In the early days of the first Trump administration—during which the GOP also held control of both Houses of Congress—'Repeal and Replace' was arguably THE top priority for the Republican party. But despite multiple attempts at such legislation, all efforts were ultimately stymied due to internal division within the party. And repeal of the ACA was not a major talking point on the campaign trail—nor does it appear to be a major focus of Trump's healthcare cabinet (which early indications suggest will be far more focused on reforming the country's approach to public health). Still, the recent Republican sweep of both Houses of Congress, alongside the impending return of President Trump to the White House, does raise the prospects of reform to the Affordable Care Act. So should healthcare leaders expect to see yet another attempt at 'Repeal and Replace?' Or will President Trump be more inclined to build on the ACA, rather than dismantling it—much in the same way that the ACA built on existing industry structures, rather than destroying them? Either way, what provisions would be most likely to see reform? In this post, we'll break down what a second Trump administration could mean for the ACA.
What a second Trump administration could mean for the ACA: Prospects for a second attempt at 'Repeal and Replace'
We won't bury the lede: we don't think a return to the 2017-era 'Repeal and Replace' effort is all that likely, for a few key reasons.
Factor #1: Political will has subsided substantially
2016/2017 landscape: In 2016, 'Repeal and Replace' was one of the hallmarks of the Trump campaign's bid for the White House. His campaign promise was unambiguous: "On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare." And on the day he was sworn into office—January 20, 2017—President Trump immediately signed an executive order pledging to "ease the burden of Obamacare as we transition from repeal and replace." Republicans in Congress acted quickly to craft their attempt at repeal, with House Republicans announcing the first proposed replacement legislation on March 7th. But internal divisions and a narrow majority in the Senate ultimately doomed the effort.
2024/2025 landscape: Repeal of the ACA was not a major talking point for the Trump campaign (and in fact, with the notable exception of reproductive rights, healthcare on the whole was not a focal point for either campaign). When prompted, Trump stated that unless a better option presented itself, his approach would be to run the ACA as effectively as it could be run.
Factor #2: Public popularity has never been higher
2016/2017 landscape: Public views on the law were a mixed bag, skewing slightly negative. In December of 2016, 46% of Americans held an unfavorable view of the law, compared to 43% who viewed it favorably.
2024/2025 landscape: By mid-2017, in the immediate wake of Congress' attempts at 'Repeal and Replace', the proportion of Americans who viewed the law favorably overtook the proportion who viewed it unfavorably—and the gap has only widened over time. As of the most recent polling in April of 2024, 62% of Americans had a favorable view of the law, with just 37% viewing it unfavorably. The reasons why are complex, but in a nutshell: all of the most unpopular provisions of the ACA were gradually repealed or diminished by the GOP after the failure of "Repeal and Replace." The individual mandate and the independent payment advisory board (IPAB, or, perjoratively, the "death panels") both got the axe in subsequent legislation, and various unpopular mandates were minimized with regulation. In short, what has remained are the largely popular elements of the law.
Factor #3: The industry is even more entrenched in the law
2016/2017 landscape: By any measure, repeal of the ACA would have been a monumental change for the industry back in 2017. For example: a majority of states (31) had already expanded Medicaid, and over 13 million Americans received healthcare coverage through the public exchanges. Repeal of the law would have had significant ramifications for many industry players, as well as many patients.
2024/2025 landscape: Repeal in 2025 (or beyond) would be even more disruptive, with an additional eight years of implementation now complete. By the same measures cited above, 41 states have now expanded Medicaid and the number of individuals purchasing coverage through the exchanges has increased to 21 million. In the intervening years, countless additional regulations have been written on the basis of the ACA, governing everything from the insurance marketplaces, to provider payments, to oversight over quality and interoperability.
In sum: Full repeal of the law is unlikely at this point (although of course not impossible)
What a second Trump administration could mean for the ACA: How 'Refine and Reform' could play out
None of this means, however, that the incoming administration won't look to tweak parts of the ACA. In fact, 'refine and reform' of the law is a near-certainty. But as we think about what a second Trump administration could mean for the ACA, the likelihood of reform—and the magnitude of the potential change—varies greatly depending on the specific provision in question.
Provision #1: Medicaid expansion
Possible refinement: The GOP is likely to look to limit Medicaid enrollment in some way. Whether that involves doubling down on the levers that were core to the 2017 proposals (i.e. work requirements and block grants—both of which were eventually offered to states as options via waiver) or through different approaches such as stricter eligibility checks remains to be seen. There has also been some discussion about reworking the federal matching system to tamp down on federal spending on the program.
Likelihood of reform: High (with a caveat). Medicaid has long been the entitlement program Republicans are least eager to defend. Substantial reforms to Medicaid were a cornerstone of every iteration of the 2017 'Repeal and Replace' effort. One caveat: as the Republicans have won power with a large working-class coalition, the party's leadership could again face internal opposition to making changes viewed as draconian, even as it works to move more Medicaid enrollees into private insurance.
Provision #2: Public exchanges
Possible refinement: During President Biden's administration, Congress passed the American Rescue Plan Act to provide relief amid the pandemic. The law included enhanced subsidies for those purchasing insurance on the public exchanges. Those subsidies were initially intended to be available for 2 years, but were extended for an additional three years (i.e. through the end of 2025) as part of the Inflation Reduction Act. Both Biden and Vice President Kamala Harris had promised to make the subsidies permanent, but with Republican control of the White House and Congress, the future of the enhanced subsidies has come into question.
Likelihood of reform: High (with another caveat). Several key Republican members of Congress has signaled an intent to let the subsidies expire. But President Trump could be a wild card here. The subsidies are highly popular, and the former/future President has grown the populist faction of the Republican party. Maintaining enhanced subsidies could be a bridge that helps the GOP limit Medicaid coverage and move enrollees into private insurance.
Provision #3: Employer mandate/dependent coverage
Possible refinement: In theory Republicans could attempt to repeal either of these provisions, or least decrease the reporting requirements for employers.
Likelihood of reform: Low. Enhanced coverage for dependents is highly popular. And although some Republicans have (over the years) floated the idea of repealing the employer mandate, such a move could prove highly destabilizing to the insurance market, and shift significant costs onto the federal government.
Provision #4: Essential health benefits/protections for pre-existing conditions
Possible refinement: Some Republicans have floated the idea of re-introducing risk pools into the insurance marketplace. And of course, in theory either of these provisions could be repealed or watered down.
Likelihood of reform: Moderate. Vice President-elect J.D. Vance has previously expressed support for the idea of reintroducing risk pools—and doubled down on that support in the 2024 Vice Presidential debate. He has also, however, committed to maintaining protections for those with pre-existing conditions, and it is not immediately clear how to reconcile those aims, which many policy experts believe to be in direct conflict with one another.
Provision #5: Value-based care
Possible refinement: Since the passage of the ACA, Democrats have focused heavily on increasing participation in value-based care programs—and have (increasingly) demonstrated a willingness to deprioritize cost savings in order to ensure and grow participation. Under the Biden/Harris administration, numerous program launches more closely resembled grant-like programs that than those tied to performance. By contrast, Republicans have focused more heavily on the cost savings generated by value-based programs. We could see a refocus and reprioritization under the incoming administration.
Likelihood of reform: High. Given that value-based care programs are largely driven through the regulatory apparatus (through CMS and CMMI), any incoming administration, but especially one of a different party affiliation than the previous administration, is likely to put its on stamp on the value-based care landscape.
Provision #6: Patient safety and quality/reporting standards
Possible refinement: The general expectation of a Republican-led administration is a focus on "deregulation"—and this could very well extend to the safety/quality regulatory apparatus that was established as part of the ACA.
Likelihood of reform: Moderate. Efforts to ensure patient safety are generally bipartisan in nature. And Trump established during his former administration that he was not afraid to break from the traditional Republican party line when it comes to deregulation. So this could one area where any push toward deregulation is more modest in nature.
Provision #7: Interoperability
Possible refinement: Same as above: the general expectation of a Republican-led administration is a focus on "deregulation"—and this could very well extend to the regulatory framework surrounding interoperability that was established as part of the ACA.
Likelihood of reform: High. While we're not likely to see the regulatory framework dismantled in a significant way, this could be an area where the incoming administration looks to scale back or least slow down the regulatory apparatus.
Parting thoughts
As the President elect has begun to assemble his healthcare team, we may have some early clues not only as to what a second Trump administration could mean for the ACA, but how big a priority the ACA—and its associated coverage expansion and delivery system reform provisions—is likely to be. Thus far, Trump's picks signal a heavier focus on reforming the public health apparatus and potentially making structural changes to federal health agencies and departments, rather than massive reforms to the insurance marketplace or delivery system. But of course, this could change quickly. As as leaders are sworn in early next year, we'll have a better idea what the administration's healthcare agenda will look like.
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