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The Trump administration’s efforts to chip away at the Affordable Care Act resulted in millions of Americans losing coverage and thousands dying prematurely between 2016 and 2019. Tasos Katopodis / Getty Images
  • A new analysis reveals that the number of Americans without health insurance increased by about 2.3 million between the years 2016 and 2019, the majority of President Donald Trump’s current term in office.
  • This drop in health coverage led to at least 3,399 and possibly as high as 25,180 premature deaths in the United States.
  • These numbers show that health in the United States was on the decline even before the arrival of the COVID-19 pandemic.
  • The decline is a direct result of efforts by the Republican Party to repeal and limit aspects of the Affordable Care Act.

Over the course of the past 4 years of tumult in American life, one area has been particularly charged: healthcare.

Debates over the Affordable Care Act (ACA), or “Obamacare,” and whether it should be limited, repealed, replaced, maintained, or expanded have dominated policy discussions from all parts of the political spectrum.

Left, right, or center, it’s been impossible to escape discussions over how the United States should provide healthcare access to its citizens.

Essentially, the health and well-being of millions of Americans have been on the line while these debates rage on. Central to all of this has been the Trump administration’s efforts to limit and ultimately repeal the ACA.

It’s taken a devastating toll.

A new analysis published on the blog for Health Affairs reveals that the number of Americans without insurance increased by about 2.3 million between the years 2016 and 2019, the majority of President Donald Trump’s current term in office.

This winnowing away at health coverage led to at least 3,399 and possibly as high as 25,180 deaths.

This is before the start of this year’s COVID-19 pandemic, which has been particularly deadly for vulnerable groups, especially Black and Latino communities, who historically face road blocks when it comes to healthcare and insurance access.

Were there any surprises from these findings?

“Until the pandemic hit, the economy was doing well and unemployment was falling — which should make the uninsurance rate fall too,” lead author Dr. Adam Gaffney, a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance, told Healthline.

Gaffney and his co-authors, Dr. David Himmelstein and Dr. Steffie Woolhandler, both of CUNY School of Public Health at Hunter College, looked at results from the American Community Survey (ACS), the Current Population Survey, and the National Health Interview Survey, three federal surveys that look at health insurance coverage data.

“The fact that all three federal surveys showed that the uninsurance rate rose over the first 3 years of the Trump administration is surprising. Things were getting worse — even before COVID-19,” Gaffney said.

Dr. Andrew Bindman, a professor of medicine, epidemiology, and biostatistics and a core faculty member at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, told Healthline that the Trump administration has “made it an explicit goal from day one to undermine” the ACA.

“While President Trump failed to deliver on his promise to overturn the ACA, he has done all he could without the approval of Congress to sabotage the law,” Bindman said.

“Unlike President Obama, who focused on expanded coverage, President Trump’s legacy is a decline in healthcare coverage, leaving Americans less protected during a pandemic when the security of healthcare coverage is more important than ever,” he said.

Bindman knows a lot about the ACA since he was one of the people who helped draft it. He made his contributions to the legislation when he served as a health policy fellow on the staff of the House Energy and Commerce Committee.

Like Bindman, John McDonough, DrPH, MPA, a professor of public health practice in the department of health policy and management at the Harvard T.H. Chan School of Public Health and director of executive and continuing professional education, is another person intimately familiar with the healthcare plan.

He worked on the development and passage of the ACA while a senior adviser on national health reform to the Senate Committee on Health, Education, Labor, and Pensions.

McDonough echoed Bindman in saying this analysis accurately pinpoints how healthcare has suffered under this current administration.

While the number of uninsured people declined for 6 years during the Obama administration — including the rate of uninsured children — they have only gone up during Trump’s time in office, he said.

“We can connect this rise in uninsurance to policy decisions by the Trump administration, including the cessation of nearly all federal support for enrollment navigators and assisters, the reduction in the individual mandate penalty to zero, and the expansion of junk, short-term health insurance plans, among other interventions,” McDonough added.

Leighton Ku, PhD, MPH, professor and director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University, said that “the reasons for the reduction in insurance coverage during the Trump years are not completely clear, but certainly, this represents a reversal from the Obama years.”

He added that the current administration has been “clear in its intent to weaken the ACA in various ways,” and that this current data “suggests that they succeeded in erasing coverage gains made during the earlier period.”

The results are stark. Ku told Healthline that this has “caused more people to go without healthcare and to die earlier.”

Gaffney echoed all the other experts in saying that while the Trump administration tried to repeal and replace the ACA — in fact, no clear replacement plan has ever been put on the table — the damage has been done.

“It has managed to undercut the healthcare coverage of millions through smaller actions, leading to thousands of deaths,” he said.

An undercurrent running through this whole period of time is the looming Supreme Court case on Nov. 10, just days after this year’s general election.

The court — which just confirmed its newest justice, Amy Coney Barrett, to replace the late Ruth Bader Ginsburg — will hear oral arguments from 20 Republican state attorneys general.

What would happen if the Supreme Court overturns the ACA?

According to Gaffney, especially in light of the poor state of American healthcare as seen by these surveys, the stakes are incredibly high.

“Full overturning of the ACA by the Supreme Court could lead to 20 million people losing coverage, including many children. This would come at the cost of tens of thousands of lives lost annually, needlessly,” Gaffney said.

Bindman agrees, adding that weakening or overturning the ACA without any kind of replacement plan at the ready will “result in significant declines in the number of Americans who are able to obtain healthcare coverage.”

“This will be particularly hard on the tens of millions of Americans with preexisting conditions who would lose the guarantees of the ACA and would likely either be turned down when seeking coverage or face costs for coverage that will make it impractical for them to obtain it,” Bindman added. “This will leave them financially vulnerable and susceptible to poor health outcomes, including premature death.”

While all four experts agree an elimination of the ACA would cause huge declines in overall health in the United States, particularly among the most vulnerable members of our society, it’s hard to know exactly what will happen at the Supreme Court this month.

“We do not know what the Supreme Court will hold. They will hold the hearing next month and probably won’t issue a decision for several months,” Ku said.

For Ku, even if portions of the law are found to be unconstitutional by the court, it isn’t clear whether that means the entire law will be canceled, “nor what the next president and Congress will do.”

“So, while that dark prediction is conceivable, it is far from certain,” he stressed.

There have already been efforts to chip away at the legislation. For instance, a 2017 congressional tax bill was passed that cut out the ACA penalty for people who didn’t already have health insurance.

McDonough said that even if the court repeals the individual mandate in and of itself, the “damage has already been done” due to the repeal of this penalty.

“If the court were to decide to go further, the damage could be considerable, including repeal of coverage for 20 million Americans who get it via ACA provisions, and the roughly 100 million with preexisting conditions who might lose those protections going forward,” he added.

“If the court were to repeal the tax increases and the Medicare payment reductions, that would trigger an immediate financial emergency for the Medicare Part A Hospital Insurance Trust Fund. And lots more,” McDonough said.

Of course, tensions are running especially high because all of this is happening in the middle of a contentious presidential election that is itself taking place while the COVID-19 pandemic rages on.

Trump and Vice President Mike Pence’s opponents, former Vice President Joe Biden and Sen. Kamala Harris, have made healthcare a focal point of their campaign.

Whether a plan to address COVID-19 or expanding the ACA with a public option, which would create a government-sponsored plan that would compete with private insurance offerings, public health and politics seem like they’re unable to be separated from one another at this point.

What if Biden wins? What if the Supreme Court overturns the ACA as a Biden-Harris administration readies to head to the White House in January?

Gaffney said a new government could “tweak the ACA” so that a negative Supreme Court decision could become “basically irrelevant.”

McDonough said that while the court is going to hear the case this month, no decision will likely come until about next June. He said a decision made by the Supreme Court would give Congress time to take some kind of alternative action.

“If Democrats win control of the White House, Senate, and House in the Nov. 3 elections, it is likely that they would pass a law quickly in late January or February to nullify the current court case, for example, by reinstating a $5 or so penalty for not having health insurance,” he explained. “Then there would be no grounds for the suit to continue.”

That being said, if Republican leaders hold on to the Senate, McDonough foresees that a new agreement would be harder to achieve.

“Federal efforts to expand insurance coverage requires a president who is committed to that goal working to gain the cooperation of Congress to pass legislation that addresses failures in the marketplace to produce that goal,” Bindman said.

He cited Biden’s pledge to make purchasing coverage through the health insurance marketplace more affordable and to “ensure those who meet poverty standards for Medicaid obtain coverage through a federal public option if the state where they live has not expanded Medicaid as a part of the ACA.”

Bindman added that the ACA has withstood challenges at the Supreme Court in the past.

“But if in this instance the Supreme Court overturns the ACA, President Biden would have a bigger challenge to achieve his goal of expanding coverage,” he said.

“The outcome of House and Senate races will determine whether he will have a Congress that is prepared to help him pass legislation that negates the Supreme Court’s actions,” Bindman explained.

For his part, Ku agreed that if Biden and Harris win and the Democrats have a Senate majority, we will see a legislative parry to the Supreme Court’s decision, which would “strengthen insurance coverage and avoid excess mortality.”

“On the other hand, if Republicans hold the majority or Trump wins, the legislative response to the Supreme Court decision becomes much less clear since Republicans don’t really have a health plan that would increase insurance coverage,” he said.

Ku stressed that the “real elephant in the room” is, of course, the pandemic and the administration’s failed efforts to contain those ever-escalating COVID-19 numbers.

“As bad as the insurance failures of the Trump administration have been, the poor handling of the pandemic have probably been more harmful,” Ku said.

Gaffney imagines that, even if Biden and the Democrats prevail in this general election, debates over how best to reform and improve healthcare in the United States will continue.

“If there is an electoral shift on Tuesday and a Democratic government comes into power, it will likely lead to a new debate over comprehensive healthcare reform, and I predict over Medicare for All as well,” Gaffney said.

“It’s not enough to reverse the harms caused by the Trump administration — 30 million were uninsured even before the COVID-19 pandemic, and the number is likely higher now. We have to ensure health protection for every American,” he said.