The modest protections of the Affordable Care Act never went far enough, but even those could be weakened under Trump.
November 29, 2024
Robert F. Kennedy, Jr. hosts a fireside chat with rapper and producer Eric B. at The Gentleman's Factory on February 18, 2024, in New York City.John Nacion / Getty Images
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The United States healthcare system is so broken, sometimes I forget that it used to be even worse. After all, 15 short years ago, pregnant people could legally be denied health insurance, just for being pregnant. Cancer, diabetes, epilepsy, Alzheimer’s, arthritis, mental illness, AIDS — all potentially disqualifying conditions, too. Or, if your health care plan did offer coverage, it might charge you an exorbitant premium based on your preexisting conditions alone. In 2009, health care was a rogue landscape of private insurers prioritizing profit above all else while making arbitrary calls over life-or-death issues for their customers.
Okay, so maybe that last point hasn’t changed too much. But when Barack Obama signed the Affordable Care Act (ACA) into law in March 2010, it undeniably expanded crucial access to health care for millions of people. In 2024, less than 9 percent of people in the U.S. are uninsured, compared to nearly 17 percent in 2009. In addition to banning private insurers from discriminating based on preexisting conditions, the ACA expanded eligibility for Medicaid coverage, introduced new health insurance subsidies and extended dependent child coverage up to age 26. (I happen to be a 1998 baby, so the impact of that last reform was felt particularly acutely by my social circle this year.)
These are worthwhile wins, but from the moment the ACA was enacted, it has suffered a crisis of dual identity. When news headlines began calling the legislation “Obamacare,” Republican detractors saw their moment to seize the term; they’ve brandished it ever since to make the ACA out as an example of Democratic overreach and liberal government run amok. Obama will forever be the face of the health care legislation he championed, in all its wins and failures, even years after his second term ended.
This is a problem. And the re-election of Donald Trump as president proves why.
This past week, a spate of viral TikTok videos have mocked posts by people who claim to have voted for Trump, without knowing that his pledge to repeal Obamacare actually means ending the Affordable Care Act. Users cite the video of one Trump voter, who supposedly said he hadn’t realized the ACA’s protections for preexisting conditions are what allowed his mother with stage 4 cancer to obtain insurance coverage.
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References to these posts have circulated extensively across social media, but I haven’t been able to track down the original posts themselves. Still, it wouldn’t be outside the realm of possibility, and it taps into a very real phenomenon. In a 2017 poll, more than a third of Americans said they didn’t know that Obamacare and the Affordable Care Act were the same thing. In a different survey released this year, more than 60 percent of respondents said they didn’t realize the ACA prohibited insurance companies from denying coverage to people with preexisting conditions. Another two-thirds of people in that study didn’t know that the ACA prevents sick people from paying higher premiums than healthy people.
It wasn’t always like this: In June 2010, 70 percent of respondents knew that the ACA prohibited insurance companies from discriminating based on medical history. But historical memory is all too short, and that number dropped to just 48 percent in 2019. Also in 2019, less than half of survey respondents knew that the ACA requires insurers to cover routine preventative services like mammograms, pap smears and cholesterol screenings at no cost to the consumer; less than 40 percent of people knew the ACA eliminated out-of-pocket costs for birth control.
It should, of course, be noted that these achievements are a far cry from the free universal health care system offered in other wealthy countries, including Canada, Australia, Germany and Norway, just to name a few. When Sen. Bernie Sanders (I-Vermont) ran for president in 2016 and 2020, he brought universal health care to the fore of the national conversation, making it a plank of the Democratic Party’s campaign pledge. But this year, the party dropped any mention of it from its platform, opting instead to focus on “lowering costs” without mention of advocating for a public option. Health care was an afterthought on the campaign trail, despite the fact that nearly half of adult Americans report having medical debt. It is yet another massive failure that many voters likely cast their ballots this election cycle without knowing what the Affordable Care Act really offered them.
While Republicans have, for more than a decade, made crusading against the ACA a focal point of their agenda, Trump actually backpedaled on his own pledge to repeal it this election cycle. In the September debate against Vice President Kamala Harris, Trump now infamously said he had a “concept of a plan” for what he’d do with it. Perhaps in light of the fact that public opinion on the legislation is generally positive — and improving — Trump has even falsely claimed he never pledged to replace Obamacare in the first place.
Regardless of what Trump has said on the campaign trail, health policy experts expect that his administration could attempt to weaken the Affordable Care Act in his second term. This includes rolling back Medicaid expansion, part of the Project 2025 playbook, and something we saw during Trump’s first term when he allowed red states to implement restrictions on Medicaid coverage. Under Trump’s first presidency, in the years before the COVID-19 pandemic, the total number of U.S. residents without health insurance grew by more than 2 million.
“The Republican plans — they don’t say they are going to repeal the ACA, but their collection of policies could amount to the same thing or worse,” Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, told KFF Health News.
Trump has now announced that Robert F. Kennedy Jr. and Dr. Mehmet Oz will helm the two federal agencies that handle the implementation of the Affordable Care Act — the Department of Health and Human Services (HHS) and the Center for Medicare and Medicaid Services (CMS), respectively. RFK Jr. is a noted vaccine skeptic and conspiracy theorist who has promised to remove enamel-strengthening fluoride from the water supply; Dr. Oz is a television doctor who has pushed aggressively for the privatization of Medicare through Medicare Advantage plans. These private-sector alternatives to Medicare have been known to deny health claims and require patients to obtain “prior authorization” for even basic procedures. The practice has created such a burden for elderly patients that the Biden administration proposed a slew of new Medicare Advantage reforms this week, including guardrails to curtail insurers’ use of the prior authorization process. But with Dr. Oz in charge of CMS, the new rules could be cut back just as quickly as they arrived.
Given their lack of government experience, it’s still unclear what Oz and Kennedy plan to do if confirmed — or what Trump’s “concept of a plan” to replace the ACA might look like in practice — but their Cabinet nominations hardly inspire confidence.
Still, it’s hard to believe that the Affordable Care Act was a mere glimmer on the horizon not long ago. And since it was enacted, the number of Americans who support free universal health care has only grown. The ACA was a starting point. But this is the long game we’re playing. Public opinion now favors a single-payer, national health plan and expanded access to Medicare. The challenge in coming months and years will be to fight to maintain the ACA’s basic protections, while informing, organizing and advocating for the truly universal health care we all deserve.
This article is licensed under Creative Commons (CC BY-NC-ND 4.0), and you are free to share and republish under the terms of the license.
Schuyler Mitchell is a writer, editor and fact-checker from North Carolina, currently based in Brooklyn. Her work has appeared in The Intercept, The Baffler, Labor Notes, Los Angeles Magazine, and elsewhere. Find her on X: @schuy_ler
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