The president was barely a year into his administration when a debate over health care began to consume Washington.
Partisan divisions emerged on Capitol Hill as many Democrats pushed for guaranteed insurance coverage for a broader group of Americans, while Republicans, buoyed by lobbying in the medical industry, warned of the costs and a slide toward communism.
It was 1945 and the new Democratic president, Harry Truman, tried but failed to convince himCongressto enact a comprehensive national lawhealthcareprogram, a defeat that Truman described as the disappointment of his presidency that “disturbed me most.” Since then, thirteen presidents have grappled with the same basic questions about the government’s role in health care, where spending now accounts for nearly 18% of the U.S. economy.
The fraught politics of health care are on display again this month as millions of people face a sharp increase in costs after the Republican-controlled Congress passed the Affordable Care Actsubsidies expire.
While the subsidies represent only a narrow, if costly, part of the issue, they have reignited long-festering grievances in Washington over the way health care is managed and the legacy of the ACA, the US president’s signature legislative achievement.Barak Obamathat passed in 2010 without a single Republican vote.
“That’s the most important thing I have to convince my colleagues to understand who hate Obamacare,” said Sen. Bernie Moreno, R-Ohio, who leads a bipartisan group of lawmakers discussing ways to expand some of the subsidies. “Let’s take two years to actually provide affordable health care to the American people.”
Democrats have heard that refrain before, claiming that Republicans have had fifteen years to provide an alternative. They believe that the options now being discussed, which largely focus on getting Americans to flow money into health savings accounts, do little to address health care costs.
“They’ve had a lot of time,” said Rep. Steny Hoyer, the Maryland Democrat who served as House majority leader during the ACA debate.
And with that, welcome back to the healthcare debate that never seems to end.
The challenge of reaching consensus
The often tortured dynamics surrounding healthcare have remained remarkably consistent. Obamacare dramatically expanded coverage, but remains—even in the minds of those who wrote the law—flawed and more expensive than many would like.
And Washington appears to be stuck in a stalemate rather than marching toward a solution.
“People hate the status quo, but they don’t like change,”Rahm Emanuelhe said as he reflected on the arc of the health care debate he has watched as the president’s top aideBill ClintonObama’s chief of staff and the mayor of Chicago. “That is the riddle of health care politics.”
Major reforms will inevitably culminate in a health care industry — a broad group of interests ranging from pharmaceutical and health care companies to hospitals and nursing homes — that will have spent more than $653 million on lobbying in 2025, according to OpenSecrets, which tracks political spending.
“Every time you try to figure out how to bring costs down, someone thinks, ‘Uh oh, I’m about to get less,’” said Hoyer, who announced last week that he will do so.not stand for re-electionafter serving since 1981.
When Obamacare was passed, opinions on the law were mixed, although views were more positive than negative.according to KFF polls. But the law has steadily grown in popularity. A September 2025 KFF poll found that about two-thirds of Americans have a positive view of the ACA.
That has gotten Trump and the Republicans into trouble.
Trump’s ‘concepts of a plan’
Since the passage of the ACA, Republicans have largely focused on destroying the law. Trump published social media posts calling for repeal as early as 2011 and spoke in generalities during each of his presidential campaigns about providing better coverage at a lower cost. During his 2024 debate against the Democratic rivalKamala Harrishe referred to ‘concepts of a plan’.
One thing he hasn’t done yet: submit his own formal proposal.
During a speech to the Detroit Economic Club on Tuesday, Trump said he would soon announce a “health care affordability framework.” During his second term, Trump criticized Obamacare for unfairly subsidizing insurers, an issue that could have been addressed if the legislation had created a so-called “public option” that would have competed alongside the private sector. Republicans – and a significant number of Democrats – objected to this approach, arguing that it would give the government an outsized role in health care.
But in a reminder that the past is never truly past, a small group of Democrats are trying to revive the debate over the public option, even as the prospects in a Republican-controlled Congress are bleak. Sens.Sheldon Whitehouseof Rhode Island and Elissa Slotkin of Michigan, along with Rep. Jan Schakowsky of Illinois, introduced legislation last week that would create a public health insurance option on the ACA exchanges.
However, last year a record 24 million people were enrolled in the ACAfewer seem to be signing upthis year because the expired subsidies make coverage more expensive. The Supreme Court has upheld the law and Republicans have failed dozens of times to repeal, replace or change it. In the most famous example, Sen.John McCainan Arizona Republican, cast the deciding vote in 2018 to keep the legislation in place, underscoring the lack of an alternative by noting that there was “no substitute for actually reforming our health care system and providing our citizens with affordable, high-quality health care.”
Democrats successfully turned repeal efforts into a rallying cry during the 2018 midterm elections and see an opportunity to do so again this year with the expired subsidies. Sen.Thom TillisRN.C., who is not seeking re-election, has warned that this moment could be even more dangerous for Republicans because, unlike the subsidies, voters lost nothing in the 2018 debate.
“The failure to put something else in place did not create this abyss,” Tillis said. “That is the fundamental difference in an election year.”
ACA veterans acknowledge challenges
Even those who created the ACA admit that the health care system created in its wake has problems. Former Sen. Max Baucus, a Montana Democrat who was one of the bill’s architects as chairman of the Finance Committee, acknowledged that “nothing is perfect,” pointing to high health care costs.
“Bending the cost curve, that’s not bent as much as we would like,” he said.
That’s partly why some Republicans have expressed openness to a deal on the subsidies. They don’t see it so much as an endorsement of the ACA, but rather as a bridge that would give lawmakers time to tackle more complex issues.
“We have to come to a long-term solution,” said Rep.Don BaconR-Neb.
However, veterans of past health care negotiations are skeptical that lawmakers can produce anything meaningful without the kind of deep negotiations that led to the ACA.
“It’s taking a long time to figure all this out,” Baucus said.
Asked if he has studied that history as he dives into the next chapter of the health care talks, Moreno noted that he has only been in Congress for a year.
“I don’t know,” he said. “What that means is that I have no scars.”
—Steven Sloan, Associated Press
Associated Press writer Amelia Thomson-DeVeaux contributed to this report.
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