The ACA's individual mandate — which required most Americans to have health insurance or pay a penalty — was eliminated as part of the Tax Cuts and Jobs Act. The mandate had been the mechanism that kept healthy young people in insurance pools, preventing adverse selection. Without it, healthy people are more likely to forgo insurance, leaving only sicker people in the pools, which drives premiums higher. The CBO projected the elimination would result in 13 million fewer insured Americans by 2027.
The ACA required insurers to reduce cost-sharing (deductibles, copayments) for low-income enrollees, then reimbursed them for the cost. Trump stopped making these payments without congressional authorization. Insurers — who were legally required to provide the reduced cost-sharing — responded by raising premiums to compensate. Premiums spiked in the 2018 plan year. Federal courts later ordered the payments reinstated.
HHS cut the ACA open enrollment advertising budget from $100 million to $10 million — a 90% reduction. Open enrollment outreach is how people who are eligible for subsidized ACA coverage learn they can enroll. Cutting outreach meant fewer eligible people enrolled, particularly in low-income and minority communities. Enrollment declined in some states during the Trump years.
The administration expanded rules allowing the sale of short-term health plans lasting up to 364 days — plans that are not required to cover pre-existing conditions, essential health benefits, or preventive care. These plans are cheaper because they cover less and can deny coverage to sick people. They pull healthy people out of ACA risk pools, increasing premiums for everyone else.
The Trump administration sided with Republican state attorneys general in a lawsuit arguing that because the individual mandate was zeroed out in the tax bill, the entire ACA was unconstitutional. In 2020, the Supreme Court took the case; in 2021, after Biden took office, it ruled 7-2 that the plaintiffs lacked standing — narrowly avoiding a ruling that would have ended coverage for tens of millions of people.
This post distinguishes between documented facts, allegations, and analysis. Where motive, intent, corruption, or illegality remains disputed in the public record, the text attributes that judgment to court findings, official records, direct quotes, or the reporting linked below.
- Individual mandate elimination — Tax Cuts and Jobs Act, December 22, 2017; CBO score: 13 million fewer insured.
- CSR payments — cut October 2017; court orders to reinstate; federal court cases documented.
- Outreach budget cut — HHS announcement; from $100M to $10M; Kaiser Family Foundation analysis.
- Texas v. United States — Supreme Court, June 17, 2021; 7-2 ruling on standing.
- Short-term plans rule — HHS final rule August 2018; expanded duration to 364 days.