President Trump’s latest executive order could make health insurance more costly for older, sicker Mainers by enticing younger, healthier individuals to purchase cheaper and less-regulated plans.

Still, it could be some time before the rule-making needed to enforce the proposed changes goes into effect.

“As of the signing of the executive order, absolutely nothing changes,” said Mitchell Stein, an independent insurance industry expert. “It only instructs agencies to look at making changes, but any changes would require standard rule-making, which is a lengthy process. It’s likely nothing would happen for the 2018 calendar year.”

The wild card, Stein said, is how individual insurance companies – most of which are already plagued with uncertainty – react to another layer of uncertainty.

“There certainly is potential to undercut the individual market,” he said.

The way insurance pools work is simple: Everybody in the pool pays in roughly the same amount. Some need benefits more than others. In that sense, younger and healthier people help subsidize older, sicker people with the understanding that those who are younger and healthier will be old and sick at some point and will need another generation of young and healthy people to subsidize them.

DISTRUPTIVE PARALLEL MARKETPLACE

At the heart of the president’s executive order is expanded access to so-called association health plans. These allow small businesses to band together and purchase insurance plans, sometimes across state lines and usually at a lower cost. While those plans are cheaper, they often don’t offer broad coverage and they lack the protections required by the ACA for maternity care, mental health, certain cancer treatments and other more costly benefits.

Kevin Lewis, president and CEO of Community Health Options, one of three companies that offers insurance plans in Maine under the ACA, said creating a parallel marketplace of association health plans would be disruptive.

“This is what has been happening in the market in general, the departure of younger, healthier people is a good part of what’s driving the rate increase for 2018,” he said.

Maine Bureau of Insurance Superintendent Eric Cioppa did not return a call for comment Thursday about the potential impact.

Republicans, though, long have bristled at the mandates imposed by the ACA. Even though the insurance marketplaces have a wide variety of options, and price points, and even though there are subsidies to help level the playing field, Republicans would rather see the marketplace, not government, set pricing and features.

Demi Kouzounas, chair of the Maine Republican Party, praised the president’s action in a statement.

“I have witnessed firsthand the harm the law has done to individuals and small businesses such as my dental practice,” she said. “The president’s action will allow Maine workers and small businesses to pool their money and exercise leverage over insurance companies to get the quality, affordable plans they want and need.”

Maine Democratic Party Chairman Phil Bartlett had a different view.

“This order is just another reckless attempt to sabotage health care markets, force working Maine people to pay more money for less care, and strip away protections for people with pre-existing conditions,” he said.

‘MAJOR IMPACT’ ON RISK POOL

The idea of association health plans might be attractive to small businesses – simply because of lower costs and fewer mandates – but Amanda Ballantyne, national director of Main Street Alliance, a national network of small-business owners, said it’s a ruse.

“Small-business owners won’t benefit from a proliferation of substandard insurance plans and market destabilization that will emerge as the result of this executive order,” she said in a statement. “Eliminating these vital protections will allow insurance companies to peddle low-quality, junk plans, while at the same time raising premiums on small businesses whose employees have a diverse set of healthcare needs.”

Most of the reaction Thursday, though, was speculative. Stein said even if the executive order leads to rule-making changes at the federal level, states can either agree with those or make changes that offer protections or lessen the harm.

The unknown, he said, remains with the insurers.

Lewis, who runs Community Health Options, said insurers ultimately have to be accountable to their customers.

“If this is going to create a migration or departure from the individual market, that is going to have a major impact on our risk pool,” he said.

Emily Brostek of Consumers for Affordable Healthcare, a Maine advocacy group, said the current debate is a reminder that not enough people think about their insurance and what it covers until they need it.

“When people were able to purchase cheap plans before the ACA we heard from people who would end up in the hospital for whatever reason and then not understand that their plan didn’t cover it,” she said. “Even if you’re healthy today, in the future you’ll find shortcomings. People ask, ‘Why should I pay for someone else’s care?’ The answer is: Because you’ll want someone to pay for you too.”