With attempts to repeal and replace the Affordable Care Act on hold, the Trump Administration is stepping up efforts to overhaul the health insurance market by loosening regulations.

The administration has proposed a raft of changes that would expand individual insurance offerings, allow states more flexibility in administering Medicaid, and provide more health insurance options for small businesses and self-employed people.

The latest move came Thursday, when the Centers for Medicare and Medicaid (CMS) issued guidelines that for the first time would allow states to impose work requirements on non-disabled adults receiving Medicaid. Though most able-bodied adults on Medicaid already work, new requirements could make it tougher for people to qualify or remain in the program.

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Last week, the Department of Labor also published a rule detailing a change—first proposed last fall—to make it easier for small businesses and self-employed people to band together in “associations” to buy health insurance that is cheaper and has fewer ACA requirements.

The Trump administration is also calling for loosening restrictions so that short-term health insurance plans, which have fewer mandates and consumer protections, could last 364 days rather than 90 days currently.

Those moves follow the passage late last year of the new tax law, which repealed the  mandate requiring most people to buy ACA health insurance or pay a penalty. The penalty goes away starting in 2019, a change that is expected to spur the creation of alternative insurance products.

“These will be incremental, not massive changes, but regulatory reform looks like it will be the path forward,” says Katherine Hempstead, a senior adviser who works on health insurance and health policy issues at the Robert Wood Johnson Foundation. “The new rules will create both winners and losers.”

People who want to buy cheaper, less comprehensive insurance should find more options. But if fewer people participate in ACA exchanges, Hempstead says, that will likely cause premiums on comprehensive plans sold in the individual health insurance market to rise even higher. 

How New Rules Might Affect You

If You Are Self-employed or Run Your Own Business
The proposed change to association health plans could spur small businesses to start offering insurance for their employees. And for the first time, it would allow people who are self-employed to band together to buy group health insurance.

These groups would have more bargaining power to negotiate lower prices.  And they would be able to cut costs by not having to meet all the ACA mandates such as coverage for things like prescription drugs and hospitalizations. Association insurance also would be exempt from an ACA rule that insurers spend at least 80 percent of premium revenue on medical care.

The association plans would still retain consumer protections such as not letting a patient's health status affect premium prices. But consumer advocates and patient groups say people could wind up with less coverage than they might need or face higher out-of-pocket costs. The alternate plans also could draw people away from the individual health insurance market, leaving those who still buy individual coverage on ACA exchanges with even higher premiums.

The public has 60 days to comment on the rule before it can be finalized.

If You Buy Your Own Health Insurance
The administration is also calling for fewer rules on short-term health insurance plans. These plans typically have lower premiums because they don't include all the ACA requirements such as maternity coverage or mental health care. The plans also don't have to cover pre-existing health conditions or be required to renew your policy if you get sick.

A detailed rule hasn't been released for comment yet. But President Trump has asked that short-term plans be available for just under one year instead of the current 90-days. That would allow people to use them for nearly year-round coverage.

Short-term plans have been around for decades. But with the elimination of the penalty for not having ACA-mandated insurance,  these plans are likely to become more attractive to people who are healthier and want a less-expensive option. That could further siphon people out of the ACA's individual market and cause those premiums to rise further.

If You Get Medicaid
Qualifying for benefits under Medicaid programs, which are run by states but also receive federal funding, may be harder under the new guidelines released by CMS. Now states that get waivers approved by the federal government could require non-disabled adults to work, volunteer, go to school, or be in a job training program to get benefits.

Friday, Kentucky became the first of 10 states that want to impose Medicaid work requirements to win approval from the federal government. Now to be eligible for Kentucky's Medicaid program, you must complete 80 hours a month of "community engagement activities", which could be working, job skills training, or community service. Also new: You may also have to pay monthly premiums, depending on your income.

It isn't clear how many people would be affected by the work requirements since most people who are on Medicaid already are employed. Six in 10 non-disabled adults on Medicaid have a job and 78 percent of Medicaid recipients are part of a household with at least one person working full-time, according to the Kaiser Family Foundation. Many of those who don’t work are caregivers for other people but that would count as a form of work under the new guidelines.  

But work requirements and other changes states are seeking, such as drug testing and eligibility time limits, could lead to fewer people in Medicaid over the long term, says Hempstead. Kentucky officials estimate that there will be 95,000 fewer people in its Medicaid program in five years. There are 1.4 million people in it now.