Trump still doesn't have a plan to replace Obamacare if the Supreme Court kills the law. But one of his top advisors is sharing these clues about what would happen next.

  • The Trump administration is supporting a lawsuit asking the courts to throw out the Affordable Care Act, even though the White House has no concrete replacement for the Obama-era healthcare law.
  • President Donald Trump has repeatedly promised a backup plan but hasn't unveiled a detailed proposal. His domestic policy chief, Brooke Rollins, said the White House is still working on one.
  • "Obviously if the Affordable Care Act is struck down, we will be ready," Rollins told Insider in an exclusive interview last week. "If it is not, then we're going to continue to improve the current system."
  • The Supreme Court is expected next month to hear arguments in the ACA case that was initiated by the conservative Texas Public Policy Foundation, which Rollins once oversaw.
  • Visit Business Insider's homepage for more stories.

The White House's policy shop lacks a clear replacement plan for the Affordable Care Act if the Supreme Court throws out the healthcare law. 

Brooke Rollins, acting director of the Domestic Policy Council at the White House, told Insider in an exclusive interview last week that a backup plan is "being worked on" but indicated that administration officials hadn't settled on a solution. 

"Obviously if the Affordable Care Act is struck down, we will be ready," she said. "If it is not, then we're going to continue to improve the current system." 

The Supreme Court will hear a challenge to the ACA a week after the November 3 election. The Trump administration argues the entire law, which was signed by former President Barack Obama, should be wiped out, threatening coverage for 20 million people. 

Democrats, including presidential candidate Joe Biden, have focused on raising alarm about the lawsuit in the weeks leading up to the election and as Senate Republicans rush to confirm the third new conservative Supreme Court justice of the Trump era. 

They warn that President Donald Trump's Supreme Court pick, Judge Amy Coney Barrett, could be the deciding vote to strike down the law even as the US continues to battle the coronavirus pandemic. Senate Republicans opened confirmation hearings Monday on Barrett's nomination and want to hold a final floor vote on her lifetime appointment before Election Day. 

Rollins told Insider that striking down the law would be "the right way" to go. "We not only think it was unconstitutional, but that it hasn't worked as promised," she said.

Read more: EXCLUSIVE: Trump's White House policy chief spells out a 2nd-term agenda, including what would happen to taxes, drug prices, and manufacturing jobs

'All to be worked out' 

Before coming to the White House's Office of Innovation in early 2018, Rollins was president and CEO of the Texas Public Policy Foundation, a powerful conservative organization that was behind the ACA lawsuit that's now before the Supreme Court. The think tank has pushed for states to take the lead in setting up their own healthcare plans. 

Rollins has overseen the Domestic Policy Council since May. The office operates largely behind the scenes but is influential in directing and coordinating the president's agenda. 

She told Insider that if the Supreme Court strikes down the healthcare law the government could "redeploy" the money that's being used to pay for the law. 

Asked whether the funds would go to states to help them set up their own healthcare systems, Rollins said there are "a lot of options" on the table.

"That's obviously where I think the Republicans have been before, but where this president wants to go is he wants to put patients back in charge of their own healthcare," she said. 

Whether to go through states or through the federal government was "all to be worked out," she said. Much of the current funding of the law goes to subsidize health insurers rather than providing help directly to patients, she added. 

Read more: Meet the 24 most powerful people advising Trump on healthcare as the president vies for a second term

Demonstrators hold signs as Democratic leaders speak in defense of the Affordable Care Act at the Capitol on June 26, 2018.Photo by Aaron P. Bernstein/Getty Images

Repeated promises to replace the ACA

The ACA has faced multiple court challenges since becoming law. It once was unpopular in part because it disrupted people's previous coverage and imposed a fine on the uninsured, and congressional Republicans successfully ran on promises to repeal it. After failing to kill the Obama-era legacy in 2017 they moved on to overhaul tax laws and zeroed out the ACA's penalty, the so-called individual mandate. 

That move raised ACA's favorability among voters but also created an opening for the latest legal challenge. The case headed before the Supreme Court for arguments on November 10 was initially waged by GOP state officials who say the law is unconstitutional. They cite a 2012 Supreme Court decision that said the fine on the uninsured was critical to making the rest of the law work. They conclude that without it, the law cannot stand.

The Trump administration supports the lawsuit but finds itself fighting off political attacks on its position. Kaiser Family Foundation polling shows that the overall law is viewed favorably by 49% of voters and unfavorably by 42% of voters. 

But specific ACA provisions that are far more popular prohibit insurers from turning away sick people and from charging them more for coverage than healthy people. Those practices were common before the ACA made it illegal for insurers to discriminate against people with pre-existing conditions. 

Trump and congressional Republicans have repeatedly promised to repeal and replace the ACA. But they haven't unified behind an alternative more than a decade since its inception and nearly four years since Trump became president. 

In a Monday tweet, Trump urged Republicans to "get the word out" that they were going to provide "much better" healthcare at "a much lower cost."

 

In September, the president signed several healthcare-related executive orders that the White House said would restore "choice and control" to patients and make healthcare more affordable. Those orders would still require action from Congress. 

In defense of the administration's position, Rollins pointed out ways that she said the ACA hadn't lived up to its promises. For instance, she said millions of people are priced out of coverage offered through the ACA-created marketplaces. 

Generally speaking, the law doesn't help people pay for coverage if they earn more than 400% of the federal poverty level or about $49,960 a year for one person. For them, accessing protections for pre-existing conditions isn't possible. 

"This sort of exalting of the Affordable Care Act is really confusing to me," Rollins said. 

Democrats have acknowledged the healthcare law's affordability problems. In June, House Democrats passed a bill that would boost how much money the government subsidizes for health insurance, which would lower what people pay for coverage directly but not impose limits on prices. That bill won't be taken up by the Republican-led Senate.

Following the interview with Rollins, the White House sent Insider additional information defending its stewardship of the ACA. It provided reports showing that ACA premiums have decreased in part because the Trump administration approved federal funds to help states stabilize their marketplaces. The number of insurers offering plans has also grown since the end of Obama's second term. 

The White House also noted that it allows employers to give workers pre-tax dollars to help them shop for their own health plans. If there's a big uptake of the plans, then insurance would become more affordable. 

"This rule is expected to lead to four times as many people purchasing coverage in the individual market with no new federal spending," the White House said of the employer offerings. 

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