Trump, Republican Congress Health Care Proposals Could Pose Risks to Access and Affordability

President-elect Donald Trump’s return to the White House and likely Republican control of Congress pose big risks to people’s ability to access and afford health coverage in Medicaid and the marketplaces. While Republicans have moved away from talking about their plans for changing health coverage in the U.S. as “repeal,” Trump’s first term and Republicans’ recently released policy agendas suggest they may pursue policies that would have much the same result: higher costs for people, reduced access to care for vulnerable groups, and more people who are uninsured.

It’s not clear what will unfold, but there are reasons to be alarmed. Trump spent his first term as President trying to repeal the Affordable Care Act (ACA) through legislation, rule changes, and the courts. (The ACA vastly increased health coverage by expanding Medicaid and providing financial help for people who lack other affordable coverage, such as through an employer, via private health plans that meet federal benefit standards and consumer protections.)

Trump said in September he has “concepts of a plan” that would differ from current policy but did not provide details. Incoming Vice President J.D. Vance described “deregulating the insurance market” and separating people who are healthy and those who have health conditions into different risk pools with different plans, which would likely drive up costs for people who have health conditions.

Meanwhile, House Speaker Mike Johnson said Republicans would seek “massive reform” of the ACA as part of a “very aggressive” first 100-days agenda if they retain control of the House. That’s consistent with Republican health coverage proposals that would raise people’s costs for health coverage, roll back protections for people with pre-existing conditions, and increase the number of people without coverage.

  

Trump’s past actions may also preview what his administration will pursue in a second term. While pursuing sweeping legislative changes, the first Trump Administration took numerous administrative steps that made it harder for eligible people to get coverage, encouraged states to make policy changes, and weakened consumer protections.

For example, as we detailed in our Sabotage Watch tracker during Trump’s first administration, he:

• slashed funding for outreach and enrollment assistance;
• supported new paperwork and verification requirements to make it harder to enroll in Medicaid and marketplace plans;
• took health coverage away from people who didn’t meet unnecessary and burdensome work requirements;
• expanded subpar health plans that are exempt from pre-existing condition protections;
• restricted access to qualified family planning providers;
• discouraged people who are immigrants and their families from enrolling in coverage they were eligible for; and
• attempted to gut anti-discrimination protections for LGBTQ+ people, women, people with limited English proficiency, and people with disabilities.

The result: Even though legislative repeal of the ACA failed, the marketplaces saw lower enrollment, higher premiums, and diminished insurer participation, and it is likely that fewer people had Medicaid coverage than should have been the case.

Here are some of the policies Republicans have floated more recently that would result in people losing coverage or facing higher costs and barriers to health care:

• Ending premium tax credit (PTC) enhancements that have been in place since 2021 and have led to record enrollment in the marketplaces. Without legislation, the enhancements will expire in 2025, making coverage more expensive for nearly all marketplace enrollees and leaving 4 million more people uninsured. The Republican Study Committee 2025 budget plan calls for eliminating PTCs as part of its proposal to convert federal funding for existing health programs into block grants.
• Dismantling the Medicaid expansion or reducing the enhanced Medicaid matching rate that the ACA gives states that elected to cover adults with incomes up to 138 percent of the poverty line (just over $20,000 a year for an individual). These policies would threaten coverage for nearly 18 million people and negatively impact children, older adults, and people with disabilities.
• Limiting and cutting Medicaid funding by implementing either block grants or caps on per-enrollee spending in a way that will not only drive deep cuts over time but change the fundamental federal-state partnership for funding Medicaid.
• Taking Medicaid coverage away from people who don’t meet burdensome work requirements, despite evidence that previous attempts to do so increased uninsured rates, worsened access to care, and did not increase employment.
• Making it harder for people to enroll in coverage they’re eligible for by adding red tape to the signup process.
• Eviscerating federal protections for people with pre-existing conditions, or undermining them by expanding enrollment in subpar plans, which would make existing coverage more expensive or even unattainable for many people.
• Inviting, encouraging, or pressuring states to adopt similar policies.

It remains to be seen which proposals the Trump Administration and leaders in Congress will prioritize, what the Administration might attempt in legislation versus regulation, and whether policymakers will move broad packages of health care changes all at once or dole them out over time. But it’s important to recognize that a series of piecemeal changes could cause as much harm as wholesale repeal.