How Trump and Republicans Could Change the Affordable Care Act and Medicaid: Shots

US Speaker of the House of Representatives Mike Johnson shakes hands with US President-elect Donald Trump during a meeting of the House Republican Conference at the Hyatt Regency on Capitol Hill on January 13 November 2024 in Washington. Andrew Harnik/Getty Images .

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President-elect Donald Trump's return to the White House could embolden Republicans who want to weaken or repeal the Affordable Care Act.

Trump, long an opponent of the ACA, expressed interest during the campaign in revamping the health law. Additionally, some senior Republican lawmakers, who now control both the House and Senate, have said overhauling the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too costly and represents an overreach of government power.

The governing trio is paving the way for potentially seismic changes that could curb the law's expansion of Medicaid, increase the uninsured rate, weaken patient protections and increase the cost of premiums for millions. But implementing such radical changes would still require overcoming procedural and political hurdles.

“Republicans are not saying they will repeal the ACA, but their package of policies could achieve the same result or worse,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities . a research and policy institute. “This could happen through laws and regulations. We are on alert for anything and everything. This could take many forms.”

Congressional Republicans have held dozens of votes over the years to try to repeal the law. They were unable to achieve this in 2017 after Trump became president, even though they held both chambers and the White House, largely because some Republican lawmakers would not support legislation that they said would lead to such a marked increase in the uninsured rate.

Similar opposition to the law overhaul could emerge again, particularly because polls show the ACA's protections are popular.

Although neither Trump nor his Republican allies have specified what they would change, House Speaker Mike Johnson said last month that the ACA needed “massive reform” and that It would be on the party's agenda if Trump won.

They could adopt several tactics. Here are a few.

Making Changes Through Congress

Congress could theoretically amend the ACA without a single Democratic vote, using a process known as “reconciliation.” The narrow margins by which Republicans control the House and Senate, however, mean that a handful of “no” votes could derail that effort.

Many of the most ambitious goals would require Congress. Some conservatives have called for changes to the funding formula for Medicaid, a federal government health insurance program for people with disabilities and low-income people.

The idea would be to use budget reconciliation to gain approval from lawmakers to reduce the share paid by the federal government for population expansion. The group that would be most affected consists largely of higher-income adults and adults without children, rather than traditional Medicaid beneficiaries such as pregnant women, children and people with disabilities.

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

“It’s similar to 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 HealthNews. “It’s repealed with a different name.”

Congress would likely be needed to pass a proposal to move a portion of consumers' ACA subsidies into health savings accounts to pay for qualified medical expenses.

Change through inaction

Trump could also choose to bypass Congress. He did so during his previous term, when the Department of Health and Human Services invited states to seek waivers to change how their Medicaid programs were paid to cap federal funds in exchange for a greater flexibility of the State in the management of the program. Waivers have been popular among blue and red states to make other changes to Medicaid.

“Trump will do whatever he thinks he can do,” said Chris Edelson, an assistant professor of government at American University. “If he wants to do something, he’ll do it.”

Republicans have another option for weakening the ACA: They simply can't do anything. Enhanced temporary subsidies that reduce the cost of premiums and have contributed to the nation's lowest-ever uninsured rate are set to expire at the end of next year without action from Congress. Premiums would then double or more, on average, for subsidized consumers in 12 states who enrolled through the federal ACA exchange, according to KFF data.

This would mean fewer people could afford coverage on the ACA exchanges. And although the number of people covered by employer plans is likely to increase, an additional 1.7 million uninsured people are projected each year between 2024 and 2033, according to federal estimates.

Many states that would be hardest hit, including Texas and Florida, are represented by Republicans in Congress, which could make some lawmakers hesitant to let the subsidies expire.

The Trump administration could choose to stop defending the law against lawsuits seeking to overturn parts of it. One of the most notable cases challenges the ACA's requirement that insurers cover certain preventative services, such as cancer screenings and alcohol counseling, free of charge. Around 150 million people now benefit from this coverage obligation.

If the Justice Department were to withdraw its request after Trump takes office, plaintiffs would not have to meet the coverage requirement, which could inspire similar challenges, with broader implications. A recent Supreme Court ruling left the door open to legal challenges from other employers and insurers seeking the same relief, said Zachary Baron, director of the Center for Health Policy and Labor Law. Georgetown University.

Change through decrees and rules

In the meantime, Trump could initiate changes on his first day in the Oval Office through executive orders, which are directives with the force of law.

“The initial executive orders will give us an idea of ​​what policies the administration plans 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 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 amending the ACA and ultimately increased consumer access to health plans which did not comply with the law. He could issue similar orders early in his new term, using them to begin the process of making mandatory changes to the law, such as increased monitoring of potential fraud.

The administration could take other steps early that run counter to the ACA, such as cutting federal funding for outreach and enrollment assistance in ACA plans. Both of these actions caused enrollment to decline under the previous Trump administration.

Trump could also use regulation to implement other conservative proposals, such as increasing access to health insurance plans that do not comply with the ACA's consumer protections.

The Biden administration has pushed back on Trump's efforts to expand what are often called short-term health plans, calling them “junk” insurance because they may not cover certain benefits and may deny coverage. coverage for people with a pre-existing health condition.

The Trump administration is expected to use regulation to reverse Biden's reversal, allowing consumers to keep and renew their plans much longer.

But writing regulations has become much more complicated following a Supreme Court ruling that federal courts no longer have to defer to federal agencies facing a legal challenge to their authority. In its wake, any rules emanating from a Trump-era HHS could spark more efforts to block them in court.

Some people with ACA plans say they are concerned. Dylan Reed, a 43-year-old small business owner from Loveland, Colorado, doesn't want to return to a time when it was difficult to get and afford insurance.

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

He worries that without the ACA's protections, it will be difficult for him to find coverage for his pre-existing conditions.

“It’s definitely a terrifying thought,” Reed said. “I would probably survive. I would just suffer a lot.”

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF's primary operating programs.

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