President-elect Donald Trump’s return to the White House could embolden Republicans seeking to weaken or repeal the Affordable Care Act, but enacting such sweeping changes would require overcoming procedural and political hurdles.
Trump, a longtime opponent of the ACA, expressed interest in overhauling the health law during the campaign. In addition, some top Republican lawmakers — who now have control of the House and Senate — have said that renewing the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too expensive and represents government overreach.
The governor’s trifecta sets the stage for seismic changes to the law that could reduce Medicaid expansion, raise the uninsured rate, weaken patient protections and increase premium costs for millions.
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“The Republican plans — they’re not saying they’re going to repeal the ACA, but their policy mix could be the same or worse,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities. , research and policy institute. “It could happen through law and regulation. We are ready for anything. It can take many forms.’
Republicans in Congress have voted dozens of times over the years to try to repeal the law. After Trump became president in 2017, they failed to win both chambers and the White House, largely because some GOP lawmakers would not pass legislation they said would cause a significant increase in the uninsured rate.
Similar opposition to the renewal of the law may appear again, especially according to the polls The ACA’s protections are well known.
While neither Trump nor his GOP allies have clarified what they would change, House Speaker Mike Johnson said last month that the ACA It needs “massive reform”. and would be on the party’s agenda if Trump wins.
Congress can theoretically change the ACA without a single Democratic vote, using a process known as “reconciliation.” The narrow margins by which Republicans control the House and Senate mean that a few “no” votes could sink that effort, however.
Many of the more ambitious goals would require Congress. Some conservatives have called for changes to the funding formula for Medicaid, a federal government health insurance program for low-income and disabled people. The idea would be to use budget reconciliation to get approval from lawmakers to reduce the federal government’s share of the expansion population. The group that would be most affected are mostly high-income adults and childless adults who are “traditional” Medicaid beneficiaries, such as pregnant women, children and people with disabilities.
A conservative idea that could use ACA subsidies for exchange plans that don’t comply with the health law would likely require Congress. This can cause healthier people to use subsidies to buy cheaper, poorer plans, raising premiums for older and sicker consumers who need more comprehensive coverage.
“It’s like a plan to repeal the ACA,” said Cynthia Cox, deputy director of the Affordable Care Act program at KFF, the health information nonprofit that includes KFF Health News. “Repealed under a different name.”
Congress is likely to implement a proposal to shift a portion of consumer ACA subsidies to health savings accounts to pay for eligible medical expenses.
Trump may also choose to bypass Congress. He did so during his previous term, when the Department of Health and Human Services urged states to refuse to change the way they pay for Medicaid programs by limiting federal funds in exchange for more state flexibility to run the program. The waivers have been popular among both blue and red states to make other changes to Medicaid.
“Trump will do whatever he thinks,” said Chris Edelson, an assistant professor of government at American University. “If he wants to do something, he’ll just do it.”
Republicans have another option for undermining the ACA: They simply can’t do anything. Temporary subsidies that keep premium costs down – and have contributed to the nation’s lowest uninsured rate – are set to expire at the end of next year without action from Congress. It would be great then double or moreon average for subsidized consumers They enrolled in 12 states using the federal ACA exchange, according to KFF data.
That would mean fewer people would pay for coverage on the ACA exchanges. Although the number of people covered by employer plans would increase, an additional 1.7 million people are projected annually from 2024 to 2033. according to federal estimates.
Many of the states that would be most affected, including Texas and Florida, are represented by Republicans in Congress, which could prevent some lawmakers from seeing the subsidies expire.
The Trump administration may choose to stop defending the law against lawsuits seeking to tear down parts of it. One of the most remarkable cases He questions the ACA requirement Some preventive services, such as cancer screenings and alcohol counseling, are covered by insurance at no cost. About 150 million people take advantage of the coverage requirement now.
If the Justice Department were to withdraw the application after Trump took office, plaintiffs would not have to comply with the coverage requirement, which could lead to similar challenges with broader implications. A recent Supreme Court ruling left the door open for legal challenges by other employers and insurers seeking the same relief, said Zachary Baron, director of Georgetown University’s Center for Health Policy and Law.
Meanwhile, Trump can initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.
“The initial executive orders will give us a sense of the policies the administration wants to pursue,” said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. “Early signaling through executive orders will send a message about what guidelines, regulations and policies they can follow.”
In fact, Trump relied heavily on those orders during his previous term: an October 2017 order allowed federal agencies to start changing the ACA and ultimately increase access to health plans that didn’t comply with the law. He may issue similar orders at the start of his new term to begin the process of credible legislative changes, such as increased oversight of potential fraud.
The administration could take other steps that initially work against the ACA, such as reducing federal funding for outreach and helping sign up to ACA plans. The two actions depressed enrollment In the pre-Trump administration.
Trump may also use the regulation to implement other conservative proposals, such as expanding access to health insurance plans that do not meet ACA consumer protections.
The Biden administration pushed back against Trump’s efforts to expand so-called short-term health plans, disparaging the plans as “junk” insurance because they may not cover some benefits and may deny coverage to those with pre-existing health conditions.
The Trump administration plans to use regulation to push back Biden’s reversal so that consumers can stay on plans much longer and renew.
But drafting regulations has become much more difficult following a Supreme Court ruling that federal courts no longer have to defer to federal agencies in the face of a challenge to their authority. In light of that, a Trump-era HHS rule may face more efforts to block it in court.
Some people with ACA plans say they’re worried. Dylan Reed, a 43-year-old small business owner from Loveland, Colorado, remembers the days before the ACA, and he doesn’t want to go back to a time when insurance was difficult to get and pay for.
In addition to attention deficit/hyperactivity disorder and anxiety, she has scleroderma, an autoimmune disease. joint pain and numbness at the ends Even with his ACA plan, he estimates he pays about $1,000 a month for the drugs alone.
He worries that without the protections of the ACA, it will be difficult for people with pre-existing conditions to find coverage.
“It’s definitely a scary thought,” Reed said. “I probably would have survived. I would be in a lot of pain.”
KFF Health Newsformerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism on health issues and is one of the leading program operators. KFF — Independent source for health policy research, polling and journalism.
