STEVE INSKEEP, HOST:
OK, so for all the words he spoke while campaigning, it is not entirely clear what the president-elect will do in a second term.
LEILA FADEL, HOST:
To give one example, it's not clear how far he will go to make good on a promise to use federal power to seek retribution from his personal and political enemies. And here's another. The new president's approach to health care is vague. During his first term, Republicans tried and failed to repeal the Affordable Care Act but never came up with a replacement. So what now?
INSKEEP: NPR's Selena Simmons-Duffin is here to talk about that. Good morning.
SELENA SIMMONS-DUFFIN, BYLINE: Morning, Steve.
INSKEEP: OK, what is the law that Trump tried to repeal the first time?
SIMMONS-DUFFIN: That would be the Affordable Care Act, also known as Obamacare. It was passed in 2010, and it transformed lots of aspects of the health care system. And for years, Republicans wanted it gone. In Trump's first year as president, Republicans tried many, many times to repeal and replace Obamacare, but they failed to do that in part because they had no clear plan on what to replace it with. This campaign, Trump spoke very differently about the law. Here he is during the presidential debate on ABC in September.
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DONALD TRUMP: I had a choice to make - do I save it and make it as good as it can be, or do I let it rot? And I saved it.
SIMMONS-DUFFIN: Then moderator Linsey Davis followed up.
LINSEY DAVIS: So just a yes or no, you still do not have a plan?
TRUMP: I have concepts of a plan.
INSKEEP: Interesting line, and interesting that he said that he saved Obamacare when he explicitly called for its repeal - just failed in the Senate by a vote. What about policy once Trump is back in power again?
SIMMONS-DUFFIN: Well, that's really hard to pin down because the signals from Trump and Republican lawmakers have been kind of unclear. It's going to depend a lot on whether Republicans retain control of the House since they've won the presidency and the Senate. It's also going to depend on who Trump chooses to run his health policy team. But all that said, it seems like the political appetite to go all in again on repeal and replace just isn't there. There still could be changes, though. Larry Levitt of the health research organization KFF said in a press briefing he thinks cuts will be coming to some federal health programs.
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LARRY LEVITT: Trump has said Medicare, Social Security and defense cuts are off the table. With Republicans looking for spending reductions to help pay for tax cuts, the math is inescapable that Medicaid and ACA cuts will then be on the table.
INSKEEP: What are some of the conservative think tanks and Republican lawmakers - people who think in depth about this - saying about what they want to cut?
SIMMONS-DUFFIN: I reached out to the Heritage Foundation, but they said they're declining interview requests right now. They did put together the somewhat famous Project 2025 document, and there are also budget priorities from a House GOP committee. Sabrina Corlette, who runs the Georgetown Center on Health Insurance Reforms, says it's clear from these documents what Republicans would like to do in this space.
SABRINA CORLETTE: They want to lift some of the regulations that govern insurance companies, including some of the protections for people with pre-existing conditions. There is also interest in reducing the amount of federal spending.
SIMMONS-DUFFIN: Corlette told me even as an academic health insurance expert she's been getting emails from regular people recently who are worried about these changes. She says they're petrified.
INSKEEP: People do get nervous about changes in health care laws. How many people could be affected?
SIMMONS-DUFFIN: Millions. I mean, more Americans have health insurance at the moment than ever before. Enrollment in HealthCare.gov, those Obamacare health plans is really high right now at more than 21 million people. That's almost doubled since President Biden took office. And the insurance industry, hospitals and doctors' groups, they all like that. They're going to be very resistant to major changes, and regular people could mobilize again to resist changes to the ACA. So there's a lot to watch in this space.
INSKEEP: NPR's Selena Simmons-Duffin, thanks so much.
SIMMONS-DUFFIN: Thank you.
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