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While Trump gets the best health care in the world, he wants to eliminate coverage for millions

Trump’s positive coronavirus test underscores the stakes of his fight against Obamacare.

White House Chief of Staff Mark Meadows speaks to reporters about the president’s positive coronavirus test on October 2.
Drew Angerer/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

After testing positive for the coronavirus, President Donald Trump can rest assured he will receive the best medical care without having to worry about the cost.

But many Americans already do not have the same guarantee of quality in care and coverage that the president enjoys. And if Republican states supported by the Trump administration succeed at the Supreme Court in overturning the Affordable Care Act, tens of millions of people could lose access to health care.

(The White House is not discussing Trump’s treatment, according to Chief of Staff Mark Meadows, but we know the president has a team of doctors to monitor his health all the time.)

Inequities, especially along racial and socioeconomic lines, are built into the US health care system. Low-income people, Black people, Latino people — all are more likely to be uninsured and less healthy than higher-income people and white people.

Christina Animashaun/Vox

Those disparities are with us all the time, but they have been starkly revealed in the Covid-19 pandemic. Black Americans are dying at twice the rate, as a share of the population, as white people. Black and Hispanic neighborhoods have less access to coronavirus testing. During the worst of the New York City outbreak in the spring, race and income helped determine a person’s odds of surviving Covid-19. And despite the federal government ostensibly covering the cost of testing and treatment for all Americans, confusion about how to implement that policy has led to some people receiving hospital bills for thousands of dollars.

Donald Trump will not be among them. But the challenges some Americans have faced in the pandemic could only get worse under the Trump agenda. Millions could lose coverage outright and protections for preexisting conditions could be overturned if the Trump administration’s argument prevails at the high court.

Millions of people now have Covid-19 as a preexisting condition. The president says he wants to protect them. But four years into office, he still hasn’t laid out a plan to do it.

Trump doesn’t have a plan if the Supreme Court ends coverage for 20 million people

The Supreme Court has scheduled oral arguments in California v. Texas for November 10, the week after Election Day. Republican-led states and the Justice Department have urged the Court to invalidate the ACA in its entirety, arguing that because the individual mandate penalty has been repealed, the rationale used to save the law in 2012’s National Federation of Independent Business v. Sebelius (for which Chief Justice John Roberts wrote the Court’s majority opinion) no longer applies — so Obamacare must fall.

Trump would be the silent author of a ruling striking down Obamacare if the three justices he’s appointed — Neil Gorsuch, Brett Kavanaugh, and, assuming she is confirmed in time to hear the case, Amy Coney Barrett — side with the archconservatives Clarence Thomas and Samuel Alito to overturn the law. A decision would likely come in the spring of 2021.

In that scenario, more than 12 million people who gained coverage through Medicaid expansion could lose that coverage. And so could most of the 11.4 million people who purchase coverage on the law’s private insurance markets, because they rely on federal subsidies that would also be nixed. Protections for preexisting conditions would be wiped off the books. The provision that guarantees free preventive care, including contraception, would be gone. The US would be effectively starting over, as if a decade of health reform never happened.

Urban Institute

But if the Court rules as Trump is asking them to, his administration does not actually appear to have a plan to replace the ACA. The president is promising something “much cheaper and far better” — such a ruling “would be a big win for the USA,” as he recently tweeted — but the White House has offered no evidence such a plan exists.

After weeks of promises about a forthcoming health care plan, the Trump administration convened a call with reporters last week to unveil some health policy news. But the details were staggeringly meager: Trump would sign an executive order that “it is the policy of the United States” that people with preexisting conditions would be protected.

That order doesn’t actually have any force of law. With Obamacare eradicated, insurers would be free to begin charging people higher premiums or denying coverage altogether because of their medical history. And it was already exposed during the Republicans’ failed Obamacare repeal fiasco that no consensus currently exists within the party about how to protect people with preexisting conditions. It would seem to require government spending and regulations for insurers, both of which are antithetical to the GOP’s stated ideology.

Some conservatives would probably be comfortable with reconstituting many of Obamacare’s policies — guaranteed issue, tax subsidies, and the like — with tweaks that they believe would make premiums cheaper.

“It’s an alternative form of the individual market, with important technical differences,” Avik Roy, president of the free market Foundation for Research on Equal Opportunity and a proponent of such a plan, told me recently. “We’d end up in a pretty similar place, but with a reformed individual market.”

But others on the right, including the Trump administration in its proposed federal budgets, still support a framework similar to 2017’s Graham-Cassidy bill, which would effectively take the money appropriated by Obamacare and turn it into block grants for states to spend as they see fit (and which would lead to millions of Americans losing coverage, according to estimates from the Congressional Budget Office). Either way, cuts to Medicaid seem likely if Republicans are reforming the health care system. Both camps are proposing them.

The pressure to act and prevent millions of people losing coverage would be enormous. But the White House still has no official plan, a month before the election and Supreme Court oral arguments, and Trump has not proven adept at passing major legislation through Congress. So it must be treated as a plausible outcome that if the Court strikes down Obamacare, no deal gets done and the law is allowed to lapse without anything to replace it.

The US uninsured rate was already ticking up under Trump, after he undermined the ACA’s private markets through regulatory action, and Covid-19 has led to several million more people losing coverage. The losses could be even greater under this worst-case scenario, up to 20 million people suddenly uninsured with no guarantee of a fix.