Executive Order 13813
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The Executive Order Promoting Healthcare Choice and Competition, also known as the Trumpcare Executive Order, or Trumpcare, is an
Executive Order In the United States, an executive order is a directive by the president of the United States that manages operations of the federal government. The legal or constitutional basis for executive orders has multiple sources. Article Two of the ...
signed by
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who is the 47th president of the United States. A member of the Republican Party (United States), Republican Party, he served as the 45 ...
on October 12, 2017, which directs federal agencies to modify how the
Patient Protection and Affordable Care Act A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...
of the Obama Administration is implemented. The order included a directive to federal agencies to end rules forbidding employers from using health reimbursement arrangements (HRAs) to pay individual insurance premiums. In a separate announcement made shortly after the order was signed, Trump announced that he would end subsidies to health insurance companies that sell to low-income consumers through the state
health insurance marketplace In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s. Some sources have described the effect of these executive actions as replacing Obamacare with a new healthcare regime; several days after signing the order, Donald Trump himself stated in a press conference that reporters should no longer refer to "Obamacare" because "it's gone, there is no such thing as Obamacare anymore". Executive Order 13813 was formally revoked by President
Joe Biden Joseph Robinette Biden Jr. (born November 20, 1942) is an American politician who was the 46th president of the United States from 2021 to 2025. A member of the Democratic Party (United States), Democratic Party, he served as the 47th vice p ...
on January 28, 2021. The Executive Order revoking Executive Order 13813, was revoked by Donald Trump on January 20, 2025.


History


Legislative efforts to repeal the Affordable Care Act

The first executive order signed by U.S. President
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who is the 47th president of the United States. A member of the Republican Party (United States), Republican Party, he served as the 45 ...
, executed just hours after he was sworn into office on January 20, 2017, was
Executive Order 13765 Executive Order 13765 is the first executive order signed by U.S. President Donald Trump during his first presidency on January 20, 2017, which set out interim procedures in anticipation of repeal of the Affordable Care Act (Obamacare). The e ...
, titled ''Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal''. The order set out interim procedures in anticipation of repeal of the
Patient Protection and Affordable Care Act A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...
(popularly known as the ACA, or Obamacare). The order came on Trump's campaign pledges to repeal the
Patient Protection and Affordable Care Act A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...
, which Trump stated would take a long time, with a replacement possibly not being ready until 2018. On May 4, 2017, the
United States House of Representatives The United States House of Representatives is a chamber of the Bicameralism, bicameral United States Congress; it is the lower house, with the U.S. Senate being the upper house. Together, the House and Senate have the authority under Artic ...
voted to pass the
American Health Care Act of 2017 The American Health Care Act of 2017 (often shortened to the AHCA or nicknamed Ryancare) was a bill in the 115th United States Congress. The bill, which was passed by the United States House of Representatives but failed the United States S ...
(ACHA) by a narrow margin of 217–213, sending the bill to the
Senate A senate is a deliberative assembly, often the upper house or chamber of a bicameral legislature. The name comes from the ancient Roman Senate (Latin: ''Senatus''), so-called as an assembly of the senior (Latin: ''senex'' meaning "the el ...
for deliberation. It would repeal the parts of the Affordable Care Act within the scope of the federal budget, including provisions contained within the Internal Revenue Code such as the " individual mandates" (in ), employer mandates (in ) and various taxes ( et. seq.), and also modifications to the federal Medicaid program (in Sections 111-116 and 121). The nonpartisan
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. I ...
projected that the AHCA would increase the number of uninsured people by 23 million over 10 years, but would decrease the federal budget deficit by $119 billion over the same period (about 1%), mainly by cutting
Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...
coverage for lower income Americans. Both the House AHCA bill and Senate BCRA bill would cut taxes largely for wealthy Americans. Insurance premiums were projected to decrease for younger, healthier, and wealthier people, while older and poorer people would likely see their premiums increase. Senate
Republicans Republican can refer to: Political ideology * An advocate of a republic, a type of government that is not a monarchy or dictatorship, and is usually associated with the rule of law. ** Republicanism, the ideology in support of republics or agains ...
initially approached the AHCA with an unprecedented level of secrecy; a group of 13 Republican senators drafted the Senate's substitute version in private, raising bipartisan concerns about a lack of transparency and about the all-male composition of the committee. On June 22, 2017, Republicans released the first discussion draft for an amendment to the bill. On July 25, 2017, although no amendment proposal had yet garnered majority support, Senate Republicans voted to advance the bill to the floor and begin formal consideration of amendments. On July 28, 2017, the bill was returned to the calendar after the Senate rejected several amendments, including , the "Skinny Repeal" package offered by Sen.
Mitch McConnell Addison Mitchell McConnell III (; born February 20, 1942) is an American politician and attorney serving as the senior United States senator from Kentucky, a seat he has held since 1985. McConnell is in his seventh Senate term and is the long ...
, which failed on a 49–51 vote. Sens.
John McCain John Sidney McCain III (August 29, 1936 – August 25, 2018) was an American statesman and United States Navy, naval officer who represented the Arizona, state of Arizona in United States Congress, Congress for over 35 years, first as ...
,
Susan Collins Susan Margaret Collins (born December 7, 1952) is an American politician serving as the senior United States senator from Maine. A member of the Republican Party, she has held her seat since 1997 and is Maine's longest-serving member of ...
, and
Lisa Murkowski Lisa Ann Murkowski ( ; born May 22, 1957) is an American attorney and politician serving as the Seniority in the United States Senate, senior United States senator from the state of Alaska, having held the seat since 2002. She is the first woman ...
were the only Republicans to vote against the measure. On September 13, 2017, Senators Graham, Cassidy, Heller, and
Johnson Johnson may refer to: People and fictional characters *Johnson (surname), a common surname in English * Johnson (given name), a list of people * List of people with surname Johnson, including fictional characters *Johnson (composer) (1953–2011) ...
released a draft amendment to the bill that "repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states". However, it was not voted upon due to lack of support. The deadline for Congressional Republicans to end the ACA as part of the Congressional budget reconciliation process (which would enable Senate Republicans to pass new legislation with 51 votes, rather than 60) then expired on September 30, 2017.


Execution of the Executive Order

Following the failure of Congress to repeal the ACA through legislation, Trump issued the new order. Both supporters and critics asserted that the provisions of the order were intended to redefine the American health care market and effectively replace Obamacare with a new health care regime. Trump briefly forgot to sign the order before leaving the signing ceremony, but was ushered back to the table by Vice President
Mike Pence Michael Richard Pence (born June 7, 1959) is an American politician and lawyer who served as the 48th vice president of the United States from 2017 to 2021 under President Donald Trump. A member of the Republican Party (United States), Repub ...
to complete this step. Senator
Rand Paul Randal Howard Paul (born January 7, 1963) is an American politician serving as the Seniority in the United States Senate, junior United States senator from Kentucky since 2011. A member of the Republican Party (United States), Republican ...
, who attended the signing, described the order as "the biggest free market reform of health care in a generation."


Provisions

The order reverses a number of aspects of Obamacare upon which that regime had relied. Section 1, title "Policy", lays out the policies supporting the provisions of the order, noting that the order directs that the government "facilitate the purchase of insurance across State lines" and prioritizes " association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs)". Whereas Obamacare had prohibited insurance companies from selling low-cost short-term health insurance plans "that can circumvent some of the mandates created under Obamacare", such as requiring coverage for persons with preexisting conditions, and requiring coverage for various medical services. The order reversed this prohibition, and also directs the Departments of Health and Human Services, Labor, and Treasury to ease access to "association health plans", which also need not provide the coverage that had been mandated by Obamacare, and expands health savings accounts. Section 2, titled "Expanded Access to Association Health Plans", directs the Secretary of Labor to take steps to "expand access to health coverage by allowing more employers to form AHPs". Section 3, titled "Expanded Availability of Short-Term, Limited‑Duration Insurance", directs the Secretaries of the Treasury, Labor, and Health and Human Services to take steps to "expand the availability of STLDI". Section 4, titled "Expanded Availability and Permitted Use of Health Reimbursement Arrangements", directs the Secretaries of the Treasury, Labor, and Health and Human Services to take steps to "increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage".


Impact

A separate decision on the same day commonly associated with the executive order resulted in no longer paying the cost sharing reduction (CSR) subsidies, which are payments to insurers to keep premiums down for low-income persons. The
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. I ...
reported in August 2017 that not making the CSR payments could increase health insurance premiums on the ACA exchanges by as much as 20% and add nearly $200 billion to the budget deficit over a decade. The deficit increase is because the premium tax credit subsidy (the largest Affordable Care Act subsidy) increases to offset increases in health insurance premium amounts, far outweighing savings from not paying the smaller CSR subsidy.


Reception


Critical response

Critics described the Executive Order as another part of an ongoing strategy to sabotage the ACA by enabling insurance companies to circumvent ACA mandates and sell insurance that does not cover mandated conditions, and excludes individuals with
pre-existing condition In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health insurance went into effect. Before 2014, some insurance policies would not cover expenses due to pre-existin ...
s. Other elements alleged to be part of the sabotage strategy include denying funding not mandated by law for cost sharing reduction (CSR) subsidies, significantly reducing funding for enrollment advertising and support efforts, asserting that the ACA exchanges are in a "death spiral" (contrary to CBO conclusions), and conducting negative advertising campaigns, among other measures. For example, President Trump tweeted on October 13, 2017, that: "The Democrats ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!". Journalist
Ezra Klein Ezra Klein (born May 9, 1984) is an American American liberalism, liberal political commentator and journalist. He is currently a ''The New York Times, New York Times'' columnist and the host of ''The Ezra Klein Show'' podcast. He is a co-founde ...
wrote that: "Trump has long held the view that if he can inflict sufficient damage to the Affordable Care Act, Democrats will have no choice but to cut a deal — on Trump's terms — to save it". Journalist Sarah Kliff wrote that: "Trump announced last week he would stop making SRpayments. But let's be clear: That decision will cause the federal government to spend billions more subsidizing insurance companies, not less." That is because the savings from reducing CSR payments is less than increases in the insurance premium tax credits, which rise along with sizable (20%+) premium increases for 2018 caused by Trump's threats to the CSR payments during 2017. Kliff used the CBO estimate of $194 billion in higher budget deficits from stopping CSR payments as an estimate of the net impact over a decade. Journalist
David Leonhardt David Leonhardt (born January 1, 1973) is an American journalist and columnist. Since April 30, 2020, he has written the daily "The Morning" newsletter for ''The New York Times''. He also contributes to the paper's Sunday Review section. His col ...
wrote on October 15, 2017: "Last week, the administration took several steps to deprive people of health insurance. In doing so, it has both a short-term goal (have the federal government do less to help vulnerable citizens) and a long-term goal (sabotage Obamacare, so that Congress can more easily repeal the law)". He continued: "When he executive ordertakes full effect, it will most likely allow a variety of cheap insurance plans that don't cover many treatments. These plans will siphon healthy families from the normal markets, raising prices on the sick. It will work nicely for healthy families, until it doesn't. If they get sick and want insurance that pays for their treatments, they will be out of luck". According to ''
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'', Trump's plans "are likely to end up inflicting the most pain on self-employed, middle- to upper-income folk—in other words, on a Republican constituency".


Murray—Alexander Individual Market Stabilization Bill

Senator
Lamar Alexander Andrew Lamar Alexander Jr. (born July 3, 1940) is an American politician and attorney who served as a United States senator from Tennessee from 2003 to 2021. A member of the Republican Party, he also was the 45th governor of Tennessee from 1 ...
and Senator
Patty Murray Patricia Lynn Murray (, October 11, 1950) is an American politician serving in her sixth term as a United States senator from Washington (state), Washington, beginning her tenure in 1993, and is the state's Seniority in the United States Senate, ...
reached a compromise to amend the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and informally as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
to fund cost-sharing reductions. President Trump had stopped paying the cost sharing subsidies and the
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. I ...
estimated his action would cost $200 billion, cause insurance sold on the exchange to cost 20% more and cause one million people to lose insurance. The plan will also provide more flexibility for state waivers, allow a new "Copper Plan" or catastrophic coverage for all, allow interstate insurance compacts, and redirect consumer fees to states for outreach. Although Trump initially expressed support for the compromise, he later reversed course by tweeting a dismissive tweet about it.


See also

*
Executive Order 13765 Executive Order 13765 is the first executive order signed by U.S. President Donald Trump during his first presidency on January 20, 2017, which set out interim procedures in anticipation of repeal of the Affordable Care Act (Obamacare). The e ...
*
Tax Cuts and Jobs Act of 2017 The Act to provide for reconciliation pursuant to titles II and V of the concurrent resolution on the budget for fiscal year 2018, , is a congressional revenue act of the United States originally introduced in Congress as the Tax Cuts and Jobs ...


References


Further reading


Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States
The White House (October 12, 2017)
Remarks by President Trump at Signing of Executive Order Promoting Healthcare Choice and Competition
The White House (October 12, 2017) {{Trump executive actions 2017 in American law Executive orders of Donald Trump Healthcare reform in the United States