If you’re confused, it’s not an accident.
Republicans are trying to have it both ways on health care during the 2024 campaign. They boast that they want to deregulate insurance and massively cut government spending, yet they also claim that they would never do anything to endanger people’s coverage.
That two-step keeps getting them into trouble. House Speaker Mike Johnson was recently caught on a tape promising to take “a blow torch to the regulatory state.” Donald Trump, Johnson said, would want to “go big” in his second term because he can’t run for a third one, the speaker told a group of Republican voters in Pennsylvania. And health care, Johnson said, would be “a big part” of the GOP’s agenda.
One attendee directly asked Johnson: No Obamacare? “No Obamacare,” Johnson said.
“The ACA is so deeply ingrained, we need massive reform to make this work. We’ve got a lot of ideas,” the House speaker added. He wasn’t more specific than that.
Kamala Harris’s campaign quickly flagged Johnson’s comments, and Republicans backtracked. The Donald Trump campaign said that was “not President Trump’s policy position” and Trump tried to distance himself further in a social media post.
Johnson insisted he had not actually promised to repeal Obamacare by emphasizing his comment that the 2010 law was “ingrained” while ignoring his subsequent promise of “massive reform.”
Trump himself has alluded to having only “concepts of a plan” for American health care. That has left other Republicans to fill in the gaps and the party’s specific proposals remain poorly defined. But if there are a lot of details still to be filled in, the theme of the GOP’s health care agenda is clear: cuts. Cutting regulations. Cutting spending.
Johnson’s comments were not an isolated incident. Just last month, Trump’s vice presidential nominee, JD Vance, hinted at “a deregulatory agenda so that people can pick a health care plan that fits them.” If you actually parse his words about health insurance risk pools, it would be a return to a world where people could be charged more for coverage if they have preexisting medical conditions, the world before Obamacare.
It was the same promise Johnson was making. That is the reality: Should they win control of the White House and Congress this election, Republicans will attempt to cut people’s health care.
Republicans still want to make big health care cuts
When Obamacare repeal died in 2017, it might have been tempting to think that a chapter had come to a close. Instead, the fight over the future of US health care had entered a new era.
Make no mistake: Republican leaders still want to slash health care spending and unwind health insurance regulations.
And Trump, whatever he might say, has proven before to be malleable to conventional conservative health policy. His people continue to put health care in the crosshairs, sometimes in ways that may not be as obvious.
Elon Musk, who sometimes appears to be campaigning to be shadow president of the United States, has pledged to cut $2 trillion from the federal government’s $6.8 trillion budget. He has acknowledged that the cuts would result in “temporary” hardship, but insisted they would be to the long-term benefit of the country.
About $1 in every $5 in the federal budget goes to health care. Barring a severe cut to the US military (unlikely), such a plan would require massive cuts to the health care programs. Trump has often said he will protect Medicare, which covers seniors, but he has in the past endorsed enormous cuts to Medicaid, the program for low-income people that insures 73 million Americans, as part of the 2017 ACA repeal-and-replace bills.
The main Republican bill to repeal and replace the ACA that nearly passed in 2017 was in fact as much about making massive Medicaid cuts by capping the program’s funding as it was about loosening health insurance regulations or repealing the individual mandate.
Republicans could try to pass another Obamacare repeal bill with a comprehensive Medicaid overhaul. Or they could chip away at health care in incremental ways, as we saw during the first Trump term after the Obamacare repeal bill failed. Trump cut funding for enrollment outreach for the ACA markets while rolling back rules for noncomprehensive plans, which resulted in catastrophic results for some patients who didn’t know what they were signing up for.
Over Trump’s four years in office, the number of people covered by the ACA fell by more than 1 million, to 11.4 million. Since Joe Biden became president, and Democrats expanded the law’s insurance subsidies as part of the Inflation Reduction Act, the number of people covered by marketplace plans has nearly doubled to 21.4 million.
If Trump takes office again, a repeat of that previous sabotage seems likely even if a bigger repeal effort fails to materialize. Republicans could cut outreach funding again. They could make subtler tweaks to the health insurance rules, such as increasing the premiums that older people can be charged compared to younger people or giving insurers more leniency in restricting benefits, networks, and other aspects of a person’s health coverage. They could make more targeted cuts to Medicaid or permit states to set up Medicaid work requirements again, as they did in the first Trump term only to be obstructed by the courts.
Why Republicans can’t be honest about their health care plan
The failure of Obamacare repeal is the reason Republicans keep insisting that their health care agenda is not what it plainly is whenever they accidentally reveal their intentions too clearly.
It’s easy to forget now, but Obamacare was a winning issue for Republicans at first. They stormed to historic congressional wins in the 2010 midterms by rallying voters against the new health care law. They then took dozens of votes to repeal all or parts of it while Barack Obama still held the veto pen. For most of its first decade, the ACA was deeply unpopular.
Then Trump won the presidency and the Republicans had to deliver on their promises to repeal and replace the law. GOP leaders did get the new president on board with a pretty conservative plan: It would have left the skeleton of the ACA, but pared back its rules and financial aid, while making those huge cuts to Medicaid.
Then something changed. As the repeal plan started to move through Congress, and projections of millions of Americans losing health insurance dominated news coverage, the politics of health care flipped. The law had quietly grown to cover a sizable chunk of people — more than 25 million — and, as importantly, it had started to change Americans’ minds about the government’s role in providing health care. “Preexisting conditions” became a loaded term, and when people understood that the GOP wanted to unwind the ACA’s health insurance rules, they loudly objected.
Medicaid also flexed a political salience not seen before, with disability advocates in particular fearful of what cuts to that program would mean for them and drawing widespread coverage for their protests. Senate Republicans from states that expanded Medicaid through the health care law were ultimately responsible for stopping the repeal effort.
By the 2018 midterms, Democrats were hammering Republicans over health care and scoring surprising electoral wins. Today, the ACA is as popular as it’s ever been and US voters say they trust Democrats more on health care than the GOP.
This series of events has left Republicans in a bind. The relative success of the ACA has expanded the welfare state and influenced Americans’ perceptions of the role of government in ways that are antithetical to conservative economic thinking. They want to claw back some of those progressive wins. But they also have to be mindful of the changed politics of health care.
Once in a while, particularly in “safe” conservative spaces, they slip up, admit they want to unwind the ACA, and then have to backtrack. Mike Johnson’s only mistake was being candid.
Update, October 31, 3:45 pm ET: This story was originally published earlier on October 31 and has been updated to include Trump’s social media post about the ACA.