Americans Really Don’t Like Trump’s Health-Care Plans

Expanding access to health care has been a shared policy priority for Joe Biden and the former Democratic presidents who joined him onstage at a lucrative New York City fundraiser last night, Bill Clinton and Barack Obama. But the politics of health care look very different for Biden than they did for his two predecessors.

Clinton and Obama faced widespread public resistance to their health-care plans that forced them to play defense on the issue. Biden and his campaign team, by contrast, see health care as one of his best opportunities to take the offensive against Donald Trump and the GOP.

Health care is one of the few major issues that more voters say they trust Biden than Trump to handle, according to national media polls. And Trump has ensured that voters will see a clear choice on the issue by renewing his pledge to repeal the Affordable Care Act passed under Obama, which now provides health insurance to more than 45 million people.

House Republicans dramatically sharpened that partisan contrast last week when the Republican Study Committee—a conservative group whose membership includes more than four-fifths of the House Republican Conference’s members and all of its leadership—issued a budget proposal that would not only repeal the ACA but also fundamentally restructure Medicare, Medicaid, and the federal tax incentive for employers to provide insurance for their workers.

The sweep of the House GOP health plans, like similar proposals in the Project 2025 policy blueprint put together by a consortium of conservative groups, “sets up a clear contrast with the direction Democrats have gone,” Larry Levitt, the executive vice president for health policy at KFF, a nonpartisan think tank, told me. “At the root of a lot of these Republican Study Committee proposals is reducing what the federal government spends on health care, and putting the risk back on individuals, employers, and states.”

Expanding access to health care has been a priority for Democratic presidents since Harry Truman. Clinton and Obama were especially focused on the issue. But politically, it proved more burden than boon for each man.

Clinton sought to remake the health-care system through the highly complex “Clintoncare” plan to expand coverage and control costs that emerged from a policy process led by then–first lady Hillary Clinton. But the plan collapsed without ever reaching a floor vote in the House or Senate. That failure helped power the GOP wave in 1994 that carried the party to control of both congressional chambers, including its first House majority in 40 years.

[Russell Berman: Republicans can’t find the votes for their health-care bill]

Obama succeeded where Truman and Clinton (and, for that matter, Republican Richard Nixon) had failed, by passing the ACA in 2010. But the deeply polarizing legislative fight over the law fueled the Tea Party backlash that led Republicans to another congressional landslide that year. Four years later, Democrats suffered yet more House and Senate losses, partly because of public discontent over the website snafus that snarled the launch of the ACA in 2013. Polls through those years consistently showed that more Americans expressed unfavorable than favorable views of the new law.

The turning point for the ACA came when Trump and congressional Republicans tried to repeal it in 2017. House Republicans passed legislation revoking the law in May that year, and Trump, who had endorsed the effort, immediately marked the occasion by summoning them to the White House Rose Garden for a victory celebration. Trump’s repeal drive failed, though, when three GOP senators voted against it—including the late Senator John McCain, who sealed the effort’s fate with a dramatic thumbs-down gesture on the Senate floor.

During the legislative struggle, public opinion on the ACA flipped. For the first time since Obama had signed the law, more Americans that spring consistently said they supported than opposed the law, in KFF’s regular tracking poll. Since then, the share of Americans who view the law favorably has always exceeded the share who oppose it; KFF’s latest survey last month produced one of the most positive ratings ever for the ACA, with 59 percent supporting it and only 39 percent opposing.

Democrats had been dinged for supporting the ACA in earlier campaigns; suddenly, defending it was a key contributor to the party’s big House gains in the 2018 election. Particularly important was the Democrats’ shift from emphasizing the ACA’s expanded coverage for the uninsured to stressing its provisions barring insurance companies from denying coverage or raising premiums for the millions of Americans with preexisting health problems. In 2020, the coronavirus pandemic provided a resonant background for Biden’s promises to expand access to health care and launch new federal initiatives to control costs.

In office, Biden has advanced his agenda as effectively on health care as on any other issue. Between the massive COVID rescue plan, passed in 2021, and the Inflation Reduction Act, approved in 2022, he won big increases in subsidies to help people buy private insurance under the ACA and a suite of policies controlling drug prices for the elderly. Those include obtaining, for the first time, authority for Medicare to negotiate with drug companies for lower prescription-drug prices, a $35 monthly cap on insulin expenses for Medicare recipients, and a $2,000 cap on total annual drug spending for seniors.

This year, Biden has proposed to make permanent the enhanced ACA subsidies (which expire at the end of 2025) and to fund coverage for millions of people in the 10 Republican-controlled states that have still refused to expand access to Medicaid under the ACA; those two proposals combined would cost nearly $500 billion over the next decade. Biden has also called for empowering Medicare to negotiate lower prices on 50 drugs a year (up from the current 10) and to extend the $2,000 cap on drug spending to all Americans, not just seniors.

In KFF’s research, the federal government and, to a much lesser extent, state and local governments, now fund nearly half of all U.S. health-care spending. Levitt noted that Biden’s plan envisions a world in which governments, sooner rather than later, pay the majority of the bills—and inevitably have more say in how the system operates.

This intensified federal effort has driven down the share of Americans without health insurance to less than 8 percent, according to federal surveys. That’s the lowest number ever recorded, and about half the level before the passage of the ACA. A record 21 million people signed up to buy private insurance coverage through the ACA this year, and about 25 million more are covered through its provision expanding access to Medicaid for low-income working adults.

The Republican plans not only target every key component of Biden’s agenda; they also go well beyond them to challenge programs that have anchored the federal role in health care for decades.

Among other things, the House Republican Study Committee blueprint would: repeal the federal protections the ACA established for people with preexisting conditions and instead allow states to decide whether to retain such reforms, transform Medicare into a “premium support” or voucher system that instead of paying seniors’ health-care bills directly would give them a stipend to purchase private insurance, end the federal entitlement to Medicaid and instead bundle the program into a block grant for states along with a separate federal program that covers children, and rescind the authority Biden won for Medicare to negotiate lower drug prices. (The Project 2025 plan embraces many of these same ideas.)

The study committee, in a view echoed by conservative health-policy analysts, argues that this comprehensive rollback is necessary because the dominant federal role in health care has inflated costs and suppressed innovation and competition. “Pervasive government control is the main reason why health-care spending is out of control,” Michael Cannon, the director of health-policy studies at the libertarian Cato Institute, told me.

[David A. Graham: The real difference between Trump and Biden]

But liberal—and many centrist—health-care analysts see the proposal as a trigger for chaos in the medical system. It’s “a recipe for taking the health-care system, throwing it up in the air, and letting it drop to the ground and seeing who survives,” Linda Blumberg, a fellow at the center-left Urban Institute’s Health Policy Center, told me. “All of these things are problematic on their own, but there is no way to do all this at the same time and not cause rampant disaster.” Blumberg, like other experts I spoke with, said the GOP plan would likely at least double the share of Americans without health insurance, raising the percentage of uninsured to a level even higher than it stood before the passage of the ACA.

Len Nichols, a longtime health economist and an emeritus professor at George Mason University, says the GOP plan is based on the fundamentally flawed assumption that withdrawing government from health-care markets now dominated by large hospital systems and insurance companies will lower prices and increase quality. They think that “if you take big government out of it, then individual buyers are going to be more effective at negotiating prices,” Nichols told me. “It is naive and unrealistic.”

The twist, as I’ve written before, is that the biggest losers in these GOP proposals would include the lower-income, older white adults who have become the cornerstone of Republicans’ electoral coalition. Severely retrenching Medicaid would doom many hospitals in red rural communities. The GOP plans to reverse the ACA’s insurance reforms, meanwhile, would likely cut premiums for younger and healthier people at the cost of raising prices and eroding access for those with greater health needs—who tend to be the older lower-income voters Republicans rely on. “It is a war on their base,” Nichols said.

The cumulative impact of the GOP plan is breathtaking: It calls for cutting federal spending on health care by $4.5 trillion over the next decade. That’s four times as much as the GOP envisioned cutting in its 2017 bill to repeal the ACA. Part of that difference can be explained by medical inflation in the interim, noted Levitt of the KFF, but even so, “the scale of the cuts proposed … dwarfs the reductions Republicans considered in the 2017 ACA repeal-and-replace debate.”

The cuts would mean not only “a lot more people without health insurance” but also massive turmoil for health-care providers, Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, told me. “It would have a huge impact on hospital revenue and provider revenue,” she said.

Brian Blase, the president of the Paragon Health Institute and a former White House adviser on health-care policy for Trump, agrees that the government can’t cut its contribution to health-care spending that much that fast without destabilizing the system. The budget from House conservatives, he argues, should be seen as a marker of the general direction the GOP would pursue on health care, not a precise guide to the legislation Republicans would try to pass if Trump is reelected and they achieve unified control of Congress.

At the same time, Blase argues that Biden’s plans are also unsustainable because they would commit the federal government to spending more than it can afford long-term on health care. “The reality of their policies is that the federal government is sending much more money to health-insurance companies to prop up the ACA,” Blase told me. Biden’s approach, Blase believes, could inadvertently encourage some employers to stop providing insurance and instead push their workers to obtain coverage through the larger subsidies available under the ACA—a dynamic that could substantially increase federal costs over time.

An open question is how much stomach Trump would actually have for any of these fights if reelected. He’s never shown much interest in or understanding of the complex trade-offs in health-care policy, and his pronouncements about them tend to be even more vague and contradictory than those on most subjects. Just this week, in a social-media post, Trump seemed to fudge his repeated pledge to repeal the ACA. But Trump and his advisers have made clear over the years their support for unraveling the ACA, ending the federal entitlement to Medicaid, and retrenching Medicare’s drug-negotiating authority. Blase, like many Republicans, predicts that Trump’s policy focus in a second term would center more on extending his tax cuts and toughening immigration law. But that disinterest could leave more room for other forces in the party to drive this agenda.

Whatever Trump’s level of engagement, the gulf is only widening between the two parties’ visions on health care. A Biden victory would allow him to defend, and perhaps further advance, his policies to reduce the number of uninsured and to more aggressively leverage federal buying power to lower health-care costs. If Trump wins, he will roll back federal health-care spending and regulation, and cede more power to providers and insurance companies—by legislation if he can, and by regulatory action if Democrats win enough seats to block him in Congress. The resistance to such ideas already evident in polls is giving Biden a chance to benefit from the issue in a way that Clinton and Obama never did.