ACA Sabotage: Deliberate Undermining of Health Insurance for Millions
Having failed to repeal the ACA legislatively (defeated by the 51-49 Senate vote, including John McCain's thumbs-down), the Trump administration used regulatory and administrative mechanisms to undermine it: eliminating the individual mandate penalty, cutting navigator and outreach funding from $63 million to $10 million, supporting a lawsuit arguing the entire ACA was unconstitutional, and expanding short-term health plans that excluded pre-existing conditions. CBO projected these actions would cause 10-13 million people to lose insurance.
Record summary
Grade
Grade 5 of 5: War Crime / Crime Against Humanity
Conduct that satisfies the legal elements of a war crime under the Rome Statute (Article 8), a crime against humanity (Article 7), or genocide (Article 6). Scale and definitions
- Status
- Concluded
- Incident date
- Record updated
- Location
- Washington, D.C.
- Category
- Federal Dismantlement
- Legal posture
- Reported
- War-crime classification
- Enabling conduct
- Verification
- Independently verified
- ICC relevance
- No
- Sources
- 5 cited
- Stable ID
trump-aca-sabotage-healthcare- Victims
- Millions of Americans who lost health insurance or paid higher premiums as a direct result of ACA sabotage; people with pre-existing conditions denied coverage by short-term plans; those who avoided seeking care due to cost
- Alleged responsible parties
- Donald Trump, President of the United States— White House
- Alex Azar, Secretary of Health and Human Services— HHS
- Seema Verma, Administrator, Centers for Medicare & Medicaid Services— CMS
Key points
- The Trump administration cut the ACA outreach and navigator budget from $63 million in FY2016 to $10 million in FY2018 — a 90% cut that reduced enrollment assistance for people navigating complex insurance options
- The administration shortened the open enrollment period from 12 weeks to 6 weeks and stopped advertising enrollment in the final weeks of the period, when advertising had historically driven significant sign-ups
- Trump halted cost-sharing reduction (CSR) payments to insurers in October 2017, which caused immediate premium increases of approximately 20%; the move was projected by CBO to increase the federal deficit by $6 billion over 10 years
- Eliminating the individual mandate penalty (via the 2017 tax law) removed the incentive for healthy people to buy insurance, causing adverse selection that raised premiums for remaining enrollees
- The administration expanded access to short-term health plans that were exempt from ACA protections including pre-existing condition coverage, effectively creating a two-tier system with junk plans available to the healthy and comprehensive plans more expensive for the sick
- The Trump administration filed briefs supporting the Texas v. U.S. lawsuit arguing the entire ACA was unconstitutional — a position that, if successful, would have eliminated coverage for approximately 20 million people simultaneously
Overview
When Congress failed to repeal the ACA — blocked by a 51-49 Senate vote — the Trump administration adopted a different strategy: administrative sabotage. The goal was the same, but the mechanism was regulatory and administrative action rather than legislation.
The administration was largely successful. Premium increases attributable to the end of cost-sharing reduction payments were documented immediately. Enrollment declined. The number of uninsured Americans stopped falling and began rising.
The Tools of Sabotage
The administration's tools were varied. It cut the budget for helping people navigate enrollment options by 90%. It shortened the enrollment window, reducing the time people had to shop for plans. It stopped advertising enrollment in the final weeks — when advertising had historically been most effective.
It eliminated the cost-sharing reduction payments that kept premiums affordable for low-income enrollees. It expanded alternative "junk plans" that could deny coverage for pre-existing conditions. It refused to defend the ACA in court when a federal judge ruled it unconstitutional.
Each measure individually was defensible as regulatory discretion. Cumulatively, they constituted a deliberate strategy to undermine a functioning health insurance system while a legislative replacement did not exist.
The Casualties
The Congressional Budget Office projected that the elimination of the individual mandate penalty alone would cause 10-13 million people to lose insurance over 10 years. Premium increases attributable to the CSR payment termination were documented in the range of 20% in markets where the administration's action directly drove the increase.
People who lost insurance or who couldn't afford higher premiums delayed or forgone medical care as a result. The attributable effects on health outcomes are difficult to isolate precisely — but the mechanism is well understood: people without insurance get less preventive care, delay treatment for serious conditions, and die at higher rates from preventable causes.
International law engaged
| Instrument | Provision | What it protects or prohibits |
|---|---|---|
| International Covenant on Economic, Social and Cultural Rights | Article 12 | Right to the highest attainable standard of physical and mental health — deliberate government action to reduce health insurance coverage undermines this right |
Update log
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Updated with full first-term ACA sabotage record before election.
Sequence of events
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Day one executive order — implement 'maximum extent possible'
Trump signs an executive order on Day One directing federal agencies to use 'maximum extent possible' regulatory discretion to waive or delay ACA requirements pending repeal legislation.
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McCain casts decisive 'no' vote on ACA repeal
The Senate vote to pass the 'skinny repeal' fails 51-49, with Sen. John McCain providing the decisive thumbs-down vote. Trump and administration allies immediately declare intent to pursue non-legislative means to undermine the ACA.
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Trump ends cost-sharing reduction payments
Trump halts CSR payments to insurance companies — payments that offset the cost of providing reduced out-of-pocket costs to low-income enrollees. Insurers respond by increasing premiums; the CBO projects the action will increase the federal deficit by billions due to larger premium subsidies required.
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Executive order expands short-term and association plans
Trump signs an executive order directing expansion of short-term health plans (not subject to ACA protections) and association health plans. The plans can exclude pre-existing conditions and offer fewer benefits.
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Navigator funding cut to $10 million
The administration reduces navigator funding — used to pay people who help consumers understand and enroll in ACA plans — from $63 million to $10 million, cutting consumer assistance capacity by approximately 90% in federally-operated marketplace states.
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Texas judge rules ACA unconstitutional
A federal judge in Texas rules the entire ACA is unconstitutional due to the elimination of the individual mandate penalty. The Trump administration declines to defend the law in court, instead supporting the ruling. The case eventually reaches the Supreme Court, which upholds the ACA in 2021.
Sources
- Trump Signs Executive Order on Obamacare, Opening Door to Cheaper, Skimpier Plans — The New York Times
- Tracking ACA Sabotage — Center on Budget and Policy Priorities
- Navigators in ACA Marketplace States — Funding Cuts — KFF (Kaiser Family Foundation)
- CBO: Effects of Eliminating the Individual Mandate Penalty — Congressional Budget Office
- ACA sabotage — what the Trump administration did and why it mattered — The Associated Press