What Trump’s 2024 Victory Means for the Affordable Care Act

Copy link to quick take

During his winning 2024 campaign, President-elect Trump made conflicting statements about the future of Obamacare, though his record during his first term suggests that big changes could be in store, especially if Republicans maintain control of the House. His first year back in office could include a number of changes to the ACA:

1. Biden-Era Enhanced ACA Subsidies Likely to Expire in late 2025 

The enhanced ACA subsidies passed under the Biden administration—which cut premium payments nearly in half for millions and doubled enrollment, particularly in Southern red states —are set to expire at the end of 2025.

Without Congress acting to extend them, these enhanced subsidies will disappear, causing net premium payments to increase by an average of 79% and more than doubling in some states. The CBO has estimated the cost to permanently extend the enhanced subsidies would be $335 billion over 10 years, and that ACA Marketplace enrollment will drop sharply from 22.8 million in 2025 to 18.9 million in 2026 if subsidies are not renewed, reaching as low as 15.4 million in 2030. A renewal of these enhanced subsidies might be considered during the lame-duck session, but an extension is much less likely than if Kamala Harris and Democrats had swept the election.

2. Broader Fate of the ACA Hinges on House Control 

If Republicans maintain control of the House, changes to the ACA could be “massive,” according to House Speaker Mike Johnson. While ACA repeal was not a winning issue in 2017, Republicans could attempt to offset tax cuts by significantly reducing ACA subsidies and making massive funding cuts and changes to how Medicaid is financed, with far reaching implications, beyond the ACA Medicaid expansion. This would be similar to the 2017 “repeal and replace” push that would have left most protections for people with preexisting conditions in place but nonetheless would have left tens of millions without affordable health coverage due to budget cuts. As was the case in 2017, changes to ACA and Medicaid funding could be done through budget reconciliation, without concern of the filibuster.

3. Regulatory Changes and Legal Challenges to the ACA

Even if Democrats managed to secure the House, Trump could take several executive actions. For example, his administration could grant state waivers to allow red states more flexibility, such as by changing Marketplace rules or tightening Medicaid eligibility through work requirements or other restrictions. Trump’s administration could use executive authority to adjust ACA regulations, for example by loosening requirements for non-ACA-compliant plans that discriminate against people with pre-existing conditions, as he did in his first term. Trump may again defund ACA marketing and outreach, which had a downward effect on signups. In response to concerns about fraud, the Trump administration could add verification requirements that make it harder for people to sign up for ACA plans. And his administration can decide whether to join legal challenges to the ACA or decline to defend the law in court.