After months of foggy promises to unveil a “great healthcare plan” for Americans and an admission that health policy is “complicated”, Donald Trump finally took a side in the debate over how to replace the Affordable Care Act during a joint session of Congress, calling for a package of recycled Republican health ideas.

Changes Trump called for would radically alter what is in the health insurance policies Americans purchase, abandoning the goal of “universal” coverage in favor of a more limited principle that Republicans say gives Americans “access” to coverage – at a price. His promises will likely reassure Republican leadership, as party in-fighting continues.

“I am also calling on this Congress to repeal and replace Obamacare, with reforms that expand choice, increase access, lower costs, and at the same time, provide better healthcare,” Trump said. “Mandating every American to buy government-approved health insurance was never the right solution for America.”

The ACA, better known as Obamacare, provided insurance to 20m Americans by subsidizing individual insurance plans, expanding the public health insurance program Medicaid, and creating consumer protections that mandate which benefits must be in health plans.

However, insurance companies’ choice to leave some state marketplaces and a sicker-than-expected population has caused costs to rise in some states, which has proved a potent criticism of the law.

The four replacement plan cornerstones laid out by the president have fundamentally different goals from Democratic plans that came before.

The most important provision Trump supported was “tax credits”. Eerily similar to the current system of subsidies for individual insurance, Republicans have proposed these credits before. The difference? Republicans want them to be less generous, and to distribute them by age – not income.

This strategy is embraced by Republican leadership, but getting conservatives on board could determine whether the ship floats. Some right-leaning news outlets criticized tax credits because they continue government spending, and key conservatives have already come out against it.

“The bill contains what increasingly appears to be a new health-insurance entitlement with a Republican stamp on it,” Republican congressman Mark Walker said, according to Fox News.



Trump promised to provide “access” to coverage for people who are already sick with “pre-existing conditions”. That probably refers to high-risk pools – government-subsidized coverage plans that 35 states had before the ACA. Most had higher premiums and deductibles, and annual and lifetime limits on care. Republicans have also proposed this solution in past plans.

Trump called for “flexibility” with Medicaid spending, harkening back to work by Trump’s nominee to head the Centers for Medicare and Medicaid, Seema Verma. In the past, she designed state plans with work requirements for the poor, lock-out periods as long as six months, and complex bureaucracy. Nevertheless, her plans were able to expand Medicaid in deeply conservative states. She faces a key committee vote on Wednesday.

Trump’s promise to “implement legal reforms that protect patients and doctors from unnecessary costs” could signal his support for medical malpractice reform, a long-time bugaboo for Republicans, especially the health and human services secretary, Tom Price, an orthopedic surgeon. He also said insurance should be sold across state lines.

But it’s not clear how these changes would be implemented, or how they would get through Congress. So far, Republicans have attempted to make good on promises to repeal the law by trying to ram a “budget reconciliation” law through Congress. That type of law needs a simple majority to pass – for which Republicans have the votes – but can only address taxes and spending. For policy changes, they need Democrats, who have proved elusive.

The single olive branch to Democrats was a call to lower prescription drug prices. Progressives in the party introduced a bill this week to allow drug imports from Canada, which many believe would lower drug prices by introducing competitive pricing. Trump later called for slashing Food and Drug Administration regulations to spur innovation, a move Democrats would almost certainly oppose.

“Everything that is broken in our country can be fixed,” he said. “Every problem can be solved.”

•An earlier version of this story misattributed a quote to Mark Warner. This version has been corrected to reflect that it was Mark Walker who gave the quote