How the cost of health care could increase after Trump‘s reelection

President-elect Donald Trump’s reelection could result in Americans spending far more on health care and losing access to certain types of care, according to health care policy experts.

If the former president follows in his own footsteps and sticks with his party’s health care policy stances, the impact on Americans could be immense, they say. Health insurance premiums could increase substantially, some Americans may lose Medicaid coverage, the federal government will lose out savings on Medicare spending and we may see new restrictions on reproductive and gender-affirming care.

Here’s what you need to know.

How Republicans would change health care policy if given the chance

Despite Republicans’ enduring disdain for the Affordable Care Act (ACA), which became law in 2010 under President Barack Obama, experts say it is unlikely that they will ever have the power to repeal it entirely, given the likelihood of a divided government.

Republicans may also lack the will to overturn the law given its popularity, how deeply embedded it has become in the American health care system, the fact that their previous attempts to repeal it have largely failed, and its successes on metrics such as decreasing the number of Americans without health insurance, according to health care policy experts.

That said, Republicans have had some success in weakening the ACA over time. Experts say that, if given the chance, Trump and other Republicans would likely continue this effort.

Given the current limitations of Congress and the executive branch, this would largely be by letting the American Rescue Plan Act’s (ARPA) generous and impactful add-ons to the ACA expire, health care policy experts say.

“I think there’ll be things they try to do, but it’s really around the edges and not the big significant pieces of the ACA,” Tufts University Public Health Professor Amy Lischko said.

How the Biden administration subsidized health insurance

One health care policy Republicans might eliminate is the changes ARPA made to ACA marketplaces. The law introduced additional subsidies on top of those enacted in the ACA to offset the cost of health insurance premiums purchased by low-income Americans through ACA marketplaces, which in Massachusetts is the Massachusetts Health Connector (MHC). ARPA also expanded ACA marketplace subsidy eligibility to many middle-income adults who were previously ineligible.

In the wake of these changes, the number of Americans enrolled in reduced-deductible plans through ACA marketplaces almost doubled, and low-income enrollees’ premium payments dropped by 44%, or $705, on average, according to the Kaiser Family Foundation (KFF). As a result, ARPA’s ACA add-ons have been extended multiple times since their enactment in 2021.

Despite the successes of ARPA’s ACA add-ons, Republicans have advocated for letting them expire, arguing that this expensive legislation was only justified as a pandemic relief effort. Lischko similarly expressed discomfort with so much taxpayer money going to private health insurers.

But Harvard T.H. Chan School of Public Health Professor John McDonough worries that the loss of the subsidies would make ACA marketplace health insurance unaffordable for many Americans. In Massachusetts, the number of people with insurance through the health connector did not increase after the implementation of the subsidies, according to the KFF, so this outcome could be muted in the Bay State.

Why health insurance premiums could increase for everyone under Trump

Even so, Massachusetts residents who purchase health insurance through the health connector would quickly see their premiums increase substantially. These increases would have an outsized impact on low-income adults, as they make up the vast majority of people enrolled in such plans, according to the Kaiser Family Foundation.

Additionally, if the number of Americans with health insurance decreases substantially nationwide, even people who are insured through their employers may eventually see their premiums go up, Smith College government and data sciences Professor Scott LaCombe said.

This is because, in a private health insurance system, having a large number of healthy people enrolled in insurance plans keeps costs low by increasing the number of customers who aren’t using their insurance to pay for expensive care, he said. Health insurance customers with health issues cut into insurers’ profits by receiving costly care that insurers must pay for, while healthy customers boost insurers’ profits by paying into the system and not utilizing its most generous benefits.

If a large number of healthy people opt out of paying for health insurance in an attempt to save money, people who actively need health insurance coverage to pay for their ongoing care will make up a larger share of customers, LaCombe said. In response to the loss of overall customers and decreased share of profit-producing customers, health insurers will likely raise premiums to maintain their profit margins.

How Trump could make health insurance less accessible on his own

Even if the only win for Republicans in November is putting Trump in the White House, Trump could still undercut the ACA.

The Trump administration previously slashed funding for navigator programs — which make it easier for people to sign up for health insurance through ACA marketplaces — by 80%, adding back barriers to enrollment. McDonough believes that if Trump were reelected, this and other similar cost-cutting measures that impact health care policy would be enacted.

We will also likely see Medicaid benefits pulled back during Trump’s second presidency, according to experts.

For one, Republicans are more likely to reject states’ requests for Medicaid waivers, which allow states to offer Medicaid benefits to people who would otherwise be ineligible, Lischko said.

Republicans may also try to enact new restrictions on who can receive Medicaid, McDonough said. For example, for many years, they’ve proposed a work requirement.

How Americans could lose government savings and lower drug prices under Trump

There’s also a good chance that Trump would back his party’s stance on Medicare drug price negotiation — which was made law by the Biden administration’s Inflation Reduction Act in 2022 — and bring it to a halt despite his past support for this policy, according to experts.

LaCombe said it is unclear whether this would mean the Trump administration would simply stop negotiating new drug prices, or if it would try to undo the new drug prices the Biden administration has already negotiated for 10 drugs.

Regardless, the Congressional Budget Office estimates that the new prices will save Medicare recipients $1.5 billion when they go into effect in 2026 and save the federal government $100 billion over the first 10 years of implementation. As such, reversing course on Medicare drug negotiation could mean the loss of meaningful savings for both recipients and government coffers.

Even so, Republicans argue that a drop in profits from drug sales to Medicare recipients disincentivizes drug companies from innovating and funneling revenue from new, expensive drugs back into research and development. They fear that this will ultimately lead to fewer new drugs and treatments.

Given that the first 10 drug price changes haven’t even gone into effect yet, it is too soon to tell if Republicans are right, Lacombe said.

The future of reproductive rights and gender-affirming care under Trump

While some Republicans have proposed the idea of enacting a national abortion ban as recently as last spring, experts believe Trump and his party likely wouldn’t actually try to do this given Americans’ strong support for keeping at least some abortions legal. For his part, Trump supports leaving the right to an abortion up to the states, convinced his party to change its platform to reflect this stance and has now promised to veto a national abortion ban despite previous reluctance to do so.

That said, Project 2025 — a wide-ranging federal policy plan drafted by Trump allies — calls for new, nationwide restrictions on abortion that would severely limit access to reproductive care, according to TIME magazine. For example, it advises the FDA to revoke approval of mifepristone — a widely-used medical abortion pill, which is also used to treat miscarriages.

Trump and Vance have tried to distance themselves from Project 2025 in recent weeks. During the October vice presidential debate, for instance, Vance said he would not follow the plan’s recommendation that the Centers for Disease Control and Prevention implement a nationwide “abortion surveillance” system.

But UMass Amherst health policy Professor Michal Horný said that, when it comes to issues like abortion, the public isn’t wrong to be skeptical of Trump and Vance’s pledges not to touch the issue. The fact remains that Trump fulfilled his 2016 campaign promise of appointing Supreme Court justices who would overturn Roe v. Wade and Republican leaders still largely oppose abortion rights.

That said, Republicans are unlikely to restrict access to in vitro fertilization (IVF) despite Senate Republican’s recent rejection of a bill that would’ve protected this fertility treatment nationwide, experts said. Trump has actually said he wants to make IVF more accessible, and IVF is so widely popular that even evangelical Republicans such as former Vice President Mike Pence have utilized it.

The same cannot be said for gender-affirming care though, according to STAT News. The president-elect has said he will ban gender-affirming care for minors and prohibit the use of federal funds to pay for sex reassignment surgeries.

How states could mitigate Trump’s impact

Some changes Trump and his party might make to federal health care policy could be mitigated at the state level, but doing so would not be easy, experts say. For instance, state legislatures could try to institute ARPA’s ACA add-ons at the state level, but recreating these programs wholly or in part would be very expensive — to a prohibitive degree.

State Sen. Cindy Friedman, D-4th Middlesex, who chairs the Joint Committee on Healthcare Financing, said that if the add-ons were allowed to expire, the Massachusetts Legislature would probably want to introduce them at the state level, but the state budget likely wouldn’t allow for it.

If this happened, Massachusetts would likely keep the health care marketplace subsidies for low-income residents instituted in 2006 under the health care reform law popularly known as “Romneycare” — which served as a model for the ACA, but they are less generous than the current federal subsidies.

Additionally, reinstituting the subsidies and other parts of Romneycare would not be a straightforward process, experts say.

LaComb said that hashing out which parts of Romneycare can or should remain in place would likely require a special session of the Legislature. Secondly, the original system was created using federal funds that may no longer be available, State Rep. Marjorie Decker, D-25th Middlesex, who chairs the Joint Committee on Public Health, said in a statement.

In general, though, Massachusetts is better positioned than other states to account for changes to the ACA due to its more “robust” health care system, LaCombe said.

The Massachusetts Legislature has already taken steps to protect health care accessibility in the Bay State in the last few years after seeing the impact of federal court decisions and the actions of other state legislatures, Friedman said. For example, Decker said, in the wake of the overturning of Roe v. Wade in 2022, the Legislature passed law that added protections for reproductive and gender-affirming health care.

“We’ve done a number of things within the health care space, and we will keep looking,” Friedman said. “We’re pretty good at protecting our health care system.”