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Health and Human Services secretary Alex Azar at his swearing-in ceremony last month with President Trump and Vice President Mike Pence. Photo: Chris Kleponis-Pool / Getty Images

This might be the best way to understand the Trump administration’s approach to the Affordable Care Act: the ACA’s exchanges, like health insurance itself, relied on healthy people subsidizing the cost of covering sick people — but they’re sliding deeper into something a lot more like a makeshift high-risk pool, in which healthy people are absent and the government simply pays to cover sick people.

Where it stands: The White House and congressional Republicans are not trying to change that reality. In some ways, they have accelerated it. At a minimum, they accept it.

  • Their focus is instead on how to create a better deal for the comparatively healthy, wealthy people who aren’t interested in the exchanges. And if more people end up ditching the marketplaces as a result, well, c’est la vie.

Yesterday’s rules are another brick in the wall. Repealing the individual mandate will pull a lot of healthy people out of the ACA’s exchanges. Association health plans will pull out a few more; expanded access to short-term health plans, a few more after that.

  • On their own, yesterday's rules on short-term plans probably wouldn't wreck the market. After all, they restored what had been the status quo until 2016.
  • “I don’t think it’s going to be a huge deal, particularly in the short term,” Avalere’s Chris Sloan told me.

Between the lines: “Really, the draw into the individual market has been the subsidy,” Health and Human Services secretary Alex Azar told reporters yesterday.

  • It’s an instructive comment about how HHS sees the exchanges, and who it sees as the potential customer base for ACA coverage.
  • More than 80% of ACA enrollees receive premium subsidies. And the consumers with the biggest subsidies are the ones who are the most insulated from steep premium increases.
  • People who aren’t eligible for premium subsidies “are just not enrolling in this market,” Sloan said.

The bottom line: All of this leaves the exchanges as a de facto home for people who really need coverage for preexisting conditions and who are poor enough to be shielded from the rising cost of that coverage. Rather than try to balance that group out by bringing more healthy people into the mix, HHS is just moving on, trying to create new options for healthy people.

Go deeper

Scoop: Gina Haspel threatened to resign over plan to install Kash Patel as CIA deputy

CIA Director Gina Haspel. Photo: Win McNamee/Getty Images

CIA Director Gina Haspel threatened to resign in early December after President Trump cooked up a hasty plan to install loyalist Kash Patel, a former aide to Rep. Devin Nunes (R-Calif.), as her deputy, according to three senior administration officials with direct knowledge of the matter.

Why it matters: The revelation stunned national security officials and almost blew up the leadership of the world's most powerful spy agency. Only a series of coincidences — and last minute interventions from Vice President Mike Pence and White House counsel Pat Cipollone — stopped it.

Updated 7 hours ago - Politics & Policy

Coronavirus dashboard

Illustration: Sarah Grillo/Axios

  1. Health: Coronavirus deaths reach 4,000 per day as hospitals remain in crisis mode — CDC warns highly transmissible coronavirus variant could become dominant in U.S. in March.
  2. Politics: Biden says, "We will manage the hell out of" vaccine distribution — Biden taps ex-FDA chief to lead Operation Warp Speed amid rollout of COVID plan — Widow of GOP congressman-elect who died of COVID-19 will run to fill his seat.
  3. Vaccine: Battling Black mistrust of the vaccines"Pharmacy deserts" could become vaccine deserts — Instacart to give $25 to shoppers who get vaccine.
  4. Economy: Unemployment filings explode againFed chair: No interest rate hike coming any time soon —  Inflation rose more than expected in December.
  5. World: WHO team arrives in China to investigate pandemic origins.

John Weaver, Lincoln Project co-founder, acknowledges “inappropriate” messages

John Weaver aboard John McCain's campaign plane in February 2000. Photo: Robert Schmidt/AFP via Getty Images)

John Weaver, a veteran Republican operative who co-founded the Lincoln Project, declared in a statement to Axios on Friday that he sent “inappropriate,” sexually charged messages to multiple men.

  • “To the men I made uncomfortable through my messages that I viewed as consensual mutual conversations at the time: I am truly sorry. They were inappropriate and it was because of my failings that this discomfort was brought on you,” Weaver said.
  • “The truth is that I'm gay,” he added. “And that I have a wife and two kids who I love. My inability to reconcile those two truths has led to this agonizing place.”

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