Trump’s Victory Puts the ACA Back on the Chopping Block

With Donald Trump winning the 2024 presidential election, the Affordable Care Act (ACA) once again faces an uncertain future. Despite Trump’s lack of a clear plan to replace the ACA, his first term as president provides clues about what may come next: deregulation, reduced subsidies, and renewed power for insurance companies to deny coverage based on pre-existing conditions. Americans who voted for cheap prices over healthcare stability may have inadvertently jeopardized their interests.

During his winning 2024 campaign, President-elect Trump made conflicting statements about the ACA’s future. However, his prior track record, coupled with Republican control of the House, suggests big changes are imminent. Analysts predict that without congressional intervention, ACA enrollment will drop sharply from 22.8 million in 2025 to 18.9 million in 2026, and as low as 15.4 million by 2030.

Biden-Era Enhanced ACA Subsidies Likely to Expire in Late 2025

One of the most significant achievements of the Biden administration was the enhancement of ACA subsidies. These changes, which cut premium payments nearly in half for millions of Americans, led to record-high ACA Marketplace enrollment, especially in Southern red states. However, these subsidies are set to expire at the end of 2025 unless Congress acts to renew them.

If the enhanced subsidies are not extended, the consequences will be severe. Net premium payments are projected to increase by an average of 79%, with costs more than doubling in some states. The Congressional Budget Office (CBO) estimates that permanently extending these subsidies would cost $335 billion over the next decade—a price tag unlikely to pass in a Republican-controlled government. Without action, millions of families will lose access to affordable healthcare.

Broader Fate of the ACA Hinges on House Control

The Republican-controlled House gives Trump significant leverage over the ACA’s future. If Congress does not renew subsidies during the lame-duck session, it will mark the beginning of a larger rollback of ACA provisions. Regulatory changes and legal challenges will be key strategies Trump may deploy to dismantle the law.

1. State Waivers and Medicaid Work Requirements
Trump’s administration could use executive authority to grant state waivers, allowing states to alter Marketplace rules or implement Medicaid work requirements. This would tighten Medicaid eligibility, particularly in red states, where such policies have been popular with Republican leadership. These waivers could significantly reduce coverage for low-income individuals.

2. Non-ACA Compliant Plans
Trump may reintroduce short-term, non-ACA-compliant health plans. These cheaper plans, while attractive to some, offer far fewer protections and often exclude people with pre-existing conditions. This move, seen during Trump’s first term, undermined the ACA by drawing younger, healthier individuals away from ACA-compliant plans, destabilizing the insurance market.

3. Defunding ACA Marketing and Outreach
Trump previously cut ACA marketing budgets, leading to a decline in enrollment. His administration could again limit funding for outreach, particularly targeting navigators who assist Americans in signing up for ACA plans. This move would exacerbate the downward pressure on enrollment numbers.

4. Tighter Verification Requirements
To address fraud concerns, the Trump administration could impose stricter verification processes for ACA signups. While framed as a measure to improve program integrity, these policies often create bureaucratic hurdles that make it harder for eligible individuals to obtain coverage.

5. Legal Challenges to the ACA
Trump’s Justice Department may once again join lawsuits challenging the ACA or refuse to defend the law in court. This approach mirrors his first administration, where legal battles repeatedly brought the ACA to the brink of collapse.

The Dark Ages of Pre-Existing Condition Denials

One of the ACA’s most popular provisions is its protection for people with pre-existing conditions, preventing insurance companies from denying coverage or charging exorbitant rates. Without the ACA, these protections could disappear, sending millions of Americans back to a time when chronic illness or past medical issues meant financial ruin or no coverage at all.

Critics argue that Trump’s lack of a replacement plan will create chaos in the healthcare system, leaving millions uninsured or underinsured. “We’re talking about millions of Americans losing their safety net,” said a healthcare policy expert. “This isn’t just about politics—it’s about real lives being impacted.”

The Road Ahead

The ACA’s future now hinges on the actions of Congress and Trump’s executive authority. With Republicans maintaining control of the House, the chances of extending Biden-era subsidies or protecting ACA provisions grow increasingly slim. The CBO’s projections paint a grim picture: millions losing coverage, skyrocketing premiums, and a healthcare system once again favoring insurance companies over patients.

For Americans who voted based on promises of cheaper prices, the reality may soon set in. Trump’s vision for healthcare lacks a clear replacement, leaving the country at risk of returning to a time when access to affordable care was out of reach for far too many. As the political battles unfold, millions of families will anxiously wait to see whether the ACA—and its protections—can survive another term of Republican control.