Trump did not salvage the Affordable Care Act — he sabotaged it.
Tall tales are always part of politics and candidate debates. America takes it for granted. But the biggest lie of the vice-presidential debate Tuesday night was quite the doozy and I could not let it go without some explanation. The big lie can be credited to GOP vice presidential candidate JD Vance. Vance attempted to concoct a story that somehow former President Trump salvaged the Affordable Care Act (ACA) when it was on the verge of collapse. This of course is true only in Vance’s and Trump’s minds.
Vance’s fanciful rewrite of history went like this. Vance said Trump “actually implemented some of these regulations when he was president of the United States. … And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I think this is an important point about President Trump. … When Obamacare was crushing under the weight of its own regulatory burden and healthcare costs, Donald Trump could have destroyed the program. …Instead, he worked in a bipartisan way to ensure that Americans had access to affordable care.”
This is similar to what Trump himself tried to spin at the presidential debate in September. He said: “Obamacare was lousy healthcare. Always was. It’s not very good today. … I had a choice to make when I was president: Do I save it and make it as good as it can be? Never going to be great. Or do I let it rot? And I felt I had an obligation, even though politically it would have been good to just let it rot and let it go away.”
I followed Trump’s views and actions on the ACA very closely. Here is what Trump actually did to the ACA. He undermined it at almost every pass!
- On coming into office, Trump used regulatory authority to massively rein in marketing and outreach dollars. He shortened the enrollment period and made a number of other changes that constrained enrollment.
- Both Barack Obama (believe it or not) and Donald Trump underfunded some critical programs meant to stabilize finances in the new Exchanges early on. This included the reinsurance and risk corridor programs.
- Trump challenged the ACA in court and failed.
- Next, he and his GOP comrades in the House and Senate attempted to repeal the act in part in favor of a mishmash of block grants to states to replace the Medicaid expansion and the Exchange program. It relied heavily on the old and tired concepts of risk pools pools and more. The GOP proposal would have massively increased the rolls of the uninsured. The repeal effort died in the Senate when a handful of courageous Republicans voted against the repeal. This included Sen. John McCain, who came back to Washington after his brain cancer diagnosis to courageously vote “no.”
- Trump sought to dissuade states from expanding Medicaid under the ACA in favor of other schemes, such as generous uncompensated hospital care funding and work requirements in Georgia for a partial expansion.
- In perhaps the most egregious example of undermining the program, Trump backed de-appropriating the cost-sharing reduction (CSR) subsidies, which are different from the premium subsidies. This actually forced plans to massively inflate premiums because they still had a duty to offer the low-income Silver CSR plans (which reduced cost-sharing for the lowest income in the prorgam) under the law. This actually cost the federal government more in premium subsidies than it saved on the CSR subsidy. Republicans pitched the story that somehow the funding was a huge giveaway to rich health plans. They accomplished their goal of destabilizing the program and insurers lost faith.
President Biden reversed many but not all of the damage done by Trump. And the proof of the hurt Trump did to the ACA can be seen in the chart below. When Trump came to office and implemented many of the regulatory changes and backed repeal, we saw Exchange premiums skyrocket, enrollment go down, and plan participation drop. The Exchanges became a financially perilous place. Premiums dropped or grew at a reasonable rate during the Biden years and plan participation increased. Enrollment surged. (Admittedly, premium increases will be very robust in 2025 and perhaps on.) The biggest damage done by Trump occurred with the defunding of the CSR subsidies, causing premiums to surge from an average of $359 in 2017 to $481 in 2018. This crippled middle-income families who received no premium subsidy under the law. Many of them joined the ranks of the uninsured because they could not afford the huge hike in premiums.
In summary, Trump’s and Vance’s declarations on salvaging the ACA are simply wild and untrue. There is nothing to back it up. And they both seem to be back on the repeal bandwagon, but with the same tired ideas as before. I am a Republican, but I am here to say that these views emanate from a twisted idea in many Republican lawmakers’ minds that healthcare is a commodity to be earned as you achieve wealth. Where is the commpassion in that?
In the end, Trump did not salvage the ACA — he sabotaged it.
Year | Enrollment | Average Silver Benchmark Premium Per Month | Average Number of Marketplace Insurers Per State |
2024 | 21.4 | $477.00 (4.6%) | 6.0 |
2023 | 16.4 | $456.00 (4.1%) | 5.8 |
2022 | 14.5 | $438.00 (-3.1%) | 5.9 |
2021 | 12.0 | $452.00 (-2.2%) | 5.0 |
2020 | 11.4 | $462.00 (-3.5%) | 4.5 |
2019 | 11.4 | $478.00 (-0.6%) | 4.0 |
2018 | 11.8 | $481.00 (34% — Silver cost-sharing reduction (CSR) subsidies were eliminated but plans had to boost premiums as they were still obligated to have Silver CSR plans — most of the increase is attributed to this change) | 3.5 |
2017 | 12.2 | $359.00 (20.1%) | 4.3 |
2016 | 12.7 | $299.00 (8.3%) | 5.6 |
2015 | 11.7 | $276.00 (1.1%) | 6.0 |
2014 | 8.0 | $273.00 | 5.0 |
#aca #exchanges #medicaid #obamacare #election2024 #trump #vance
— Marc S. Ryan