Trump and the Affordable Care Act: Congressional Repeal Efforts, Executive Federalism, and Program Durability

This article assesses the politics and partial success of Congress in repealing the Affordable Care Act (ACA), known as Obamacare, with particular attention to lobbying by governors. Most Republican governors behaved as members of a vertical partisan coalition supporting the national party rather than defending insurance coverage in their states. But the activities of a significant minority of these governors impeded ACA retrenchment. We also examine the role of executive federalism, highlighting how state responses to Trump administrative initiatives affected ACA durability. The Trump administration drew on waivers, executive orders, funding decisions, administrative rules, the social media, and other executive branch tools to sabotage the health insurance exchanges and undercut Medicaid. As of 2018, the Trump administration actions had contributed to some erosion in exchange coverage, but far less than many had anticipated. The degree to which Medicaid waivers encouraged by the Trump administration will precipitate enrollment declines in that program remains to be seen.