Changes to health care that President-elect Donald Trump has placed on the table in his statements and social media posts could affect millions. But many of them, such as voters who were three years old when the Affordable Care Act was signed into law, may not know it.
“Every Georgian is, or has the potential to be, impacted ... in some way,” said Jaqueline Nikpour, an assistant professor at Emory University’s Woodruff School of Nursing.
Trump and his campaign have said little about his specific policy goals for a second term. The very specific “Project 2025″ plan for Trump developed at the Heritage Foundation has been much discussed but has not received his public endorsement.
However, health experts in interviews after the election have tried to flesh out what they know for public understanding. They say significant things can be gleaned from what Trump and his campaign have said about what his priorities are, and what they aren’t.
“Trump has said Medicare, Social Security and defense cuts are off the table,” said Larry Levitt, executive vice president for health policy of KFF, a health research organization. “With Republicans looking for spending reductions to help pay for tax cuts, the math is inescapable that Medicaid and ACA cuts will then be on the table.”
Trump said in a Truth Social post last year that the ACA is “not good healthcare,” and that he was “seriously looking at alternatives.” He said the failure to repeal the ACA was “a low point for the Republican Party, but we should never give up!”
In Georgia and across the nation, researchers interviewed last week said those affected could include the 1.3 million Georgians on Affordable Care Act insurance, along with people with diseases they don’t know about until they get routine screenings; families with adult kids on their parents’ employer health plans; elderly nursing home residents whose beds are funded by Medicaid; and more.
As to what Trump would replace the ACA with if it were repealed, he said in the presidential debate only that he has “concepts of a plan.”
The ACA: More than a marketplace
The Affordable Care Act, also known as Obamacare, created a marketplace of subsidized private insurance, where about 1.3 million Georgians currently have plans.
From a bumpy start and declines during the Trump administration, it now runs fairly smoothly, Cynthia Cox, director of KFF’s program on the ACA, said. Since 2018, she said, premium prices on the Marketplace before subsidies are factored in have grown an average of half a percent per year.
Experts speculate that one of the first cuts expected after Trump takes office could affect Georgia ACA enrollees. Some 700,000 in Georgia signed up on the ACA after “enhanced subsidies” during the pandemic lowered premium prices for both low- and upper-middle income earners.
The subsidies are funded through December 2025, but if Congress and Trump allow the subsidies to expire to save money, enrollees would see a price spike with January 2026 premiums.
The ACA had impacts beyond subsidizing plans to make premiums cheaper.
All along, ACA plans have had guardrails mandating that those marketplace plans provide basic essential benefits, such as drug coverage and coverage for pre-existing conditions.
It forces insurers to spread the cost of more expensive care, like for people who have chronic diseases, across the whole pool of patients. That means people are now able to get coverage who before might have been simply denied, or given a lifetime cap.
But those who are relatively healthy and willing to risk less coverage might be able to find cheaper plans without the ACA.
And the impact of potential changes could go well beyond health insurance plans sold on the marketplace. The ACA forces employer plans to cover things they may not have before. For example, recommended preventive screenings for potential disease. Or allowing parents to keep their kids on their family plans up to the age of 26.
Medicaid and Georgia
The Medicaid program insures about 2 million people in Georgia. Medicaid is the state-federal government insurance for poor children and some poor adults, including those who are federally declared disabled and some who are elderly and who are in long-term care homes.
Trimming the program could affect a slice of them, or any of them.
“Most of the people on the (Medicaid) program are kids, but of course, the largest share of expenses are for people with disabilities, and people who qualify based on age and their use of long term services,” said Robin Rudowitz, director for KFF”s Program on Medicaid and the Uninsured.
In Georgia, Gov. Brian Kemp’s office worked closely with the first Trump administration to devise “waivers” or pilot projects tailored to Georgia on both the ACA and Medicaid. Georgia’s customized Medicaid project, called Pathways to Coverage, expands coverage to poor adults who work or perform other activities 80 hours a month. It has struggled, enrolling just over 4,000 people out of about 240,000 poor uninsured Georgia adults.
A spokesman for Kemp, Garrison Douglas, said the election bodes good things for Georgia patients that Kemp’s office is trying to help. He pointed to the Biden administration’s delays of the program, and said Kemp’s office is looking at adjustments that can be made to Pathways to help it succeed.
“Thanks to (the) Trump administration’s previous approval, our state was able to develop and launch innovative programs that addressed Georgia’s specific health care needs,” Douglas said. “We look forward to working with the Trump administration again and all our partners to extend, improve and streamline these programs - making them even more accessible for hardworking Georgians.”
Dr. Michelle Au, who is also a Democratic state representative from Johns Creek who supports the ACA and Medicaid coverage, expects drastic changes.
“I think we’re going to see things like people being denied care for things that are considered pre-existing conditions, including maternity care,” Au said.
She said the important thing to note about Tuesday’s election is that the Republicans also swept the U.S. Senate and were close to taking the House, and they no longer include people like the late U.S. Sen. John McCain of Arizona, a Republican who was willing to oppose Trump in previous efforts to repeal the ACA.
Caylee Noggle serves both as the director of the Georgia Hospital Association and chair of the state’s Comprehensive Health Coverage Commission, a group looking at ways to expand coverage. She doesn’t share Au’s pessimism.
She’s looking forward to the first 90 or 100 days of the Trump administration to see who is appointed to lead the federal health agencies. “I think there’s opportunity.”
EDITOR’S NOTE: This story has been corrected to note that Dr. Michelle Au is currently a state representative. She was previously a state senator.
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