The Affordable Care Act has been through many iterations since being signed into law in 2010. Donald Trump's second presidential term could bring about more changes.
The New York Times gathered perspective from experts across the political spectrum to outline what could happen next based on limited information from the campaign trail and Mr. Trump's historical view of the ACA.
Here are 17 key points.
1. Renewed ACA reform momentum. With a Republican-controlled Congress, Trump's administration may seek to reform the ACA, potentially allowing key subsidies to expire, impacting millions of Americans who rely on ACA marketplaces for affordable coverage. There are 20 million people who purchase their health insurance through ACA plans.
The Congressional Budget Office estimates around 4 million people could lose their coverage in 2026 because they can't afford it without financial support from the ACA.
2. Possible ACA repeal. While there's no consensus among Republicans to fully repeal the ACA, some GOP leaders indicate that “massive reform” is on the agenda. However, Trump's stance on total repeal remains unclear, as his comments have oscillated between maintaining and replacing the ACA.
Despite Mr. Trump's historical stance against the ACA, some Republican leaders, including Representative Brad Wenstrup, have indicated limited interest in a full repeal, according to the Times. Instead, there may be a focus on “evaluating success” and improving aspects of the ACA rather than dismantling it entirely.
3. Subsidy expiration. Enhanced subsidies under the ACA, implemented by the Biden administration, could lapse without legislative action. This would likely result in a surge of uninsured Americans, with an estimated 3.4 million losing coverage if premium costs rise.
"Allowing enhanced subsidies to expire would push the uninsured rate back to double-digits and would cause unintended problems in the healthcare system, costing states more money due to uncompensated care," said Mark Bertolini, CEO of Oscar Health, told Becker's. He added, "A certain percentage of Americans still need subsidies. While Republicans may not be supportive of subsidies in their current form, we expect some level of subsidy continuation post 2025. Republicans have good reason to find a permanent solution."
4. Potential decrease in ACA enrollment. Higher premiums due to subsidy expiration would likely cause enrollment in ACA marketplaces to drop, with low- and middle-income individuals especially vulnerable to losing affordable coverage, according to NBC News.
5. Possible ACA enrollment restrictions. The Trump administration could reinstitute policies limiting ACA outreach efforts, such as cutting funding for marketplace navigators and reducing enrollment periods, potentially dampening ACA enrollment gains made in recent years.
6. State-level premium hikes. If ACA subsidies lapse, Southern and rural states, where ACA sign-ups have surged under enhanced subsidies, would see the steepest premium increases. States with high ACA enrollment would feel a greater impact on coverage affordability.
7. Focus on fraud, waste and abuse. Trump administration veterans are signaling a focus on cracking down on fraud within ACA programs. This includes addressing issues such as brokers enrolling individuals in ACA plans without consent, a concern disputed by Biden administration officials. It could also lead to stricter oversight and perhaps attempts to streamline ACA operations or reduce administrative overhead.
8. Short-term health plan promotion. Mr. Trump could revive his previous strategy of endorsing short-term health plans, which bypass ACA protections. This move might attract younger, healthier people away from the ACA, potentially destabilizing the insurance pool and increasing costs for sicker patients.
9. Medicaid expansion rollbacks. Medicaid, which saw significant expansion under the ACA, may face funding cuts. Deep cuts were proposed in 2017's GOP healthcare plan, and a similar approach could surface, particularly to finance proposed tax cuts. Mr. Trump could provide guidance to change Medicaid eligibility or renewal policies, according to Kaiser Family Foundation, to change the financial structure and cut spending. Previously, Mr. Trump emphasized work requirements and other eligibility restrictions.
10. Impact on rural healthcare. Policies targeting ACA reforms and Medicaid cuts would disproportionately affect rural Americans and those in lower-income brackets, according to the report. Without subsidies, rural Americans could face monthly premium hikes of nearly $90, adding strain to already vulnerable communities.
11. "Docs Caucus" proposals. The “Docs Caucus” within the House GOP, composed of Republican lawmakers who are medical professionals, is reportedly working on various reform proposals. Although specific plans aren't public, their perspectives may shape future policy discussions around ACA adjustments, potentially prioritizing provider-focused reforms.
12. Medicaid Impact in GOP-led states. GOP-led states could see a significant impact if Medicaid funding is cut. With higher ACA sign-ups in states like those in the South, reductions in Medicaid coverage or funding could amplify disparities in access to care, especially in regions that benefited from ACA's Medicaid expansion.
13. Uncertain stance on pre-existing condition protections. While pre-existing condition protections are highly popular, Mr. Trump's lack of clarity around ACA alternatives leaves some uncertainty. Any significant alterations to the ACA could affect these protections if they're not explicitly prioritized in future GOP healthcare legislation.
14. Expanding health savings accounts. Historically, Mr. Trump and many Republicans have supported expanding HSAs as a way to give patients more control over healthcare spending. Further support for HSAs might be part of any reform package, aligning with broader GOP healthcare goals.
15. Potential rollback of essential health benefits. The ACA mandated essential health benefits that all ACA-compliant plans must cover, such as maternity care and mental health services. If Republicans push for more flexible plan requirements, it could mean a shift away from these standardized benefits.
16. Strategic cuts for tax reform financing. GOP discussions have included using Medicaid or ACA subsidy cuts as potential financing mechanisms for tax reforms. Executives should be aware that healthcare reforms may be linked to broader fiscal policies aimed at achieving GOP economic goals.
17. Continued legal and administrative battles. Even with a potential GOP-led Congress, the ACA may face ongoing legal challenges or administrative hurdles that could slow or complicate reforms, especially with lingering judicial challenges regarding the ACA's individual mandate and other provisions.