Trump has attacked Obamacare relentlessly—and millions more Americans were uninsured during his presidency

At the end of the first two years of Joe Biden’s presidency, 3.3 million more U.S. residents had health insurance than in 2019, according to a Capital & Main analysis of U.S. Census data conducted with the support of Thomas Data Consulting. That increase led to a 1.2% decline in the national uninsured rate and the lowest rate of residents without health insurance in U.S. history.

By contrast, Donald Trump oversaw an increase of 2.3 million uninsured people during the first three years of his presidency and a 0.6% increase in the national uninsured rate.

Health care affordability may not dominate the media coverage of this year’s presidential campaigns, but it remains a critical issue for many Americans, with 57% describing it as a “very big problem,” according to a Pew Research Center survey released in May. Health care is especially unaffordable for the roughly 27 million people who still lack insurance. That unaffordability makes uninsured people more likely to skip or delay medical treatment, leading to worse health care outcomes, according to a KFF report.

Under Trump, 39 states saw increases in their uninsured rates, and the number of uninsured people swelled by more than 440,000 across the key battleground states of Arizona, Georgia, Michigan, Nevada, North Carolina, Pennsylvania, and Wisconsin, according to census data. Meanwhile, in the first two years of the Biden administration, all but three states saw decreases in their uninsured rates. The number of uninsured fell in six out of seven swing states under Biden, resulting in 580,000 fewer uninsured people in those states.

Experts attribute the shifts in coverage to contrasting health policy approaches. During his presidency, Trump sought to undermine the Affordable Care Act (ACA), former President Barack Obama’s health care law, which expanded health coverage and mandated health insurance as a means to reduce health care costs. By contrast, Biden focused on expanding and protecting the ACA and signed executive orders to reverse Trump’s policies.

The reduction in the number of uninsured people under Biden also stemmed from pandemic-era policies that were put in place under both presidents. Some of those protections expired in 2023, and more will expire in 2025. Uninsured rates are expected to rise again absent federal action.

In 2016, Trump campaigned on a policy of repealing and replacing the Affordable Care Act. Trump nearly succeeded in dismantling the ACA in 2017, but it was saved by a single vote when Republican Sen. John McCain cast a dramatic “no” vote, joining two other Republican senators in preserving the law. Instead, Trump weakened the act’s effectiveness while in office.

Trump’s health care approach involved “a mix of both undermining and attacking the ACA coupled with attacks on the Medicaid program,” said Natasha Murphy, director of health policy at the Center for American Progress, a progressive think tank in Washington.

Those attacks involved making it harder to apply for coverage through the act’s health insurance marketplace, a service designed to help people find and enroll in coverage. The open enrollment period was halved; promotional advertisements were canceled, and the ACA’s $100 million advertising budget was slashed by 90% under Trump.

Trump also eliminated the financial penalty for failing to secure health insurance, effectively making the mandate “toothless,” according to Paulette Cha, health policy research fellow at the Public Policy Institute of California. A month before Trump eliminated the penalty, the Congressional Budget Office estimated that doing so would raise premiums and result in millions more uninsured people.

Finally, Trump expanded the public charge rule, a policy that allowed the government to deny green cards and visas to immigrants who have received public assistance, such as Medicaid.

ACA marketplace open enrollment fell every year from 2016 to 2020.

Under Trump, Texas saw its uninsured population balloon by nearly 700,000 people; Florida by more than 240,000; and Arizona by almost 130,000 from 2016 to 2019, according to census data.

When COVID-19 began upending American life in 2020, the Trump administration temporarily abandoned its strategy of attacking Medicaid, and Trump signed a Democrat-sponsored bill that increased funding to states that prolonged people’s Medicaid coverage until the end of the federal health emergency instead of disenrolling them when their eligibility would have typically expired.

“That was a policy that really made a huge difference in ensuring access to much needed COVID treatment, testing and, subsequently, vaccines,” Murphy said. In fact, according to Centers for Disease Control and Prevention estimates, uninsured rates ticked down in 2020 from 2019. However, they still remained higher than when Trump took office.

In contrast to Trump, Biden campaigned for president in 2020 on a promise of expanding and protecting the ACA. Eight days after his inauguration, he signed an executive order that made it easier to enroll in Medicaid and private plans by giving people more time to sign up for insurance. He also reversed some of Trump’s executive orders that weakened the ACA by granting federal agencies broad discretion to change, delay or waive provisions of the law they considered financially burdensome.

In addition, Biden signed the American Rescue Act in March 2021, which expanded the availability of subsidies and tax credits for low- and moderate-income people seeking health insurance through the ACA. His signature climate and health bill, the Inflation Reduction Act, extended those provisions through 2025.

By proposing an updated tax law, the Biden administration also managed to fix the “family glitch,” an Internal Revenue Service interpretation of the ACA that made employer-sponsored family health insurance unaffordable for more than 5 million people. If an employer’s coverage plan was too costly, the fix allowed family members to access federal subsidies to make the insurance more affordable.

All those policies helped send the uninsured population plummeting.

Black and Latino populations, who have historically had lower coverage rates than white people, experienced some of the highest rates of coverage gains.

But attributing all coverage gains to Biden’s policy agenda may not be the whole story, according to Cha.

“The last four years, it’s been extremely hard to disentangle any policy from the fact that we’ve been operating in a pandemic and post-pandemic era,” Cha said.

Though the uninsured rate has significantly declined since 2019, recent data suggests Biden’s record of overseeing historic coverage gains may be in jeopardy.

A CDC report released this month estimated that the uninsured rate jumped from 7.7% in the first quarter of 2023 to 8.2% in the same quarter of 2024. The jump was largely the result of states’ disenrolling people from Medicaid after the expiration of pandemic-era protections, according to the Congressional Budget Office. Not all such people are now without insurance. Some may have signed up for health plans through the ACA’s health insurance marketplace, which has seen record enrollment. Some may have secured health insurance in another way. But if trends continue, the budget office estimates that the uninsured population will grow by about 6 million people by 2034.

This election cycle, Trump has shifted away from his 2016 pledges to eliminate the ACA but has yet to offer clear alternative policies. His campaign’s official platform, Agenda 47, is generally light on policy specifics but states that Republicans “will increase transparency, promote choice and competition, and expand access to affordable healthcare.”

Project 2025, a blueprint for the next Republican administration created by conservative think tank the Heritage Foundation, calls for the next GOP president to implement lifetime caps on Medicaid benefits, a move that Murphy estimated could imperil the health care coverage of more than 18 million people. Trump has distanced himself from Project 2025, but reports suggest that dozens of Project 2025 personnel have worked for Trump and that he has praised the Heritage Foundation’s work on laying the groundwork for a future administration.

In mid-August, Vice President Kamala Harris unveiled her economic agenda, which included a proposal to expand subsidies for ACA plans and to work with states to “cancel medical debt for millions of Americans.”

According to Cha, much of the progress in increasing coverage rates was accomplished during the Obama administration with the passage of the ACA, which reduced the number of uninsured people by almost 20 million over the course of his term. What’s remaining, Cha said, is largely the “unglamorous” work of closing loopholes and “sweeping up all the last stragglers who aren’t eligible or don’t have access.”

—Jeremy Lindenfeld, Capital & Main

This piece was originally published by Capital & Main, which reports from California on economic, political, and social issues.