If you want to understand President Donald Trump’s attempt to sabotage Obamacare, look no further than Michigan.
The state has made major gains over the past few years in reducing the rate of its uninsured. But like everywhere else across the country it now is seeing those gains put at risk by an administration that seems hell-bent on attacking a health care law that they’re tasked with administering.
The latest salvo came this month, when the Center for Medicare and Medicaid Services informed health care officials across the country that their budgets for helping individuals enroll in the Affordable Care Act were being cut drastically. In Michigan, some groups tasked with enrolling people in health care coverage, so-called navigators, saw budget reductions up to 90 percent. Inside the state, officials were left to scramble as this cycle’s enrollment period fast approaches.
Some Michigan organizations have cut their entire staffs and dialed back substantially on community outreach efforts. Others have turned to college interns for help signing people up for insurance on ACA exchanges. In some cases, a number of counties will now simply not receive assistance from navigator programs, leaving it up to people to sift through often complex insurance-purchasing decisions, if they make that decision at all.
“It’s a true and major disservice to Michigan consumers,” Dizzy Warren, executive director of a large network of navigator groups, Enroll Michigan, told The Daily Beast in a phone interview. “To the best of our ability, we will be there. With that kind of reduction, there’s no way I can say we will definitely be there.”
Death by a Thousand Cuts
The Trump administration said it cut the navigator programs because recipients had not met previous enrollment goals (PDF). But navigators say this deliberately ignores the work they do, from educating people about their health care options to convincing those they do enroll to persuade others to do the same. For them, the dialing-back of the program reeks of a White House trying to gut a law they couldn’t legislatively undo.
And they have a case. While the funding cuts to the navigator program were draconian, they were also just the latest in a months-long effort to unwind Obamacare. To date:
• The president has signed executive orders weakening the mandates requiring individuals to purchase insurance.
• His administration has ended contracts with firms who have provided in-person assistance to states using healthcare.gov.
• The Department of Health and Human Services has produced videos designed to undermine public support for Obamacare while using funds that were appropriate to help promote the law.
• HHS has reconfigured its website to make enrollment information harder to access.
• There has been little apparent effort to engage non-government partners that have worked in the past to reach uninsured populations.
• And at the end of August, CMS announced that it would slash funds for marketplace outreach by 90 percent.
• Even more recently, the HHS decided not to participate in pre-enrollment events with a health advocacy groups.
• Additionally, HHS announced that it will shut down the federal exchange site for 12 hours for all but one Sunday during the open enrollment season.
In Michigan, it’s not just administrative actions that have sabotaged Obamacare. The Trump White House has also introduced a level of policy uncertainty that has hampered markets in the state—from its unwillingness to drop pursuit of repeal to its refusal to provide a long-term guarantee of cost-sharing reductions (CSRs) for insurers.
The impact is becoming increasingly noticeable. In mid-September, it was reported that Health Alliance Plan would no longer sell insurance on the marketplace in Michigan citing uncertainties related to CSRs. The company said it was prepared to re-enter the marketplace “if and when the individual market stabilizes.” Earlier in the month, the Department of Insurance and Financial Services Director Patrick McPharlin explicitly tied the higher premiums individuals were paying for insurance to the lack of a commitment that the CSR payments would be made.
One navigator who spoke with The Daily Beast said that they’ve encountered potential enrollees who were either convinced that Obamacare had actually been repealed or were so confident in its impending demise that they didn’t want to bother taking the time to sign up for insurance.
“They were trying to paint it as if the ACA was in a death spiral,” Rep. Sander Levin (D-MI) said in an interview. “They were trying to create as much uncertainty as possible to support their notion that Obamacare was imploding. And now they’re providing the gasoline.”
A Failure of Communication
What has compounded the problem in Michigan is that the Trump administration has steadfastly declined attempts by lawmakers to try and work through operational disagreements. Levin’s staff said he wrote two letters to CMS Administrator Seema Verma this month and neither of them were returned.
And it’s not just members of Congress who’ve been left in the dark. Navigators interviewed by The Daily Beast said that they’ve been in touch with their local CMS contacts. But those officials are similarly confused or unaware about federal policy directives. When CMS announced at the end of August that it would cut navigator funding nationally by about 40 percent (PDF), navigators in Michigan said they could not get answers as to what it would mean for their specific operations.
“The first news we heard was from a news alert saying Trump was cutting off funding. Our program officer said nothing about it,” recalled Madiha Tariq, deputy director of the community health and research center at ACCESS Community Health and Research Center. “I was at the mosque and got an alert on my phone. I was like, ‘Thank God I could immediately pray to God to make sure we can get something.’”
It would be weeks before preliminary budget numbers were sent out to Tariq and others. Now, they have until Wednesday of this week to alert CMS as to how they will spend that reduced funding. CMS may choose to cut more. Final approval could take up to 30 days.
In the meantime, navigators in Michigan are doing what they can with what little they have left. ACCESS is among the fortunate: It received a roughly 33 percent budget cut compared to the 90-percent-plus cuts felt by others in the state. In the past, ACCESS has used its money to reach metro Detroit area’s large Arab-American population, including refugees and immigrants for whom English may be a second language. This year, it will be forced to do less.
“Right when we got the announcement, things had to go on pause for a bit,” Farah Erzouki, public health coordinator for ACCESS told The Daily Beast. “Those outreach events are definitely going to be slowing down and I think overall, our enrollment numbers are going to be a lot lower because we’re not able to dedicate as much staff time.”
Others groups are bracing for even worse setbacks. Enroll Michigan, a large statewide network of navigators that provides free enrollment support services to consumers, saw its funding go from $1.2 million to just under $130,000. Instead of contracting with 28 subgrantee navigators in 83 counties, it will now work with 22 subgrantees in 75 counties.
“You might imagine that I was more shocked than surprised especially since we’ve consistently performed as a network really well in all of these categories that they were counting at the time,” said Warren.
What frustrates Warren and other navigators is the sense that they’re being punished despite their work. Obamacare has been vital in lowering the uninsured population in Michigan, where the rate fell from an estimated 11 percent in 2013 to 5.4 percent by 2016 according to census data (PDF). Combined with the Medicaid Healthy Michigan Plan, nearly 1 million people are covered in the state. And part of that shift can be attributed to navigators. That Trump would cut this program, so close to the enrollment period, has the distinct feel of sabotage.
“I think it’s becoming clear that the Trump administration has very little interest in making the health care exchanges work well,” Nicholas Bagley, a professor of law who specializes in health law at the University of Michigan said in a phone interview. “Right now, the Trump administration is in charge of the individual market. Taking steps to undermine those individual markets strikes me as political malpractice.”