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President-elect Donald Trumps return to the White House could embolden Republicans who want to weaken or repeal the Affordable Care Act, but implementing such sweeping changes would still require overcoming procedural and political hurdles.

This story also ran on NPR. It can be republished for free.

Trump, long an ACA opponent, expressed interest during the campaign in retooling the health law. In addition, some high-ranking Republican lawmakers who will now have control over both the House and the Senate have said revamping the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too expensive and represents government overreach.

The governing trifecta sets the stage for potentially seismic changes that could curtail the laws Medicaid expansion, raise the uninsured rate, weaken patient protections, and increase premium costs for millions of people.

The Republican plans they dont say they are going to repeal the ACA, but their collection of policies could amount to the same thing or worse, said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a research and policy institute. It could happen through legislation and regulation. Were on alert for anything and everything. It could take many forms.

Congressional Republicans have held dozens of votes over the years to try to repeal the law. They were unable to get it done in 2017 after Trump became president, even though they held both chambers and the White House, in large part because some GOP lawmakers wouldnt support legislation they said would cause such a marked increase in the uninsured rate.

Similar opposition to revamping the law could emerge again, especially because polls show the ACAs protections are popular.

While neither Trump nor his GOP allies have elaborated on what they would change, House Speaker Mike Johnson said last month that the ACA needs massive reform and would be on the partys agenda should Trump win. Email Sign-Up

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Congress could theoretically change the ACA without a single Democratic vote, using a process known as “reconciliation.” The narrow margins by which Republicans control the House and Senate mean just a handful of “no” votes could sink that effort, though.

Many of the more ambitious goals would require Congress. Some conservatives have called for changing the funding formula for Medicaid, a federal-state government health insurance program for low-income and disabled people. The idea would be to use budget reconciliation to gain lawmakers approval to reduce the share paid by the federal government for the expansion population. The group that would be most affected is made up largely of higher-income adults and adults who dont have children rather than traditional Medicaid beneficiaries such as pregnant women, children, and people with disabilities.

A conservative idea that would let individuals use ACA subsidies for plans on the exchange that dont comply with the health law would likely require Congress. That could cause healthier people to use the subsidies to buy cheaper and skimpier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

Its similar to an ACA repeal plan, said Cynthia Cox, a vice president and the director of the Affordable Care Act program at KFF, a health information nonprofit that includes KFF Health News. Its repeal with a different name.

Congress would likely be needed to enact a proposal to shift a portion of consumers ACA subsidies to health savings accounts to pay for eligible medical expenses.

Trump could also opt to bypass Congress. He did so during his previous tenure, when the Department of Health and Human Services invited states to apply for waivers to change the way their Medicaid programs were paid for capping federal funds in exchange for more state flexibility in running the program. Waivers have been popular among both blue and red states for making other changes to Medicaid.

Trump will do whatever he thinks he can get away with, said Chris Edelson, an assistant professor of government at American University. If he wants to do something, hell just do it.

Republicans have another option to weaken the ACA: They can simply do nothing. Temporary, enhanced subsidies that reduce premium costs and contributed to the nations lowest uninsured rate on record are set to expire at the end of next year without congressional action. Premiums would then double or more, on average, for subsidized consumers in 12 states who enrolled using the federal ACA exchange, according to data from KFF.

That would mean fewer people could afford coverage on the ACA exchanges. And while the number of people covered by employer plans would likely increase, an additional 1.7 million uninsured individuals are projected each year from 2024 to 2033, according to federal estimates.

Many of the states that would be most affected, including Texas and Florida, are represented by Republicans in Congress, which could give some lawmakers pause about letting the subsidies lapse.

The Trump administration could opt to stop defending the law against suits seeking to topple parts of it. One of the most notable cases challenges the ACA requirement that insurers cover some preventive services, such as cancer screenings and alcohol use counseling, at no cost. About 150 million people now benefit from the coverage requirement.

If the Department of Justice were to withdraw its petition after Trump takes office, the plaintiffs would not have to observe the coverage requirement which could inspire similar challenges, with broader implications. A recent Supreme Court ruling left the door open to legal challenges by other employers and insurers seeking the same relief, said Zachary Baron, a director of Georgetown Universitys Center for Health Policy and the Law.

In the meantime, Trump could initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.

The early executive orders will give us a sense of policies that the administration plans to pursue, said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. Early signaling through executive orders will send a message about what guidance, regulations, and policy could follow.

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to begin modifying the ACA and ultimately increased consumer access to health plans that didnt comply with the law. He could issue similar orders early on in his new term, using them to start the process of compelling changes to the law, such as stepped-up oversight of potential fraud.

The administration could early on take other steps that work against the ACA, such as curtailing federal funding for outreach and help signing up for ACA plans. Both actions depressed enrollment during the previous Trump administration.

Trump could also use regulations to implement other conservative proposals, such as increasing access to health insurance plans that dont comply with ACA consumer protections.

The Biden administration walked back Trumps efforts to expand what are often known as short-term health plans, disparaging the plans as junk insurance because they may not cover certain benefits and can deny coverage to those with a preexisting health condition.

The Trump administration is expected to use regulation to reverse Bidens reversal, allowing consumers to keep and renew the plans for much longer.

But drafting regulations has become far more complicated following a Supreme Court ruling saying federal courts no longer have to defer to federal agencies facing a legal challenge to their authority. In its wake, any rules from a Trump-era HHS could draw more efforts to block them in the courts.

Some people with ACA plans say theyre concerned. Dylan Reed, a 43-year-old small-buiness owner from Loveland, Colorado, remembers the days before the ACA and doesnt want to go back to a time when insurance was hard to get and afford.

In addition to attention-deficit/hyperactivity disorder and anxiety, he has scleroderma, an autoimmune disease associated with joint pain and numbness in the extremities. Even with his ACA plan, he estimates, he pays about $1,000 a month for medications alone.

He worries that without the protections of the ACA it will be hard to find coverage with his preexisting conditions.

It’s definitely a terrifying thought, Reed said. I would probably survive. I would just be in a lot of pain. Stephanie Armour: sarmour@kff.org, @StephArmour1

Sam Whitehead: swhitehead@kff.org

Julie Rovner: jrovner@kff.org, @jrovner Related Topics Elections Health Care Costs Health Industry Insurance Obamacare Plans Trump Administration U.S. Congress Contact Us Submit a Story Tip

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Stars rule forward Hintz out for Game 3 vs. Oilers

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Stars rule forward Hintz out for Game 3 vs. Oilers

EDMONTON — Dallas forward Roope Hintz has been ruled out for Game 3 of the Stars’ Western Conference finals series against the Edmonton Oilers on Sunday.

Hintz was a game-time decision for Dallas after leaving the third period of Game 2 on Friday with an injury. The center took a slash from Edmonton defenseman Darnell Nurse less than four minutes into that final frame and was helped off the ice without appearing to put weight on his left leg.

Stars’ coach Pete DeBoer said on Saturday they were awaiting test results on Hintz before determining his status for Game 3. Hintz travelled with the team from Dallas and arrived at Rogers Place on Sunday without wearing a walking boot.

DeBoer still declared Hintz’s status uncertain about an hour before puck drop. Hintz took warmups with the Stars before Game 3 but left several minutes early without participating in line rushes.

Hintz has five goals and 11 points in 15 postseason games and ranked fourth on the Stars in regular-season scoring with 28 goals and 67 points in 76 games.

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Hurricanes: ‘Tough look’ not sticking up for Aho

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Hurricanes: 'Tough look' not sticking up for Aho

FORT LAUDERDALE, Fla. — The Carolina Hurricanes regretted not sticking up for star center Sebastian Aho when he was mauled by Florida Panthers winger Matthew Tkachuk late in their Game 3 loss on Saturday night.

In the third period, with the Panthers cruising to a 6-2 win and a 3-0 lead in the Eastern Conference finals, Tkachuk went after Aho with a series of shoves and cross-checks, eventually putting him in a headlock and bringing him down to the ice. The incident was seen as retaliation for Aho’s low hit on Florida’s Sam Reinhart that injured him in Game 2 and kept the forward out of the lineup on Saturday.

“I don’t really look at it as intent or intimidation at all. It’s just sticking up for teammates,” said Tkachuk, who was given a roughing penalty and a 10-minute misconduct. “We’re a family in there. It could happen to anybody and there’s probably 20 guys racing to be the guy to stick up for a teammate like that. That’s just how our team’s built. That’s why we’re successful. I don’t think any of us would be thrilled at that play in Game 2.”

But while Tkachuk was on top of Aho, who remained in the game, there was no chaotic response from the Hurricanes, nor any retaliation for the rest of the game. Carolina forward Taylor Hall said, in hindsight, there needed to be some reaction.

“I think what happened is that we don’t want to take penalties after the whistle, and they’re very good at goading you into them. But we have to support each other and make sure all five of us are having each other’s backs,” Hall said. “That was a tough look there, but we’ll battle for each other to no end.”

Coach Rod Brind’Amour said there needed to be a response, especially since the game was all but over on the scoreboard

“In that situation, there probably does. There’s a fine line. You don’t want to start advocating for that kind of hockey, necessarily. But with the game out of hand, yes, we have to do a better job of that with the game out of hand,” he said.

The Hurricanes face elimination on Monday night in Sunrise. They also face a 16th straight loss in the Eastern Conference finals, a streak that stretches back to 2009.

“We’re going to give our best tomorrow,” Hall said. “I think that we have a belief in our room, honestly. We’re playing for our season.”

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Horse trainer Clement dies from rare eye cancer

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Horse trainer Clement dies from rare eye cancer

Christophe Clement, who trained longshot Tonalist to victory in the 2014 Belmont Stakes and won a Breeders’ Cup race in 2021, has died. He was 59.

Clement announced his own death in a prepared statement that was posted to his stable’s X account on Sunday.

“Unfortunately, if you are reading this, it means I was unable to beat my cancer,” the post said. “As many of you know, I have been fighting an incurable disease, metastatic uveal melanoma.”

It’s a type of cancer that affects the uvea, the middle layer of the eye. It accounts for just 5% of all melanoma cases in the U.S., however, it can be aggressive and spread to other parts of the body in up to 50% of cases, according to the Melanoma Research Alliance’s website.

The Paris-born Clement has been one of the top trainers in the U.S. over the last 34 years. He learned under his father, Miguel, who was a leading trainer in France. Clement later worked for the prominent French racing family of Alec Head. In the U.S., he first worked for Hall of Fame trainer Shug McGaughey.

Clement went out on his own in 1991, winning with the first horse he saddled at Belmont Park in New York.

“Beyond his accomplishments as a trainer, which are many, Christophe Clement was a kind and generous man who made lasting contributions to the fabric of racing in New York,” Dave O’Rouke, president and CEO of the New York Racing Association said in a statement.

Clement had 2,576 career victories and purse earnings of over $184 million, according to Equibase.

“I am very proud that for over 30 years in this industry, we have operated every single day with the highest integrity, always putting the horses’ wellbeing first,” he wrote in his farewell message.

One of his best-known horses was Gio Ponti, winner of Eclipse Awards as champion male turf horse in 2009 and 2010. He finished second to Zenyatta in the 2009 Breeders’ Cup Classic.

In the 2014 Belmont, Tonalist spoiled the Triple Crown bid of California Chrome, who tied for fourth. Tonalist won by a head, after not having competed in the Kentucky Derby or Preakness that year.

Steve Coburn, co-owner of California Chrome, caused controversy when he said afterward the horses that hadn’t run in the other two races took “the coward’s way out.” He later apologized and congratulated the connections of Tonalist.

Clement’s lone Breeders’ Cup victory was with Pizza Bianca, owned by celebrity chef Bobby Flay, in the Juvenile Fillies Turf. Clement had seven seconds and six thirds in other Cup races.

“It was Christophe’s genuine love for the horse that truly set him apart,” Eric Hamelback, CEO of the National Horseman’s Benevolent and Protective Association, said in a statement. “He was a consummate professional and a welcoming gentleman whose demeanor was always positive, gracious and upbeat.”

Clement’s statement said he would leave his stable in the hands of his son and longtime assistant, Miguel.

“As I reflect on my journey, I realize I never worked a day in my life,” Clement’s statement said. “Every morning, I woke up and did what I loved most surrounded by so much love.”

Besides his son, he is survived by wife Valerie, daughter Charlotte Clement Collins and grandson Hugo Collins.

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