Everyone is talking about Republicans’ proposed Medicaid cuts, but hardly anyone is calling this what it really is: the strategy by Elon Musk, President Trump, and the Republican Party to dismantle the Affordable Care Act, one piece at a time.
The ACA, a historic piece of legislation that extended health coverage to millions of Americans, celebrated its 15th anniversary on March 23. Signed by President Barack Obama in 2010, the ACA expanded Medicaid and provided subsidies so that more working and middle-class Americans could have access to our expensive and complicated health care system. The law also made it illegal to drop or deny coverage to those with preexisting conditions and allowed children to stay on their parents’ coverage until age 26.
Over the years, the ACA has successfully reduced the country’s uninsured rate to 8.2 percent in 2024 from 15 percent in 2013 before its implementation. Though the law initially drew nationwide protests, it has become extremely popular as more Americans have benefited from its provisions.
Unfortunately, the ACA is under attack again, and proposed Medicaid cuts are the next step. This time, there are no repeal and replace efforts in Congress like in Trump’s first term. Instead, the Trump administration will fiscally starve it out of existence. If they succeed, Americans’ health care access will revert to the substandard quality that was our reality before the ACA, in blue and red states alike.
I’ve been researching the impact of the ACA on health care access for over a decade and have seen firsthand how different funding streams come together to help millions access health insurance.
First and foremost, 72 million Americans receive their coverage through Medicaid, which expanded under the ACA. The Republican budget bill, meanwhile, proposed $880 billion in devastating cuts to the Medicaid program. Despite vocalizing concerns about Medicaid cuts for red-state constituents, many Republicans voted to advance House legislation including that cut.
Meanwhile, the subsidies that allow middle class Americans to purchase coverage are set to expire at the end of this year. Another 2.2 million Americans could lose coverage if this happens.
Finally, Trump has unilaterally slashed funding for ACA navigators from $100 million to $10 million. These navigators are a crucial part of the system by helping patients sign up for health insurance. All these supposed “savings” will be used to offset tax cuts for the wealthy.
Trump and the Republicans tried doing the same thing in 2017. When their numerous ACA repeal attempts failed, they used the Tax Cuts and Job Act of 2017 to remove the ACA’s federal tax penalty for the individual mandate that required Americans to have health coverage. Trump also reduced funding for ACA navigators. As a result, for the first time since the ACA’s implementation, the uninsured rate for Americans ticked upward and continued to go up for the remainder of Trump’s first term.
At the time, I was conducting research for my new book to understand how the ACA reconfigured health care access for Latinos in greater Boston. My research revealed that Massachusetts would be very vulnerable if the ACA were to disappear. I spoke with state health bureaucrats and advocates about how the state was preparing for a repeal.
One way Massachusetts legislators bolstered the health care system was by keeping the individual mandate, requiring residents to have coverage. This maintained residents’ access to care. But one bureaucrat I interviewed confided that Massachusetts’s health care system could not function without the ACA’s federal Medicaid and subsidy funds. It would have buckled under a successful ACA repeal.
And if Massachusetts, arguably one of the best states for health care, struggled to reconcile what an ACA repeal could mean, then states with far fewer resources, hospitals and less political will to provide adequate care to their people will face a health care catastrophe. Simply put, people and health care facilities in red states will suffer more if the ACA is gutted.
Throughout my book, I write about the cascading effect of policies beyond those who are their direct targets. Though reducing access to affordable coverage disproportionately affects lower and middle-income people, it results in higher medical costs and insurance premiums for everyone. Defunding the ACA won’t just hurt the millions of Americans covered under the ACA, it will destabilize the health care system so much that the health care of all Americans will deteriorate.
Defunding the ACA piece by piece will not Make America Healthy Again. It will make Americans sicker than they have been in modern history, just for Trump to make permanent his tax cuts for the wealthy.
Tiffany D. Joseph is Associate Professor of Sociology and International Affairs at Northeastern University and the author of “Not All In: Race, Immigration, and Healthcare Exclusion in the Age of Obamacare.”
