By eliminating Medicaid expansion, reversing the Affordable Care Act would make President Donald Trump’s plan to eliminate HIV vastly more expensive. | Saul Loeb/AFP/Getty Images health care How killing Obamacare could backfire for Trump President Donald Trump's renewed push to gut Obamacare could sabotage the rest of his health agenda.

President Donald Trump wants to eliminate HIV in the U.S., contain the opioid crisis and lower the cost of prescription drugs — but all of those need Obamacare to be successful. And Trump just promised to kill it.

His HIV plan relies on key pieces of Obamacare to expand access to prevention and treatment services for Americans at risk of contracting the deadly virus. Expanding opioid prevention relies heavily on Medicaid, which expanded under Obamacare. And Trump’s push to lower drug prices would use an innovation program that tests drug cost modeling — and was created by Obamacare.


So while the notion of killing Obamacare altogether arouses the GOP base, the reality is that the decade-old law is so intertwined with the entire U.S. health care system that repealing large chunks of it would destroy the ability to do things Trump actually likes.

Even members of Trump’s team have raised red flags. Outgoing Food and Drug Administration Commissioner Scott Gottlieb said Thursday that overturning Obamacare could thwart an initiative to get cheaper forms of insulin on the market. Carl Schmid, an AIDS Institute leader and co-chair of Trump’s HIV advisory board, called the ACA decision “an unfortunate distraction from ending the HIV epidemic initiative.”

“He’s just completely consigning his own initiatives to the ash heap if the ACA goes down," said Sara Rosenbaum, a health law and policy expert at George Washington University. “It has become the fabric of the health care system.”

COUNTDOWN TO 2020 The race for 2020 starts now. Stay in the know. Follow our presidential election coverage. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

If the law is struck down in court, as the president is rooting for, an estimated 25 million people will lose coverage through private insurance and Medicaid expansion, and insurers would no longer be required to cover people with pre-existing conditions like HIV/AIDS.

The HIV and opioid crises are intertwined because HIV infections have increased with people sharing needles for injecting drugs. Any Obamacare changes that hurt one of those efforts will have serious ramifications for the other.

“Trump’s attempt to dismantle the ACA would critically undermine the goal of ending the HIV epidemic in the United States in the near term,” said Rep. Barbara Lee (D-Calif.), co-founder and co-chair of the bipartisan congressional HIV/AIDS caucus.

“It would be like pulling the chair out from under the initiative,” said Jen Kates, director of Global Health and HIV Policy at the Kaiser Family Foundation. In the days before Obamacare’s guarantees of coverage despite pre-existing conditions, people with HIV seeking individual insurance were denied 100 percent of the time, she said.

Advocates and lawmakers have similar concerns about the national response to the opioid crisis, which Trump declared a public health emergency in 2017. The Affordable Care Act’s expansion of Medicaid covers about 1.2 million people getting mental health and addiction treatment, according to a study published in Health Affairs.

Finally, Trump’s plan to lower drug prices to what patients pay overseas depends on various parts of the ACA, including the Centers for Medicare and Medicaid’s Innovation Center — a vehicle for testing new payment models.

The president last week abruptly shifted his position and signaled support for a federal judge’s ruling that the ACA in its entirety should be thrown out, despite objections from his health secretary and attorney general. Obamacare’s fate is likely to once again be settled by the Supreme Court. Trump has promised something better in its place, but no one knows what that might be.

If Obamacare goes, prevention services and screening requirements provided under the ACA’s essential health benefits would be eliminated. This would occur as Obamacare was expected to soon require that PrEP, a drug that can prevent new HIV infections, be made available for free in all health insurance plans.

Without those protections, fewer people could be diagnosed and get care — directly undermining a key goal of the Trump administration’s HIV strategy: to detect infections and treat people early to avoid spread of the disease. Recent data from the Centers for Disease Control and Prevention show about 8 in 10 new infections are transmitted by people who don’t know they’re infected.

Public health experts are deeply concerned by any potential rollback in services, particularly in Medicaid, which covers more than 40 percent of all people living with HIV, according to data from the Kaiser Family Foundation. Obamacare’s Medicaid expansion is credited with increasing coverage of people with HIV — which jumped from 36 percent in 2012 to 42 percent in 2014 and probably has grown since many more states have bolstered their Medicaid rolls.

The Trump HIV plan doesn’t count on states expanding Medicaid, but “they were also not expecting a state to lose access to Medicaid expansion as a result of a court case,” said Bill McColl, AIDS United’s vice president of advocacy and policy.

To make its HIV plan work, the Trump administration planned to rely on nonprofit health clinics and hospitals that receive steep discounts on drugs. Obamacare expanded this program, known as 340B, to rural, critical access and community hospitals. That drug savings money is credited with keeping many of these facilities open and alleviating some of the burden on health centers that treat uninsured and low-income HIV patients.

If financially strapped rural hospitals lose their 340B status due to the elimination of Obamacare, it would place a huge burden on other places that treat HIV patients, like the Ryan White Clinics, said Peggy Tighe, the lead lobbyist for Ryan White Clinics for 340B Access.

The cuts to 340B would also hurt anti-addiction treatment because some of the patients treated for HIV infections in rural hospitals and clinics are also opioid users, Tighe said.

More than 170 hospitals were added to the drug discount program thanks to Obamacare in the seven states the Trump administration's HIV plan targets, according to the Health Resources and Services Administration. About 1,000 rural hospitals throughout the country joined the program, according to 340B Health, which lobbies for these health care facilities.

By eliminating Medicaid expansion, reversing the ACA would make Trump’s plan to eliminate HIV vastly more expensive, “although still a worthy goal,” Schmid said.

The billions Congress has appropriated to expand opioid treatment services would be undermined without the health care law’s coverage and consumer protections, such as the requirement that insurers cover addiction care the same way they cover other medical services.

“You cannot strengthen a response to these problems if your foundation is weak,” said Andrew Kessler, founder and principal at Slingshot Solutions.

When it comes to drug prices, ending Obamacare immediately would raise costs for seniors and state governments, while other Americans might see their drug coverage disappear entirely thanks to the loss of the ACA’s mandate that all health plans cover prescription medications.

Seniors would likely spend about $2,000 or more in out-of-pocket drug costs each year without Obamacare, estimates Juliette Cubanski, Kaiser Family Foundation’s associate director of Medicare policy. That’s because the ACA requires drugmakers to provide big discounts to seniors in the coverage gap phase of Medicare Part D. And states would no longer be entitled to the larger discounts on drugs provided to Medicaid programs under Obamacare.

Meanwhile, Trump administration efforts to get cheaper medicines to market could falter. Obamacare created the biosimilar pathway, a way for companies to bring more affordable versions of some of the most costly and complex biologic medicines to market.

Eliminating the biosimilar pathway could cripple efforts to get more affordable versions of insulin to patients. Starting in 2020, insulin will be regulated as a biologic, finally giving companies seeking to make cheaper copycats a way to get a product approved that could be automatically substituted for branded insulin, whose cost has been rising.

Gottlieb, who as FDA chief has made biosimilars a priority, acknowledged at a Senate Appropriations hearing Thursday that if Obamacare is overturned it would thwart FDA’s plan to increase access to them.

“It’s a very important pathway and we fully support it, obviously,” Gottlieb said in response to questions from Sen. Jon Tester (D-Mont). “We think it has been profoundly impactful with consumers.”

Other Trump plans to lower the cost of medicines also would be stymied, like the president’s idea to test aligning Medicare payments for pricey doctor-administered drugs to the lower costs paid by other wealthy nations.

This and other similar demonstrations can’t be done without Obamacare's Innovation Center, which gives the government broad powers to test new health policies without congressional approval.

