 2017.
Klein, Ezra (October 16, 2017). "On Obamacare, Donald Trump is sabotaging himself". Vox. United States: Vox Media. Retrieved October 16, 2017.
Kliff, Sarah (October 18, 2017). "Trump's stance on insurance "bailouts" is completely incoherent". Vox.
Leonhardt, David (October 15, 2017). "How to Fight the New Trumpcare". The New York Times. New York City: The New York Times Company. Retrieved October 15, 2017.
H.C. (October 13, 2017). "Donald Trump's health-care orders will hurt middle-class, self-employed Americans". The Economist. Westminster, London: The Economist Group. ISSN 0013-0613. Retrieved October 13, 2017.
Kaplan, Thomas; Pear, Robert (October 17, 2017). "2 Senators Strike Deal on Health Subsidies That Trump Cut Off". The New York Times. New York City: The New York Times Company. Retrieved October 18, 2017.
Kliff, Sarah (August 15, 2017). "CBO says Trump's Obamacare sabotage would cost $194 billion, drive up premiums 20%". Vox. United States: Vox Media. Retrieved October 17, 2017.
Kaplan, Thomas; Pear, Tobert (October 18, 2017). "Trump Pulls Back From Senate Deal to Fund Health Subsidies". The New York Times. New York City: The New York Times Company. Retrieved October 18, 2017.