Executive Order 13813

{{See also|Patient Protection and Affordable Care Act#Implementation history|Efforts to repeal the Patient Protection and 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).{{Cite news|url=https://www.yahoo.com/news/trump-signs-first-executive-order-targeting-obamacare-003207661.html?soc_src=mail&soc_trk=ma|title=Trump signs first executive order, targeting Obamacare with few specifics|last=Knox|first=Olivier|date=January 20, 2017|work=Yahoo! News|publisher=Yahoo!|language=en-US|location=Sunnyvale, California|access-date=October 13, 2017}} The order came on Trump's campaign pledges to repeal the Patient Protection and Affordable Care Act,{{cite news|url=https://www.nytimes.com/2017/01/20/us/politics/trump-executive-order-obamacare.html|title=Trump Issues Executive Order Scaling Back Parts of Obamacare|last1=Davis|first1=Julie Hirschfeld|date=January 20, 2017|last2=Pear|first2=Robert|work=The New York Times|location=New York City|access-date=January 23, 2017}} which Trump stated would take a long time, with a replacement possibly not being ready until 2018.{{cite news|url=https://www.usnews.com/news/health-care-news/articles/2017-02-06/donald-trump-obamacare-replacement-could-take-a-year|title=Trump Appears to Push Back Obamacare Replacement|first=Kimberly|last=Leonard|work=U.S. News & World Report|publisher=U.S. News & World Report, L.P.|location=Washington, D.C.|date=February 6, 2017|access-date=October 13, 2017}}

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.{{cite news|url=https://www.nytimes.com/2017/05/04/us/politics/health-care-bill-vote.html|title=House Passes Measure to Repeal and Replace the Affordable Care Act|first1=Thomas|last1=Kaplan|first2=Robert|last2=Pear|date=May 4, 2017|work=The New York Times|location=New York City|access-date=October 12, 2017|url-status=live|archive-url=https://web.archive.org/web/20170504193733/https://www.nytimes.com/2017/05/04/us/politics/health-care-bill-vote.html|archive-date=May 4, 2017|df=mdy-all}}{{cite news|last=Sanger-Katz|first=Margot|author-link=Margot Sanger-Katz|title=Who Wins and Who Loses in the Latest G.O.P. Health Care Bill|url=https://www.nytimes.com/2017/05/04/upshot/who-wins-and-who-loses-in-the-latest-gop-health-care-bill.html |date=May 4, 2017|work=The New York Times|location=New York City|access-date=October 12, 2017|url-status=live|archive-url=https://archive.today/20170504211701/https://www.nytimes.com/2017/05/04/upshot/who-wins-and-who-loses-in-the-latest-gop-health-care-bill.html?_r=0|archive-date=May 4, 2017|df=mdy-all}}{{cite web|url=http://clerk.house.gov/evs/2017/roll256.xml|title=Final Vote Results for Roll Call 256|last1=Clerk of the United States House of Representatives|date=May 4, 2017|work=United States House of Representatives|publisher=United States Congress|location=Washington, D.C.|archive-url=https://web.archive.org/web/20170504235141/http://clerk.house.gov/evs/2017/roll256.xml|archive-date=May 4, 2017|url-status=live|df=mdy-all|author1-link=Clerk of the United States House of Representatives}}{{cite news|url=https://edition.cnn.com/2017/05/04/politics/health-care-vote/|title=House Republicans pass bill to repeal and replace Obamacare|first=MJ|last=Lee|work=CNN|publisher=Turner Broadcasting System|location=Atlanta|date=May 4, 2017|access-date=May 4, 2017|url-status=live|archive-url=https://web.archive.org/web/20170505115246/http://edition.cnn.com/2017/05/04/politics/health-care-vote/|archive-date=May 5, 2017|df=mdy-all}}{{cite news|url=https://www.foxnews.com/politics/republican-health-care-bill-whats-in-it|title=Republican health care bill: What's in it?|author=Associated Press|work=Fox News|publisher=Fox Entertainment Group|location=New York City|access-date=October 12, 2017|url-status=live|archive-url=https://web.archive.org/web/20170504141458/http://www.foxnews.com/politics/2017/05/04/republican-health-care-bill-whats-in-it.html|archive-date=May 4, 2017|df=mdy-all}} 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 {{USIRC|205}}), employer mandates (in {{USIRC|206}}) and various taxes ({{USIRC|201}} et. seq.), and also modifications to the federal Medicaid program (in Sections 111-116 and 121).{{cite web|url=https://www.congress.gov/bill/115th-congress/house-bill/1628/all-info#summary|title=All Bill Information (Except Text) for H.R.1628 – American Health Care Act of 2017|last1=Clerk of the United States House of Representatives|work=United States House of Representatives|publisher=United States Congress|location=Washington, D.C.|date=May 4, 2017|access-date=October 12, 2017|url-status=live|archive-url=https://web.archive.org/web/20170419234437/https://www.congress.gov/bill/115th-congress/house-bill/1628/all-info#summary|archive-date=April 19, 2017|df=mdy-all|author1-link=Clerk of the United States House of Representatives}}

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.{{cite news|url=https://www.npr.org/2017/05/24/529902300/cbo-republicans-ahca-would-leave-23-million-more-uninsured|title=GOP Health Plan Would Leave 23 Million More Uninsured, Budget Office Says|first=Danielle|last=Kurtzleben|work=NPR|publisher=National Public Radio, Inc.|location=Washington, D.C.|date=May 24, 2017|access-date=October 13, 2017|url-status=live|archive-url=https://web.archive.org/web/20170621121045/http://www.npr.org/2017/05/24/529902300/cbo-republicans-ahca-would-leave-23-million-more-uninsured|archive-date=June 21, 2017|df=mdy-all}}

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{{cite news|title=Secrecy Surrounding Senate Health Bill Raises Alarms in Both Parties|url=https://www.nytimes.com/2017/06/15/us/politics/secrecy-surrounding-senate-health-bill-raises-alarms-in-both-parties.html|first1=Thomas|last1=Kaplan|first2=Robert|last2=Pear|work=The New York Times|location=New York City|date=June 15, 2017|url-status=live|archive-url=https://web.archive.org/web/20170618182849/https://www.nytimes.com/2017/06/15/us/politics/secrecy-surrounding-senate-health-bill-raises-alarms-in-both-parties.html|archive-date=June 18, 2017|df=mdy-all}}{{cite news|url=https://www.washingtonpost.com/news/politics/wp/2017/06/13/the-remarkable-steps-republicans-are-taking-to-obscure-whats-in-their-health-care-bill/|title=The remarkable steps Republicans are taking to obscure what's in their health-care bill|first=Philip|last=Bump|newspaper=The Washington Post|publisher=Nash Holdings LLC|location=Washington, D.C.|date=June 13, 2017|access-date=October 13, 2017|url-status=live|archive-url=https://web.archive.org/web/20170620082523/https://www.washingtonpost.com/news/politics/wp/2017/06/13/the-remarkable-steps-republicans-are-taking-to-obscure-whats-in-their-health-care-bill/|archive-date=June 20, 2017|df=mdy-all}}{{cite news|url=http://www.nbcnews.com/politics/congress/senate-s-health-care-bill-remains-shrouded-secrecy-n772456|title=The Senate's Health Care Bill Remains Shrouded in Secrecy|first1=Benjy|last1=Sarlin|first2=Leigh Ann|last2=Caldwell|work=NBC News|publisher=NBC|location=New York City|date=June 15, 2017|url-status=live|archive-url=https://web.archive.org/web/20170619162148/http://www.nbcnews.com/politics/congress/senate-s-health-care-bill-remains-shrouded-secrecy-n772456|archive-date=June 19, 2017|df=mdy-all}} and about the all-male composition of the committee.{{cite magazine|first=Mehreen|last=Kasana|url=https://www.bustle.com/p/the-13-senators-working-on-the-health-care-bill-are-all-men-56291|title=The 13 Senators Working on the Health Care Bill Are All Men|magazine=Bustle|publisher=Bustle Digital Group|location=New York City|date=May 7, 2017|access-date=October 13, 2017}}{{cite news|first=Robert|last=Pear|url=https://www.nytimes.com/2017/05/08/us/politics/women-health-care-senate.html|title=13 Men, and No Women, Are Writing New G.O.P. Health Bill in Senate|work=The New York Times|location=New York City|date=May 8, 2017|access-date=October 13, 2017}}{{cite news|first=Michael A.|last=Cohen|url=https://www.bostonglobe.com/opinion/2017/06/07/why-are-men-behind-closed-doors-writing-health-care-bill/cIqCDEcFo29uxirxbouPbI/story.html|title=Why are 13 men — behind closed doors — writing the health care bill?|work=The Boston Globe|publisher=Boston Globe Media Partners, LLC|location=Boston|date=June 7, 2017|access-date=October 13, 2017}} On June 22, 2017, Republicans released the first discussion draft for an amendment to the bill.{{cite web|url=https://www.budget.senate.gov/imo/media/doc/SENATEHEALTHCARE.pdf|title=H.R. 1628, Better Care Reconciliation Act of 2017, discussion draft ERN17282|first=Diane|last=Black|author-link=Diane Black|work=Senate Budget Committee|publisher=United States Senate|location=Washington, D.C.|date=June 22, 2017|access-date=October 13, 2017}} 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{{cite web|url=https://www.congress.gov/crec/2017/07/27/CREC-2017-07-27-pt1-PgS4415-2.pdf|title=Congressional Record p. S4415|work=United States Senate|publisher=United States Congress|location=Washington, D.C.|date=July 27, 2017|access-date=October 13, 2017}} after the Senate rejected several amendments, including {{USBill|115|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.{{cite news|url=https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=115&session=1&vote=00179|title=On the Amendment S.Amdt. 667|first=Diane|last=Black|author-link=Diane Black|date=July 28, 2017|work=United States Senate|publisher=United States Congress|location=Washington, D.C.|access-date=October 13, 2017}} On September 13, 2017, Senators Graham, Cassidy, Heller, and Johnson released a draft amendment to the bill{{cite web|url=https://www.lgraham.senate.gov/public/index.cfm?a=Files.Serve&File_id=06822F49-B801-4D9F-95F5-D7B5406E9AA9|title=Amendment in the nature of a substitute to H.R. 1628, discussion draft LYN17709|first=Lindsey|last=Graham|author-link=Lindsey Graham|work=United States Senate|publisher=United States Congress|location=Washington, D.C.|date=September 13, 2017|access-date=October 13, 2017}} that "repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states".{{Cite web|url=https://www.lgraham.senate.gov/public/index.cfm/press-releases?ID=DC1FC472-3D15-4948-BB29-548F13ADA9C0|title=Press Release: Graham-Cassidy-Heller-Johnson Background and Endorsements|first=Lindsey|last=Graham|author-link=Lindsey Graham|work=United States Senate|publisher=United States Congress|location=Washington, D.C.|date=September 13, 2017|access-date=October 13, 2017}} 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.{{cite magazine|url=http://www.washingtonexaminer.com/deadline-for-fast-track-obamacare-repeal-bill-expires-sept-30/article/2633213|title=Deadline for fast track Obamacare repeal bill expires Sept. 30|first=Robert|last=King|magazine=Washington Examiner|date=September 1, 2017}}

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.{{cite web|url=https://www.foxnews.com/politics/trump-clears-way-for-obamacare-alternatives-in-new-executive-order-goes-around-stalled-congress|title=Trump clears way for ObamaCare 'alternatives' in new executive order, goes around stalled Congress|first1=Kaitlyn|last1=Schallhorn|first2=Serafin|last2=Gomez|work=Fox News|publisher=Fox Entertainment Group|location=New York City|date=October 12, 2017|access-date=October 12, 2017}}{{dubious|"Replacing" Obamacare?|date=October 2017}} 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.{{cite news|url=https://www.independent.co.uk/news/world/americas/us-politics/donald-trump-forget-sign-executive-order-healthcare-obamacare-mike-pence-a7997661.html|title=Donald Trump almost forgets to sign executive order before reminder from Mike Pence|first=Alexandra|last=Wilts|work=The Independent|publisher=Independent Print Limited|location=London|date=October 12, 2017|access-date=October 12, 2017}} Senator Rand Paul, who attended the signing, described the order as "the biggest free market reform of health care in a generation."

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", 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.

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".

{{Main|Cost sharing reductions subsidy}}

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.{{cite news|url=https://www.cbo.gov/publication/53009|title=The Effects of Terminating Payments for Cost-Sharing Reduction|work=Congressional Budget Office|publisher=United States Government|location=Washington, D.C.|date=August 15, 2017|access-date=October 17, 2017|archive-url=https://web.archive.org/web/20171016183722/https://www.cbo.gov/publication/53009|archive-date=October 16, 2017|url-status=bot: unknown}}

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.{{cite web|url=https://www.vox.com/policy-and-politics/2017/10/12/16070724/trump-cost-sharing-reductions-pulled|title=Trump will pull Obamacare subsidies in another attack on health law|first=Dylan|last=Scott|work=Vox|publisher=Vox Media|location=United States|date=October 12, 2017|access-date=October 13, 2017}}{{cite web|url=https://www.nytimes.com/2017/10/12/opinion/editorials/congress-cant-let-mr-trump-undo-obamacare-on-his-own.html|author=Editorial Board|title=Congress Shouldn't Let Mr. Trump Kill Obamacare on His Own|work=The New York Times|location=New York City|date=October 12, 2017|access-date=October 13, 2017}}

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".{{cite news|url=https://www.vox.com/policy-and-politics/2017/10/16/16480438/obamacare-trump-csrs|title=On Obamacare, Donald Trump is sabotaging himself|first=Ezra|last=Klein|author-link=Ezra Klein|work=Vox|publisher=Vox Media|location=United States|date=October 16, 2017|access-date=October 16, 2017}}

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.{{Cite web|url=https://www.vox.com/health-care/2017/10/18/16499806/trump-insurance-bailouts-completely-incoherent|title=Trump's stance on insurance "bailouts" is completely incoherent|first=Sarah|last=Kliff|date=October 18, 2017|website=Vox}}

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".{{cite news|url=https://www.nytimes.com/2017/10/15/opinion/columnists/how-to-fight-the-new-trumpcare.html|title=How to Fight the New Trumpcare|first=David|last=Leonhardt|author-link=David Leonhardt|work=The New York Times|location=New York City|date=October 15, 2017|access-date=October 15, 2017}}

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".{{cite magazine|url=https://www.economist.com/blogs/democracyinamerica/2017/10/poor-pain-management|author=H.C.|title=Donald Trump's health-care orders will hurt middle-class, self-employed Americans|magazine=The Economist|location=Westminster, London|issn=0013-0613|date=October 13, 2017|access-date=October 13, 2017}}

{{Main|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-sharing reductions.{{Cite news|url=https://www.nytimes.com/2017/10/17/us/politics/alexander-murray-deal-obamacare-subsidies.html|title=2 Senators Strike Deal on Health Subsidies That Trump Cut Off|first1=Thomas|last1=Kaplan|first2=Robert|last2=Pear|work=The New York Times|location=New York City|date=October 17, 2017|access-date=October 18, 2017}} 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.{{cite news|url=https://www.vox.com/2017/8/15/16153094/voxcare-cbo-trump-obamacare-sabotage-premiums|title=CBO says Trump's Obamacare sabotage would cost $194 billion, drive up premiums 20%|first=Sarah|last=Kliff|work=Vox|publisher=Vox Media|location=United States|date=August 15, 2017|access-date=October 17, 2017}} 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.{{cite web|url=https://www.nytimes.com/2017/10/18/us/politics/trump-obamacare-subsidies-tweet-opposition.html|title=Trump Pulls Back From Senate Deal to Fund Health Subsidies|first1=Thomas|last1=Kaplan|first2=Tobert|last2=Pear|work=The New York Times|location=New York City|date=October 18, 2017|access-date=October 18, 2017}}

• Executive Order 13765
• Tax Cuts and Jobs Act of 2017

{{reflist}}

• [https://trumpwhitehouse.archives.gov/the-press-office/2017/10/12/presidential-executive-order-promoting-healthcare-choice-and-competition Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States], The White House (October 12, 2017)
• [https://wayback.archive-it.org/all/20171013015248/https://www.whitehouse.gov/the-press-office/2017/10/12/remarks-president-trump-signing-executive-order-promoting-healthcare Remarks by President Trump at Signing of Executive Order Promoting Healthcare Choice and Competition], The White House (October 12, 2017)

{{Trump executive actions}}

Category:2017 in American law

Category:Executive orders of Donald Trump

Category:Healthcare reform in the United States