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At the end of last year’s prolonged health care battle, many Americans breathed a sigh of relief. Some may have let down their guard too soon.

That’s because it’s clear the war on health care is far from over. Or, more precisely, the war has shifted from a ground war to a cold war. It’s shifted from major clashes in Washington, DC, heavily covered by the media, to more obscure battlefields: the states and the offices at the Health and Human Services Department where regulatory policymaking is done.

Yet this quieter fight could prove to be just as dangerous to the public.

The defeat of the Republican legislative push to repeal Obamacare was essential. Had it been passed by Congress, the American Health Care Act, which passed the House almost exactly a year ago, would have caused 23 million Americans to lose coverage by the middle of the next decade, according to the nonpartisan Congressional Budget Office. Most of those losing coverage would have been lower-income or older citizens.

Preexisting condition protections affecting as many as 130 million Americans would have been substantially weakened. Insurance companies would have been permitted to add surcharges of hundreds of thousands of dollars for people with, for example, a prior cancer diagnosis.

And the Medicaid program would have seen hundreds of billions of dollars in cuts and an end to Medicaid expansion, cutting off low-income adults. The program’s open-ended commitment to low-income people, children, seniors, and people with disabilities would have ended, replaced by a capped program.

The frontal assault was turned back, but Republicans this year pivoted to a more covert attack on the ACA. This cold war has the same aims as last year’s controversial legislation. All that’s different are the tactics.

The president is using his bully pulpit to shake confidence in the Obamacare markets

In December, the administration finally achieved its goal of eliminating the individual mandate, tucking the provision into a package that cut rates for corporations, people with wealthy estates, and, to a lesser and varying degree, individuals.

This month, former Secretary of Health and Human Services Tom Price acknowledged that he knows this move will increase premiums. As healthy people forgo coverage, the price for everyone else goes up. That statement contradicted his repeated assertions while in office that despite what all the experts said, the mandate somehow was driving premiums up.

The individual mandate was a central tenet of the ACA. The CBO concluded that eliminating it would increase health insurance premiums by about 10 percent almost every year over the next decade in the individual market.

President Trump continues to use his bully pulpit to tear down, rather than bolster, the insurance markets that continue to exist (thanks to Obamacare). He has routinely called the ACA “dead” and “over,” rhetoric that has the effect of depressing potential competition and increasing the pricing power of insurance companies. Trump’s bombastic statements don’t always have consequences, but markets do respond to psychology, and insurers often won’t expand if they believe policies won’t be supported.

Last fall, the administration cut the marketing budget for ACA enrollment by 90 percent; even before that, it had slashed the budget for programs that provide “assisters” to match people up with good health care plans. Those ads had targeted younger people, so these cuts were a double whammy, reducing enrollment and increasing premiums (since young people tend to be healthy and therefore subsidize coverage for other Americans).

Virginia became the first state to file preliminary insurance rates for 2019, and the numbers show the effect of these actions. The state will see rate increases of up to 64 percent, before factoring in premium subsidies to those who qualify. Insurers pointedly blame Trump policies for the rise. Other states that have released filings are showing similar effects.

Protections for people with preexisting conditions — as many as 130 million Americans, and growing every day — are also under attack. The Trump administration is using its executive authority to approve the sale of junk insurance plans that had been outlawed or severely limited under President Barack Obama.

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Such plans aren’t subject to the rules requiring 85 percent of premiums to be spent on medical costs, nor by rules that forbid the insurance companies to decide what to cover and what not to. These plans would exist outside the ACA system. ACA plans would still be available, but they would become less viable and more expensive as insurers become more reluctant to offer plans that cover more if they have to compete with plans that cover less.

Medicaid, which Republicans had targeted for a major rollback last year, has not escaped this new phase of the Republican assault either. Using state-by-state waivers, the administration is aiming to add features to the Medicaid program that cause people to lose coverage.

Rules have been proposed and approved in Kentucky, Arkansas, and New Hampshire (with other states considering similar moves) that would cause people to lose coverage if they’re not working, and that charge very poor people premiums or lock them out of coverage for not registering with the program annually.

The stated reason for these changes is to give people the incentive to work. The real purpose is to cut Medicaid rolls. There’s no evidence that employment will be positively affected, and there are estimates in each of these states that many will lose coverage.

The number of uninsured Americans is rising

The cold war on Obamacare is having an effect. The uninsured rate has begun to creep back up since Trump became president. After several years of major declines under Obama, the uninsured rate has grown from 10.9 percent to 12.2 percent, according to Gallup. It’s not hard to imagine, in just one Trump term, that we could see half of the gains made under the ACA, which led to 20 million Americans being newly covered, erased.

Poll after poll shows the public wants this assault on the ACA to stop. After all this time, the program remains at a record level of popularity. Fifty percent approve, even as the administration badmouths and undercuts it.

Mostly, Americans want this assault on their ability to care for their families to end so we can begin the process of building back what has been allowed to erode. Americans want to pay less, not more, for health insurance. They don’t want insurance companies to be given unlimited authority again.

They want to see Medicaid strengthened, not weakened. They want the basic dignity of being able to afford medication and an end to the constant fear that grips so many that if they get sick, they will lose everything.

Americans didn’t want last year’s war on Obamacare, and they don’t want this new cold war either.

Andy Slavitt served as the acting administrator of the Centers for Medicare and Medicaid Services under President Obama. Find him on Twitter @ASlavitt.

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