President Donald Trump hasn’t fulfilled his campaign promise to repeal Obamacare outright, but he’s fundamentally reshaped the debate over health care in America in myriad ways during his two years in office. Along with chipping away at the landmark Affordable Care Act, the Trump administration has made a historic and controversial change to Medicaid, allowing states to require many participants who gained coverage through Obamacare to work or lose their benefits. Another major focus of the President: the cost of drugs. Like Democrats, Trump has repeatedly decried the rising price of drugs, and his administration has unveiled multiple proposals to try to contain costs. When it comes to Medicare, the administration has continued to make private Medicare plans more attractive. And in keeping with conservative positions, officials have rolled back access to contraceptives as well as abortion. Here’s what’s changed so far: Obamacare Trump made his first move to weaken the Affordable Care Act only hours after his inauguration, signing an executive order directing agencies to interpret regulations as loosely as possible and to minimize the financial burden of the law through waivers, exemptions or delays. But after the Republican-controlled Congress failed to repeal Obamacare, Trump unleashed a series of executive changes to further undermine the law. The President also signed another executive order making it easier for Americans to access alternative policies that have lower premiums than Affordable Care Act plans – but in exchange for fewer protections and benefits. His administration cut the Obamacare open enrollment period in half and slashed funding for advertising and outreach, while at the same time increasing the visibility of insurance agents who also sell non-Obamacare plans. And Trump signed into law the GOP tax cut bill that effectively eliminated the individual mandate by reducing the penalty to $0 – the basis for a federal court ruling invalidating the entire Affordable Care Act. That ruling is currently being appealed. Trump also eliminated federal payments that help reduce deductibles and out-of-pocket costs for low-income participants, prompting insurers to raise premiums to cover the loss of these cost-sharing subsidies. More recently, the Trump administration told states that they could apply for waivers to make more substantial changes to their Obamacare marketplaces, including altering the rules for who is eligible for federal help paying monthly premiums. These premium subsidies are essential to keeping Obamacare functioning, experts say. Trump officials say their moves are aimed at providing greater access to more affordable health insurance options. They are particularly concerned about younger Americans and those who earn too much to qualify for federal subsidies. But Obamacare supporters say these actions will fray the strong protections for older consumers and those with pre-existing conditions. The Obamacare exchanges, however, have proven surprisingly resilient. Some 8.4 million people signed up on the federal exchange for 2019. Still, that’s down from roughly 9.2 million who picked plans for 2017. Much of the drop stems from fewer new consumers selecting policies. The Trump administration plans to make even more changes to the Affordable Care Act for the coming year. It recently released a proposal that would increase the maximum amount enrollees have to pay out of pocket – a change that would affect those in large-employer plans too. At the same time, it would make the federal premium subsidies a bit less generous, which it estimates would decrease enrollment by 100,000 people. But even more consequentially, it is formally exploring eliminating that annual automatic renewal of Obamacare plans. This would have a devastating impact since 1.8 million people in the 39 states using the federal exchange were rolled over this year. Officials are also seeking input on “silver loading,” in which carriers increased their rates for silver plans to offset the loss of the cost-sharing subsidy payments. They did this to minimize rate increases on enrollees because federal premium subsidies are based on the second lowest-cost silver plan. Medicaid A year ago, the Trump administration made history and fulfilled a longtime Republican goal by allowing states to impose work requirements on certain Medicaid recipients. So far, eight states have received permission to do so, and more applications are under review. The controversial move has already sparked lawsuits in two states, temporarily delaying the start of work requirements in Kentucky until later this year. So far, only Arkansas has actually implemented the new rules, which require beneficiaries to work, go to school, volunteer or search for jobs for at least 80 hours a month. The impact has been pronounced: More than 18,000 residents have lost coverage. Drug prices On the campaign trail, Trump repeatedly promised to reduce the cost of drugs. While he has issued many tweets lambasting the industry for raising prices and his administration has unveiled many proposals, he hasn’t moved the needle too much. The administration also laid out his vision for reducing drug prices in a 44-page blueprint unveiled last May. It contains a bevy of proposals for increasing competition, reducing regulations and changing the incentives for all players in the pharmaceutical industry. One of the boldest and most controversial efforts involves setting Medicare’s reimbursement level for certain pricey drugs administered in doctors’ offices and hospital outpatient centers based on their cost in other countries, which is typically far lower. This idea prompted howls of “price fixing” from the industry and conservative lawmakers. Patient advocacy groups are concerned about another administration effort that would give Medicare Advantage plans the ability to restrict what medications they’ll cover. The American Cancer Society Cancer Action Network, backed by nearly 60 organizations, just launched a print and digital ad campaign to oppose the policy changes. Pharmaceutical companies aren’t heeding the President’s call. Sixty drug makers kicked off 2019 by raising list prices on nearly 300 medications, according to an analysis by Rx Savings Solutions. And more drug manufacturers are expected to quietly follow suit in coming weeks. Companies do appear to be tempering their hikes in 2019, however. The average increase was 6.3%, down from nearly 9% a year ago, taking into account different dosages of the same drug. An official with the Department of Health & Human Services pointed to the lower rate of increases this January. One thing that the Trump administration has accomplished is approving a record number of generic drugs, which typically have lower prices. The White House Council of Economic Advisers estimates this has saved consumers $26 billion over the first 18 months of Trump’s administration. Medicare Unlike other Republican leaders, Trump does not want to make wholesale changes to the Medicare program. Instead, officials are continuing efforts to reform how Medicare pays providers and to enhance the standing of private Medicare Advantage plans. More than 21 million senior citizens are already enrolled in Medicare Advantage plans, and the Trump administration has made them more attractive by expanding the definition of supplemental benefits they can provide. Now, insurers can cover grab bars in bathrooms, transportation to doctor’s offices and even home health aides. Trump officials also gave the insurers a hefty rate increase. Trump officials are also trying to rein in costs. For instance, the Centers for Medicare & Medicaid Services is overhauling how it compensates doctors for office visits, reducing the tiers of payments from five to three, starting in 2021. But it also expanding reimbursements for telehealth services. Another target: The Medicare Accountable Care Organization program, which has more than 10.4 million participants. Established by the Affordable Care Act, these organizations are groups of doctors, hospitals and other providers who voluntarily work together to better coordinate patients’ care and reduce health care costs by avoiding duplication of services and medical errors. Known as ACOs, they share in the savings they achieve for Medicare, but only a few are on the hook for any losses they generate. Currently, ACOs in the Medicare Shared Savings Program have up to six years before they must take on costs if their spending per patient exceeds their targets. Officials want to reduce that to as little as one year. “His administration has not proposed directly reducing Medicare benefits or increasing beneficiary payments,” said Mark McClellan, a former administrator of the Centers for Medicare & Medicaid Services under former President George W. Bush and director of the Duke-Margolis Center for Health Policy. “Instead, their proposals seek to continue to grow the Medicare Advantage program and continue to push for more payments based on value, not volume.” Access to birth control The administration is rolling back regulations that conflict with some Americans’ religious beliefs. It issued two rules last year that would free more employers from Obamacare’s contraceptive mandate. The first one would allow non-profit and for-profit employers, including publicly traded companies, to receive an exemption based on their religious beliefs. The second would let all but public companies obtain an exemption based on moral objections. Government employers cannot request exemptions. The rules were set to take effect January 14. However, they were blocked by federal district judges in Pennsylvania and California. The administration also proposed regulations that would no longer permit federally funded family planning services at the same place where abortions are provided. And it has also proposed requiring Obamacare insurers to bill separately for abortion coverage and to offer plans that do not cover abortions in states that don’t mandate it.