President-elect Donald J. Trump never revealed the “concepts” of the plan he said he had to replace the Affordable Care Act, the law that he tried unsuccessfully to kill during his first term.
But the fact that Republicans have gained control of the Senate — and possibly the House — could give Mr. Trump an opening to try and transform the 2010 health law and remake the nation’s health care system.
Key to that strategy, health policy experts said, is simple inaction. Major subsidies that lawmakers approved during President Biden’s term that have lowered the cost of plans are set to expire next year. Republicans could allow them to sunset, a move that could deprive roughly 20 million Americans of extra financial help for coverage on the Affordable Care Act’s marketplaces.
The subsidies, which are estimated to cost more than $300 billion if extended for a decade, helped Obamacare enrollment almost double during President Biden’s term, shattering records. The Congressional Budget Office estimates that 3.4 million people will lose insurance if the subsidies expire and the cost of plans rises. Lower-income Americans would still receive some federal assistance, while higher-income people would lose it altogether.
“Because premium payments would go up for so many people, you’re likely to see a lot of people dropping coverage,” said Cynthia Cox, an Obamacare expert at KFF, a nonprofit health policy research group. And since the marketplaces are a last resort for many Americans, she said, many of those with plans now would likely be uninsured.
The future of the law has taken on new urgency, not just because of Mr. Trump’s record in office seeking to reverse it. Speaker Mike Johnson, who would likely continue in his role in a Republican majority, said last week at a campaign stop that his caucus would seek “massive reform” if Mr. Trump was elected again, with health care a top priority in the early months.
“No Obamacare?” a voter called out at the event.
“No Obamacare,” Mr. Johnson responded. “The A.C.A. is so deeply ingrained, we need massive reform to make this work, and we’ve got a lot of ideas on how to do that.”
Mr. Johnson later said that his comments had been misconstrued, and that he meant “the opposite” of calling for a repeal.
It is not yet clear how Republicans would coalesce around major health care legislation next year. At the campaign event, Mr. Johnson cited plans from the “docs caucus” in the House, a group of Republican lawmakers who are also medical providers, who he said had a “menu of options.”
Representative Brad Wenstrup, Republican of Ohio and a co-chairman of the caucus, who is retiring when his term is up at the end of the year, said in an interview on Wednesday that there were no “written out” plans to repeal Obamacare, nor was there appetite to reverse the law. He pointed to an information sheet published by the caucus that describes recommendations for improving the health of Americans.
“I don’t know that the Affordable Care Act is going away, but are we looking at it to say, ‘Is it being successful? Are we actually healthier?’” he said.
Representative Earl L. “Buddy” Carter, Republican of Georgia and another member of the caucus, said in a statement that Republicans were “taking a hard look at needed reforms to build an affordable, accessible and high-quality health care system,” describing the current version as “ripe with waste, fraud and abuse, to the tune of tens of billions of dollars annually.”
Major health care changes next year could also be more difficult to achieve in a Senate without a filibuster-proof majority, and as lawmakers are busy working on tax legislation.
As Democrats leaned on the Affordable Care Act’s popularity on the campaign trail this year, the subject operated as a kind of inconvenience for Mr. Trump, a dynamic reflected in his vague, seesawing comments. Late last year he said he was “seriously looking at alternatives” and that Republicans should “never give up” in seeking its repeal. Months later, he retreated.
In the vice-presidential debate last month, Senator JD Vance claimed that Mr. Trump had “salvaged” Obamacare, despite his repeated efforts to undermine it.
“We’re going to keep the Affordable Care Act, unless we can do something much better,” Mr. Trump said earlier this year. “We’ll keep it. It stinks. It’s not good. If we can do something better, we’re going to do something with it if we can do better, meaning less expensive and better health care for you.”
Mr. Trump also accused Vice President Kamala Harris of misleadingly claiming he was seeking to end Obamacare. “I never mentioned doing that, never even thought about such a thing,” he said in a post on Truth Social, a statement at odds with his longstanding efforts to weaken and overturn the law as president and his recent debate promise to propose an alternative approach.
“President Trump was just really reluctant to talk about it,” said Dr. Benjamin D. Sommers, a health economist at Harvard and former Biden administration official. “When he did, what was clear was the lack of clarity around what their goal was. I don’t know that he comes in with a real strong view on it. And I don’t know if there’s a strong mandate from the election for him to take a certain approach.”
Even without Congress, Mr. Trump could recycle a playbook from his first term that dampened demand for Obamacare coverage by limiting advertising of its marketplaces, shortening the time to enroll in plans and cutting out spending on so-called navigators who help Americans choose their coverage. Enrollment plateaued during his first term.
Federal health officials are also likely to once again encourage the use of short-term health plans that skirt Affordable Care Act regulations. Some health policy experts have also warned of potential cuts and changes to Medicaid, which the Affordable Care Act dramatically expanded to cover more adults.
Ms. Cox pointed to Republican repeal efforts in 2017 that could serve as a kind of model for next year even if lawmakers do not seek a complete overhaul of the Affordable Care Act — a plan that included deep cuts to Medicaid spending. “That could help pay for tax cuts,” she said.
Brian Blase, a former senior official in the Trump administration who could rejoin the White House, said the top priority for Mr. Trump in reforming the Affordable Care Act should be preventing a fraudulent practice of brokers enrolling Americans in plans without their knowledge, a phenomenon that Mr. Blase has claimed was rampant during Mr. Biden’s term. The extent of the problem is disputed by Biden administration officials and other health policy experts.
“The Biden administration enabled that fraud, and new policies and management must end that wasteful spending,” Mr. Blase said.
Many of Mr. Trump’s voters could be deeply affected by Republican proposals, including to Medicaid funding. The Biden administration published a report last week showing that nearly three million rural Americans had Obamacare plans, while more than 12 million had Medicaid coverage. Rural Americans who purchase coverage on the Affordable Care Act’s marketplaces would see costs go up by almost $90 on average every month if the enhanced subsidies expire, federal researchers wrote.
Republican-led states, Ms. Cox said, “would see some of the steepest premium increases if these subsidies expire.” Southern states, she added, have seen the most growth in sign-ups since the increased subsidies became available.
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