President Trump has never been coy about his desire to repeal and replace the Affordable Care Act. While that pledge has faced setbacks in Congress , his administration has managed to gut Obamacare by other means, like cutting financial support. The executive branch can also undermine the law in subtler ways. According to a new report, the Trump administration has been systematically wiping crucial information about the ACA from government websites over the past two years. Unlike changes to funding, these modifications often happen with little fanfare or government oversight, but they can still have a dramatic impact on Americans' access to health care resources.
The report was published Wednesday by the Sunlight Foundation, an open government group whose Web Integrity Project monitors some 30,000 government pages for updates and alterations. Looking at sites administered by the Department for Health and Human Services, it documents 26 instances in which information related to the Affordable Care Act was substantially altered or removed. Some of the changes were subtle. Others, including the disappearance of an 85-page website devoted to the ACA, were sweeping. Taken together, the researchers argue, the modifications are tantamount to government censorship and point to an increasing need for oversight of government websites.
"People rely on government information, and there’s a presumption of objectivity that comes from the [government] address," says Sarah John, director of research for the Web Integrity Project and one of the paper's coauthors. "If a website says one thing one day and a different thing the next day, what is a citizen to make of that?" HHS did not respond to a request for comment.
Issie Lapowsky covers the intersection of tech, politics, and national affairs for WIRED.
That the Trump administration would whittle away at these online resources may not come as a surprise; it has already effectively gutted the financial resources that the Obama administration dedicated to promoting the law. Shortly after President Trump took office, the Center for Medicare and Medicaid Services announced it would cut funding for Affordable Care Act–related outreach and advertising by 90 percent, from $100 million to $10 million. The following year, the center slashed funding even further for so-called navigators, who help people sign up for insurance.
The website changes appear to be an extension of this strategy to make it harder for the average American, and particularly the most vulnerable Americans, to find information about coverage. Among the biggest changes was the removal of an entire 85-page website listing "facts and features" about the ACA. It had included 29 fact sheets about the law, as well as a breakdown of the impact of the law in each state.
Other changes appeared to take direct aim at communities that have been disproportionately uninsured or who would be entitled to special benefits under the ACA. Some time in the weeks after President Trump's inauguration, for example, the Affordable Care Act page on the website for the Office of Minority Health was removed. Later, a page offering guidance for American Indians and Alaska Natives was also removed. The Department of Health and Human Services removed multiple pieces of content noting that women could no longer be charged more or denied coverage under the ACA, and the Office of Women's Health removed a page informing women about breast cancer screening options. Still another page on MentalHealth.gov was altered to remove text explaining that most health plans cover preventative services like depression screening and behavioral assessments for children.
In most cases, the government made these changes without any official announcement. "What’s interesting and potentially dangerous about website changes is they can be done without due process," says Rachel Bergman, director of the Web Integrity Project and another coauthor on the report. "Ultimately it can have the same consequences as a formal policy change."
"People rely on government information, and there’s a presumption of objectivity that comes from the government address."
Sarah John, the Sunlight Foundation
Many of the modifications and removals do mirror formal policies the administration is pursuing. In August of 2018, several agencies finalized a rule to expand what are known as short-term, limited-duration insurance plans, which aren't bound by the ACA. That means that under those plans, women can be charged more for insurance, and people can be turned down for preexisting conditions. That could explain why some changes to government websites appear to downplay the rights afforded to people under the ACA. Similarly, the researchers found that some training materials for navigators had been removed, echoing the administration's broader reduction of the navigator program.
Some changes the researchers discovered may appear tiny but could have a big impact. On one Frequently Asked Questions page maintained by the Department of Health and Human Services, a page called "Affordable Care Act" was replaced with a page called "Health Insurance Reform." It's a slight difference, but according to Josh Peck, former chief marketing officer for Healthcare.gov, it matters.
During the Obama administration, Peck says, search engine advertising was a key driver of new signups. Now that the advertising budget has been drastically reduced, organic searches for information related to the ACA are even more critical. And yet, he says, "Something as simple as changing 'Affordable Care Act' to 'health care law' can have a big impact on search engine optimization." Tinkering with the language in this way could force government websites farther down the page of Google results for certain queries, boosting websites and paid ads placed by companies that aren't always reputable.
"There’s some unscrupulous actors out there who are happy to pose as government entities to mislead consumers," Peck says.
Peck says it's important to remember that these changes don't happen by accident. "It is a choice," he says. "Someone has to proactively go through the bureaucracy to take it all down."
The problem is, once government officials decide to take this information down, they rarely tell the public or leave any trace, beyond what exists in internet archives like the Wayback Machine. For a long time, this wasn't a huge issue. The George W. Bush administration disseminated far fewer policies and resources via government websites than the Obama administration did. But in the digital age, it stands to reason that each incoming occupant of the Oval Office will want to overhaul government websites to reflect their own priorities. Some past administration's pages do get archived, but these archives don't always cover incremental changes over time.
The Sunlight Foundation researchers believe the US needs a system that tracks all of those changes. Specifically, they propose that government agencies write formal memos to propose website changes, maintain archives of content that's been removed, and issue press releases on those removals. This, they say, would at least create a digital trail and lend some transparency to the process.
It's difficult to measure the exact impact website changes have had on people seeking coverage under the ACA. Under the Trump administration, enrollment in the ACA has declined substantially, but that decline undoubtedly has a lot to do with the reduction in outreach and the elimination of the so-called individual mandate, which penalized people for forgoing insurance. The report's authors are careful not to draw a straight line between this drop and the website changes. But it's hard not to see how they're part of a larger pattern. As Bergman put it, "A public that is less aware and knowledgeable about the law is less likely to access important health care services the ACA affords."
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