A new round of Republican proposals to restructure the Affordable Care Act (ACA) has revived the same core challenge the party has struggled with since Donald Trump’s first term: their health care plans disproportionately hurt key voter groups within today’s Republican coalition.
With enhanced ACA subsidies scheduled to expire soon, millions of Americans could face steep premium increases or lose coverage entirely. To avoid that political fallout, Trump and several GOP lawmakers have suggested redirecting ACA subsidies into direct payments that individuals could use for health-related expenses.
While this approach may appear beneficial for younger, healthier buyers, most health policy experts say it would lead to higher costs and reduced access for older, working-class, and lower-income Americans — voters who increasingly form the backbone of the modern GOP.
In essence, despite new packaging and updated mechanisms, Republican leaders such as Sens. Rick Scott and Bill Cassidy are revisiting the same policy dilemma that emerged during the 2017 “repeal and replace” effort: the tension between conservative ideology and the economic interests of their own supporters.
Sabrina Corlette of Georgetown University noted that while Republicans are discussing multiple ideas, none would avoid higher ACA premiums and reduced protections for people with preexisting conditions.
A Two-Track Republican Push Against the ACA
This new Republican movement marks a surprising shift after the party spent much of the recent election cycle avoiding direct clashes over the ACA. Yet the GOP is now targeting both major components of the law that helped reduce the uninsured rate to just 8% in 2023 — the lowest in U.S. history.
Their 2023 “One Big Beautiful Bill Act” proposed deep cuts to Medicaid expansion, which currently covers around 20 million low-income adults. According to the Congressional Budget Office, the bill would eliminate coverage for roughly half of those individuals and reduce Medicaid spending by over $900 billion in 10 years.
Simultaneously, Republicans aim to reshape the ACA’s private insurance marketplace, used by more than 24 million people, either by allowing enhanced subsidies to lapse or by replacing them with direct cash transfers.
Combined, these aggressive moves place Republicans back in the center of a health care debate they once hoped to sidestep.
Larry Levitt of KFF described the GOP’s latest ambitions as a renewed attempt at “repeal and replace,” even if the language is different.
New GOP Strategy: Direct Payments Instead of Subsidies
Trump has floated the idea of converting ACA tax credits entirely into direct payments deposited into health savings accounts. Scott’s proposal would shift all ACA subsidies into “Trump Health Freedom Accounts” for participating states. Cassidy is working on a more limited plan that would convert only Biden’s enhanced subsidies, not the original ACA tax credits.
Policy experts say these ideas resurrect the central issues Republicans faced in 2017. Before the ACA, individuals with preexisting conditions often could not find affordable coverage, and insurers regularly charged older adults several times more than younger buyers.
The ACA mitigated those problems through broad risk-sharing — requiring all customers, including healthy young adults, to participate in the same insurance pool with robust coverage standards. The GOP proposals would weaken this system and risk returning the market to one where insurers favor the young and healthy at the expense of older and sicker consumers.
While Republicans argue their plans offer more freedom and lower costs for healthier individuals, Democrats — and many analysts — warn these changes would push comprehensive plans into a dangerous “death spiral” as healthy customers opt for cheaper, high-deductible alternatives.
Political Risks for the GOP
The party’s challenge is amplified by its shifting voter base. Large numbers of older, working-class, rural, and non-college-educated Americans — many with chronic health issues — now lean heavily Republican. These voters would likely suffer most under the GOP’s proposals.
Studies from KFF and NYU show that preexisting conditions are more prevalent among people over 45, those without college degrees, and those with lower incomes — all demographics that are disproportionately represented in Republican-held districts.
Democratic strategist Leslie Dach predicts the GOP’s revived assault on the ACA will play a major role in upcoming elections, potentially more so than in 2018, when the push to repeal the ACA contributed to major Republican losses.
Even conservative policy voices acknowledge the dilemma. Michael Cannon of the Cato Institute argues Republicans risk backlash whether they extend or eliminate subsidies — and likely lack the consensus needed to implement a replacement plan quickly.
Ultimately, the recurring debate reflects the broader philosophical divide between the parties:
• Republicans prioritize consumer choice and market flexibility, even if it separates healthy people from sicker ones.
• Democrats prioritize risk-sharing, aiming to ensure everyone — regardless of health status — has affordable coverage through collective systems like the ACA, Medicaid, and Medicare.
Health care remains one of the clearest markers of the parties’ contrasting visions of the role of government and the responsibilities citizens owe each other.
