Sabotage, Not Reform
The ACA threatened Republican power and Project 2025 finishes the job
Republicans have voted more than 70 times to repeal or undermine the Affordable Care Act. 1 Yet, if the ACA were truly the disaster they claim, they would have replaced it years ago. They controlled Congress. They held the White House. They had the votes, and still, nothing. 2 What they offered instead was repeal without replacement, sabotage without accountability, and a decade-long campaign to make the law fail by design. That pattern tells us something important. The problem was never the ACA’s flaws. The problem was that it worked, and in doing so, exposed how much of American healthcare was never about care at all.
It is about power. Who has it, who loses it, and why some freedoms are always labeled “too expensive” the moment everyone might share them.
The real reason Republicans hate the ACA is that it disrupts the business model that underpins modern Republican power. When the ACA became law in 2010, it loosened the grip that employers, insurers, and politicians held over who gets to live securely and who does not. Since then, the GOP has worked steadily to weaken the program, not only because they ultimately want it gone, but also because they fear it could evolve into something larger - a universal healthcare system like those operating successfully in other wealthy democracies. To that end, Republicans have targeted the ACA in ways that raise costs, reduce enrollment, and increase insecurity - especially for healthier and lower-income people - without taking the political hit for ending coverage outright.
1. The ACA Breaks the Employer Control System
Before the ACA, health insurance functioned as a form of labor discipline. Coverage was tied to employment, excluding low-wage, part-time, and gig workers. Changing jobs often meant losing care. Pre-existing conditions were routinely excluded, locking people into bad jobs simply to stay insured. The ACA weakened that control by guaranteeing coverage regardless of health status, offering subsidies independent of employment, and expanding Medicaid to low-income adults. 3 That shift is structurally threatening to a political economy built on low wages, weak labor power, and worker dependence.
In 2012, the Supreme Court upheld the Affordable Care Act but ruled that states could not be required to expand Medicaid, effectively making expansion optional and allowing Republican-led states to block coverage for millions of low-income adults. 4
2. Universal Healthcare Weakens Corporate Leverage Permanently
Health insurance is not just a “benefit.” It is a control mechanism. Employers use it to suppress unionization, discourage job mobility, and enforce compliance - don’t rock the boat or you lose coverage. Universal healthcare would break that leverage by increasing worker bargaining power and decoupling survival from employment. That outcome is unacceptable to a party structurally aligned with large employers and capital.
3. It Proves Government Can Work and Work Well
The ACA demonstrated several forbidden truths. Government can regulate private markets, lower uninsured rates, and subsidize care efficiently. Public programs can outperform private ones. Every successful public program undermines the core Republican ideological claim that “government can’t do anything right.” Universal healthcare would be the ultimate rebuttal.
4. It Threatens a Massive Donor Ecosystem
Even in its compromised form, the ACA reduced profit extraction by insurers, pharmaceutical companies, hospital chains, and private-equity-backed healthcare firms. Universal healthcare would go further - capping prices, eliminating rent-extracting intermediaries, and shifting bargaining power to the public. That directly threatens billions in political donations. This is not theoretical. It is transactional.
5. It Disrupts Hierarchy
The ACA violated an unspoken rule of American governance. Care should be stratified by class. It extended coverage to low-income adults without children, people previously deemed uninsurable, and workers in unstable or informal labor. Universal healthcare goes further still. Everyone gets the same coverage, and the same dignity. That vision clashes with a worldview rooted in deserving vs. undeserving populations - a worldview explicitly reinforced by Project 2025.
6. It is Inseparable from Race and Backlash Politics
Opposition to the Affordable Care Act is inseparable from what political scientists call backlash politics. It is not driven by evidence that a policy failed, but by resentment over social and demographic change and over who benefits from that change. The law expanded coverage to groups long excluded from stable healthcare, including low income adults without children, people with pre-existing conditions, and workers outside traditional full time jobs. It was also closely tied to Barack Obama, federal authority, and a changing electorate.
For many opponents, the problem was not that the ACA failed, but that it succeeded in extending to people who had previously been denied it. The backlash intensified, not because the law did not work, but because it worked for the wrong people.
In fifteen years, Republicans have never offered a replacement for the Affordable Care Act. That is not an accident. If their objection were truly about design, they would propose alternatives, compete on coverage and cost, or offer a better system.
The clearest example of this strategy came in 2017, when Republicans zeroed out the ACA’s individual mandate penalty through the tax code rather than repealing the law outright. 5 The mandate was designed to keep insurance pools broad and affordable by encouraging healthy people to stay enrolled. Eliminating it did not end the ACA, but it weakened it structurally by shrinking the pool, driving up premiums, and destabilizing markets. It allowed Republicans to claim they had not taken coverage away, even as they made coverage more expensive and less reliable for everyone who remained.
Every other wealthy democracy has already answered the question Republicans refuse to engage. 6 How to cover everyone, control costs, and separate healthcare from employment. These systems are not flawless, but they are broadly accepted by the public that relies on them. Satisfaction with performance may fluctuate, but support for universality does not. Even in the United States, large majorities say the government should ensure healthcare coverage for all. 7 The obstacle is not public opinion. It is political will.
What the One Big Beautiful Bill Did to the ACA
First, it weakened Medicaid expansion by stealth. Caps, work-requirement pathways, and block-grant-style financing make expansion harder to sustain, pushing states to cut eligibility, reduce benefits, or abandon expansion altogether. 8
Second, it increased out-of-pocket costs for ACA enrollees. By constraining subsidy growth while costs continue to rise, the bill leaves coverage technically “available” but practically unaffordable, especially for people just above subsidy thresholds.
Third, it destabilized insurance markets by reinforcing policies that siphon healthy people into non-ACA plans while leaving sicker enrollees in ACA risk pools.
Fourth, it accelerated administrative churn. New eligibility checks, reporting requirements, and expanded state discretion increase coverage loss through paperwork, not income changes.
The result is fewer people covered, higher premiums and out-of-pocket costs, and deeper regional inequality—not all at once, but cumulatively over several years. The bill preserves the appearance of the ACA while quietly undoing its promise, turning healthcare from a guaranteed floor into a conditional benefit that disappears through paperwork, affordability gaps, and state discretion rather than a single, politically accountable repeal. It is also structured so that the worst effects land after the 2026 elections, allowing responsibility to be shifted onto whichever party inherits oversight and implementation.
Who is Affected and When
The effects are not hypothetical. Over the next one to five years, millions of people are expected to lose coverage or be priced out of meaningful care through cumulative erosion. Medicaid expansion adults, low-wage workers with fluctuating hours, older enrollees aged 50–64, rural residents, and people with chronic conditions are hit first. In the near term, losses occur through paperwork churn. Within one to two years, premiums rise as enrollment pools shrink. Over three to five years, insurer exits accelerate and coverage deserts re-emerge. Tens of millions more remain technically insured but increasingly underinsured.
*“Accelerating eligibility churn” means intentionally making people fall off health coverage faster and more often - not because they stopped qualifying, but because the rules are designed to trip them up. Coverage disappears without lawmakers ever having to vote to take it away. 9
Example: Maria works full-time at a grocery store, but her hours fluctuate. One month she qualifies for Medicaid. The next, her paycheck triggers a review. She misses a confusing ten-day reporting deadline while caring for her mother and loses coverage, even though nothing meaningful has changed. Two weeks later she is sick, skips care, and reapplies. Coverage returns, but her medications were interrupted and bills piled up. Over a year, Maria qualifies the entire time, yet spends months uninsured because the system is designed to drop her when life gets messy.
Why the Pool Matters
Health insurance only works when costs are spread across a large mixed population that includes both healthy and sick people. The One Big Beautiful Bill deliberately shrinks that pool. Paperwork barriers, and rising out-of-pocket costs push out healthier enrollees first - the very people who keep premiums stable. As the pool gets smaller, older, and sicker, insurers raise prices or leave markets. The damage doesn’t stay contained. Everyone who remains pays more. This is the economic engine of sabotage.
Republicans accelerated this dynamic in 2017 by zeroing out the Affordable Care Act’s individual mandate penalty. The mandate was designed to keep healthier people enrolled so costs could be spread broadly. Eliminating it did not free people from a failed requirement. It encouraged healthier and younger enrollees to exit the market, shrinking the pool and driving up premiums for those who remained. This was not an unintended consequence. It was a known outcome, and it is central to why affordability worsened even when the ACA itself remained intact.
Project 2025: Emboldenment, Not Accident
This is where Project 2025 comes in - not as a departure from this strategy, but as its culmination. After years of partial resistance, Republicans are now operating under an enforcement-light regime shaped by figures like Vought and Miller, emboldened by a Trump movement that no longer pretends incremental harm is accidental. Project 2025 codifies what the One Big Beautiful Bill advances in practice: block-granting Medicaid, capping federal responsibility, stripping benefit guarantees, weakening enforcement, and returning healthcare governance to states and employers where hierarchy, exclusion, and leverage thrive. Sabotage softened the ground. The OBBB accelerates the damage. Project 2025 makes it permanent.
Republicans didn’t fail to repeal the ACA.
They learned how to dismantle it quietly - and Project 2025 is the blueprint that ensures it stays that way.
Footnotes:
Brilliant breakdown of the employer-insurance lock. The part about labor discipline being baked into healthcare access is spot-on, dunno why more people dont see how tying survival to employment is the point, not a bug. I've seen it first-hand when friends stayed in toxic jobs purely for family coverage. The 'shrink the pool' strategy through adminstrative churn is particularly cynical because it makes people lose coverage while technically keeping it available.