Former President Donald Trump recently brought up the possible repeal of the Affordable Care Act (ACA) and has put his (and my) party in a bind. Republicans suffered at the polls on the very issue Trump has resurrected. Why is he raising the status of the landmark act again?
In a post on Truth Social on November 25, Trump declared: “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives.” He clearly caught his party by surprise. You could hear the collective signs and groans coming from Capitol Hill Republicans who survived the issue in the past. After some criticism, Trump sought to clarify his remarks but actually reiterated his stand. On November 29 on Truth Social, Trump stated: “I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!” Fellow candidate and FL Gov. Ron DeSantis echoed Trump on December 3 on Meet the Press, saying he would “replace and supersede” the Affordable Care Act with “a better plan” and that “Obamacare has not worked.”
From both a policy and political issue, Trump’s stand is terrible and most in his party know it. Trump may be relying on polls that suggest that healthcare in general and the ACA in particular are taking a back seat to other issues, such as inflation and moving the economy in a better direction. But it does give Democrats an issue to seize upon. And that they did. The Biden administration came out swinging, arguing Trump and Republicans want to take healthcare away from at least forty million people.
Can that number be right? For sure. Over twenty million have now obtained healthcare through Medicaid expansions in thirty states and the District of Columbia. Just ten states have thus far refused to expand Medicaid. In recent years, we have seen purple, reddish, and even red states expand Medicaid. This was both through legislative action and through public referenda. These facts as well as polls show Medicaid is supported by most Americans, including most Republicans. On the Exchange front, enrollment reached over sixteen million people in 2023 and the rolls should grow again in 2024.
Trump may be right about one thing – the Exchanges are expensive. But here are a few points that counter what he is saying. Medicaid coverage is the most cost-effective way to provide consistent coverage to those who are uninsured and it has worked. And while the ACA reforms may have pushed up costs and could be reined in a bit from a benefit perspective, it is still true that upfront coverage is cheaper in the Exchanges than people seeking care at high-cost emergency rooms and inpatient settings because they are uninsured. We all pay for this through insurance premiums.
Where is the GOP plan for much better healthcare? Neither Trump nor DeSantis offered any details on their plans to replace the ACA. Tearing it down is not a policy. When in control of Congress and the White House, the GOP failed to put anything credible on the table. Various GOP proposals would have repealed much of the ACA in favor of block grants to states, health savings account expansions, cheap insurance product expansions, and dollars for state high-risk funds. Analyses of these various proposals showed the uninsured rate rising, not going down.
While our uninsured rate will grow as eligibility rules are re-established in Medicaid post the COVID pandemic, the uninsured rate has dropped dramatically since the ACA was implemented. While most developed countries have an uninsured rate that is about 1%, America dropped to below 8% in early 2023. Tremendous progress from pre-2014 when the ACA technically took effect.
That we still have a major uninsured problem adds tremendously to our costs. This, coupled with a price problem and little focus on care management, means we spend the most of any developed nation as a percentage of gross domestic product (GDP) – 50% to 100% more – and have the worst quality outcomes.
Let’s get back to the idea that Trump thinks healthcare and the ACA are minor issues and that such social media declarations will not impact him or his party. It is true that healthcare and the ACA have taken more of a back seat in voters’ minds, but such issues are still very important for many. If forty million or so have benefited from the ACA’s coverage, it is also true that manyfold more know people that now have coverage due to the ACA.
A recent Kaiser Family Foundation (KFF) survey (link below) found that about half of voters (49%) viewed the ACA as a very important issue: 70% of Democrats, 32% of Republicans, and 45% of independents. What’s more, 59% of respondents said they trusted the Democratic Party more on the future of the ACA; 39% trust the Republicans more. As important, 75% of respondents say that the future of Medicare and Medicaid are very important issues for candidates to discuss; 64% say prescription drug costs are very important for candidates to discuss. The polling does suggest more Americans trust Democrats on healthcare. Indeed, after Trump’s announcement on the ACA, the Biden campaign began airing ads in swing states covering healthcare.
So, Trump’s remarks on the ACA serve as red meat to the right flank of his party in the primary; but it seems clear that Republicans are vulnerable on healthcare in the general election and Trump dug the party a deeper election-year hole to get out of for November 2024. While inflation and economic issues are sure to resonate in 2024, Americans are also an exceedingly compassionate people, believing that family, friends, and neighbors in need should be helped. That is most true about healthcare.
Trump and GOP candidates tend to have what I call a compassion gap, which is elucidated in part by the ACA and healthcare issues. And the compassion gap could play a real role in the next election. The election may again come down to a handful of moderate swing states — and even counties — in America. Trump’s views on the ACA could play into how these citizens vote. That is why many Republicans let out those collective sighs and groans when Trump raised repeal of the ACA again.
#aca #obamacare #exchanges #medicaid #trump #desantis #biden #healthcare #healthcarereform #healthinsurance #coverage #universalaccess #affordableaccess
— Marc S. Ryan
