How Trump could weaken the Affordable Care Act

President-elect Donald Trump’s return to the White House could embolden Republicans who want to weaken or repeal the Affordable Care Act, but implementing such sweeping changes would still require overcoming procedural and political hurdles.

Trump, a longtime opponent of the ACA, expressed interest in overhauling the health care law during the campaign. In addition, some senior Republican lawmakers, who will now control both the House and Senate, have said that overhauling the landmark 2010 law known as Obamacare will be a priority. They say the law is too expensive and an abuse of power.

The ruling triple bill sets the stage for potentially seismic changes that could limit the law’s expansion of Medicaid, raise the uninsured rate, weaken patient protections and increase the cost of insurance premiums for millions of people.

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“The Republican plans — they’re not saying they’re going to repeal the ACA, but their set of policies could mean the same thing or worse,” said Sarah Luke, vice president for health policy at the Center on Budget and Policy Priorities. , a research and policy institute. “This can happen through legislation and regulation. We are on guard about anything and everything. This can take many forms.”

Republicans in Congress have led dozens of votes over the years to try to repeal the law. They failed to achieve this in 2017 after Trump became president, although they controlled both chambers and the White House, in large part because some GOP lawmakers did not support legislation they said would lead to such a dramatic increase in rates for uninsured people.

Similar opposition to overhauling the law could arise again, especially as polls show that ACA protection is popular.

While neither Trump nor his GOP allies have specified what they would change, House Speaker Mike Johnson said last month that the A.C.A. needs ‘massive reform’ and will be on the party’s agenda if Trump wins.

Congress could theoretically change the ACA without a single Democratic vote, using a process known as “reconciliation.” But the narrow margin by which Republicans control the House and Senate means just a few dissenting votes could doom the effort.

Many of the more ambitious goals will require Congress. Some conservatives have called for changes to the funding formula for Medicaid, the federal government’s state health insurance program for low-income people and the disabled. The idea would be to use budget reconciliation to get lawmakers’ approval to reduce the share the federal government pays for population increases. The group that will be hit the hardest consists primarily of higher-income adults and adults who do not have children, rather than “traditional” Medicaid beneficiaries such as pregnant women, children and people with disabilities.

A conservative idea that would allow people to use ACA subsidies for exchange plans that don’t comply with the health law would likely require Congress. That could lead healthier people to use subsidies to buy cheaper, skimpier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

“This looks like a plan to repeal the ACA,” said Cynthia Cox, vice president and director of the Affordable Care Act program at KFF, a nonprofit health information organization that includes KFF Health News. “It’s cancellation by another name.”

Congress would likely need to pass a proposal to transfer a portion of the ACA consumer subsidies to health savings accounts to pay for qualifying medical expenses.

Trump may also decide to bypass Congress. He did so during his previous tenure, when the Department of Health and Human Services invited states to apply for a waiver to change the way their Medicaid programs are paid for — limiting federal funds in exchange for greater state flexibility in implementing the program. The waivers were popular among both blue and red states due to other changes to Medicaid.

“Trump will do whatever he thinks he can get away with,” said Chris Edelson, an assistant professor of government at American University. “If he wants to do something, he just does it.”

Republicans have another option to weaken the ACA: They simply can’t do anything. Temporary expanded subsidies that lower the cost of insurance premiums and have contributed to the nation’s lowest uninsured rate on record are set to expire at the end of next year without any action from Congress. Then the bonus double or moreon average, for subsidized consumers 12 states have signed up using the federal ACA exchange, according to KFF.

This will mean fewer people will be able to afford coverage on the ACA exchanges. And while the number of people covered by employer plans is likely to increase, an additional 1.7 million people are projected to become uninsured each year from 2024 to 2033. according to federal estimates.

Many of the states that will be hit hardest, including Texas and Florida, are represented by Republicans in Congress, which could lead some lawmakers to consider ending the subsidies.

The Trump administration may decide to stop defending the law against lawsuits seeking to overturn parts of it. One of the most striking cases defies ACA requirement that insurers cover some preventive services, such as cancer screenings and alcohol counseling, free of charge. About 150 million people now benefit from the requirement for insurance coverage.

If the Justice Department had withdrawn its petition after Trump took office, the plaintiffs would not have had to comply with the insurance requirement, which could have triggered similar problems but with broader implications. The recent Supreme Court ruling left open the door to lawsuits by other employers and insurers seeking the same protections, said Zachary Baron, director of the Center for Health Policy and Law at Georgetown University.

Trump, meanwhile, can initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.

“The first executive orders will give us a sense of the policies the administration plans to pursue,” said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. “Early communication through executive orders will send a message about what guidance, regulations and policies may follow.”

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to begin modifying the ACA and ultimately expanded consumer access to health plans that did not comply with the law. He could issue similar orders at the start of his new term, using them to begin the process of making significant changes to the law, such as strengthening oversight of possible fraud.

The administration could proactively take other steps that would work against the ACA, such as cutting federal funding for outreach and helping sign up for ACA plans. Both actions depressive set during the previous Trump administration.

Trump could also use the rules to pursue other conservative proposals, such as expanding access to health plans that fall short of the ACA’s consumer protection requirements.

The Biden administration has rejected Trump’s efforts to expand so-called short-term health insurance plans, calling the plans “junk” insurance because they may not cover certain benefits and can deny coverage to those with pre-existing health conditions.

The Trump administration is expected to use the regulation to reverse Biden’s policies, allowing consumers to keep and renew their plans for much longer.

But rulemaking has become much more difficult following a Supreme Court ruling that federal courts no longer have to defer to federal agencies facing legal challenges to their authority. As a result, any Trump-era HHS rules may require more effort to block them in the courts.

Some people with ACA plans say they are concerned. Dylan Reed, a 43-year-old small business owner from Loveland, Colorado, remembers the days before the ACA and doesn’t want to go back to a time when insurance was hard to get and afford.

In addition to attention deficit/hyperactivity disorder and anxiety, he has scleroderma, an autoimmune disease associated with joint pain and numbness in the limbs. Even with the ACA plan, he estimates he pays about $1,000 a month for medications alone.

He’s concerned that without the ACA’s protections, he’ll have a hard time securing coverage for pre-existing conditions.

“It’s definitely a terrifying thought,” Reed said. “I probably would have survived. I would just 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 primary operating programs in KFF is an independent source of health policy research, polling and journalism.