Trump has made repealing and replacing the Affordable Care Act part of his platform since 2017, when Republicans failed to repeal the ACA. During his 2024 campaign, he promised to replace the ACA, saying he had “concepts of a plan." Throughout 2025, Trump and his allies in Congress have set out to undermine the ACA, with his signature “One Big Beautiful Bill Act” attacking the ACA and Medicaid. Trump even led his party into the longest government shutdown in U.S. history, all so they could allow the ACA's enhanced premium tax credits to expire at the end of the year, further undermining the ACA and access to affordable health insurance for everyday Americans.
- Donald Trump tried – and failed – to repeal the Affordable Care Act during his first presidency. (The Guardian)
- According to The Guardian, "Donald Trump suffered a major legislative reversal on Friday as Republicans were forced to pull their repeal of the Affordable Care Act from the House floor. After weeks of contentious negotiations over the American Health Care Act (AHCA), Republicans had to admit defeat as they could not gain sufficient support from their own side for the plan to overhaul US health insurance." [Guardian, 3/25/17]
- Donald Trump promised to replace the Affordable Care Act during his first presidency and his 2024 presidential campaign. (NBC News)
- According to NBC News, "Trump has repeatedly vowed to repeal and replace the ACA, also known as Obamacare, both during his first term and again on the 2024 campaign trail — but his current administration has yet to provide details about what his new plan would like like or how it would affect people who rely on the law for coverage. More than 24 million people got coverage through the ACA in 2025, according to government data." [NBC News, 10/22/25]
- On July 4, 2025, the One Big Beautiful Bill Act became Public Law 119-21, legislating major changes to Medicaid and the ACA marketplaces. (congress.gov)
- The law requires Medicaid expansion adults to file massive new paperwork burdens involving “community engagement” (work/education/service) of at least 80 hours, verified by states and not waivable, beginning no later than the first quarter after December 31, 2026. (congress.gov)
- The law mandates new costs on families for expansion enrollees over 100% of the federal poverty line beginning in FY2029. (congress.gov)
- The law restricts states’ ability to fund health care, barring federal matching for Medicaid provider taxes and by directing CMS to limit certain Medicaid state-directed payments to Medicare rates. (congress.gov)
- CBO projects the law will increase the number of people without insurance by about 10 million in 2034 and reduce federal spending on Medicaid and the marketplaces by roughly $1.06 trillion over 10 years. (aha.org)
- The law tightens ACA premium tax credit eligibility for immigrants, eliminating access for lawfully present immigrants under 100% FPL who are ineligible for Medicaid due to immigration status (effective Jan 1, 2026). (congress.gov)
- Beginning Jan 1, 2027, premium tax credits are limited to U.S. citizens, lawful permanent residents, Cuban/Haitian entrants, and COFA migrants; KFF estimates 1.4 million lawfully present immigrants will lose coverage due to these and related changes. (congress.gov)
¶ Trump and Republicans Added New Barriers And Burdensome Paperwork To Try To Kick Families – Up To 2 Million People – Off Of Health Care
- Trump’s CMS finalized the 2025 “Marketplace Integrity and Affordability” rule adding a $5 monthly bill for auto-reenrolled $0-premium enrollees unless they confirm eligibility, eliminating the monthly SEP for ≤150% FPL, requiring pre-enrollment SEP verification, changing income verification to require documentation when IRS data are unavailable, and shortening the federal open enrollment period to Nov 1–Dec 15 starting in plan year 2027. (cms.gov)
- The rule removes DACA recipients from “lawfully present” eligibility for exchanges (cms.gov)
- CMS and AHA note the agency estimated 750,000–2,000,000 people could lose coverage due to the rule’s combined changes. (aha.org)
- Ending the enhanced ACA subsidies will be devastating for the ACA, even if Trump and the GOP technically have not repealed it outright. (KFF)
- According to KFF Health News, "Loss of those enhanced subsidies, coupled with other changes set in the House bill, will mean 'the ACA will still be there, but it will be devastating for the program,' said Katie Keith, founding director of the Center for Health Policy and the Law at Georgetown University." [KFF Health News, 6/3/25]
- Allowing the enhanced premium tax credits under the Affordable Care Act to expire would increase out-of-pocket premiums by an average of 114 percent for 22 million enrollees. (KFF)
- According to KFF, "If enhanced premium tax credits under the Affordable Care Act (ACA) are allowed to expire at the end of the year, out-of-pocket premiums for 22 million enrollees that receive premium assistance will increase by an average of 114%, or $1,016 per person. Democrats have pushed for the enhanced tax credits to be extended, and a vote is expected on their proposal in December. There have also been some bipartisan negotiations and proposals to extend the tax credits for up to two years, with changes like a cap on who is eligible by income and efforts to address any fraudulent signups by insurance brokers. Meanwhile, proposals have emerged from some Republicans in Congress to effectively repeal some or all of the ACA premium tax credits and replace them with contributions to Health Savings Accounts (HSAs) or something similar. President Trump posted recently: 'THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH. THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE.'" [KFF, 11/21/25]
- Senator Rick Scott’s proposed “Trump Health Freedom Accounts” would allow healthy people to use government tax credits to buy insurance outside of ACA marketplaces, leading to what experts call a “premium death spiral” for people forced to remain in the ACA due to pre-existing conditions. (KFF)
- According to KFF, "The most expansive health account proposal was recently introduced by Senator Rick Scott of Florida. It would allow the enhanced premium tax credits to expire but keep the value of the ACA premium tax credits from the original law. States could submit a waiver to the federal government to replace the original ACA premium tax credits with contributions by the federal government to accounts similar to HSAs. These 'Trump Health Freedom Accounts' could be used for out-of-pocket health care costs, or to pay health insurance premiums (unlike traditional HSAs). Unlike ACA premium tax credits, which can only be used for ACA Marketplace plans, the accounts in the Scott proposal could be used for any type of health insurance plan, including short-term plans that can exclude people based on pre-existing conditions. States could also waive certain provisions of the ACA, including the requirement to cover certain benefits. While ACA plans would still be required to cover people with pre-existing conditions under the Scott proposal, it is likely that the ACA Marketplace would collapse in states that seek a waiver under his approach. Healthy people would be able to buy less expensive coverage that does not cover pre-existing conditions, or forgo insurance altogether and use their health accounts to pay for health care directly (carrying over any unused balanced from year to year). People with expensive health conditions would only be able to get coverage in ACA Marketplace plans, leading to a premium 'death spiral' for those plans. Insurers would likely leave the ACA Marketplaces. " [KFF, 11/21/25]
- Economists and policy experts suspect that Trump and GOP lawmakers are proposing such plans in order to undermine and replace the Affordable Care Act, something they have failed to do in the past. (POLITICO)
- According to POLITICO, "Republicans are putting their own spin on subsidizing Americans’ health care: Route money away from insurers and put cash directly in consumers’ hands to give them more choice over their coverage. Economists and policy experts suspect President Donald Trump and GOP lawmakers are presenting this alternative to extending the enhanced Affordable Care Act subsidies because they want to undermine or even replace Obamacare — something the party has repeatedly failed to do in the past. With direct cash payments from the federal government into special accounts, 'healthy people could get much cheaper insurance that has medical underwriting and doesn’t cover preexisting conditions, but that would leave much sicker people in the ACA pool, and likely send it into a death spiral,' said Larry Levitt, executive vice president for health policy at KFF, a nonpartisan research organization." [POLITICO, 11/11/25]