Could Re-Expanded STLDI Be Part of Trump's 'Concepts of a Plan' for Healthcare?

A memorable healthcare debate moment in an election year focused largely on other issues.

A new federal regulation went into effect Sept. 1, 2024, that once again limits the coverage term of short-term limited-duration insurance (STLDI).

If Sept. 1 came and went without you noticing, you're probably not alone. If you did notice — and watched Tuesday's Presidential debate — you might wonder if Donald Trump's "concepts of a plan" to improve the ACA could once again include STLDI if there is an Executive branch party change come November.

The "concepts of a plan" remark came after ABC News co-moderator Linsey Davis asked Trump about his plans for an alternative to the ACA, with the former president adding: "If we can come up with a plan that's going to cost our people, our population, less money and be better health care than Obamacare, then I would absolutely do it . . . But until then I'd run it as good as it can be run."

When STLDI was part of the plan

In its recap of the exchange, The New York Times noted that "the congressional plans he [Trump] later endorsed as president would have decreased insurance coverage overall, cut funding to states, and erased protections for many Americans with pre-existing conditions" — adding that "Congressional Republican leaders . . . have shown little appetite for advancing such bills again."

It's worth noting that expanding STLDI coverage was a plan that Trump executed during his Administration. While STLDI plans are designed to provide a stop-gap when individuals lose their health insurance (e.g., after a job loss), the Administration's 2018 rule expanded coverage from six months to three years, a term that the Biden Administration has reduced again, this time to four months.

The ACA's awkward years

The ACA was at first "broadly unpopular". This includes the Marketplace — from its early years, when premiums were higher and many large insurers had temporarily exited the Exchanges, to as recently as 2020.

But even in this climate, STLDI never took off as an ACA alternative. Earlier this year, HealthLeaders explored this proposition in a two-part series. Our coverage noted that STLDI:

• lacks the federal coverage mandates of Marketplace plans: 10 Essential Health Benefits, out-of-pocket maximums (MOOP), free preventive services, and no denials for pre-existing conditions;
• is also often much cheaper and the benefits it may exclude aren't benefits that younger, healthier, childless individuals may need; and
• lack of data makes it difficult to demonstrate its real costs and value, although it is widely viewed as "junk insurance" when used as a form of comprehensive coverage.

A report from the National Association of Insurance Commissioners noted that STLDI enrollment was just under 236,000 at the end of 2022 — far less than the 1.5 million that the Congressional Budget Office had projected.

And now, times have very much changed. The American Rescue Plan Act of 2021 (COVID-19 relief) increased and expanded Marketplace subsidies. As The Times noted: "Almost 50 million Americans have signed up for plans through the Affordable Care Act's marketplaces since 2014 . . . [while m]illions of lower-income Americans now have Medicaid coverage in states that expanded the program" through the ACA.

Past is prologue

Forbes' coverage of the Presidential debate noted that Harris's plan would be to "maintain and grow the Affordable Care Act" while continuing to support Medicare and Medicaid. The Times coverage, meanwhile, quoted a Trump campaign spokesperson that POTUS 45's "overall position on health care remains the same: bring down costs and increase the quality of care by improving competition in the marketplace."

A Harris Administration's would surely maintain and grow, not change, the new STLDI coverage term limits. And it's far more likely that a Trump Administration would improve competition in the marketplace by improving competition with it. If past is prologue, that could once again include enrollment options for longer-term STLDI plans — just not at critical mass.