Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It.

The Trump administration has always seen the Affordable Care Act as an abominable roadblock to the less regulated insurance market it prefers. Last year, it tried to knock it down and failed.

Now, it’s building a set of detours.

More customers who want to avoid buying health insurance can now find a way out of the law’s individual-mandate penalty, which will disappear completely next year. Those who want skimpy plans not covering maternity care or bills exceeding a set annual amount may soon have that option in many states — provided they don’t have pre-existing conditions.

The downside: Many who do want Obamacare-style coverage are going to have to pay more.

The Obama health care law’s many rules about insurance — meant to make coverage accessible to Americans regardless of their health status, and comprehensive enough to cover their needs — still exist. Obamacare plans will still have to cover a basic set of health benefits and accept customers who have a history of illness. But, through a series of regulatory maneuvers, the Trump administration is making the insurance market governed by those rules increasingly optional. Alongside the Obamacare market it couldn’t destroy, it is helping to build a second market, free of many rules, and more like the market that health care law replaced.

On Monday, the Centers for Medicare and Medicaid Services, which oversees the marketplaces, unveiled a series of policies that Seema Verma, the agency’s administrator, made clear were aimed at working around the health law’s requirements.

“Americans shouldn’t be punished by its failure to provide choices,” she said, referring to the Affordable Care Act. “Until the law changes, we won’t stand idly by as Americans suffer.”

Rules and other guidance released Monday provide some ways out. People who live in a county where only one insurer offers Obamacare-compliant health plans now can get an exemption to the law’s individual mandate penalties right away. (They’ll go away for everyone next year under legislation passed as part of tax overhaul.) The administration is allowing older plans that predated Obamacare and that don’t follow all its rules to stick around another year. It’s also allowing health plans to cover a slightly less robust set of benefits, although those changes are mostly marginal.

Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options.

It is hard to predict precisely who will choose what. The administration wrote in its rule proposals that it didn’t anticipate either the short-term or association plans to be very popular, even as it lauded them as important alternatives to the current options under the health law. The new options may mostly attract people who are uninsured now, because they were priced out of the current market. Outside experts think the alternatives could siphon away a substantial percentage of healthy people from the Obamacare markets.

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.

Subsidies set up under the law were devised to automatically rise when prices increase, which means that customers who earn little enough to qualify won’t notice if Obamacare prices go up. But people who pay the full cost of their own insurance — somewhere in the neighborhood of 6 million people — will feel the sting of increased prices.

Those healthy enough to be able to access the new, cheaper options may choose them instead if the Obamacare prices get too high. But people with pre-existing health conditions may face a choice between more expensive insurance and nothing.

“They will still have access to those plans, even if they are prohibitively expensive,” said John Graves, an assistant professor of health policy at Vanderbilt University.

Graves has seen up close what can happen when consumers are given Obamacare alternatives. Tennessee has allowed its farm bureau to offer health plans that don’t follow Obamacare rules. And that option has been attractive to healthy customers, leaving the remaining market more expensive. Graves predicts that options like the farm bureau are likely to become even more attractive once the mandate to buy comprehensive coverage disappears. The administration has left one more potential disruptive option on the table. Last year, when President Donald Trump canceled a disputed set of payments to insurers, state insurance regulators allowed the health plans to shuffle around prices to absorb the loss. In a call with reporters Monday, Verma said her agency was considering barring that practice. Without the price adjustment, consumers in the Obamacare-compliant market will have a harder time finding an affordable plan.

The result may look a lot like the kind of markets that Republicans in Congress imagined when they wrote their health bills last year. One plan, proposed by Sens. Ted Cruz of Texas and Mike Lee of Utah, would have allowed unregulated health plans, as long as there were also options that would cover people with pre-existing conditions. Another leading plan would have established “high-risk pools” for people too sick to buy unregulated insurance.

Those bills failed, in the face of large public protests. But the new regulations will quietly bring us closer to the reality they imagined.