Millions of Americans who rely on the federal government to subsidize their health care could face an erosion in their benefits following Donald Trump’s victory in last month’s presidential election.
As Republicans take control of Congress and Trump prepares to take office and begin his second term next month, the GOP trifecta will likely attempt to chip away at federal health care programs like Medicare and the Affordable Care Act.
Experts and state lawmakers say how successful they’ll be, and what that means for Minnesotans, is still up in the air.
Chipping away at the ACA
The Affordable Care Act (ACA), informally known as “Obamacare,” was the landmark piece of legislation enacted in 2010 during President Barack Obama’s first term that aimed to make health insurance more affordable and more accessible for millions of Americans. Today, more than 45 million people are enrolled in health care coverage they received through the ACA.
During the early months of Trump’s first term, he tried to deliver on his campaign promise to repeal and replace the ACA, issuing an executive order on his first day in office in January 2017 that attempted to roll back provisions of the law. Trump then pushed the Republican-controlled House of Representatives to pass legislation repealing the law — which they did that May — but Republicans in both chambers couldn’t get behind a plan to replace the ACA, which led lawmakers, and Trump, to abandon the effort.
Trump then spent the rest of his first term chipping away at various provisions of the ACA. The president-elect will likely pursue the same game plan in his second term, though this time Republicans will be more discreet, said Andrea Ducas, vice president of health policy at the Center for American Progress, a left-leaning Washington think tank.
“I think what’s going to be challenging this time is you’ll see lots of little attacks that happen outside of public view that make it a little harder to organize around,” she said. “It’ll feel technical, and people aren’t necessarily going to be following or understanding [that these] are connected to the Affordable Care Act.”
As one example, Republicans could let a tax credit provided by the Inflation Reduction Act expire at the end of 2025, Ducas said. That credit, which made coverage more widely affordable and accessible, would cut health insurance for 5 million people. The White House could also refuse to defend in court an ACA provision that bans insurance companies from charging for preventive services like breast cancer screenings.
“Those aren’t like repeal votes,” she said. “They’re just inaction that will lead to some devastating losses.”
The lack of a plan to replace the ACA is not likely to stop Trump and congressional Republicans from trying to either repeal it in full or do away with many of the law’s provisions, said University of Minnesota political science professor Timothy Johnson. But, he said, the popularity of the ACA and the coverage it provides to millions of Americans, as well as fear from lawmakers of losing re-election may prevent those efforts.
“I’m sure there are things that they can do to try to weaken it, but if they start going after the key provisions, like the idea that [protections for] pre-existing conditions no longer exist when you switch out from health insurance to health insurance, or the idea that you can cover your kids until they’re 26 years old — these are wildly popular,” he said. “I think they’re going to try to pull out all the stops, I just am not certain that even at this stage, in this political climate, that this particular effort will be successful.”
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Future of Medicare
Another question is whether Trump and his allies will go after Medicaid and Medicare, which provides health care for more than 140 million seniors, people with lower incomes, children and people with disabilities.
Project 2025, a 900-page conservative policy blueprint backed by many linked to Trump includes a proposal to place a 36-month lifetime maximum on Medicaid, which currently provides health care coverage for nearly 20% of all Americans. The cap would affect more than 18 million Americans who qualify for the coverage due to their lower income alone.
About 307,000 Minnesotans receive health care coverage from the expansion to Medicaid, which is another provision that is in danger, said Laura Smith, Minnesota lead for advocacy organization Protect Our Care.
“I think that that’s not only unconscionable, but it makes overall health worse,” Smith said. “It harms our most in need communities here in Minnesota and everywhere in the U.S.”
Another proposal would make Medicare Advantage the default enrollment option for all Medicare beneficiaries. Recipients currently have a choice between Medicare Advantage and traditional Medicare.
Minnesota Attorney General Keith Ellison last week held a news conference with multiple senior advocacy groups to raise awareness before the enrollment period closes on Saturday about a number of health care providers across the state withdrawing from particular Medicare Advantage plans.
The providers have cited reasons such as reimbursements that don’t cover the costs of care, plans denying care that providers believe is medically necessary and late payments from the plans. The move leaves more than 60,000 Minnesotans with Medicare Advantage plans to now face an even more limited pool of providers.
“This means that Medicare Advantage plans enrollees will see much higher out-of-pocket costs for services at these providers, or even worse, their services at those providers won’t be covered at all —– this could be true even for providers that Medicare Advantage plan members have been using for years,” Ellison said. “Health care costs and medical debt are already challenging for far too many Minnesotans and that can get worse if folks aren’t able to make informed decisions.”
Traditional Medicare is the plan that people are most familiar with — beneficiaries get their coverage from the federal government directly, which pays for their medical, hospital and prescription costs. They can see nearly any doctor in the country, but if an enrollee wants additional coverage like dental or vision, they’d have to purchase a supplemental, or Medigap, plan separately, which can sometimes be pricey.
Under Medicare Advantage plans, however, companies receive a lump sum from the government to provide the same level of benefits as traditional Medicare. This plan can be attractive because they’ll often bundle additional coverage like dental and vision with the standard plans that cover medical, hospital and prescription at no additional cost.
The trade-off, however, is that the networks for these private plans are much narrower than traditional Medicare plans, and more of the services they provide are subject to barriers like prior authorization, Ducas said.
“You have to deal with all of the red tape associated with going through a corporate insurance company and the experience of care might be more challenging or difficult,” she said. “So if you get really, really sick and you’re in a Medicare Advantage plan, the doctor you might want to see might be somebody you can’t see because they’re not in your network. Or if you need an MRI, it might take months because you’re waiting for your insurance company to approve it, and there might only be a certain set of facilities you could even go to get it.”
Ducas said the problem with making Medicare Advantage the default is that many people won’t compare two plans if one is chosen for them automatically.
That could lead to situations where someone with a pre-existing condition like cancer, who initially chose Medicare Advantage and isn’t getting the care they need, decides to switch to traditional Medicare. Because supplemental Medigap plans are not bound by the ACA provision on pre-existing conditions, they could be either stuck in their Medicare Advantage plan or forced to accept a care plan that requires them to pay much more of their costs out-of-pocket.
“Choice architecture, which is the idea of constructing a choice for someone and making the default choice, is very powerful — most people don’t opt out of something that they’re defaulted into,” she said. “The plan that you’re defaulted into might not work for you, and we already know that many people don’t realize that they can’t get out of these plans and get a Medigap policy in the future.”
In Minnesota, the Legislature passed a bill that bans Medigap plans from discriminating based on pre-existing conditions last session. That makes it one of just a handful of states with such protections, said state Representative Tina Liebling, DFL-Rochester, who authored the bill.
Liebling said she and others are concerned that allowing the privatization of Medicare encourages private health insurance companies to profit at the expense of the taxpayer.
The Medicare Payment Advisory Commission, an independent congressional body, found that in 2024 Medicare will pay $83 billion more to companies administering Medicare Advantage plans than it would cost if those same enrollees were on traditional Medicare.
“It’s really troubling,” Liebling said. “It’s the wrong way to go because it puts more in the hands of private insurance companies who have a profit motive, and it basically lets corporate greed have control over more people’s health care.”
Liebling said that while there isn’t much the state can do to stop the rollback of federal programs, DFL lawmakers will work to try to insulate Minnesotans from its effects. But, she said, a likely 67-67 split between Democrats and Republicans in the Minnesota House will make it more difficult.
“That’s going to further limit us in whatever we might be able to do to protect Minnesota from what Trump might do,” she said
