The former president’s failure to deliver on health policy is partly why the Republican refrain of ‘repeal and replace’ has become a punch line.
Instead of embracing entitlements, Trump’s would-be challengers should press him on his failure to repeal the Affordable Care Act.
D onald Trump may want to avoid talking about Obamacare during the 2024 presidential primaries, but his challengers would be unwise to grant that wish.
“The 2024 Republican primary is likely to be the first in which the Affordable Care Act is treated as settled law over a decade into its embattled existence,” Semafor’s Joseph Zeballos-Roig wrote last week. As evidence, he quoted Senator J. D. Vance (R., Ohio), who has already endorsed Trump. “I haven’t seen any evidence that people are looking to relitigate at this point a twelve-year-old law,” Vance said.
Vance is a feeble surrogate for this message; he fought against the GOP’s Obamacare-repeal efforts in 2017 because he supports Obamacare’s expansion of Medicaid to nondisabled, working-age adults with no children.
While it’s true that even conservative and libertarian activists have given up on anything like an outright repeal of Obamacare, the Republican refrain of “repeal and replace” didn’t become a punch line overnight.
Pressed on his past support for single-payer socialized medicine, in a July 2015 CNN interview, Trump said that his plan for Obamacare was to “repeal and replace” it “with something terrific,” emphasizing his enthusiasm for letting Americans buy health insurance from a state other than their own.
Trump said dozens of times during the 2016 primaries that he would repeal Obamacare. When he took office, he was the first Republican in the White House since Obamacare had become law in 2010 — and he had a Republican House and Senate. Shepherding an Obamacare-repeal bill through Congress was a tall order, but Trump’s entire brand was built on his prowess at making bigger, better deals than anyone had ever seen.
“Nobody knows the system better than me,” Trump famously said at the 2016 Republican National Convention. “Which is why I alone can fix it.” “Obamacare is a disaster. . . . It’s gotta be repealed and replaced,” he told Sean Hannity during a March 2016 Fox News interview. “When we win on November 8 and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare. We have to do it,” Trump insisted a week before the 2016 election.
In 2017, President Trump signed an executive order expanding access to association health plans and other coverage options. He issued another important executive order in 2019 to require price transparency from hospitals and help Americans take advantage of health-savings accounts. “Obamacare, . . . it’s a disaster and people understand that it’s failed and it’s imploding. And if we let it go for another year, it’ll totally implode,” Trump said during a March 2017 cabinet meeting during repeal negotiations in the House of Representatives.
And yet he ultimately failed to deliver on his health-policy promises.
“I think every Republican in the House right now is already on record and voted to repeal Obamacare in its entirety, so I think we have to fulfill our promises to the voters,” Florida governor Ron DeSantis — then a congressman and a leader of the House Freedom Caucus — told Fox News in April 2017. The American Health Care Act (AHCA) passed the following month, with DeSantis and 216 other House Republicans voting in favor, despite some right-of-center policy analysts’ critiques of AHCA’s many flaws.
Instead of working with Speaker Paul Ryan to improve the bill, however, Trump attacked it from the left. While Senate Republicans drafted their own version, the Associated Press reported that Trump had told GOP senators that the AHCA was “mean” and had instructed them to be “more generous.” The rest is history; Obamacare is not.
Public support for Obamacare is greater than it was during Trump’s first presidential campaign, and its supporters have celebrated their success by badgering states to accept billions of dollars of new federal spending to expand Medicaid. But the latest polling on the issue from the left-wing Kaiser Family Foundation found that Republican opposition to Obamacare was 79 percent in March 2022 — a point higher than it had been six years earlier.
Florida and South Carolina are among the holdout states refusing to implement Obamacare’s Medicaid expansion. It would be fair for Governor DeSantis or former South Carolina governor Nikki Haley to ask Trump why, given a Republican trifecta, he didn’t even fix the Medicaid expansion’s 90 percent federal match. Under this provision of Obamacare, the federal government pays a greater share of expansion-benefit costs for states to put able-bodied, working-age, childless adults on Medicaid than the share it pays states for the elderly, blind, and disabled enrollees Medicaid was created for.
If Republicans have accepted Obamacare as settled law, someone forgot to tell Russ Vought, Trump’s former budget director who now heads the Center for Renewing America. Vought’s latest budget proposal would “eliminate the Obamacare expansion of coverage for able-bodied working age adults, allowing states to disentangle their Medicaid programs from Obamacare.” Vought estimates that this would save $1.1 trillion.
Vance’s dismissal of Obamacare as a topic for primary debate comes as he and Trump adopt the Democratic position on entitlement reform. Difficult as it would be to balance the federal budget without changes to Social Security and Medicare, suggesting that Obamacare, too, be off-limits would make a balanced budget impossible. Long before the Biden administration stopped states from dropping ineligible Medicaid enrollees during the Covid pandemic, many states’ Medicaid expansions had already doubled enrollment and cost projections (while the opioid crisis — which Obamacare supporters said the expansion of Medicaid would ease — worsened).
Failure may be an orphan, as the saying goes, but Donald Trump could pass a paternity test for the GOP’s missed opportunity to repeal Obamacare. Health policy doesn’t need to be the headline issue of the 2024 primaries for another candidate to exploit this weakness in Trump’s record.