Trump and the Affordable Care Act: From Repeal Efforts to Subsidy Expiration
Since its enactment in 2010, the Affordable Care Act (ACA), popularly known as Obamacare, has become a centerpiece of U.S. health policy. The ACA expanded health insurance eligibility through Medicaid and created subsidized insurance marketplaces and premium tax credits. For nearly a decade, President Trump has sought to repeal or significantly alter the ACA. At the end of 2025, ACA subsidies that were extended during the pandemic expired, affecting the healthcare premiums of millions of Americans and causing many to drop their coverage.
During his first presidential campaign in 2016, Trump repeatedly promised to repeal the ACA and replace it with an alternative. When he began his first term, he signed two executive orders regarding the ACA. The first directed relevant agencies to reduce the ACA’s regulatory burdens and to prepare for its repeal. The second encouraged the sale of less comprehensive insurance plans and the expansion of health savings accounts, which would weaken parts of the ACA.
After signing the executive orders, Trump hoped Congressional Republicans could repeal and replace the ACA. In early March of 2017, Trump backed a House Republican health care plan, which eliminated the ACA’s “individual mandate” that required Americans obtain health insurance or pay a penalty. It also included a reduction in individual tax credits for health insurance and cuts in federal Medicaid funding. This plan also included nearly $1 trillion in tax cuts over 10 years, including $274 billion in cuts for individuals earning over $200,000 a year. The Congressional Budget Office initially estimated that the plan would reduce the federal deficit by $337 billion over 10 years, but would also increase the number of uninsured people by 24 million in the same period.
The bill immediately faced objections from both moderate and conservative Republicans. The former worried that too many people would lose affordable coverage, while the latter complained that the plan left too many burdensome ACA provisions in place. The anxieties of moderates, for example, the Tuesday group, were amplified by the outrage they faced at town hall meetings across the country from constituents who feared losing their health insurance. Unable to bridge the differences between the two factions, House leadership withdrew the bill in late March without a vote.
After the House effort failed, Senate Republicans, backed by Trump, secretly drafted their own ACA replacement without Democratic input. They initially called their plan the Better Care Reconciliation Act (BCRA). According to analyses released by the Congressional Budget Office in late June, the BCRA would have decreased the budgetary deficit but would have significantly increased the number of uninsured people and insurance premiums in the first year after its passage.
The BCRA faced the same problems as the House bill, dividing Senate Republicans between those who wanted to limit health insurance reductions in their states and those who wanted to repeal as much of the ACA as possible. Eventually, in a single week in late July, the Senate voted on three bills: the first was a repeal of major ACA provisions without immediate replacement, the second was a complete repeal and replacement of the ACA and the final bill was a smaller “skinny” repeal and replacement. Despite considerable political pressure from the Trump administration on Senate Republicans, all three bills failed.
Some states, like Texas, responded to the legislative failure by suing to overturn the entire ACA in 2018. They argued that the ACA’s individual mandate to maintain health insurance or face penalties stemmed from Congress’s taxing power. However, the penalty for failing to maintain insurance coverage was reduced to zero under a 2017 tax law. The states claimed that, without the penalty, the requirement to maintain coverage was unconstitutional, rendering the rest of the ACA also unlawful. While Trump backed the argument, the Supreme Court rejected the challenge on standing grounds in California v. Texas.
Trump also shifted his focus from outright repealing the ACA to minimizing its effects. His Department of Health and Human Services slashed funding for ACA outreach and navigators that help people sign up through online marketplaces. These marketplaces help consumers and small businesses shop for and purchase private health insurance and connect them to public health insurance programs (e.g., Medicaid). These cuts likely contributed to lower enrollment.
After Trump left office in 2021, he became considerably less vociferous about the ACA. During his 2024 reelection bid, Trump claimed he had never opposed the ACA, as it had persisted for so long.
But when Trump returned to office for his second term, his efforts to minimize the ACA continued, as his administration failed to renew ACA subsidies set to expire at the end of 2025. The expiration led to rising insurance premiums, with more than 20 million subsidized enrollees in Affordable Care Act programs seeing average premiums rise by 114% in 2026. With no indication that the subsidies would be renewed, millions of Americans have begun dropping ACA coverage due to higher costs.
Trump has recently outlined a new healthcare proposal that would “fund a cost-sharing reduction program,” which the administration says would “reduce the most common ACA plan premiums by over 10%. Whether anything comes of this and any future plans that Trump might envision for the ACA is up to Congress.
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