The Affordable Care Act: A Strong Card for Harris and the Democrats as Trump Says He Can Improve Upon It

Third of five parts

It has been just over 14 years since former President Barack Obama signed the ACA into law, and it has been on a political and legal roller-coaster ride ever since. At least 25 members of Congress who voted for the ACA lost their reelection bids, changing the House of Representatives to a Republican majority. When the new Marketplace enrollment platform crashed in 2013, only 33% of Americans viewed the ACA favorably, and four years later in 2017, the efforts of the Trump administration to repeal and replace the law were nearly successful.

But according to KFF’s tracking polls, the percentage of Americans who view the ACA favorably has been climbing steadily since 2014, and as of April 2024, 62% felt that way.

Zachary Baron, J.D.

“Like any major law, it took years for protections to be in place,” says Zachary Baron, J.D., director of the Health Policy and the Law Initiative at Georgetown University’s O’Neill Institute. “People realized what it meant to eliminate those benefits.” KFF polling does reveal a sharp partisan difference in opinion about the ACA. In April 2024, 87% of Democrats viewed the law favorably, and 66% of Republicans viewed it unfavorably.

Biden iwas closely identified with the ACA, and in 2020 he ran on strengthening it when other candidates, including Harris, were pushing Medicare for All plans. As the Democratic presidential nominee, Harris has moved to Biden’s position and also referenced the law’s provisions on preexisting conditions as she riffs on “not going back” in her stump speeches. She has run ads accusing Trump of wanting to end the ACA.

On his social media platform, Trump has said he isn’t running to terminate the ACA and would make it “much better, stronger and far less expensive.” The platform crafted by Trump and adopted by the Republican National Convention does not mention the ACA. But as president,

As president, Trump pushed for “repealing and replacing” the ACA, and his administration took steps that were widely viewed as undercutting the laws, such as reducing outreach during open enrollment periods,shortening enrollment periods and allowing cut-rate insurance coverage that didn’t meet ACA benefit standards. The Biden administration reversed much of what Trump did.

The country now faces another political showdown with different visions for the government’s role in healthcare, regulation and entitlement programs overall, even if Trump’s political appetite for full-on ACA-bashing has waned. “It’s fair to say that whoever is president, and the composition of Congress, will have a major impact in terms of the continued growth in enrollment, vitality and vibrancy of the ACA,” said Baron.

Enrollment in ACA Marketplace plans hit a record high this year, with 21.4 million Americans selecting a plan during the open enrollment period. Subsidies that are part of the Inflation Reduction Act of 2022 (IRA) reduced premiums to less than $10 a month for 80% of the enrollees, according to a CMS news release. Before the ACA went in effect in 2010, 16% of the public was uninsured. That was down to 7.7% as of late 2023. The expansion of Medicaid under the ACA has also been a key factor in reducing the proportion of uninsured people in the U.S.

Larry Levitt

Trump’s retreat from repealing and replacing the ACA makes sense, says Larry Levitt, KFF’s executive vice president for health policy. The 2017 attempt “backfired in a spectacular fashion,” he said, and “it doesn’t seem that Republicans want to replay that movie.” A majority of Republican voters (about 75%) still support repeal, but legislators are more wary. “Republicans are hesitant to try [to] repeal the law after getting burned in 2017,” said Levitt.

The Republicans aren’t steering clear of healthcare entirely. The Republican Study Committee’s fiscal year 2025 budget proposal includes cuts to premium subsidies and Medicaid, along with reinstituting work requirements for Medicaid enrollees.

In the absence of a total ACA change, here are elements to watch.

Enhanced premium subsidies:Republicans may focus on a total or partial repeal of enhanced premium subsidies, passed during the IRA. They expire at the end of 2025. “It’s not a big issue on the campaign trail yet, but the outcome of the election could be quite consequential for the future of the enhanced premium subsidies,” Levitt said. If Congress is divided or Republicans are in charge, “I think it’s much more uncertain if subsidies get renewed.” As a result, millions of people nationwide, including in red states, would see premium hikes, Levitt said. Although the subsidies are costly, “there will be a lot of political pressure on both parties to keep subsidies going,” he said. KFF polls show that about 70% of Americans across both parties favor these enhanced subsidies. Biden had said he wants to make the subsidies permanent, and Harris is likely to do the same.

Medicaid coverage gap:If Harris is elected, her administration may try to close the Medicaid coverage gap in the 10 states that haven’t expanded Medicaid. In those states, about 1.5 million adults have incomes that are too high for them to be eligible for their state’s Medicaid programs but too low for them to be eligible for ACA Marketplace subsidies (the law set a threshold for subsidy eligibility that was predicated on expanded Medicaid programs that now occur on a state-by-state basis because of a Supreme Court decision).

Plan offerings: Requiring insurance companies to cover preexisting conditions has been popular across the board, and Republicans don’t have a good alternative solution, Baron said. But a Trump administration may allow limited duration plans, allowing companies to offer a wider array of health plans that don’t cover preexisting conditions, he said. Trump expanded those plans, while Biden narrowed them. “How would a second Trump administration manage the ACA Marketplace and try to promote certain offerings, and what that would mean for consumer protections?” Baron said.

Marketplace enrollment is at an all-time high. Out-of-pocket premiums are also at their lowest levels, said Levitt. “So much of ACA’s success hinges on the enhanced subsidies. Previously coverage was not affordable and enhanced subsidies directly address that,” he said.

The highest enrollment increases between 2020 and 2024 were in historically red states such as Texas (195%), and Alabama (125%).