<p>Unrelenting attacks on the availability of quality affordable health care, particularly for children, people with disabilities, older adults and people with serious or chronic health conditions, marked the first year of the Trump administration. Although most of the Congressional onslaught ended in failure, 2017 was a year in which the Republicans used their position in the majority to take steps that <a href=will result in higher premiums for millions of people. At the same time, they failed to refinance the Children’s Health Insurance that provides coverage to nine million low- and moderate-income children.

On the administrative front, the Trump administration undertook multiple actions to sabotage the operation of the ACA Marketplaces and weaken consumer protections. Documents Senator Casey’s office obtained show the actions both taken and contemplated are part of a deliberate effort to create a “self- fulfilling prophecy” of ACA failure. Despite these efforts, a strong open enrollment period, still going on in some states, has proven again that people need and value health insurance, and are eager to acquire it if it is affordable.

Moving into 2018

Undeterred by either the stubborn refusal of facts to conform to their narrative or the unpopularity of their efforts to undermine the ACA and Medicaid, the Trump administration has picked up right where they left off—unveiling new policy that would allow states to place unprecedented barriers to Medicaid enrollment in front of beneficiaries. Especially troubling is the administration’s reliance on through-the-looking-glass “logic” that since providing work supports can be beneficial, conditioning people’s access to health insurance on meeting work requirements will improve people’s health.

Nor is there any reason to believe that the administration’s sabotage efforts are now complete. Waiting in the wings is a proposal to expand the availability of health insurance plans that don’t provide the consumer protections the ACA affords. Coupled with the repeal of the penalty for not carrying insurance (aka the “individual mandate”), the expansion of “junk insurance” would raise premiums especially for small employers and individuals who are not eligible for ACA premium tax credits.

Although mandate repeal will raise premiums for many, one unexpected side-benefit is that it has lowered the cost of renewing CHIP. That’s because the CBO calculates the “cost” of renewing CHIP by looking at the difference between refinancing CHIP and not refinancing it. Without CHIP, more children would be enrolled in Marketplace coverage. And without the mandate, the cost of Marketplace coverage is now estimated to be higher than it otherwise would have been. The bottom line is that over the long run, it actually costs more NOT to refinance CHIP.

How Congress reacts to this new reality may become clear as soon as the end of this week, since the stop-gap funding bill that was passed at the end of last year expires on Friday. Also hanging in the balance is action on numerous other priorities that did not get addressed at the end of the year as tax-cut legislation took priority over all else, including funding for Community Health Centers, the maternal home visiting program and more. In particular, the fate of the teens and young adults whose parents brought them to the U.S. as young children and who know no other country as home remains unresolved. Many advocates are calling on Democrats to withhold their votes from a spending bill that does not address the fate of the “DREAMers” through a long-term solution to the end of the DACA program. If Republicans cannot find the votes for a spending bill in their own caucus, a government shutdown will result. At this point, it is hard to say what will happen in just a few days. However, one likely possibility is that Republicans will put a short-term spending bill on the floor along with CHIP funding and dare the Democrats to vote no.

One thing that is not hanging on the outcome of the negotiations over the spending bill is that fate of the “market stabilization” measures Senator Susan Collins demanded as the price of her vote last year for the tax package that included individual mandate repeal. In the aftermath of repeal, Democrats feel that the Collins proposals may not even be helpful, and certainly wouldn’t be sufficient. At the same time, many House Republicans remain opposed to anything intended to make the ACA work better. As a result, the likelihood Collins will get what she sought in exchange for her vote has grown much smaller.

On a positive note, the other likelihood that has gotten smaller is the likelihood of another serious run at ACA repeal and Medicaid caps this year (aka some variant of Graham-Cassidy). Although it is too soon to be sure, there is some indication that even Paul Ryan is waking up to the notion that proposing to rip health care away from millions of people and undermine the finances of health care systems and state government in an election year might not be such a great idea. However, while the “smart money” may be betting against a replay of last year’s repeal fight, we have already seen that right-wing donors can move the Republican caucus. If incumbents fear attacks from primary challengers for not repealing the ACA more than they fear the anger of the general electorate, the zombie repeal could come back from the dead yet again.

And, in honor of Dr. King’s birthday this past Monday, a shout out to Senator Cardin for asking Alex Azar a question about minority health during his Senate Finance confirmation hearing. Although Secretary designee Azar offered assurances that he would work to address health disparities, the commitment rings hollow in the face of the action CMS has taken to make it harder for people to get and keep Medicaid coverage. Finally, ICYMI, check out Health Policy Hub’s Twitter feed for tweets and links to articles about health equity posted in honor of Martin Luther King Jr. Day.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.