Overview
As of late November 2025, President Trump is proposing a healthcare framework that represents a significant
shift from earlier Republican efforts to repeal the Affordable Care Act (ACA). The plan is still being
finalized and is facing internal Republican debate and delays.
Key Components of the Trump Healthcare Proposal
- ACA Subsidies Extension (With New Limits): 2-year extension of enhanced ACA premium tax
credits, but limits eligibility to those earning up to 700% of the federal poverty level. All enrollees
would pay a minimum premium, and zero-premium plans would be eliminated.
- Health Savings Accounts (HSAs): Option for ACA enrollees with lower-tier or
catastrophic plans to get some tax credit in an HSA. HSA expansion allows millions more Americans to
save pre-tax for health expenses.
- Eligibility Verification: Requires full verification before subsidies are issued and
ends automatic re-enrollment.
- Other Changes: Medicaid work requirements, shorter ACA open enrollment, new
short-term/copper plans, most-favored-nation (MFN) drug pricing.
How Does It Differ From the Affordable Care Act?
| Aspect |
Current ACA |
Trump's Proposal |
| Income Eligibility |
No limit for subsidies |
Cap at 700% FPL
(~$109,550 individual) |
| Minimum Premiums |
Zero-premium plans available (for low-income) |
2% of income or $5 minimum for all |
| Subsidy Distribution |
Paid directly to insurers |
Can go to consumer HSAs |
| Enrollment Process |
Automatic re-enrollment |
Pre-enrollment verification only |
| Plan Options |
ACA-compliant only |
Expand short-term/copper plans |
| Medicaid |
No federal work requirement |
Mandatory work requirements (2027+) |
Estimated National Uninsured Increase by Group
Impact By Population
1. Employer-Sponsored Insurance
- Minimal immediate change. The tax status of employer insurance remains, and telehealth/HSA features
expand for many workers.
- Some may shift to employer plans if priced out of ACA/Medicaid; small businesses could be impacted if
future incentives shift.
2. Medicare (Traditional and Advantage)
- Drug prices may fall under expanded negotiation rules for common prescriptions.
- Medicare Advantage gets a 5.1% payment bump, higher premiums (+out-of-pocket max increases), and
sometimes fewer "extra" benefits.
- Some increased prior-authorization requirements and deductible changes.
3. Medicaid Recipients
- Major impacts: New 80-hour/month work requirement starting 2027 (with exemptions for several groups),
more frequent eligibility checks, retroactive coverage period shrinks, asset and provider restrictions.
- CBO estimates over 5 million will lose Medicaid by 2034 from work requirements alone; 10 million more
could lose coverage from all provisions combined.
4. Uninsured Americans
- Low/middle-income may maintain coverage if ACA subsidies are extended; premiums expected to more than
double if not.
- Above 700% FPL lose access to premium assistance and face full costs, likely increasing the uninsured
rate among the middle and upper-middle class.
- Short-term/catastrophic/HSA-compatible plans expand but lack protection for pre-existing conditions and
essential health benefits.
| Group |
Likely Impact |
| Employer-covered |
Minor changes; more HSA/telehealth flexibility |
| Medicare |
Slight cost increases, expanded drug price negotiation |
| Medicare Advantage |
Higher payments, premiums, and possible changes to "extras" |
| Medicaid |
Major new work requirement, millions lose eligibility |
| Uninsured |
Earlier ACA subsidy expiration or new income cap may increase uninsured rates |
Critical Context & Political Landscape
- Deep partisan divide: Some Republicans resist any ACA subsidy extension; moderates support
limited extension. Democrats demand no new limits.
- Millions at risk: Without federal action, up to 24 million individuals could lose their ACA plan
subsidy or coverage by January 2026.
- Uncertainty: Rollout delayed, final law not passed; open enrollment window closes December 15,
2025. Impacted individuals face dramatic premium hikes or policy loss in 2026.
Summary Table: Who's Impacted, and How
| Group |
Major Change |
Risk/Benefit |
| Employer-Insured |
Minimal |
Status quo, more HSA/telehealth |
| Medicare |
Slight increases in cost |
Benefit: Drug price negotiations |
| Medicare Advantage |
Bigger payments, higher OOP max |
Mixed: Higher payments, plan changes |
| Medicaid |
Work requirement, shorter retroactive period |
Risk: Millions could lose coverage |
| ACA Marketplace |
Subsidy expiration or income cap at 700% FPL |
Risk: Higher premiums, increased uninsured |
| Uninsured |
May not qualify; limited affordable options |
Mixed: Some low-income subsidized, others exposed to high costs |
