With two weeks to go before election day, Donald Trump's Department of Health and Human Services dropped some new rules designed to further undermine Obamacare by allowing states to sell healthcare plans that don't protect people with preexisting conditions. Why, yes, that is the same administration led by the guy who tweeted last week that "All Republicans support people with pre-existing conditions, and if they don't, they will after I speak to them." It's just that when Rs "support" people with pre-existing conditions, that means they send thoughts and prayers,not any actual protections against higher rates or coverage exclusions. Let's Wonksplain this latest step in the Republicans' delightful plan to "expand" insurance coverage that covers very, very little.

First thing to know is that, unlike other steps Team Trump has taken to gut the Affordable Care Act nationwide, this new guidance from HHS is aimed only at letting individual states fuck you over. And for you policy nerds, here's the laugh, haha: The waivers will be granted under a part of Obamacare that was designed to let states experiment with, say, single-payer coverage, as long as everyone got the basic benefits guaranteed by the ACA.

The new rules will instead allow states to seek waivers from the Obamacare requirement that all health insurance cover a mandatory set of benefits. That means states can let insurers sell plans on the exchanges that offer really crappy "coverage," just as long as some plans still conform to the ACA guidelines. See? It's offering people a "choice" that will save them money -- on premiums, at least, and as long as they never get sick. We can probably thank Idaho for announcing, then withdrawing, a plan to do pretty much that earlier this year.

Where that original waiver program was designed to encourage creative public options for coverage, the new rules require states to emphasize private insurance, because socialism is bad unless it's tax money going to private insurers. Under the new rules, HHS would consider people with "short term" or "association" health plans to have "coverage," even though both are allowed to cover only some services and to charge more for preexisting conditions -- and both are allowed to include annual and lifetime coverage caps. Most such plans don't even cover prescriptions.

Best of all? Under the new rules, states will be allowed to use public funds to subsidize the purchase of junk insurance that doesn't meet Obamacare standards, allowing companies to sell shitty plans and get taxpayer subsidies for 'em! Isn't that a beautiful thing? A lot of health care analysts are comparing the new rules to Ted Cruz's brilliant (failed) plan from last year, which would have split the individual healthcare market into two segments: 1) Fuck You, I'm Young And Healthy And Want Skimpy Coverage Because I'll Never Be Sick, and 2) You're Fucked If You Want Full Coverage, Welcome To The Premium Death Spiral. The key difference between the two markets is that one is in italics. No, wait, there is more to it than that, as the New York Timesexplained back when Cruz floated his stupidbad idea:

"There have been Nobel Prizes in economics awarded for the finding that when you allow an insurance market to segment like that, you end up with basically an unstable market," said John Graves, an assistant professor of health policy at Vanderbilt University.

Gee, what happens in unstable markets? Premium prices increase sharply. For people who qualify for subsidies, those higher costs are blunted, although of course the cost for subsidies goes higher. Folks who don't qualify for subsidies will either be shunted into one of the crap plans where they can hope for the best (and have their preexisting conditions not covered), or they may just be priced out of the market altogether.

Andy Slavitt, the former head of HHS's Center for Medicare and Medicaid Services under Barack Obama, explains how the new rules fundamentally twist the ACA waiver process: The old waivers allowed states to experiment, usually reducing premiums and expand coverage as long as "the number of [people] covered, affordability and comprehensiveness of coverage aren't reduced." But these new waivers would instead mean

• Insurance coverage will now be defined as having ACCESS to it. Not actually having it.
• Junk plans can count as coverage
• Everyone doesn't need to be better off. Some can be better, some worse
• Two risk pools for sick/healthy

If you're really into policy nerdery, check out this Twitter thread from New York Times health correspondent Margot Sanger-Katz, who points out that while the new rules go into effect right away, the earliest any state would be able to field a new set of shitty insurance plans (with very expensive full coverage for some) would be 2020. And golly, that may be the year to get a president who isn't trying to wreck everything nice, too.

[Vox / NYT / Andy Slavitt on Twitter / Margot Sanger-Katz on Twitter]

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