The data on other welfare programs’ work requirements, as well as analyses of the Medicaid population, suggest that the only guaranteed outcome of such a provision would be mass disenrollment of people on Medicaid, especially those able-bodied, low-income adults who only became eligible under the ACA’s Medicaid expansion. Many of these adults report significant barriers to work—like a disability, caregiver responsibilities, or felonies—that keep them from stable jobs, and they’d lose coverage were Medicaid altered this way. The AHCA would have led to many more people disenrolling from Medicaid, because of its own work requirements and per-capita caps on funding. But an employment provision added to current Medicaid programs would also weaken the safety net, as Medicaid itself is work support. In addition, Verma’s CMS appears to be considering approving other waiver provisions that could reduce Medicaid coverage and benefits, including requiring premiums and health-savings account contributions, moving more people to privately managed plans, and cutting benefits like the provision of medical transportation for enrollees.
The administration is also in charge of many of the annual regulations that have to be pushed to make the ACA work. Obama’s White House constantly made small tweaks to the law in order to avert potential hiccups. Larger crises, like the disastrous rollout of HealthCare.Gov and the associated rejection of state-run exchanges by several states, required more dramatic federal intervention. Even if the Trump administration had the will to put out sporadic fires, those fixes would require not only savvy and a deep knowledge of health policy from top to bottom, but also a full bench of officials to do the work. As it is, the White House hasn’t shown much interest in the intricacies of health policy, and the federal bureaucracy is depleted.
Even under Obama, rising premiums and major exits by insurers from the exchanges seemed to mystify the president and his army of experienced bureaucrats. Health care is hard work, and it’s hard work even when there aren’t legislative fights in the news.
Whether on purpose or not, the Trump administration will probably weaken Obamacare on its own. But a Republican-dominated Congress will still be working, too, and recent history shows that some of their most successful anti-Obamacare moves have been smaller bites, even under the threat of an Obama veto. Enacted legislation has delayed the so-called “Cadillac tax” and other revenue-generating taxes, changed the categorization of small employers, and reduced appropriations to the Prevention and Public Health Fund. Congress could always make more of these smaller cuts to the health law. With legislation as complex and big as the ACA, each quantum of instability those measures create could have much larger downstream effects.