In the second year of the Trump presidency, the Affordable Care Act is troubled.
Such is the case today—and such was the case eight years ago.
On Feb. 8, 2018, the RN&R‘s cover story looked at the state of Nevada’s Affordable Care Act health-insurance marketplace.
Here’s how Jeri Davis started the piece:
Despite an uncertain future for the Patient Protection and Affordable Care Act—a.k.a. the ACA or Obamacare—more than 91,000 Nevadans enrolled in health insurance complaint with its provisions for 2018.
The ACA has been under threat since long before Donald Trump became president on Jan. 20, 2017.
Since it was enacted nearly eight years ago, there have been many dozens of attempts made in Congress to repeal, amend, delay and defund the ACA—all unsuccessful. Yet, when Trump came to power with the benefit of a Republican-controlled Congress, many thought it would only be a matter of time before the ACA was dismantled.
And concerted attempts to do so were made during 2017, beginning with a Jan. 12 vote in the Senate to pass a budget resolution containing language allowing repeal to happen through the budget reconciliation process—which, importantly, prohibits a filibuster in the Senate and allows for passage of legislation with only a simple majority, rather than the three-fifths majority otherwise needed.
Less than two months later, House Republicans revealed their replacement for the ACA—called the American Health Care Act. But it was withdrawn a few weeks later, on March 24, because it had not garnered enough support to pass. More than a month of Republican Party infighting followed before the bill was put to a vote and narrowly passed the House by a margin of 217 to 213. From there, it was sent to the Senate for deliberation.
The Senate quickly rejected the House’s measure, choosing instead to write its own bill—the Better Care Reconciliation Act of 2017—which was unveiled on June 22. After another month and several delays in voting, the bill failed in a vote of 43 to 57, with nine Republican senators voting against it. And, just two days later, on July 27, the Health Care Freedom Act, a.k.a. the “skinny repeal” bill, was introduced and quickly defeated in a 49 to 51 vote, when Republicans Susan Collins of Maine, Lisa Murkowski of Alaska, and John McCain of Arizona voted against it, alongside Democrats.
A final repeal attempt—an amendment to the House’s American Health Care Act, named the Graham-Cassidy bill after its sponsors, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana—was introduced in September but never brought to a vote.
The repeal attempts, while ultimately unsuccessful, were not without effect. The months-long debates surrounding them created massive uncertainty in insurance markets across the country—an issue that was exacerbated by very real blows dealt to the ACA by the executive branch.
Despite having criticized Obama for the frequency of his executive orders—which, in February 2016, Trump called “a basic disaster”—the new commander-in-chief signed his first one on the day he was sworn into office. It was an order designed, according to then Press Secretary Sean Spicer, to “ease the burden of Obamacare as we transition from repeal and replace.”
The order gave the heads of all executive departments with “authorities and responsibilities” related to the ACA the power to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision” of the ACA that they deemed to place a burden on states, individuals, insurers or health care providers. And it was only the first of many.
During 2017, the Trump administration also made decisions to stop paying cost-sharing subsidies (CSRs) that reimburse insurers for the discounts they’re required to give some ACA enrollees; gave states more control over Medicaid implementation, including allowing them to impose work requirements; encouraged states to submit waivers to the Centers for Medicare & Medicaid Services (CMS) to make additional changes to their Medicaid programs, like charging recipients premiums, testing them for drugs and cutting them off from benefits if they fall behind on payments or paperwork; cut the open enrollment period for insurance sign-ups in half, from 90 to 45 days; and slashed federal funding for enrollment advertising and in-person enrollment support by 90 percent and 40 percent, respectively.
As a result of all of this, some insurance carriers, like Humana, stopped offering ACA plans, counties in many states faced months of uncertainty about whether their residents would have any ACA plans available to them at all, and about a half a million fewer people signed up coverage in 2018 than did in 2017.
In Nevada, however, despite facing these challenges, 2018 enrollment numbers exceeded the previous year’s.
Of course, the Affordable Care Act is still around—but it’s been weakened, due to rising plan costs and the end of enhanced subsidies as of this year (despite Trump-scuttled attempts by Democrats and some Republicans in Congress to extend them).
As a result, a lot fewer people have health insurance, and many of the people who still do have insurance have been forced to opt for lower-tier plans—because that’s all they can afford.
On Jan. 22, the Nevada Current reported:
Nevada Health Link, the state-run health insurance marketplace, announced Thursday that 104,286 people enrolled in health coverage during the open enrollment period, which ran from Nov. 1 to Jan. 15.
That’s a nearly 6% drop from the prior year, when more than 110,000 enrolled.
Comprehensive open enrollment data is not yet available for all states, but preliminary numbers released by the U.S. Centers for Medicare & Medicaid Services earlier this month suggested open enrollment was down 3.5% nationally from the previous year.
According to Nevada HealthLink, nearly 7 in 10 enrollees actively shopped the exchange for 2026 insurance, a 32% increase in engagement over the prior year.
Of people that enrolled, 20,911 were new enrollees and 42,652 were active re-enrollees. Compared to the prior year, that is nearly 6,000 fewer new enrollees, and almost twice as many active re-enrollees.
Engagement by re-enrollees may have been driven by a desire to find cheaper plan options after premiums for their existing plans skyrocketed.
A Jan. 27 story from NBC News looks at the risks families take by downgrading their insurance plans:
Once a safety net for healthier adults, bronze plans are becoming the default choice for a growing share of ACA enrollees in 2026, according to state officials.
The shift marks a sharp break from past years, when most people gravitated toward silver plans that balance higher monthly premiums with lower deductibles. Now, many people are opting for the cheapest option available—not because they want to, but because it’s all they can afford. …
Bronze plans cover ACA benefits, including annual physicals, well-woman visits, cancer screenings and prescription drugs. But as the lowest tier, they often require people to pay thousands of dollars out of pocket before most other coverage kicks in.
The average annual deductible for a bronze ACA plan in 2026 is roughly $7,500 for an individual, according to KFF, a nonpartisan health policy research group.
In other words, a lot of Nevadans are going to be paying much more for health care this year—and/or skipping preventative care and other doctor’s visits they can’t afford.
—Jimmy Boegle
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