September 30, 2016 | Rosemarie Day

The Election at a Glance: What Does It Mean For Health Reform?

This election year brings us two presidential candidates with stark differences in style, approach, and experience.  Hillary Clinton and Donald Trump’s differences show up in every arena, including their approaches to health reform.  To simplify things, I’ll focus here on how each would approach one of the Affordable Care Act’s biggest goals:  reducing the number of uninsured people.

In a nutshell, here is where the law and its results stand today, and here are the projected consequences of the candidate’s positions:


Sources: See Footnotes Below



  • Clinton: Clinton’s health reform policy proposals build on the foundation of the Affordable Care Act (ACA).  Her goals include making health insurance even more affordable and continuing to reduce the number of uninsured people.  It is not yet clear how she would fund these proposals.  And the proposals require changes in the law, which to date, Congress has largely opposed.  She will have an uphill battle without a change in the make-up of Congress.  For the Senate, she needs 5 states to swing Democratic (a possibility) and for the House, she needs 28 seats to get to a Democratic majority (unlikely).
  • Trump: Trump has stated that he “will repeal and replace disastrous Obamacare.”1 He has not indicated if/how he would replace it, but he has proposed some modest alternatives, including reducing the barriers to selling health insurance across state lines.



  • Clinton: Clinton is proposing several initiatives to expand enrollment in public exchanges, including expanding the tax credit subsidies, investing $500 million annually in enrollment campaigns and adding a “public option” for health insurance.2
  • Trump: Trump’s repeal of the ACA would eliminate the support of tax subsidies for public exchange enrollees, which would affect over 83% of enrollees (10.5 million people).3


There are currently 13 state-based health insurance exchange marketplaces. The rest are partly or completely supported operationally by the federal government.4

  • Clinton: Under Clinton, the number of state-based exchanges is likely to remain stable, or possibly increase, as her administration would be more likely to find ways to support existing and emerging exchanges.
  • Trump: With a repeal of the ACA, public exchanges would no longer have the support that comes from enrollees’ tax subsidies. Without that sizeable customer base, they would be forced to close.


Currently, 32 states (including DC) have opted to expand Medicaid, and 19 states have not.5

  • Clinton: Clinton is proposing to increase the incentives for states to expand Medicaid (e.g., offering 100% funding for first 3 years).  Some prospects for state expansion include Alabama, Oklahoma, Tennessee, Virginia, and possibly Florida.6 Expansion in these states alone would cover up to 1.4 million more people.7
  • Trump: Trump has made mixed statements about Medicaid, saying he would use it to care for low-income people, but does not appear to support expanding it.8 His website indicates that he would “block grant” Medicaid to the states,9 a proposal that usually means capping the amount of funds states have to run Medicaid (as contrasted with the current federal match program) – this would have the likely effect of reducing Medicaid coverage.


According to recent Census data, there are 29 million uninsured people in the US, which is 9% of the population.10 This is a reduction of 20 million people since the ACA was passed.11 If Clinton’s ACA-related proposals are enacted, this number will further decrease (by 4 million, according to a Rand analysis).12 If Trump’s repeal of the ACA is enacted, the number of uninsured will increase, likely returning to its original levels or worse (estimated increase of uninsured of 19.7 million, according to Commonwealth Fund).13


The differences in the candidates’ approaches and their projected effects are dramatic.  The choice is ours.



Table Notes: