Why You Should Take Trump’s Health Care Repeal Talk Seriously

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A lot of people were surprised two weeks ago when Donald Trump started posting on social media about trying to repeal the Affordable Care Act. I certainly was.

The attempt to wipe out “Obamacare” in 2017 was one of his administration’s most spectacular policy failures, and one of its most damaging political failures too. The backlash to the unpopular effort was a big reason Democrats took back the House in 2018. Two years later, it helped put Joe Biden in the White House, while giving Democrats a narrow hold on the Senate as well.

A sensible, thoughtful politician mindful of that experience would do everything to avoid the subject altogether. Or, if they were truly committed to the repeal cause out of principle, they would return to it only after developing a well-considered strategy to succeed where the last attempt failed.

Suffice to say it does not appear Trump did that.

The likely backstory, according to a report in Politico, is that a Wall Street Journal editorial on the Affordable Care Act “piqued his frustration” with the program, enough that he decided to post on Truth Social that he was “seriously looking at alternatives” to Obamacare and imploring fellow Republicans to “never give up” on trying to get rid of the law.

Trump’s own advisers didn’t seem to expect the post, based on the Politico story, and Republicans in Congress certainly didn’t. In the days that followed, they made clear their reluctance to try repeal again ― in no small part, I’m sure, because so many of them were around last time and remember how that all turned out.

Sen. Chuck Grassley, Iowa Republican and senior Finance Committee member, told a local radio station that “I don’t hear any Republicans talking about it.” His GOP colleague from South Dakota, Majority Whip John Thune, offered similar thoughts to Politico: “Boy, I haven’t thought about that one in a while.”

Translation: “Are you f**king kidding me?”

Their ambivalence makes even more sense given that repealing the Affordable Care Act now would likely be more difficult than it was in 2017, when the then-fledgling program’s widely publicized implementation problems ― like the catastrophic rollout of the HealthCare.gov online shopping site, or insurers pulling out of markets because they were losing so much money ― made it an easy target for political attacks.

Six years later, the website works great, insurers have figured out how to offer a profitable product and the markets are stable. People buying coverage on their own can have access to lower premiums and out-of-pocket costs because Biden and the Democrats have added to the program’s financial assistance.

That’s one reason that, relative to 2017, even more people are getting insurance through the program. Another is that voters in conservative states like Idaho and Missouri have since approved Medicaid expansions that their state Republican officials had been blocking, adding hundreds of thousands to the long list of Americans with something to lose if Obamacare goes away.

In short, the program is a lot more entrenched than it was before ― and, as the polls show, a lot more popular too. Just this week, a new Navigator survey found support for the Affordable Care Act at 61%. That’s the highest the poll ever recorded, and consistent with findings from the KFF monthly poll, which has been tracking support for the Affordable Care Act since it first became law in 2010.

All of that makes it tempting to dismiss the threat of repeal ― and significance of the issue more generally. But that would be a mistake.

One reason is that a win in 2024 is bound to leave Trump feeling more emboldened than ever, especially when it comes to acting on his grievances and grudges. And while it’s impossible to know what’s really going on inside his head, it doesn’t stretch the imagination to think he remains determined to undo the legacy of former President Barack Obama ― and to show he can succeed at what he couldn’t accomplish before.

And there are signs that Trump has learned at least a few things from last time. The word “repeal” was conspicuously missing from his initial post, as well as a follow-up he posted a few days later. I don’t think that’s accidental. The word has become politically toxic. Instead, he’s talking only about the better alternative he says he has in store.

Not that he actually has one. And the same goes for other Republicans, like Ron DeSantis, the Florida governor and 2024 presidential hopeful, who after Trump’s posts announced on NBC’s “Meet the Press” on Dec. 4 that he too would “replace and supercede” Obamacare ― and that he would be unveiling this great mystery plan “probably” in the spring.

The reason neither Trump nor DeSantis nor any other Republican has a conservative plan to replace Obamacare is that no such plan exists. The actual Republican agenda on health care consists of reducing government spending, scaling back regulation and cutting taxes on high-earning Americans ― which are perfectly fine goals if you’re conservative and believe this would make America a better place, but almost inevitably mean taking away government programs and rules that today make insurance available to millions.

Remember, independent studies of every plan Republicans proposed back in 2017 yielded predictions of massive insurance losses, as well as fewer coverage guarantees (and higher medical bills) for people with serious health problems. Those predictions fueled public skepticism of repeal and, most likely, would do so again – maybe enough to stop a renewed push for repeal.

But “maybe” is hardly “definitely.” At the very least, Republicans might focus on particular pieces of legislation — like cuts to Medicaid or a scaling back of rules on insurance — that wouldn’t generate the same devastating headlines, but would still have pretty devastating effects on some of the people who depend on government for their access to health care.

Another reason to take repeal seriously is that it’s an indicator of how Trump and Republicans would approach domestic policy more generally if they had control of the government — and how different that is from the way Biden and the Democrats would govern if they get the opportunity after 2024.

Those three essential ingredients of Obamacare repeal — cutting taxes, reducing government spending, rolling back regulations — are the essential ingredients of what Republicans want to do on a variety of other issues.

You see it in their approach to climate, where they want to end subsidies for clean energy and reverse new regulations on polluters. You see it in their ongoing crusades to cut spending on programs that provide food for low-income Americans, and in their resistance to spend more on programs that prop up child care.

And of course you see it in their approach to other issues on health care, including prescription drugs.

In every other economically advanced country, the government sets pharmaceutical prices through some kind of negotiation with manufacturers. Republicans have long opposed bringing that approach to the U.S. — an argument that prevailed until 2022, when Biden and the Democrats enacted the Inflation Reduction Act. One of the law’s provisions will allow the federal government to negotiate some drug prices in Medicare. Some Republicans in Congress have already proposed legislation to repeal it.

The new drug pricing reforms are relatively modest, with all sorts of limits on their reach, which means millions of Americans will continue to struggle with prescription costs. In much the same way, millions still don’t have insurance — and millions more still have inadequate insurance — even with the Affordable Care Act in place.

But just as the Biden administration has worked to bolster the Affordable Care Act, it is already pursuing new ways to bring down drug prices. The latest move came on Thursday, when the administration announced it was laying the groundwork to intervene when a drug developed with government funding is unaffordable.

It would do so by invoking “march-in” authority under a 1980 law that allows the government to license production of a drug to new companies if the original manufacturer, which holds the patent, hasn’t made it available on a “reasonable basis.”

The Biden administration, like its predecessors, has previously resisted calls from progressive activists and experts to invoke march-in rights for specific drugs. But now it is writing regulations that would allow it to take precisely that sort of action in the future.

Like any policy initiative, the potential use of march-in rights has its detractors — including the drug industry itself, which says that threatening patents and the high profits that come with them would make it harder to fund the research and development of breakthrough treatments. It’s an argument that makes a lot of sense to some experts and appeals especially to conservatives, which helps explain why Trump as president tried to block such use of march-in rights.

But whatever the effects or merits of using march-in rights, the contrast between the approach of Biden and Trump is yet another example of how differently they would approach policy in the next presidential term — and why 2024 voters should keep that contrast in mind.