cheerup domain was triggered too early. This is usually an indicator for some code in the plugin or theme running too early. Translations should be loaded at the init action or later. Please see Debugging in WordPress for more information. (This message was added in version 6.7.0.) in /home/keepcalmnprofit/public_html/wp-includes/functions.php on line 6114In an otherwise<\/span> confident debate performance on Tuesday, the Republican vice-presidential nominee, J. D. Vance, conspicuously dodged questions from the CBS moderators about his views on health care. For weeks, Vance has made clear his desire to dismantle one of the central pillars of the Affordable Care Act: the law\u2019s provisions that require the sharing of risk between the healthy and the sick. On Tuesday, though, Vance refused to elaborate on his plans to reconfigure the ACA, instead pressing the implausible argument that Donald Trump\u2014who sought to repeal the law, and presided over a decline in enrollment during his four years in office\u2014should be viewed as the program\u2019s savior.<\/p>\n Vance\u2019s evasive response to the questions about health care, on a night when he took the offensive on most other subjects, exposed how fraught most Republicans still consider the issue, seven years after Trump\u2019s attempt to repeal the ACA died in the Senate. But Vance\u2019s equivocations should not obscure the magnitude of the changes in the program that he has signaled could be coming in a second Trump presidency, particularly in how the law treats people with significant health problems.<\/p>\n The ACA provisions that mandate risk-sharing between the healthy and sick underpin what polls show has become its most popular feature: the requirement that insurance companies offer coverage, at comparable prices, to people with preexisting conditions. In numerous appearances, Vance has indicated<\/a> that he wants to change the law to restore to insurance companies the ability to segregate healthy people from those with greater health needs. This was a point that Tim Walz, the Democratic vice-presidential nominee, accurately stressed during the debate.<\/p>\n The political paradox of Vance\u2019s policy is that the trade-off he envisions would primarily benefit younger and healthier people, at a time when most young people vote Democratic. Conversely, the biggest losers would be older adults in their last working years before they become eligible for Medicare. That would hit older working-class adults, who typically have the biggest health needs, especially hard. Those older working people are a predominantly white age cohort that reliably favors the Republican Party; in 2020, Trump won about three-fifths of white voters ages 45 to 64, exit polls found. The threat that the GOP\u2019s ACA alternatives present to these core Republican voting groups represents what I called in 2017 \u201cthe Trumpcare conundrum.\u201d<\/a><\/p>\n \u201cGoing back to the pre-ACA days of segregated risk pools would lower premiums for young and healthy people, but result in increased cost and potentially no coverage at all for those with preexisting conditions,\u201d Larry Levitt, the executive vice president for health policy at the nonpartisan KFF (formerly known as the Kaiser Family Foundation), told me.<\/p>\n Vice President Kamala Harris\u2019s campaign hopes to exploit that tension by launching a major advertising campaign<\/a> across swing states this week to raise an alarm about the plans from Trump and Republicans to erode the ACA\u2019s coverage. Support for the ACA\u2014in particular, its provisions protecting people with preexisting conditions\u2014may be one of Harris\u2019s best assets to hold support from older and blue-collar white women, who may otherwise be drawn to Trump\u2019s argument that only he can keep them safe from the threats of crime and undocumented immigration.<\/p>\n [Helen Lewis: Did Donald Trump notice J. D. Vance\u2019s strangest answer?<\/a>]<\/p>\n The efforts of<\/span> Republicans like Vance to roll back the ACA this long after President Barack Obama signed it into law, in 2010, are without historical precedent: No other major social-insurance program has ever faced such a lengthy campaign to undo it. After Franklin D. Roosevelt signed Social Security into law in 1935, Alf Landon, the GOP presidential nominee in 1936, ran on repealing it<\/a>. But when he won only two states, no other Republican presidential candidate ever again ran on repeal. And no GOP presidential candidate ever ran on repealing Medicare, the giant health-care program for the elderly, after President Lyndon B. Johnson signed it into law in 1966.<\/p>\n By contrast, this is the fourth consecutive election in which the GOP ticket has proposed repealing or restructuring the ACA\u2014despite polling that shows the act\u2019s broad popularity<\/a>. During Trump\u2019s first year in office, House Republicans passed a bill to rescind the law without support from a single Democrat<\/a>. The repeal drive failed in the Senate, when three Republican senators opposed it; the final gasp came when the late Senator John McCain voted no, giving a dramatic thumbs-down<\/a> on the Senate floor.<\/p>\n Most health-care analysts say that, compared with 2017, the ACA is working much better today. At that point, the ACA exchanges had begun selling insurance only three years earlier, following a disastrously glitchy rollout of the federal website that consumers could use to purchase coverage. When congressional Republicans voted on their repeal plans, about 12 million people were receiving coverage through the ACA, and the stability of the system was uncertain because insurers feared that too many of those buying insurance on the exchanges were sicker people with more expensive health needs.<\/p>\n \u201cIn 2017, not only did we have rising premiums because insurance companies were worried the market was getting smaller and sicker, but we also had insurance companies exiting markets and raising the risk that parts of the country would have nobody to provide coverage,\u201d Sabrina Corlette, a professor at Georgetown University\u2019s Center on Health Insurance Reforms, told me.<\/p>\n Today, however, \u201cwe are in a very, very different place,\u201d she said. \u201cI would argue that the ACA marketplaces are thriving and in a very stable\u201d condition. The number of people purchasing insurance through the ACA exchanges has soared past 21 million, according to the latest federal figures<\/a>. Premiums for plans sold on the ACA exchanges, Corlette said, are rising, but generally not faster than the increase faced by employer-provided insurance plans. And enough insurers are participating in the markets that more than 95 percent of consumers have access to plans from three or more firms, according to federal figures<\/a>.<\/p>\n Despite Vance\u2019s portrayal of Trump as the program\u2019s savior, the number of people receiving coverage through the ACA exchanges actually declined during Trump\u2019s term, to 11.4 million<\/a>, after he shortened the enrollment period and cut the advertising promoting it. The big leap forward in ACA participation came when the Democratic-controlled Congress in 2021 passed a major increase in the subsidies available to people for purchasing insurance on the exchanges. That made a mid-range (\u201csilver\u201d) insurance plan available for people earning up to 150 percent of the poverty level<\/a> at no cost, and ensured that people earning even four times that level would not have to pay more than 8.5 percent of their income on premiums.<\/p>\n \u201cThe biggest criticism of the ACA from the start, which in many ways was legitimate, was that the coverage was not truly affordable,\u201d Levitt said. \u201cThe enhanced premium subsidies have made the coverage much more affordable to people, which has led to the record enrollment.\u201d<\/p>\n Neera Tanden, the chief domestic-policy adviser for President Joe Biden, told me that the steady growth in the number of people buying insurance through the ACA exchanges was the best indication that the program is functioning as intended. \u201cA way to determine whether a program works is whether people are using it,\u201d Tanden said. \u201cNo one is mandated to be in the exchanges, and they have grown 75 percent in the past four years. This is a program where people are voting with their feet.\u201d<\/p>\n Conservative critics of the law nonetheless see continuing problems with the system. Michael Cannon, the director of health-policy studies at the libertarian Cato Institute, points out that many insurers participating in the ACA exchanges limit their patients to very narrow networks of doctors and hospitals, a trend acknowledged even by supporters of the law. And Cannon argues that the continued rise in premiums for plans sold on the ACA show that it has failed in its initial ambition<\/a> to \u201cbend the curve\u201d of health-care spending, as Obama often said at the time.<\/p>\n The ACA \u201chas covered marginally more people but at an incredible expense,\u201d Cannon told me. \u201cDon\u2019t tell me it\u2019s a success when it is exacerbating what everyone acknowledges to be the main problem with the U.S. health sector\u201d\u2014the growth in total national health-care spending.<\/p>\n Other analysts see a more positive story in the ACA\u2019s effect on coverage and costs. The insurance exchanges established by the ACA were one of the law\u2019s two principal means of expanding coverage for the uninsured. The second prong was its provision providing states with generous grants to extend Medicaid eligibility to more working, low-income adults. Although 10 Republican-controlled states have still refused<\/a> to extend eligibility, nearly 24 million people now receive health coverage through the ACA\u2019s Medicaid expansion.<\/p>\n Combined with the roughly 21 million receiving coverage through the exchanges, that has reduced the share of Americans without insurance to about 8 percent<\/a> of the population, the lowest ever recorded and roughly half the level it was before the ACA was passed.<\/p>\n Despite that huge increase in the number of people with insurance, health-care spending now is almost exactly equal to its level in 2009 when measured as a share of the total economy, at slightly more than 17 percent, according to KFF figures<\/a>. (Economists usually consider that metric more revealing than the absolute increase in spending.) That share is still higher than the equivalent figure for other industrialized countries, but Levitt argues that it counts as an overlooked success that \u201cwe added tens of millions of people to the health-insurance rolls and did not measurably increase health-care spending as a result.\u201d<\/p>\n [David Frum: The Vance warning<\/a>]<\/p>\n The ACA\u2019s record<\/span> of success underscores the extent to which the continuing Republican opposition to the law is based on ideological, rather than operational, considerations. The GOP objections are clustered around two poles.<\/p>\n One is the increase in federal spending on health care that the ACA has driven, through both the generous premium subsidies and the costs of expanding Medicaid eligibility. The repeal bill that the House passed in 2017 cut federal health-care spending on both fronts by a total of about $1 trillion over a decade. This spring, the conservative House Republican Study Committee released a budget<\/a> that proposed to cut that spending over the same period by $4.5 trillion; it also advocated converting Medicaid from an entitlement program into a block grant. Every serious analysis conducted of such proposals has concluded that they would dramatically reduce the number of Americans with health insurance.<\/p>\n Even if Republicans win unified control of Congress and the White House in November, they may not be able to muster the votes for such a sweeping retrenchment of federal health-care spending. (Among other things, hospitals in reliably red rural areas heavily depend on Medicaid.) At a minimum, however, Trump and congressional Republicans would be highly unlikely to extend<\/a> the enhanced ACA subsidies that expire at the end of 2025, a move that could substantially reduce enrollment on the exchanges.<\/p>\n The other main Republican objection is the issue that Vance has highlighted: the many elements of the ACA that require risk-sharing between the healthy and the sick. The ACA advanced that goal with an array of interlocking features, including its core protection for people with preexisting conditions.<\/p>\n In varying ways, the GOP alternatives in 2017<\/a> unraveled all of the law\u2019s provisions that encouraged risk-sharing\u2014by, for instance, allowing states to override them. That triggered the principal public backlash against the repeal effort, as Americans voiced their opposition to rescinding the ACA\u2019s protections for people with preexisting conditions. But Vance has made very clear that a second Trump administration would resume the effort to resurrect a pre-ACA world, in which insurers sorted the healthy from the sick.<\/p>\n