VoxCare: Trump hates Obamacare. He’s also in charge of running it.

I took a two-day reporting trip to Detroit this week, and, well, apparently I  missed a few things back here in DC!  As Obamacare repeal falters, it becomes increasingly likely the Trump administration will be in charge of a law it hates. Today I want to explore how that plays out, and what it means for the people who rely on the Affordable Care Act for coverage. by Sarah Kliff The Trump administration will, in the coming weeks and months, need to make a decision: Does it want to force Obamacare's collapse? President Trump for months now has predicted Obamacare's implosion. His most recent forecast came Monday night, as Senate Republicans' repeal effort began to falter. Trump often talks about Obamacare's "failure" like a predetermined, fixed event on the horizon. That is hardly the case: Much of Obamacare's success or failure rests on the decisions the Trump administration will make.  "There is little question in my mind that through active mismanagement, you could do a lot of damage," says Andy Slavitt, who previously served as Medicare administrator under President Obama. "There are an untold number of ways you could mismanage this thing." Obamacare is not a program that runs on autopilot. It requires active management and policy decisions about how to allocate resources, and how to communicate with the health plans that sell coverage. These decisions will need to be made in the coming months, and they'll determine whether Trump's predictions come true.  Slavitt, an advocate for the Affordable Care Act, demurred when I asked him about what opportunities for mismanagement exist — he didn't want to hand the White House a playbook for sabotage. Still, it's not hard to come up with a list of key decision points that sit in front of the Trump administration right now: Do they commit to paying cost-sharing reduction subsidies or continue to stoke uncertainty? The Trump administration has been aggressively ambiguous when asked about whether it will continue making these payments to cover the bills of low-income Obamacare enrollees. Not making these payments or stoking uncertainty about their future is an easy way to encourage insurance plans to raise premiums or quit the marketplaces altogether. Do they actively recruit health plans to join the marketplaces? About this time last year, Obama administration officials were crisscrossing the country, ensuring that each county would have at least one health plan selling coverage in the next open enrollment. There is no indication that the Trump administration — which sends out press releases highlighting how few insurers want to sell Obamacare — is taking similar steps. That would be an easy way to depress health plan competition under the health law. Do they advertise the Affordable Care Act's open enrollment period?One of the Trump administration's first actions on health care was to attempt to pull Affordable Care Act advertisements that let people know they could sign up for coverage. Whether the Trump administration publicizes enrollment opportunities or does little in public education will make a big difference for the marketplaces' stability. So far, we've generally seen the Trump administration make policy decisions that hurt Obamacare. It won't commit to paying the law's cost-sharing reduction subsidies. Office of Management and Budget Director Mick Mulvaney reportedly told health insurance officials this week that "we are looking at the cost-sharing payments on a month-to-month basis. We made them today. We'll make them tomorrow. But I don't think we'll see a long-term commitment from this administration." At the same time, the Trump administration doesn't seem quite ready to press the explode button yet. This was made apparent last week when Health and Human Services approved funding for a program that would make Obamacare work better in Alaska. It was the rare Trump administration action that Slavitt praised.  "It was a really good decision, and I applaud it," he says. Myriad decisions face the Trump administration in the coming weeks and months. It will be these decisions that determine whether Trump's prediction ultimately comes true.  Vox