Former President Donald J. Trump’s suggestion in Tuesday’s debate that he had “concepts of a plan” to replace the Affordable Care Act instantly became one of the night’s most memorable lines, transposed into memes across social media.
It was also a continuation of a strategy Mr. Trump has practiced since he first ran for president nearly a decade ago: promise an overhaul to the health care system, then surrender to the political and practical challenges of developing such a plan.
“If we can come up with a plan that’s going to cost our people, our population, less money and be better health care than Obamacare, then I would absolutely do it,” he said at the debate. “But until then I’d run it as good as it can be run.”
Mr. Trump’s position straddled two seemingly contradictory ideas. He could both replace the Affordable Care Act with something better, and keep it in place making incremental changes, as he did during his first term. The growing popularity of the law — around 60 percent of Americans approved of it in a recent poll, and a record number of people signed up for plans this year — has made any renewed push to repeal it politically perilous.
Yet Mr. Trump suggested that he might try anyway, promising a health plan “in the not-too-distant future.” In Mr. Trump’s telling on Tuesday, his administration took over flailing health care marketplaces and sturdied them, allowing the Affordable Care Act to mature even as his own health officials, Republican lawmakers and his Justice Department sought to restrict and nullify the health law.
“I had a choice to make when I was president: Do I save it and make it as good as it can be? Never going to be great. Or do I let it rot?” he said. “And I felt I had an obligation, even though politically it would have been good to just let it rot and let it go away.”
The Affordable Care Act’s insurance markets, which were rocky in 2016, have indeed become more stable and robust. But Mr. Trump pursued multiple policies meant to undermine, not strengthen, the program.
In budgets and other proposals, some congressional Republicans have continued calling for major changes to the Affordable Care Act. But producing legislation to overhaul the law and getting it through a closely divided Congress would be challenging, something Mr. Trump appeared to concede on Tuesday.
Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, said that any effort to introduce a less expensive health plan with strong health benefits would likely require devastating trade-offs, such cutting subsidies that allow people to afford their plans or taking away protections for patients with pre-existing conditions.
“It’s very challenging to try to deliver the same degree of access and coverage at a lower cost than the Affordable Care Act,” she said. “There’s only so many ways to get to cheaper.”
As a presidential candidate in 2015, Mr. Trump vowed to replace the Affordable Care Act “with something terrific.” In office, he offered regular promises to “soon” release a plan that would install a cheaper, improved version of health care.
But the congressional plans he later endorsed as president would have decreased insurance coverage overall, cut funding to states, and erased protections for many Americans with pre-existing conditions.
Congressional Republican leaders, discouraged by earlier legislative failures and subsequent midterm electoral losses in 2018, have shown little appetite for advancing such bills again.
Mr. Trump has practiced a kind of seesaw strategy with the Affordable Care Act in recent months. Last November, he said he was “seriously looking at alternatives” and that Republicans should “never give up” in seeking its repeal. He later softened those threats.
“The confident rhetoric of ‘Obamacare is dead’ in 2017 has been replaced by: ‘I saved it. We’ll keep it, and I’ll make it better if I can,’” said Dr. Benjamin D. Sommers, a health economist at Harvard and former Biden administration official.
Mr. Trump appeared to bet that ambiguous calls for change would not carry the same kind of political liability now that many voters and campaigns are focused on other issues, such as the economy and immigration.
A survey published on Tuesday by KFF, a nonprofit health policy research group, showed that just 6 percent of Democrats and 2 percent of Republicans viewed health care costs as the most important issue determining their vote.
“Health care is still very important for people,” said Dan Judy, an analyst at North Star Opinion Research, a Republican polling firm. “But it’s important as part of a broader economic and inflation and cost of living issue right now.”
After it was signed into law, the Affordable Care Act was broadly unpopular, becoming an avatar for the health system’s deficiencies. Only around a third of Americans approved of it by the time the law’s marketplaces were open in 2014, according to survey data from KFF.
The law’s repeal became a rallying cry for Republican politicians in several election cycles. But opposition to Obamacare is no longer a motivating force in the Republican Party, a shift that health policy experts have attributed to the law’s increasingly expansive reach.
Almost 50 million Americans have signed up for plans through the Affordable Care Act’s marketplaces since 2014, the Biden administration said on Tuesday. Millions of lower-income Americans now have Medicaid coverage in states that expanded the program to cover more adults, an option introduced by the Affordable Care Act. And with help from substantial subsidies that brought down the costs of plans for buyers, a record number of people signed up for plans on the law’s marketplaces this year.
The health law’s consumer protections for Americans with pre-existing conditions are also enormously popular, and they have become more associated with the law since the 2017 repeal efforts.
Voters began approving more of the law as they learned about the details of the Republican repeal proposals.
“We never saw the Affordable Care Act as popular as it was when it was under threat of repeal,” said Linda Blumberg, a research professor of public policy at Georgetown University and health analyst at the Urban Institute.
That puts Mr. Trump in a difficult position. His old repeal rhetoric is no longer helpful, even among many Republicans. He has yet to articulate a specific improvement proposal that voters like. That has left him with only “concepts of a plan.”
“As President Trump said, he will release more details,” Karoline Leavitt, a Trump campaign spokeswoman, said in a statement on Wednesday. “But his overall position on health care remains the same: bring down costs and increase the quality of care by improving competition in the marketplace.”
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