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Donald Trump reiterated his desire to “replace” the Affordable Care Act in Tuesday’s debate, but said he had only “concepts of a plan” that he’d flesh out later.
The cryptic exchange highlighted one of the most consequential missing pieces of his agenda this cycle: How he would handle trillions of dollars in health care spending.
While Trump has pledged not to make significant changes to Medicare, his administration sought significant cuts and changes to both the ACA’s private insurance marketplace and to Medicaid. He has given little indication as to whether he’d pursue a similar approach in a second term. He also faces a new policy challenge since leaving office: Increased ACA subsidies under President Biden that are set to expire at the end of 2025 and that Vice President Kamala Harris has said she would extend.
Trump has largely discussed his plans for tax cuts more than spending cuts and argued that a combination of economic growth and money raised from tariffs would reduce deficits, even as economic experts mostly dismiss the claim as wishful thinking. But he also recently announced he would empower Elon Musk to lead a commission in order to identify trillions of dollars in savings, which could be especially difficult without touching entitlement programs.
Looking to fill in the gaps on his platform, Semafor asked the campaign last week for his position on whether he would consider cuts and significant structural changes to Medicaid or the Affordable Care Act, whether he would ask Congress to pursue similar efforts to the House and Senate ACA replacement bills he endorsed in office, whether he stood by the White House’s last budget that included a $1 trillion reduction in health care spending, and whether he would rule out undoing the ACA’s Medicaid expansion in 40 states and the District of Columbia.
A spokeswoman for Trump did not directly address the questions, but offered a broad set of goals in response.
“President Trump is not running to terminate the Affordable Care Act,” Trump campaign spokeswoman Karoline Leavitt said. “He is running to make healthcare actually affordable, in addition to bringing down inflation, cutting taxes, and reducing regulations to put more money back in the pockets of all Americans who have been robbed by Kamala Harris’ disastrous economic policies.”
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Benjy’s and Joseph’s View
Depending on how seriously you take Trump’s and other Republicans’ deficit concerns, it’s easy to see how Medicaid and the Affordable Care Act could become a target for savings to offset his other priorities. That makes his position especially relevant, even if he hasn’t formulated a clear plan yet.
Trump is currently promising to cut trillions in spending while also proposing upwards of $10.5 trillion in tax cuts over a decade, according to a Bloomberg estimate. He’s also walled off Social Security and Medicare from consideration for major changes, two of the largest drivers of future spending. That leaves other health care programs as an obvious alternative, especially given that many of his top allies are eager to take a hatchet to its spending already. The most recent budget proposal by the conservative Republican Study Committee in Congress envisions reducing spending on Medicaid, CHIP, and Affordable Care Act subsidies by more than half through a mix of cuts and regulatory changes.
Rep. Kevin Hern, chair of the RSC, said that the state of health care since the ACA was “not a sustainable path” even as he preferred a “bipartisan solution” to address concerns about its efficiency.
“We got to make sure that we’re taking care of those people who need it and make sure the people that don’t need it are working their way into insurance,” Hern said.
In 2016, Medicaid was included in Trump’s first no-cuts entitlement pledge, but he backed significant alterations to the program as part of the various Obamacare repeal bills in his first year, namely capping its spending on a per-capita basis and unwinding the ACA’s optional state expansion, which all but 10 states have now taken up. Republicans portrayed the changes as efficiency savings; the Congressional Budget Office predicted one Senate proposal would reduce Medicaid spending by over $800 billion while enrolling 15 million fewer people. Subsequent Trump budgets also proposed reducing health care spending by $1 trillion.
Passing major cuts would hardly be a sure thing, even with a Republican majority. Many Republicans still feel burned by their Obamacare repeal misadventure, many are in states that receive significant Medicaid funding through the ACA, and Democrats have had prior success running on the issue.
“So much time has passed that it’s not as simple as just an outright repeal of the Affordable Care Act,” Sen. Thom Tillis of North Carolina, told Semafor. “You’re going to have to fill some gaps…what we have to do is try and figure out what’s the best way to reduce cost, improve access, and then by doing that, you’re going to improve outcomes.”
Tillis and Sen. Bill Cassidy of Louisiana — the Senate architect of a past repeal-and-replace package — both talked about finding changes to the ACA capable of drawing Democratic support and winning at least 60 votes. That would rule out a significant rollback given the other side’s strong support for the program.
But Congress also came extremely close to advancing repeal-and-replace bills with significant cuts in 2017 on party-line votes — and with some Republicans already balking at the costs of Trump’s tax proposals, it could be a tempting route to meet their deficit concerns. The Trump campaign did not answer a question on whether ACA and Medicaid programs would be shielded from cuts in the Musk-led spending commission.
Notable
- Politico Pulse noted Trump’s silence on Medicaid and looked at some potential policy options on the right, like greenlighting states to approve work requirements. Project 2025, the conservative policy platform Trump has distanced himself from, also calls for “targeted time limits or lifetime caps” on Medicaid.
- The Wall Street Journal notes that the next president may have to reach a deal on expiring ACA subsidies first before addressing Trump’s tax cuts, given the annual enrollment schedule.