The righteous considereth the cause of the poor: but the wicked regardeth not to know it (Proverbs 29-7).

Wicked is a fitting description for the actions of the Trump administration in sabotaging Obamacare which has been a godsend for millions of poor Americans. Trump’s very first executive order signed just hours after he was sworn in established the plan for dismantling Obamacare:

• Section 1. It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act, as amended. In the meantime, pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open healthcare market.

• Section 2. To the maximum extent permitted by law, the secretary of Health and Human Services (secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any state or a cost, fee, tax, penalty or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance or makers of medical devices, products, or medications.

Trump failed in his effort to repeal Obamacare thanks to the conscientious votes of three Republican senators, Murkowski, Collins and McCain. However, the transparent sabotage attempts have continued unabated. The Center on Budget and Policy Priorities (CBPP) is keeping a record of the actions by the Trump administration to harm the Affordable Care Act.

It is called “Sabotage Watch: Tracking Efforts to Undermine the ACA.” This timeline tracks administration actions that would destabilize private insurance markets or reverse gains in health coverage. The list is currently 15 pages long and includes 44 acts of sabotage.

Our own wicked senator, Tom Cotton, proposed one of the more damaging blows to the stability of Obamacare. In the same legislation that provided massive tax cuts for corporations and the wealthy he included the elimination of the individual mandate.

Under Cotton’s change, beginning in 2019, people will no longer have to pay a penalty if they do not obtain health insurance. This action alone is projected to cause premiums on the individual market to increase by 10 percent. Cotton then had the audacity to go on “Face the Nation” and tell the bald-faced lie that the elimination of the individual mandate would have “no impact on anyone.”

The CBPP noted the obvious impact of Cotton’s sabotage: “Without the mandate, fewer healthy people will sign up for coverage, increasing average health care costs in the individual market and causing premiums to rise by 10 percent, according to Congressional Budget Office (CBO) estimates. CBO also estimates that mandate repeal will cause 13 million people to become uninsured, increasing the non-elderly uninsured rate by almost 50 percent.” Some other notable incidents of sabotage documented by CBPP include:

February 2018: The Trump administration proposes rules to expand the use of short-term health plans as an alternative to plans that meet more stringent standards under the Affordable Care Act. This would let a parallel market for skimpy plans operate alongside the market for comprehensive individual health insurance, exposing consumers to new risks and raising premiums for people seeking comprehensive coverage, especially middle-income consumers with pre-existing conditions.

June 2018: In a case challenging the constitutionality of the Affordable Care Act, the Trump administration through the Department of Justice files a brief asking the court to strike down two critical consumer protections: the provision that bars insurers from denying coverage to people with pre-existing conditions (guaranteed issue) and the prohibition on charging higher premiums to people because of their health status (community rating).

June 2018: The Labor Department finalizes rule changes expected to increase enrollment in association health plans, coverage offered by trade and professional associations. Under the new rules, these associations could sell coverage to small businesses and self-employed individuals without meeting key Affordable Care Act standards that would otherwise apply to plans sold to these customers.

July 2018: The Centers for Medicare and Medicaid Services announces that Affordable Care Act risk adjustment transfers for 2017 may be delayed. Risk adjustment is a federal program that transfers revenues from insurers that enroll a healthier-than-average group of consumers to those that enroll a sicker-than-average group.

July 2018: The Centers for Medicare and Medicaid Services slashes funding for consumer enrollment assistance and outreach through the navigator program to just $10 million for the 34 states whose Affordable Care Act marketplaces ae facilitated by the federal government. Combined with the large cut last year, navigator funding has now fallen more than 80 percent from its 2016 level.

In January 2018, the Department of Health and Human Services sent a letter to state Medicaid directors concerning “opportunities to promote work and community engagement among Medicaid beneficiaries.” The letter stated: “The Centers for Medicare and Medicaid Services (CMS) is announcing a new policy designed to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability. Subject to the full federal review process, CMS will support state efforts to test incentives that make participation in work or other community engagement a requirement for continued Medicaid eligibility or coverage for certain adult Medicaid beneficiaries in demonstration projects …”

The very next day the Department of Health and Human Services approved Kentucky’s Medicaid waiver to require some Medicaid beneficiaries to work or participate in work related activities. The waiver also included provisions for reporting requirements, premium payments, coverage lockouts and restrictions on retroactive coverage.

Fifteen Kentucky Medicaid recipients filed a class-action lawsuit against the Trump administration challenging the waivers to the Medicaid expansion program. The plaintiffs were represented by the National Health Law Program, Kentucky Equal Justice Center, and the Southern Poverty Law Center. The preliminary statement of the lawsuit included these assertions: “This case challenges the efforts of the executive branch to bypass the legislative process and act unilaterally to ‘comprehensively transform’ Medicaid, the cornerstone of the social safety net. Purporting to invoke a narrow statutory waiver authority that allows experimental projects ‘likely to assist in promoting the objectives’ of Medicaid, the executive branch has instead effectively rewritten the statute, bypassing congressional restrictions, overturning a half century of administrative practice, and threatening irreparable harm to the health and welfare of the poorest and most vulnerable in our country. The Medicaid program provides health insurance to more than 75 million low-income people in the United States. On Aug. 24, 2016, Kentucky Gov. Matt Bevin submitted an application to the secretary requesting a waiver of various Medicaid Act requirements to implement the ‘Kentucky HEALTH’ project. Kentucky was candid about its goal: it aimed ‘to comprehensively transform Medicaid.’ True to its word, the Kentucky HEALTH program sought to radically alter Medicaid in Kentucky, including by requiring Medicaid enrollees to work in order to receive health insurance and by imposing new and substantial premiums and restrictions. By the State’s own estimate, Kentucky HEALTH would reduce Medicaid enrollment over a five-year period by over 95,000 adults and reduce payments for health care for low income Kentuckians by approximately $2.4 billion. The secretary’s issuance of the letter to State Medicaid Directors and approval of Kentucky’s request sharply deviate from the congressionally-established requirements of the Medicaid program and vastly exceed any lawful exercise of the Secretary’s limited waiver authority.”

United States District Court Judge for the District of Columbia James Boasberg granted plaintiff’s motion for aummary judgment, vacated the secretary’s approval of Kentucky HEALTH, and remanded the matter back to the Department of Health and Human Services. In his decision the judge ruled that the Secretary of Health and Human Services did not properly consider the basic objectives of the Medicaid Act in granting the waivers.

In the key part of the decision, Judge Boasberg restated the plaintiff’s case: “Plaintiff’s position is simple: ‘The purpose of the Medicaid Act is to provide coverage and care to the most vulnerable’ and, more precisely, ‘to provide that care generally free of charge.’ The secretary, they believe, ‘failed to consider adequately’ the impact of Kentucky HEALTH on Medicaid coverage. Indeed, he ‘entirely failed to consider ‘Kentucky’s estimate that 95,000 persons would leave its Medicaid rolls during the 5-year project. Those failures, they urge, make his decision arbitrary and capricious. Plaintiffs are correct.”

Kentucky Gov. Matt Bevin clearly demonstrated his vindictive nature following the court ruling by cutting off dental and vision coverage under the state’s Medicaid plan to as many as 460,000 Kentuckians. Faced with criticism for his callous actions, Bevin did come to his senses and reinstate the dental and vision coverage although he has threatened to completely end the Medicaid expansion program if the work requirements are not eventually imposed.

The Trump administration will likely appeal the Kentucky decision and Arkansas is already implementing a similar Medicaid work requirement program. Indiana and New Hampshire have also been given work requirement waivers and several other states are in the application process. It seems there are a lot of governors and state legislators with a strong desire to harm poor people.

A recent Kaiser Family Foundation study concluded that only about 6 percent of able-bodied adults on Medicaid are not already working and unlikely to qualify for an exemption.

The study found that as many as four million people would lose Medicaid coverage if work requirements similar to those in Kentucky and Arkansas were adopted nationwide.

With the large number of poor people who will be harmed if the courts allow the Medicaid waiver policies to proceed, how could the state and federal officials involved not know that their actions have been incredibly wicked?