Trump’s allies claim he’s incapable of gutting Obamacare. He’s already doing it.

These assurances conveniently ignore the basic facts of California v. Texas — in which the plaintiffs argue the entire ACA should be struck down as a result of its individual mandate penalty being brought to zero in 2017 legislation. That lawsuit has the full support of the Trump administration and 18 Republican-led states, and has already received favorable rulings from conservative, lower-court judges — whom these same senators helped install. These assurances also paper over the Senate Republicans’ recent vote rejecting a measure to halt federal support for the lawsuit. All of this fits into a larger pattern: Since he took office, Trump’s budgets have called for not only repealing the Affordable Care Act, but even deeper cuts to the Medicaid program. But when it comes to Trump’s plans for health care, the best thing he and his Republican allies have going for them is skepticism that they can pull them off.

Proposals to do away with the ACA’s protections are deeply unpopular — in the years since its passage in 2010, both the ACA as a whole and its individual components have gained public support. Trump has nonetheless benefited from a common narrative that his attacks on the Affordable Care Act are mere posturing. His bombastic tweets, his confusing insistence that Obamacare is already gone, and his empty promises to protect preexisting conditions have created a misleading impression that Trump has done little to change health-care policy beyond rebranding existing law. But the truth is that Trump’s opposition to the Affordable Care Act is not simply rhetorical — in fact, his policy record reflects a maximally aggressive approach to undoing the law through every legislative, administrative, and judicial channel available.

That started with the administration and its congressional allies using their precious year-one political capital to try to repeal the law through Congress. But for an unexpected, last-minute thumbs-down from Sen. John McCain (R-Ariz.), the Trump White House, the Republican House and 49 Republican senators were ready to proceed with undoing the ACA even though they never agreed on the “replace” part of their “repeal-and-replace” promise. In the wake of that legislative failure, the Trump administration pushed on by taking aggressive actions on its own to limit access to health care. One of the cruelest was urging states to put in place work requirements for Medicaid — measures that have been shown to significantly reduce health coverage without actually increasing employment. (Before a judge stayed work requirements in Arkansas — the first state to put them in effect — 18,000 adults had lost coverage in the first year.)

The Trump administration’s concerted effort to undermine participation in the ACA marketplaces — by rolling back outreach efforts, shortening open enrollment periods, and removing the individual mandate — has, by design, reduced the number of people enrolled. And the administration has taken steps to expand short-term coverage and “association health plans” that are not required to abide by ACA rules protecting people with preexisting conditions or limiting insurance company profits — both increasing the number of people with insufficient coverage and raising costs for those who seek more comprehensive insurance. The “public charge” rule — which puts immigrants’ legal status at risk if they participate in programs like Medicaid — has already had a chilling effect of discouraging people from getting benefits they are legally entitled to, due to fear of jeopardizing a family member’s immigration status or their own.

These actions have involved rulemaking processes that have mostly occurred away from the headlines, or malign neglect designed to make health programs less accessible and less effective. But their impact has been substantial: As a recent analysis by one of us shows, the number of uninsured rose by 2.3 million from 2016 to 2019 — climbing each year of the Trump administration — including 726,000 additional uninsured children. That figure, of course, does not yet include people who have lost insurance as a result of the current economic crisis — with census data showing 1.9 million adults becoming uninsured from May to July alone. The result: millions fewer people have coverage in the midst of a pandemic.

At the same time, the Trump administration’s actions have also resulted in higher costs for those who still have coverage. The average annual premium on the ACA marketplaces is $404 higher than it would be without ACA sabotage. Meanwhile, Trump administration actions to tinker with the ACA’s payment formulas have reduced the amount that enrollees receive in subsidies and increased maximum out-of-pocket costs.

Moreover, both the administration’s executive actions and California v. Texas offer a preview of how — even beyond the current Supreme Court case — Trump’s efforts to reshape the courts could put affordable health care at risk. Rulings in the courts, which have either blocked or delayed Medicaid work requirements and the public charge rule, have been a partial check on the Trump administration’s executive actions to limit access to health programs. But a Barrett confirmation — and the broader project of installing conservative judges across the Federal judiciary — could make it easier for the administration to enact such aggressive steps cutting health care even without Congress. At the same time, they could jeopardize future measures to expand health care coverage and affordability through Congress, by creating a more favorable venue for spurious challenges to new legislation.

The current Republican health strategy has benefited from the power of disbelief: It is hard to imagine that in the middle of a pandemic, a president seeking reelection would really support an effort in the courts to end health coverage for more than 20 million people and eliminate massively popular protections for tens of millions more. That disbelief — reinforced by Trump’s broken promises in many other areas — encourages attempts to dismiss the actual policies the administration has spelled out in court briefs and budget proposals as a mirage or a sideshow. But a closer look at the last few years shows that when it comes to cutting access to health care and other crucial social insurance programs, the Trump administration and its allies have been sincere in their desires and aggressive in their actions. As we consider what a second Trump term and an even more conservative federal judiciary might hold, both the administration’s record and its very public agenda should serve as a warning.

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