President Trump talked to seniors about health care in central Florida in early October. "We eliminated Obamacare's horrible, horrible, very expensive and very unfair, unpopular individual mandate," Trump told the crowd. BRENDAN SMIALOWSKI/AFP via Getty Images hide caption
toggle caption BRENDAN SMIALOWSKI/AFP via Getty Images 
President Trump talked to seniors about health care in central Florida in early October. "We eliminated Obamacare's horrible, horrible, very expensive and very unfair, unpopular individual mandate," Trump told the crowd.
BRENDAN SMIALOWSKI/AFP via Getty Images
The very day President Trump was sworn in — Jan. 20, 2017 — he signed an executive order instructing administration officials "to waive, defer, grant exemptions from, or delay" implementing parts of the Affordable Care Act, while Congress got ready to repeal and replace President Obama's signature health law.
Months later, repeal and replace didn't work, after the late Sen. John McCain's dramatic thumbs down on a crucial vote (Trump still frequently mentions this moment in his speeches and rallies, including in his recent speech on Medicare).
Sponsor Message
Obamacare Replacement After Top GOP Leader Nixes The Idea" width="" />
After that, the president and his administration shifted to a piecemeal approach as they tried to take apart the ACA. "ObamaCare is a broken mess," the president tweeted in the fall of 2017, after repeal in Congress had failed. "Piece by piece, we will now begin the process of giving America the great HealthCare it deserves!"
Two years later, what has his administration done to change the ACA, and who's been affected? Below are five of the biggest changes to the federal health law under President Trump.
What is it? The individual mandate is the requirement that all U.S. residents either have health insurance or pay a penalty. The mandate was intended to help keep the premiums for ACA policies low by ensuring that more healthy people entered the health insurance market.
What changed? The 2017 Republican-backed tax overhaul legislation reduced the penalty for not having insurance to $0.
What does the administration say? "We eliminated Obamacare's horrible, horrible, very expensive and very unfair, unpopular individual mandate. A total disaster. That was a big penalty. That was a big thing. Where you paid a lot of money for the privilege [. ] of having no healthcare." — President Trump, The Villages, Florida, Oct. 3, 2019
Sponsor MessageWhat's the impact? First of all, getting rid of the penalty for skipping insurance opened a new avenue of attack against the entire ACA in the courts, via the Texas v. Azar lawsuit. Back in 2012, the ACA had been upheld as constitutional by the U.S. Supreme Court, because the penalty was essentially a tax, and Congress is allowed to create a new tax. Last December, though, a federal judge in Texas ruled that now that the penalty is $0, it's a command, not a tax, and is therefore unconstitutional. He also reasoned that it cannot be cut off from the rest of the law, so he judged the whole law to be unconstitutional. A decision from the appeals court is expected any day now.
Eliminating the penalty also caused insurance premiums to rise, says Sabrina Corlette, director of the Center on Health Insurance Reforms at Georgetown University. "Insurance companies were getting very strong signals from the Trump administration that even if the ACA wasn't repealed, the Trump administration probably was not going to enforce the individual mandate," she says. Insurance companies figured that without a financial penalty, healthy people would opt not to buy insurance, and the pool of those that remained would be smaller and sicker.
So, even though the $0 penalty didn't actually go into effect until 2019, Corlette says, "insurance companies — in anticipation of the individual mandate going away and in anticipation that consumers would believe that the individual mandate was no longer going to be enforced — priced for that for 2018." According to the Kaiser Family Foundation, premiums went up about 32%, on average, for ACA "silver plans" that went into effect in early 2018, although most people received subsidies to offset those premium hikes.
What is it? Medicaid expansion was a key part of the ACA. The federal government helped pay for states (that chose to) to expand Medicaid eligibility beyond families to include all low-income adults, and to raise the income threshold, so that more people would be eligible. So far, 37 states and Washington have opted to expand Medicaid.
Sponsor MessageWhat changed? Under Trump, if they get approval from the federal government, states can now require Medicaid beneficiaries to prove with documentation that they either work or go to school.
What does the administration say? "When you consider that, less than five years ago, Medicaid was expanded to nearly 15 million new working-age adults, it's fair that states want to add community engagement requirements for those with the ability to meet them. It's easier to give someone a card; it's much harder to build a ladder to help people climb their way out of poverty. But even though it is harder, it's the right thing to do." — Seema Verma, administrator of the Centers for Medicare and Medicaid Services, Washington, Sept. 27, 2018
What's the impact? Even though HealthCare.gov and the state insurance exchanges get a lot of attention, the majority of people who gained health care coverage after the passage of the ACA — 12.7 million people — actually got their coverage by being newly able to enroll in Medicaid.
Medicaid expansion has proven to be quite popular. And in the 2018 election, three more red states — Idaho, Nebraska and Utah — voted to join in. Right now, 18 states have applied to the federal government to implement work requirements; but most such programs haven't yet gone into effect.
"The one work requirement program that's actually gone into effect is in Arkansas," says Nicholas Bagley, professor of law at the University of Michigan and a close follower of the ACA. "We now have good data indicating that tens of thousands of people were kicked off of Medicaid, not because they were ineligible under the work requirement program, but because they had trouble actually following through on the reporting requirements — dealing with websites, trying to figure out how to report hours effectively, and all the rest."
If more states are able to implement work requirements, Bagley says, that could lead "to the loss of coverage for tens of thousands — or even hundreds of thousands — of people."
Sponsor MessageCMS administrator Verma has pushed back on the idea that these requirements are "some subversive attempt to just kick people off of Medicaid." Instead, she says, "their aim is to put beneficiaries in control with the right incentives to live healthier, independent lives."
