How has Trump weakened the Affordable Care Act and how can it be strengthened?

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In the run-up to the presidential election, BrandeisNOW asked faculty to provide analysis and insight into some of the most pressing issues facing the country. This is part of the series.

The Affordable Care Act (ACA) provided coverage to over 25 million uninsured people and protects millions more with preexisting medical conditions from being denied coverage or charged higher premiums. 

While opponents of the ACA were unable to repeal the law wholesale in Congress, the Trump administration damaged the law through regulatory efforts, executive order and legislative action. 

The Trump Administration and Congress did five main things to weaken the ACA. 

• They effectively eliminated the individual mandate -- the penalty imposed for failing to purchase health insurance. 

• They eliminated federal government subsidies for co-payments, leading to major increases in premiums for many people in the marketplace.  

• The administration allowed “skinny plans,” plans that might have super high deductibles and do not cover all required benefits. 

Under the Obama administration, these “skinny plans” were meant to be short-term options of three months or less to help people transition between plans. Trump’s rules allow these cheap, less-than-full coverage plans for 364 days with the opportunity to renew for three years, effectively undercutting the market for the standard, more robust type of insurance.

• The administration cut funding for the healthcare.gov website and for marketing and advertising, both essential to build the program. 

• The administration encouraged states to submit waivers that add work requirements to Medicaid expansion and to be exempt from requirements that insurance cover all essential benefits.

A second Trump administration is unlikely to have the 60 votes necessary in the Senate for full repeal, but continuing these types of waivers and neglect could put the ACA on life support. 

A Biden administration could reverse much of what the Trump administration did through executive order, regulatory changes and appointing people in the Department of Health and Human Services who would care about the law.

However, Biden would need Congress to take additional steps to reinstate the individual mandate, add a public option to state marketplaces, or bolster subsidies to make health insurance truly affordable for middle-class families.

Two additional wildcards. 

Change will be easier under a Biden administration with a Democratic Senate, but it will be a challenge. Health care reform always is. 

And the Supreme Court could tip the ACA table over with a ruling that the whole law is unconstitutional.  

The final step of universal affordable comprehensive coverage for all residents of the country, however, will remain a work in progress. Elections matter.

Associate Professor Michael Doonan, PhD ’02, is director of the Master of Public Policy Program at the Heller School for Social Policy and Management. He is also executive director of the Massachusetts Health Policy Forum and director of the Council for Health Care Economics and Policy.