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The Trump presidency is over, and Obamacare is still alive

Trump managed to accomplish very little on health care, despite Republicans’ decade-long obsession with repealing the Affordable Care Act.

Donald Trump waiting to step outside at his inauguration in 2017.
Patrick Semansky/AP
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.

Mere days before his 2016 election to the presidency, Donald Trump boldly promised his voters: “When we win on November 8th and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare.”

Now Trump is on his way out of the White House, and the health care law is still standing.

Trump, who had promised on the campaign trail to deliver “great health care at a tiny fraction of the cost — and it’s going to be so easy,” quickly realized how wrong he was. Republican congressional attempts to repeal and replace the Affordable Care Act consumed most of Trump’s first year in office. They wanted to deliver on a years-long obsession with undoing the previous president’s signature legislative achievement.

The repeal push ultimately failed with Sen. John McCain’s thumbs-down in July 2017. Though Republicans said they would make a second attempt that fall, it quickly sputtered and never came up for a vote.

Trump and Republicans failed to figure how to satisfy the outsized promises they had made. Rather than make health insurance more affordable, their plans would have shrunk federal assistance and hiked premiums for millions. Rather than cover everybody, as Trump said he wanted to do, millions of people would have lost their insurance. Rather than protect Medicaid, as the president pledged he would, their proposals would have cut hundreds of billions of dollars in spending and led to millions falling off its rolls. People with preexisting conditions would have lost the iron-clad protections that Obamacare had given them, that they would not be denied coverage or charged a higher premium because of their medical history.

“Nobody knew health care could be so complicated,” Trump said just one month into his term.

The Trump White House paid the price for its miscalculation. Democrats, campaigning heavily on preserving health care, won back the House in the 2018 midterms. The GOP’s Senate majority was lost in 2020. Biden pummeled Trump over his health care agenda and made the latter a one-term president.

Not every president passes a landmark health care bill, as Barack Obama did. But Republicans swept into power four years ago having promised to fix what they said Obama had broken. Trump said he would not only repeal and replace Obamacare, but he’d put into place ambitious plans to bring down drug prices.

The Covid-19 pandemic response was a disaster, with 400,000 Americans now dead, and the repercussions will be felt for years. That will be Trump’s legacy more than any affirmative steps his administration took to change US health care. As Trump surrenders power, what’s remarkable is how little of a mark he will leave on American health care.

“We spent four years waiting to see Trump’s health care plan, which may or may not have ever existed,” Larry Levitt, executive vice president at the Kaiser Family Foundation, told me. “His promise of ‘great’ health care was certainly never realized.”

The denouement to Trump’s failed health care record should come later this year when the US Supreme Court, of which he’s appointed a third of the members, is expected to reject the latest challenge to the ACA — a lawsuit that the Trump administration had supported.

Biden begins his term looking to quickly build on the ACA, expanding the welfare state that the outgoing president tried so hard but failed to shrink. There are still serious problems in US health care: tens of millions still uninsured and medical care left unaffordable for many others who do have an insurance card. But Biden will pick up where Obama left off, almost as if the Trump administration never happened.

Why Trump failed to change US health care

Legislation is the surest way to change US public policy for good, and Trump’s most comprehensive health care plans failed to pass Congress. Even though Republicans did succeed in repealing the individual mandate as part of their tax bill, experts were around the same time concluding that the mandate was not as essential to the law functioning as previously believed. Obamacare enrollment stayed mostly steady in the first year after the mandate penalty was zeroed out.

Trump’s record on health care is largely his administrative actions — and those are most vulnerable to being undone by the courts or the incoming Biden administration. Many of his most significant achievements already appear to be at risk.

The Trump administration approved, for the first time in history, Medicaid work requirements in several states, conditioning a person’s eligibility for health insurance on whether they are working or looking for work. But those requirements were blocked by the courts, which questioned whether they met Medicaid’s objectives as it quickly became clear that thousands of people would lose coverage.

The Supreme Court will hear a lawsuit challenging Medicaid work requirements in the coming year, and legal experts actually believe there is a chance the conservative-leaning high court will side with the lower courts and block work requirements from taking effect. Alongside the Obamacare case, the justices could spell the end to another one of Trump’s health care priorities.

A sense of desperation clearly kicked in during the final months of Trump’s term. Trump’s No. 2 health official, Seema Verma, worked overtime in the final days of the administration to ensconce some of the administration’s agenda for Medicaid. A waiver to establish Medicaid spending caps in Tennessee, also known as block grants, was approved, as were waivers proposed by conservative governors in Tennessee and Florida.

The problem, according to experts, is that these Medicaid waivers are approved at the discretion of the federal government. The Biden administration is not going to be friendly toward work requirements or block grants. Verma has tried to put in place procedural barriers to unwinding these last-minute approvals, but the consensus of experts is that Biden should be able to reverse them, though it will surely take time and a lot of paperwork.

Some of Trump’s other actions — such as cutting Obamacare outreach funding — can be nixed with the stroke of a pen. Others, like various plans to cut drug prices, have been proposed but never finalized as regulations and therefore will not actually take effect unless Biden takes them across the finish line.

This shoddy legal and regulatory work has exposed Trump’s health care policies to being quickly and permanently nullified. Even his administration’s most successful action could be weakened if Biden succeeds in passing the Covid-19 stimulus plan he has proposed.

Having failed to repeal Obamacare, the Trump health department proposed and did actually finalize a regulation expanding short-term limited-duration insurance. Those plans are not subject to the ACA’s rules about preexisting conditions and, under these new regulations, they would be allowed to last as long as three years. Trump officials portrayed them as a cheaper, free-market alternative to Obamacare, though their sales have been plagued by misleading marketing, and patients have sometimes found that these plans do not provide the level of coverage they were led to believe.

Nevertheless, enrollment in those plans did grow under Trump, up to about 3 million consumers, according to the best estimates. The merits could be debated, but the impact was real.

When I asked health policy experts about what Biden could do administratively to change health care, I was surprised when several of them said they weren’t sure whether he would be able to reverse Trump’s expansion of short-term plans. Their thinking was that the Biden team might be hesitant to yank those plans, cheap and substandard though they are, away from people without giving them an alternative.

But then Democrats won both Georgia Senate runoffs, and with them control of the Senate, and suddenly Biden’s legislative agenda had some life. As part of his Covid-19 stimulus plan, Biden is proposing to make Obamacare’s premium assistance more generous and to make more people eligible for it. People might be more willing to drop a short-term plan and sign up for Obamacare if those proposals pass and ACA-compliant plans are cheaper.

There was one Trump policy that Levitt thought could leave a lasting impression: new requirements that health care providers and insurers disclose more data about the prices paid for medical services. But there’s a twist.

“The data that will become available could shine a spotlight on how high prices are and how much they vary,” he said. “Perhaps ironically, Trump’s market-oriented price transparency regulation could help build support for more regulatory approaches to deal with high costs.”