The Newly Uncertain Fate of the Affordable Care Act

In the week between November 5 and November 12, at least 20 times I was asked whether President-elect Donald Trump would ever nominate Robert F. Kennedy Jr. to be the next US Secretary of Health & Human Services. “I can’t answer,” I would reply. “And I would be thoroughly astounded if his team let him make such a risky choice.” Consider me astounded!

Now I am asked, “Is there any chance that President Trump will try again to repeal the Affordable Care Act?” My response: “I can’t answer. And I would be thoroughly astounded if his team let him make such a risky choice.”

The Affordable Care Act is the 2010 law that survived six initial years of rocky and contentious implementation and withstood a full-frontal assault by Trump and the Republicans’ governing trifecta in 2017. As polling demonstrates, prior to 2017, public opinion about the ACA was mostly unfavorable. Literally beginning in January 2017, public opinion on the ACA turned permanently favorable by growing margins ever since. By threatening to kill the ACA, President Trump made it more popular than ever.

Now some 40 million Americans have obtained affordable, quality health insurance through the ACA’s Medicaid expansion or with subsidized private coverage through the law’s health insurance marketplaces. In 2021 and 2022, President Joe Biden won passage of laws to enhance ACA subsidies for all its purchasers, triggering millions of new enrollees. Fully 20.8 million had enrolled following the 2024 open enrollment. “Nearly 50 million Americans have been covered through the Affordable Care Act’s health insurance marketplaces over the last decade,” noted Treasury Secretary Janet Yellen this past September.

One major 2025 ACA controversy will be whether Congress and President Trump will extend the enhanced subsidies beyond its current 12/31/2025 sunset, a priority for Senate and House Democratic minorities, and a headache for the newly emergent Republican trifecta. Would the narrow Trump trifecta trigger 79% premium increases and four million in coverage losses at the start of 2026, the mid-term election year when their governing coalition will face voters? Many who would be hurt belong to Trump’s growing working and lower-middle class base.

Republicans will have no shortage of other potential health policy fights on safer ground than an ACA assault. On Medicaid, Republicans want to promote work requirements, perhaps even making them mandatory for states, and block grants to squeeze savings to finance their tax cuts. They hope to decrease the federal financing match for the ACA’s Medicaid expansion down to the traditional and much lower Medicaid match rate even as at least nine states have statutory mandates to rescind automatically their expansions if Congress were to lower the ACA’s match rate at all. They will promote expansion of short-term “junk” health insurance plans that erode the stability of marketplace coverage and strengthen employer association health plans to boot. They will expand their newest favored reform, Individual Coverage Health Reimbursement Arrangements (ICHRA, pronounced “ick-rah”) that permits employers to give workers tax-preferred lump sum payments to buy health insurance as individuals, accelerating the demise of employer sponsored coverage. They could actively push all seniors—or just new enrollees—into privatized Medicare Advantage plans. 

With so many juicy choices, why would they tackle the hoary beast of ACA repeal and relive their 2017 nightmare? Let’s revisit the confusing Republican ACA narrative during the 2024 campaign. 

On November 23, 2023, Trump posted on the ACA on his Truth Social site: “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives … we should never give up!”

At a campaign speech in Newton, Iowa on January 6, 2024, Trump declared: “We’re gonna fight for much better health care than Obamacare. Obamacare is a catastrophe. Nobody talks about it. You know, without John McCain, we would have had it done.”

On March 26, 2024, Trump again posted on Truth Social that he doesn’t want to terminate the ACA, but instead wants to make it “better…I’m not running to terminate the ACA,” he wrote. Instead, he said he would make the law “MUCH BETTER, STRONGER, AND FAR LESS EXPENSIVE.”

On August 14, 2024 Trump told a rally in Asheville, North Carolina: “We’re going to keep the Affordable Care Act, unless we can do something much better … We’ll keep it. It stinks. It’s not good. If we can do something better, we’re going to do something with it if we can do better, meaning less expensive and better health care for you.”

In Trump’s September 11, 2024 debate with Vice President Kamala Harris, he again weighed in. “Obamacare was lousy health care. Always was. It’s not very good today. And what I said, that if we come up with something, and we are working on things, we’re going to do it and we’re going to replace it.” Pressed by debate moderators on whether he has a plan, he replied, “I have concepts of a plan,” intending to release “concepts and options … in the not-too-distant future.” He refused to provide a more specific timeline adding: “We could do much better than Obamacare.”

In the October 1, 2024 Vice Presidential debate, Republican contender J.D. Vance argued that Trump has “salvaged” the ACA during his time in office: “When Obamacare was crushing under the weight of its own regulatory burden and health care costs, Donald Trump could have destroyed the program. Instead, he worked in a bipartisan way to ensure that Americans had access to affordable care.” 

Earlier in September, Vance had proposed dividing covered populations into healthy versus unhealthy risk pools: “You want to make sure that preexisting coverage—conditions—are covered … you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he told NBC’s Kristen Welker. “We want to make sure everybody is covered,” he added. “But the best way to do that is to actually promote some more choice in our health care system and not have a one-size-fits-all approach that puts a lot of people into the same insurance pools, into the same risk pools, that actually makes it harder for people to make the right choices for their families.”

On October 28, Republican House Speaker Mike Johnson (R-LA) told a Pennsylvania crowd of “massive” health care changes in America if Donald Trump wins the election. “Health care reform’s going to be a big part of the agenda. When I say we’re going to have a very aggressive first 100 days agenda, we got a lot of things still on the table.” One attendee asked: “No Obamacare?” Johnson replied: “No Obamacare…The ACA is so deeply ingrained, we need massive reform to make this work, and we got a lot of ideas on how to do that.”

Trump national press secretary Karoline Leavitt told Fox News Digital: “This is not President Trump’s policy position.”

In November, President-Elect Trump identified his picks for key health officials in his upcoming Administration: Robert F. Kennedy Jr. as Secretary of Health & Human Services; and Dr. Mehmet Oz as Administrator of the Centers for Medicare and Medicaid Services. Kennedy and Oz will have primary authority for policies pertaining to the future of the ACA. In prior statements, both individuals’ positions on the ACA have varied from support to opposition at different times.

Is this all clear?

What should be clear is that the prospects for a renewed Republican assault on the ACA are not. Like so much in Trump-world, the message and intention can change from day-to-day. While Trump and Republican antipathy toward the ACA has not abated, senior Republican leaders have made no judgment or decision on whether to confront the GOP’s great white whale of Obamacare repeal.

My prediction remains: “I can’t answer. And I would be thoroughly astounded if his team let him make such a risky choice.”

John E McDonough is a professor of practice at the Harvard T.H. Chan School of Public Health in Boston.

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