Trump’s order sends an important signal about what he wants health insurance to look like. Photo: Evan Vucci / AP

President Trump left little doubt yesterday that he intends to do as much damage as he can to the Affordable Care Act's insurance markets. And he can do a lot.

The bottom line: The executive order Trump signed yesterday aims to undercut some of the ACA's core ideas about how insurance markets should work. His decision to halt the law's cost-sharing subsidies will blow up those markets in the short term. And his administration has taken a slew of other steps to undermine enrollment. There's one constant here — to wound the ACA as badly as possible.

The impact: Here's what will happen once the insurer subsidies are cut off:

  • Insurers have already locked in their premiums for next year. Many them will try to find some way to go back and tack on a premium major increase or, if they can't do that, to pull out of some markets entirely.
  • This will create even more pressure on Congress to guarantee funding for the subsidies, as part of a newly urgent bipartisan ACA fix. Having a fresh health care crisis on the front burner can't be good for tax reform, and getting an agreement on the ACA won't be easy.
  • If Congress doesn't act quickly, there's a decent chance insurers will sue the administration. They're still legally obligated to reduce their customers' out-of-pocket spending, and the law says they're supposed to be compensated for that.
  • The Democratic attorneys general of California and New York are already threatening to sue, too.

The fix: Congress can solve this. University of Michigan law professor Nicholas Bagley, an expert on this issue, told me that if Congress appropriates the money for these subsidies, they would begin flowing again immediately. The problem is, Republicans aren't in the mood to do that without some big concessions from Democrats — and the Senate bipartisan talks aren't anywhere close to a deal.

The executive order: It's short. It's vague. It leaves critical questions unanswered. But it does tell us where this administration wants to take the health care system — what it wants insurance, and insurance markets, to look like. It tells us Trump will at least try to get there on his own. And that alone tell us a lot.

Be smart: Insurance can cover a lot and cost a lot, or cover less and cost less. The ACA said insurance should be reasonably comprehensive and accessible to people who need it, even if that meant healthier people had to pay more. That foundational view of insurance is what Trump's order would attempt to reverse.

The ACA sought to flatten out the disparate experiences of the healthy and the sick. Trump would begin to resegregate them.

How it works: Association health plans — letting small businesses pool together to buy insurance coverage as if they were one large business — got most of the attention in the lead-up to yesterday's announcement. But, depending on how all this is actually implemented, the order's other provisions might pose a greater threat to the ACA's core principles.

  • "AHPs, I do not believe are going to sell junk insurance," said Chris Condeluci, an attorney and policy consultant who worked on the Republican side of the Senate Finance Committee during the ACA debate.
  • Association health plans are regulated a lot like the health plans offered by larger employers. Some of the ACA's consumer protections still apply: the plans cannot impose annual or lifetime caps on benefits, for example. They also can't charge one person in the association a higher premium because of a pre-existing condition.
  • The bigger threat to the ACA's framework might come from expanded access to short-term insurance plans, which are subject to hardly any benefit mandates and provide few coverage guarantees.

Go deeper

Updated 49 mins ago - Politics & Policy

Coronavirus dashboard

Illustration: Sarah Grillo/Axios

  1. Global: Total confirmed cases as of 8:30 a.m. ET: 12,740,971 — Total deaths: 565,716 — Total recoveries — 7,022,846Map.
  2. U.S.: Total confirmed cases as of 8:30 a.m. ET: 3,247,782 — Total deaths: 134,815 — Total recoveries: 995,576 — Total tested: 39,553,395Map.
  3. Politics: Trump wears face mask in public for first time.
  4. Public health: Fauci hasn't briefed Trump on the coronavirus pandemic in at least two months — We're losing the war on the coronavirus.
  5. States: Louisiana governor issues face mask mandate.
  6. World: India reimposes lockdowns as coronavirus cases soar.
2 hours ago - World

Hundreds of thousands vote in Hong Kong's opposition primaries

Photo: Isaac Lawrence/AFP via Getty Images

Organizers say more than 500,000 Hong Kong residents have voted in primary elections held by pro-democracy opposition groups on Saturday and Sunday, despite fears of a government crackdown under Beijing's draconian new national security law, Reuters reports.

Why it matters: The primaries, which aren't part of the city's official political process, are intended to whittle down the field of pro-democracy candidates in order to avoid splitting the vote against pro-China ruling politicians in September's legislative elections.

Biden's doctrine: Erase Trump, re-embrace the world

Photo illustration: Sarah Grillo/Axios. Photo: Bastiaan Slabbers/NurPhoto, and Bastiaan Slabbers/NurPhoto via Getty Images

Foreign policy will look drastically different if Joe Biden defeats President Trump in November, advisers tell Axios — starting with a Day One announcement that the U.S. is re-entering the Paris Climate Agreement and new global coordination of the coronavirus response.

The big picture: If Trump's presidency started the "America First" era of withdrawal from global alliances, Biden's team says his presidency would be the opposite: a re-engagement with the world and an effort to rebuild those alliances — fast.