Biden to take action on ACA marketplaces, Medicaid

President Biden will direct federal agencies this week to reopen the ObamaCare marketplaces and roll back the Trump administration’s changes to Medicaid in a repudiation of his predecessor’s health care policies.

Biden’s executive orders are expected to set the stage for his presidency by reinforcing his belief that the federal government should make it easier — not harder — for people to get health care.

According to documents obtained by The Hill, Biden will sign executive orders Thursday that take “steps to strengthen Medicaid and initiate an open enrollment period under the ACA.”

Democrats and experts have long accused former President Trump of “sabotaging” the Affordable Care Act (ACA) and broader health care safety net by cutting enrollment efforts and approving work requirements for Medicaid.

“The goal should be once again about coverage and access, not about making it harder for people to enroll or receive the care that they need,” said Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy.

Federal data shows the uninsured rate increased for the first time in years under the Trump administration, even before the coronavirus pandemic.

Millions more are believed to have lost their health insurance after losing their jobs due to the COVID-19 recession.

“I think the most urgent issues with Medicaid and the ACA have to do with the fact that millions of people lost employer coverage, and it’s an ongoing problem,” said Eliot Fishman, senior director of health policy at the advocacy group Families USA.

“There needs to be not just a reopening of the marketplaces but aggressive advertising, outreach and enrollment assistant resources to help people sign up for insurance.”

The Trump administration declined to reopen healthcare.gov, despite pressure from health experts and Democrats who pointed to the importance of being insured during a pandemic.

Biden’s executive order, first reported by The Washington Post, would likely instruct the Department of Health and Human Services (HHS) to open a special enrollment period to allow anyone to sign up for ACA coverage outside of the standard sign-up period, which runs for six weeks at the end of the calendar year.

Several states that run their own marketplaces have already taken similar steps.

HHS is also likely to increase funding for outreach and enrollment programs. Under Trump, the agency significantly reduced the amount of funds spent on those programs, leaving $1 billion on the table that could be used by the Biden administration to boost enrollment efforts, according to an analysis by the Kaiser Family Foundation.

Cuts to those programs likely contributed to the higher uninsured rate, in addition to rising premiums. Experts say that fear of the Trump administration’s public charge rule, which dissuades immigrants and their children from signing up for Medicaid, likely played a role as well.

Enrollment in ACA plans dropped every year since 2016 before increasing slightly in 2020, likely due to the newly unemployed seeking other insurance options.

According to the Census Bureau, 2.3 million more people, including 700,000 children, became uninsured between 2016 and 2019.

“One priority for strengthening Medicaid would be reversing the significant coverage losses that have occurred among kids over the last few years,” Park said.

Patricia Boozang, senior managing director at Manatt Health, said she expects the executive order to direct agencies to work with states on expanding Medicaid to more low-income adults. ObamaCare gave states that option, but 12 refused to do so, including Texas, Florida and Georgia.

Biden may also direct HHS to rescind guidance to states encouraging work requirements, block grants and other programs or changes that experts say reduce coverage and access to care.

“We can at least expect the president will direct the [Centers for Medicare and Medicaid Services] that it is no longer the policy to approve those types of waivers — that it’s not the policy or intention of the administration,” Boozang said. 

The Trump administration argued that Medicaid work requirements, which are not in effect in any state due to legal challenges, help lower dependency on federal programs and help beneficiaries recognize the value of work.

Critics of that approach note that most Medicaid beneficiaries already have jobs, and burdensome reporting requirements could lead to coverage losses, even among people who are employed.

More than 18,000 people lost coverage by the end of 2018 after work requirements took effect in Arkansas.

The Supreme Court will soon hear oral arguments in a case that will determine whether Medicaid work requirements are legal, putting more pressure on Biden to take action quickly, Fishman said.

“I think that’s a pretty urgent priority to establish new administration policy around that case,” he said.