Donald Trump says he is still interested in repealing the Affordable Care Act, which means health care for tens of millions of people would be in jeopardy if he becomes president again next year.
Trump said Saturday on his website Truth Social that he was “looking at alternatives” to the 2010 health care law, also known as “Obamacare,” which has reduced the number of Americans without health insurance to historic lows and established basic guarantees of coverage for all Americans regardless of pre-existing conditions.
The vow echoes promises that Trump made as a first-time candidate and as president, when he and Republican leaders in Congress made repeal a top legislative priority.
That effort failed. It also proved spectacularly unpopular, fueling a backlash that eventually helped Democrats win back the House, the Senate and the White House. President Joe Biden, long a vocal supporter of the ACA, has since worked with Democrats to bolster the law.
Republicans, for their part, have grown relatively quiet on the topic. That may have something to do with polls showing the law to be relatively popular, as well as memories of just how much the last repeal effort alienated voters.
But Republicans have never really renounced the idea of repeal, or given up on its core principles. The Affordable Care Act’s funding for expanded Medicaid is precisely the sort of government spending that GOP leaders have long opposed, just as the rules on how insurers sell policies are precisely the sorts of regulations they are always looking to roll back.
Among those leaders is the highest-ranking elected Republican in Washington, House Speaker Mike Johnson (La). He was chairman of the Republican Study Committee in 2019 when it issued a budget blueprint that included all of repeal’s key concepts, even though the word “repeal” barely appeared.
The word didn’t show up in Trump’s Truth Social post, either. And he may not have the deep commitment to conservative economic principles that other GOP leaders do. But Trump certainly remembers failing at what was supposed to be his crowning achievement, and now it looks like he’s determined to try again.
What Happened Last Time
“The cost of Obamacare is out of control, plus, it’s not good Healthcare,” Trump posted on Truth Social this weekend. “I’m seriously looking at alternatives. We had a couple of Republican Senators who campaigned for 6 years against it, and then raised their hands not to terminate it. It was a low point for the Republican Party, but we should never give up!”
The line about the Republican senators was almost certainly a reference to three who broke ranks with party leaders and voted “no” during a late-night vote in July 2017, effectively killing the repeal effort. The last one to do so was Arizona’s John McCain, who at the time was dying of cancer and gave a dramatic thumbs down on the Senate floor.
It was a crushing blow for Trump and the GOP, a failure to undo former President Barack Obama’s signature legislative accomplishment as promised.
But Republicans had also said they’d replace the Affordable Care Act with something else ― a new system that Trump vowed would be “terrific” and “phenomenal” and “fantastic” because, supposedly, it would provide “insurance for everybody.” “Everybody’s going to be taken care of much better than they’re taken care of now,” Trump said at one point.
In reality, Republicans had no such plan. Their alternatives all involved dramatic cuts to government spending on health care ― especially through Medicaid, which the ACA expanded and which is the primary reason so many more Americans have insurance today.
Their alternatives also called for rolling back the ACA’s rules on insurance, like prohibitions against insurance companies denying coverage to people because of their health status.
Had any of those GOP initiatives become law, some people would have been able to get cheaper coverage, but only because insurance policies would cover less or be less available to people with serious health needs. Others, including many older Americans or people with serious medical conditions, would have faced higher health care costs.
And then there were all the people who would lose insurance altogether ― more than 30 million under some proposals, according to the Congressional Budget Office. That particular projection was probably too high, as Republicans argued at the time, but few independent analysts disputed that the coverage losses would be massive.
None of that sat well with the public. The ACA had plenty of problems, like limited choices of insurers in some parts of the country and high out-of-pocket costs in many plans. But polls showed repeatedly that Americans from across the political spectrum didn’t want to give up the new protections for people with pre-existing conditions ― or to see millions of people lose insurance.
Many Republicans hadn’t realized the trade-offs and costs that their legislation entailed, much less figured out how to justify them to the American people. And the electorate remembered, despite the best efforts of Republican candidates to make voters forget.
What Could Happen Now
American health care still has all kinds of problems, as almost anybody who has been to a doctor or pharmacy ― or had to pay a medical bill ― knows firsthand. It still costs more, and is more confusing to use, than in any other developed nation. That’s true for people with insurance and it’s true for those without, a group that still exists in large numbers even with the ACA in place.
But a long and growing list of studies on the law’s effects have shown that Americans are more financially stable, have more flexibility over what jobs to take, have better access to care, and are healthier, too. In other words, the ACA hasn’t fixed American health care. But it’s helped a lot of people.
Biden can take some credit for that ― and not simply because he helped to pass the law as Obama’s vice president.
Early on in the pandemic, Biden worked with Democrats to increase financial assistance provided under the law, making it possible for Americans buying insurance on their own to save money on premiums or buy more generous coverage. It was a temporary measure that Biden and the Democrats extended for another three years in 2022, as part of the Inflation Reduction Act, and that he has said he wants to continue funding into the future.
The Inflation Reduction Act also included a truly groundbreaking measure designed to reduce the prices of prescription drugs in Medicare by capping insulin costs, penalizing manufacturers for big year-to-year cost increases, and allowing the federal government to negotiate directly with drugmakers over the price of some treatments.
These efforts, Biden has said, represent critical steps toward creating a system of truly universal coverage, where health care is a basic right as it is in other economically advanced nations. Democratic leaders have supported and worked toward this goal since the time of Harry Truman.
Republican leaders have generally been on the other side of this fight, arguing that such systems entail too much regulation, government spending and taxes ― and that they ultimately do more harm than good. They argue that cuts to Medicaid, looser rules on insurers, and a reduction of the high-income taxes that finance coverage expansions would lead to a more dynamic economy, as well as better health care.
That argument didn’t carry the day in 2017. That doesn’t mean they won’t try it again.