The Trump administration issued a ton of regulatory changes Monday that chip away at the Affordable Care Act (ACA). Moving forward, states will have more flexibility to set their own standards and people will be given new exemptions to avoid the health care law’s individual mandate penalty.

The 523-page regulation is one that comes out every year, and is intended to outline what ACA plans will look like for consumers next year.

Monday’s rule gives consumers two new ways to avoid penalties. People who live in counties with only one insurance company — roughly 26 percent of current enrollees — won’t have to pay the individual mandate penalty. Anti-choice people who live in areas where the only affordable plan also covers abortion will also be exempt from paying the penalty if they’d rather not have insurance.

The individual mandate is especially critical for insurance companies. Without the requirement that people have insurance or pay a penalty, insurers are less assured and could hike premiums or exit the marketplace altogether. As a result, the Congressional Budget Office expects fewer people will be covered and get subsidized care.


Republicans failed to repeal the ACA last year, but they were able to repeal the health care law’s individual mandate penalty beginning in 2019. Monday’s exemptions, however, take effect immediately — thus undermining the law.

“Until the law changes, we won’t stand idly by as Americans suffer,” the Centers for Medicare and Medicaid Services Administrator Seema Verma said on a conference call to some reporters.

But gutting the ACA isn’t really doing much in the way of providing relief.

Most people who purchase health insurance on the ACA marketplace are low-income people who buy subsidized care or people who really need care because of an existing medical condition. In addition to undermining the marketplace overall, Monday’s rule also further signals zip code will determine a resident’s health plan.

The Trump administration tweaked the essential health benefits provision, which specifies ten benefits health plans must cover. Starting in 2020, health plans generally still need to cover these benefits, but states have greater flexibility in determining the specifics and consumers could see less comprehensive coverage in some respects.


“For a consumer, it does create the potential for variation in terms of coverage and coverage standards depending on where you live,” said Elizabeth Carpenter, Senior Vice President, who leads the Policy Practice at Avalere. “And in some cases may change some of the options available to consumers in the market.”

For example, “plans subject to essential health benefits will continue to have to cover prescription drugs,” Carpenter told ThinkProgress. “Depending on the benchmark a state chooses, [a plan] may have to cover fewer prescription drugs but that category of coverage is still guaranteed.”

The Trump administration did also throw a bone to insurance companies in Monday’s rule. If it means a more stable market, states could modify medical loss ratio (MLR), or the amount an insurer spends on a costumer’s care versus the return in profit. States could adjust the 80/20 MLR rule, which means 80 percent goes to health care and 20 percent goes to administrative costs or profit, in a way that attracts insurers. Of course, most of these changes are up to states.

Monday’s final rule is a small piece of the pie in regards to what’s to come. Experts say what’s likelier to affect marketplace stability is the repeal of the individual mandate next year. Other questions that are more critical are: Will the Trump administration permit “silver loading” (a way states safeguarded consumers from premium hikes and actually made 2018 plans cheaper or free)? And to what extent will freeing up skimpier health plans (like short-term health plans) undermine the marketplace?

The ACA marketplace has proven more resilient than expected during President Donald Trump’s first year in office, but the challenge going forward is how to further stabilize and strengthen the marketplace for the sake of those who need insurance.

Despite repeated, deliberate attacks from the Trump administration — like cutting outreach and advertisement — 11.8 million people signed up for 2018 health plans, only 400,000 fewer than last year. According to a recent poll, most people buy insurance on the ACA marketplace to protect themselves from financial catastrophe.


Still, the marketplace isn’t very affordable for those who aren’t shielded by premium spikes and do not qualify for federal subsidies, namely people who make 400 percent of the federal poverty level or $81,000 for a family of three. As Trump continues to chip away at the health care law, it’s not clear where those who can’ turn.