Dan Gorenstein: This fall, the United States has a decision to make: another term for Donald Trump or a new administration led by Joe Biden.

That decision could lead our country’s health care policies down two very different paths.

Over the next two weeks, we’re diving in on both candidates’ positions on health care with the help of experts from across the ideological spectrum.

First, a look at President Trump’s record. Each day this week, we’ll examine a different area of policy — the administration’s goals, their actions and the impact. 

Today — and for the next two weeks — from the Annenberg Studio at the University of Pennsylvania, it’s all the presidents’ … health policies.

I’m Dan Gorenstein and this is Tradeoffs.

DG: We start with arguably Trump’s biggest health policy goal of them all.

President Donald Trump: Repealing and replacing the disaster known as Obamacare.

DG: …getting rid of the Affordable Care Act.

Trump: You’re going to have such great health care at a tiny fraction of the cost and it’s going to be so easy.

Brian Blase: We were trying to figure out how to best deliver on those campaign promises and what we wanted to do to provide Americans relief from the Affordable Care Act. 

DG: Brian Blase spent two and a half years in President Trump’s administration as a top health care advisor. 

BB: That was what I spent 95% of my time on the first part of 2017.

DG: Going into office, the president had plenty of momentum. 

Republicans in Congress had voted nearly 70 times to repeal the law. 

Major insurers like UnitedHealthcare and Aetna had fled many of the ACA markets leaving one in five people with just one insurer to pick from. 

And premiums for a mid-level plan had jacked up more than 20%.

BB: The individual market was, in most places of the country, a state of chaos. There were very few insurers participating and premiums and deductibles were very high.

DG: The administration argued repealing Obamacare would lower the price of insurance and reduce federal spending.

Republicans would replace it with a plan that offered less generous federal aid for people buying insurance and allow insurers to cover less care. 

BB: So we were trying to provide more choices for consumers, improve government health care spending and take as much power out of Washington, D.C. as possible.

DG: One version of that plan narrowly passed the House — four votes.

But senators killed it.

A stripped down effort to simply repeal the requirement that people buy insurance or face a fine was left in the hands of Arizona Republican Sen. John McCain.

Clip: Mr. McCain … no.

DG: Some senators gasped as McCain, with a flair for the dramatic, turned his thumb down. 

Democrats cheered.

Republicans hung their heads.

BB: That was a big failure. There was an opportunity to really reform America’s health care system in lasting ways by passing legislation. And that effort collapsed.

DG: By the fall of 2017, Republicans in Congress had failed to come up with a plan to replace the ACA.

And President Trump unveiled what amounted to plan B.

BB: The president gives these press conferences, very informal press conferences while he’s waiting to board Marine One. And he said that he had an executive order that he would be signing in the coming days 

Trump: And that will be probably signed next week. It’s being finished now. It’s going to cover a lot of territory and a lot of people, millions of people.

BB: But the president said this, and there was no such executive order that we had in place.

DG: Blase and his colleagues had been working on a more generic executive order on health care, but they quickly pivoted to something more specific.

BB: We took this as a signal — the president wants to lead here, he’s giving us direction. And we inserted three policies into that executive order. Most of what I talk about with the Trump administration’s health policy accomplishments focuses back on those three actions.

DG: Trump and congressional Republicans eventually got rid of the individual mandate and slashed funding for ACA marketing and outreach.

But within days of failing to outright repeal the law, Trump was already looking for new ways to lower monthly premiums and give consumers more choice.

He outlined three policies in his mid-October 2017 executive order.

BB: Association health plans, short term, limited duration insurance and health reimbursement arrangements.

DG:. So-called association health plans — allowing small businesses and self-employed people to band together to buy insurance across state lines — got blocked by the courts a few months after it took effect.

To understand the impact of the second policy, what are called short-term plans, we talked with Emily Gee, a health economist who worked at the Department of Health and Human Services in the Obama Administration. 

She says they’re called “short-term” for a reason.

Emily Gee: So these are insurance plans that are intended to bridge the gap between two types of coverage. You might lose your job and intend to get another one or go to school, and you’re just going to buy a little bit of coverage. 

DG: In 2016, the Obama administration limited these policies to three months.

The Trump administration extended that to a full year.

The president liked these policies because premiums for the cheapest short-term plans are often 20% or less of the lowest priced ACA plans.

That’s because short-term plans are not required to cover all the things ACA plans cover, like maternity care, mental health or pre-existing conditions.

EG: They can exclude things or cap things like prescription drugs or hospital care. And they can also discriminate against people on the basis of gender or medical history or their age.

DG: But that hasn’t stopped people from buying these plans.

EG: There’s a report that the House Energy and Commerce Committee released earlier this summer. And they found that by looking at eight of the largest providers of short term plans, enrollment’s up by roughly a third to about 3 million people.

DG: That same report also found that some people were surprised to learn what their plans covered.

EG: Some of these people are being deceived. The marketers for these plans often use very unfair and deceptive techniques to convince people that pre-existing conditions are covered when they aren’t.

DG: Brian Blase and other Republicans dismiss the report’s findings as partisan, and the Trump administration’s rule does require short-term plans to include a 14-point bold disclaimer stating they are less comprehensive than ACA plans. 

Some states have responded by banning short-term plans, and at least half of states have some kind of restrictions in place.

Finally, there’s the administration’s expansion of Health Reimbursement Arrangements.

BB: That to me is the most significant policy change that the administration has made on health policy.

DG: We asked Brian Blase to explain how these work.

Normally, employers select the plans that they will offer to their employees.

But with HRAs…

BB: The employer provides a contribution to their workers, the worker then takes that contribution, and they can use it to purchase any ACA-compliant plan that they want.

DG: It fits in perfectly with the administration’s goal of providing more choices.

BB: Rather than the employer being in charge, this is transferring power and control to the worker to pick the coverage that works best for them.

DG: Some worry this option could be more attractive to companies with sicker workforces, raising premiums on the individual market. 

And that it lacks strong enough guardrails to make sure employees end up with high-quality insurance.

Unlike most aspects of the president’s health policy agenda, though, this idea gets bipartisan support.

That’s at least in part because all coverage would have to be ACA-compliant.

The rule went into effect at the beginning of 2020. The administration projects that within a decade, more than 11 million people will use HRAs to buy insurance.

BB: I think the HRA rule has a potential to reshape the way employers provide health insurance in the United States and does so in a way that is gradual and that is thus politically sustainable.

DG: Blase says it’ll take a few years to know if HRAs and short-term plans deliver on the president’s goals to reform insurance.

Even if they succeed, they’re unlikely to have anywhere near the impact of a full repeal of the ACA.

EG: The Trump administration has chipped away at the edges of the ACA. They’ve poked a hole here, knocked off a corner there. But all in all, the ACA has had tremendous staying power. 

BB: I think in retrospect, it would have made more sense to take more time and to build the consensus that was needed to do health reform. Now I say that three-and-a-half years later. I think at the time, we didn’t really know how the process was going to unfold. 

DG: There is still a chance President Trump sees his pledge through to end Obamacare.

News clip: Big breaking news out of the Supreme Court announcing just in the last hour it will consider the fate of Obamacare once again.

DG: If the Supreme Court knocks down the law next year and Trump wins a second term, the president could play a decisive role in what the future of health care looks like in this country.

If the law stands, both Emily Gee and Brian Blase agree that a second Trump term would likely pick up where it left off — looking for ways to offer options beyond the ACA, options that may be cheaper but cover less care.

Thanks for joining us for Day 1 of our weeklong look at the health policy record of President Trump.

Tomorrow, we’ll examine how the administration has approached prescription drugs.

Ben Ippolito: They’ve actually proposed a number of fairly substantive proposals, not that many of them have actually gone into effect.

DG: I’m Dan Gorenstein, this is Tradeoffs.