The Affordable Care Act, also known as Obamacare, remains popular with the public, garnering the approval of 54% of U.S. adults, according to a recently released Gallup poll. But experts say that may not insulate the federal health insurance program from change as President-elect Donald Trump and his fellow Republicans look to renew $4 trillion in expiring tax cuts.

Many provisions of the 2017 Tax Cuts and Jobs Act (TCJA), a signature law passed during Trump’s first term, are due to sunset at the end of 2025. Republican leaders are now strategizing on how to extend the cuts, while the president-elect has also pledged to slash corporate taxes and eliminate taxes on workers’ tips and overtime pay. 

But renewing the TCJA tax breaks alone without reducing federal spending would add nearly $4 trillion to the nation’s deficit through 2035, according to the Committee for a Responsible Federal Budget, an advocacy group focused on reducing the nation’s debt.

Trump has already taken two of the biggest government programs — Social Security and Medicare — off the table for potential cuts. Reduced defense spending is also viewed as unlikely, meaning nearly half of federal spending would be protected, Larry Levitt, executive vice president for health policy at KFF (formerly Kaiser Family Foundation,) said in a recent JAMA article. 

That leaves “Medicaid, which is the next largest source of federal spending, and the ACA as prime targets for spending cuts. The math is inescapable,” Levitt stated.

Will Trump repeal the ACA?

By contrast, an outright repeal of the ACA is unlikely. While Trump has continued to criticize the health care expansion measure, he has retreated from his previous vows to axe the ACA entirely.

“President Trump will deliver on his pledge to make his highly successful tax cuts permanent and ease the financial burden on families across the country. He will also end the drain on our health care system so that our country can continue to care for Americans who rely on Medicaid, Medicare and Social Security,”  Trump-Vance Transition Spokesperson Anna Kelly told CBS News.

Support for the ACA hit a record 55% in 2017, the first time a majority of Americans approved of the health care law since Gallup started asking about it in 2012. That high watermark came a month after failed efforts by then-President Trump and the GOP to repeal and replace the law.

“The Affordable Care Act is still politically divisive, but overall more popular with the public than ever,” Levitt told CBS MoneyWatch. “It’s unlikely Republicans will try to repeal the ACA again, but cuts to the ACA and Medicaid are quite possible if Republicans are looking to pay for tax cuts.”

Brad Ellis, senior director at Fitch Ratings, noted that Trump and Republican lawmakers have expressed interest in changing how the ACA operates, including introducing high-risk participant pools and possibly reducing subsidies for public exchange business. Such changes could hurt enrollment, he said in a recent report. 

During the presidential campaign, Trump said he had “concepts of a plan” to replace the ACA. 

“Obamacare stinks,” Trump recently told NBC News’ “Meet the Press. “If we come up with a better answer, I would present that answer to Democrats and to everybody else and I’d do something about it.”

Big cuts without lifting a finger

Republicans can make big cuts to the ACA simply by standing pat. That’s because enhanced ACA premium subsidies, which were enacted after President Biden was elected and the Democrats took control of Congress, are scheduled to lapse along with the 2017 tax cuts at the end of 2025. The drop in financial aid ACA enrollees would increase out-of-pocket premiums by an average of $705 a year, or 79%, according to a KFF analysis.

The Congressional Budget Office projects that letting the additional ACA subsidies expire would reduce the federal deficit by $335 billion over a decade, relative to extending them permanently. 

Enrollment in the ACA nearly doubled to a record 21 million after the enhanced subsidies went into effect. The CBO estimates that 6.9 million fewer people would be enrolled in ACA Marketplace plans without the subsidies, and 3.4 million more would be uninsured. 

The impact would be felt nationwide, but particularly in Southern states that have not expanded Medicaid eligibility under the ACA, according to Levitt, who noted that the five states with the fastest growth in ACA enrollment since 2020 are Georgia, Mississippi, South Carolina, Tennessee and Texas. 

“Health care was not a big topic during the campaign, so I can imagine that voters could be surprised to see cuts to Medicaid and the ACA that they didn’t hear about during the campaign,” Levitt said. “As frustrated as people are with the current state of health insurance, disrupting the status quo makes them nervous.”

Medicaid a target for cuts?

Medicaid accounts for more than $600 billion a year in federal spending and covers 81 million people, according to KFF. 

“There are indications that support for Medicaid will decrease under the new administration, suggesting lower enrollment and revenue headwinds for this program,” stated Fitch’s Ellis. 

Trump was silent on Medicaid during the 2024 campaign, but his budget proposals during his first administration included a plan to cap federal spending on Medicaid. The Project 2025 plan prepared by the Heritage Foundation and a coalition of conservative groups, is recommending changes to Medicaid including a limit on federal spending.

“The centerpiece of several prominent plans — Project 2025, the Republican Study Committee fiscal year 2025 (RSC) budget and the fiscal year 2025 House GOP budget resolution — is to cap and deeply cut federal Medicaid funding,” Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families, noted in September.

Trump sought distance himself from Project 2025 in the months leading up to the election, criticizing some of its policy proposal as “abysmal.”

But Levitt said the ACA and Medicaid could still end up facing cuts as the Republicans, who will control the White House and both houses of Congress, hash out their fiscal plans after President-elect Trump assumes office. 

“So much depends on whether there is pressure to pay for tax cuts with spending reductions. If Republicans are willing to cut taxes and increase the deficit, we may not see big cuts to the ACA and Medicaid,” said Levitt. “There are Republicans who may insist on spending cuts to offset tax cuts. If that’s the case, the ACA and Medicaid are very likely to be on the chopping block.”