Since becoming president, President Donald Trump's efforts regarding Obamacare have been almost all geared at undermining it. Now that Congress has failed to repeal the law, he's acting as much as he can on his own. And depending on how it's implemented, the executive order Trump signed Thursday could be his most significant step yet to sabotage the law.
It will expand the availability of plans that are loosely regulated and don't have to provide essential health benefits, which could pull people off the Obamacare exchanges. Here's a look at the range of options available to Trump to either fix, save, undermine or gut Obamacare, and where this new executive order fits on that scale.
Prop up Obamacare. Trump could support a bipartisan effort in Congress to provide regular subsidies to insurers to cover the cost of lower-income people who pay less under Obamacare.
Has he done this?
No. Trump seems entirely uninterested in this. In fact, one of the reasons Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., are trying to make these subsidies payments more regular is that they are concerned Trump could suddenly stop issuing them. That could be calamitous for thousands of people who rely on the subsidies. Experts also warn the unpredictability is bad for all health insurance markets, because insurers don't know how much the government will be helping them out.
Trump has suggested he might work with Democrats to pass some kind of ambiguous health care reform. But no one in Washington is taking that seriously, especially given his 180 on an immigration deal with Democrats.
Undermine Obamacare: If Obamacare is going to be the law of the land, Trump can try to cut holes in it so big that the law is unrecognizable. The approach seems to be to force Obamacare to fail, forcing Congress to fully repeal it.
"As I have always said, let ObamaCare fail and then come together and do a great healthcare plan. Stay tuned!"
- Donald J. Trump (@realDonaldTrump) July 18, 2017
Has he done this?
Trump has slashed by 90 percent the federal government's budget to advertise and help enroll people on the exchanges
The Washington Post's Juliet Eilperin reports he's told the federal government to refuse to help Iowa prop up its struggling marketplace, which is a federal-state partnership.
Add this executive order to the list. The Post's Amy Goldstein reports the order will allow small businesses to form an association negotiate health benefits, called association health plans. Under Trump's rule, these disputed plans could soon be sold across state lines with no regulation on what health benefits they have to cover.
Many state insurance commissioners, both Republican and Democrat, oppose expanding associations because doing so could allow a plan formed in Ohio that, say, doesn't include protections for preexisting conditions to be sold in Indiana, and there's nothing Indiana officials can do about it.
Goldstein reports that the National Association of Insurance Commissioners warned Congress in February that something like this "would result in less protections for the most vulnerable populations and the collapse of individual markets."
In fact, aside from a few ideologically rigid conservatives, association health plans aren't really a mainstream discussion, said Paul Ginsburg, a health policy expert and director of the USC Brookings-Schaeffer Initiative.
"To aggressively pursue association health plans is very much an attempt to undermine the markets in the Affordable Care Act," Ginsberg said.
Trump will also direct the government to expand the availability short-term health-insurance plans, from three months to a year. That "could do serious damages to the marketplaces and the individual market," said Gary Claxton, an analyst with the Kaiser Family Foundation.
These plans are designed to be short term - say, if you're between jobs and can't get on the exchanges. They don't have to cover essential health benefits, and they are not renewable, and they are cheaper. But Trump's order would make them closer to an alternative for full health insurance, which could make them an attractive plan for healthy people, which could increase the volume of sicker people on the exchanges.
"If you leave the sicker people on the exchanges, then premiums will rise more, and it gets you back to the possibility of a death spiral," said Alice Rivlin, a health policy expert with Brookings Institution.
Fully gut Obamacare: Trump can't do this, since it's a law Congress passed. But he could put nonstop pressure on Congress to repeal the entire law.
Has he done this?
Yes and no. Trump has made very clear how frustrated he is that Republicans were unable to repeal Obamacare. But he has largely pivoted to tax reform.
There's one more thing health policy experts say Trump could do on his own to rip up Obamacare: end the payments to insurers that cover lower-income people's premiums. (The very same payments Congress is trying to shore up.) Most health-policy experts agree that if these subsidies are taken away without a change in how much lower-income people pay for their health insurance, insurance markets would implode, forcing insurance companies to leave Obamacare exchanges, causing Obamacare itself to implode.