With six weeks left before the health insurance premiums of nearly 22 million Americans skyrocket, Republicans in Washington are floating alternatives to the Affordable Care Act that would fundamentally reshape how Americans buy coverage — and which, health experts warn, could “collapse” the entire marketplace.
The political stakes are enormous: In 2017, the last time Republicans tried to gut the ACA, they paid for it with a wave election that cost them the House and effectively derailed much of President Donald Trump’s first-term legislative agenda.
Now, less than a year before 2026 midterms, they’re wading back into the same treacherous waters — and some GOP strategists are experiencing a dizzying sense of deja vu.
“Republicans are very good on issues like taxes and national security. We don’t do healthcare very well,” said Brendan Buck, a former top adviser to Speakers John Boehner and Paul Ryan, the latter of whom he helped in 2017 to shepherd the GOP’s doomed attempt to repeal and replace the ACA. “We fell flat on our face in 2017.”
In the midterms that followed, 15 House Republicans who voted for a partial repeal of the ACA law lost reelection, while an additional 19 members opted to forgo their reelection and retired.
The immediate issue is the expiration of certain Covid-era ACA tax credits at the end of December. Some 74 percent of Americans support extending the ACA tax credit, including 50 percent of Republicans, according to recent polling from KFF, the nonpartisan health care research group. But that looming deadline has spurred a broader conversation among Republicans eager to make progress on Trump’s longtime goal of rescinding President Barack Obama’s signature policy achievement.
“It would be a back-door way of returning to the old system where healthy people may have had cheaper insurance, but sick people had no options.”
Larry Levitt
This time, Republicans are not necessarily using the words “repeal and replace.” But the plans floated by Trump and other top Republicans would effectively do just that, said Larry Levitt, KFF’s executive vice president for health policy.
“It would be a back-door way of returning to the old system where healthy people may have had cheaper insurance, but sick people had no options,” said Levitt. “Healthy people would buy cheaper insurance that doesn’t cover pre-existing conditions or simply go without insurance altogether and use their health account dollars to pay for health care directly. ACA plans would be left with a sicker pool of people, leading to a premium death spiral and ultimate collapse.”
Mindful of all of this — and the potential for political blowback from rising health care costs — some Capitol Hill Republicans have floated extending the credits for a year to allow a more fulsome policy conversation to take place.
Standing in their way is the president of the United States.
“The only healthcare I will support or approve is sending the money directly back to the people,” Trump wrote Tuesday in an all-caps post on Truth Social. “Congress, do not waste your time and energy on anything else.”
But even if it’s clear what Trump does not want, specifics about what policy he actively supports — and which can pass both chambers of Congress — remain elusive.
In April 2019, Trump posted online that Republicans “are developing a really great Healthcare Plan” that would “be far less expensive & much more usable than ObamaCare.” No comprehensive plan ever came to fruition.
In 2020, his first administration asked the Supreme Court to strike down the law and its exchanges, but the high court rejected the lawsuit the following year.
On the 2024 campaign trail, Trump said he had “concepts of a plan” to replace the ACA. A year later, Republicans have yet to issue one.
After a resounding defeat in this month’s elections, Trump has attempted to win back the high ground on “affordability” as Americans continue to voice concerns about the cost of living. Trump first suggested in a Truth Social post that the government, instead of subsidizing the ACA exchange, should send the money “DIRECTLY TO THE PEOPLE SO THAT THEY CAN PURCHASE THEIR OWN” health care plans. On Sunday night, upon returning to Washington from his Florida estate, Trump again offered few details, saying Americans could put money “in a health account.” “We can do it a lot of different ways, but they buy their own health insurance,” Trump said of ideas he’s discussing with Republicans on the Hill. “They can negotiate price, and it’s going to be locked — so they can’t go out and buy a Cadillac.” For his part, Buck, a veteran of Capitol Hill, told MS NOW he is “very skeptical that there’s some actual type of meaningful replacement for the ACA in the shelves.” Though Senate Majority Leader John Thune, R-S.D., promised Democrats a vote on extending the expiring ACA subsidies in exchange for support to reopen the government, his counterpart in the House, Speaker Mike Johnson, R-La., has so far refused to guarantee a vote. Pressed recently on whether the Trump administration had a plan to replace the ACA, Mehmet Oz, the administrator of the Centers for Medicare and Medicaid Services, denied that the White House was currently pursuing that goal. “I actually did not say I was going to ‘replace’ Obamacare,” Oz said on CNN. “There are many ideas out there. Some of them could replace Obamacare. Many of them will not. There’s tactics that we’re discussing right now.” Democrats have been quick to respond. Connecticut Sen. Chris Murphy responded to Trump’s unspecific proposal, calling it “unsurprisingly, nonsensical” and warning it could “bankrupt” people diagnosed with terminal illnesses. Rep. Don Bacon, R-Neb., argued the ACA is “unaffordable” and “requires more and more subsidies.” “My advice is find an interim plan to cut premiums, but we need to seek a deeper long term fix,” said Bacon, who voted in 2017 for repealing the Affordable Care Act and was one of few Republicans to hold onto his seat in 2018. But asked if Republicans were potentially heading toward a repeat of 2018 losses over health care, Bacon told MS NOW, “it’s very possible.”
Vaughn Hillyard
Laura Barrón-López
Laura Barrón-López covers the White House for MSNBC. Previously, she covered the White House and national politics for PBS NewsHour and Politico. Recommended
