The Ugly Real-World Consequences of Trump’s Loudmouth Campaign Rants

He’s made his expectations on health care and immigration perfectly clear to Republicans in office.

Medicaid patient, Thomas Crippen rests his head in his after being treated by Family Nurse Practitioner, Amy Quinone at Denver Health's Adult Urgent Care Clinic. ]](Photo By Craig F. Walker/The Denver Post via Getty Images)

DONALD TRUMP IS SO DANGEROUS in so many ways that, inevitably, some threats will be overlooked. Here’s one that shouldn’t be: his pernicious influence over what happens in Congress and the states.

Call it the opposite of virtue signaling.

Trump’s harsh 2025 immigration agenda of travel bans, large-scale raids, detention camps, and “the largest deportation operation in the history of our country,” along with a House bill reflecting his views, are hanging over Republican senators as they try to negotiate a border security deal crucial to passing a bipartisan aid package for Ukraine, Israel, and Gaza. The Republicans are acting as if Trump is “looking over their shoulders,” a Democratic source told Washington Post writer Greg Sargent.

Health care is the next test for conservatives trying to out-conservative each other. By suddenly renewing his vows to kill the 2010 Affordable Care Act, Trump has now signaled what he expects from them. As in fealty, or else.

The law is not in immediate danger, but Trump’s rhetoric is not without cost. That’s because ten states—all with conservative Republican legislatures, governors, or both—still have not expanded Medicaid insurance to an estimated 1.9 million adults, mostly the working poor. This option is largely federally funded, but the chance of further expansions was always iffy in the ten GOP-dominated holdout states. It seems still more remote now, even as the ACA and its Medicaid component have proven both helpful and durable. Why?

“It literally is a fear of not being seen as a real conservative. It’s fear of not being a member in good standing of the conservative club,” says Stuart Stevens, a Mississippi native and onetime GOP strategist who now writes books like It Was All a Lie: How the Republican Party Became Donald Trump (2020) and The Conspiracy to End America: Five Ways My Old Party is Driving Our Democracy to Autocracy (2023).

It used to be, Stevens told me, that his clients would brag to voters about the federal money and projects they’d secured. “States like Mississippi have traditionally elected people to go to Washington to get every cent they can. That was the whole idea of electing senators for life,” he said. Now, “you are willing to penalize your own state for your own personal ambition.”

The stakes in Mississippi are human and high. A 2023 Commonwealth Fund study of all the states and Washington, D.C., ranked Mississippi’s health system performance 51 out of 51. What’s worsened the most? Premature deaths from preventable causes, the mortality rate among women age 15–44, and—perhaps relatedly—adults with all recommended cancer screenings.

Of the ten non-expansion states, many limit Medicaid coverage to parents and limit their eligibility to household incomes well below the federal poverty line. In Mississippi, the cutoff is 28 percent of poverty for parents (less than $5,000) and 74 percent for seniors and disabled people. Childless non-senior adults are not eligible at all.

The expansion would eliminate complicated definitions of who is deserving and who is not. It covers almost all adults, parents or not, with household incomes up to 138 percent of poverty ($20,120 for one person, $41,400 for a family of four). If Mississippi adopted the expansion, about 200,000 people—mostly low-income uninsured workers—would be newly eligible for coverage.

Democrat Brandon Presley centered his 2023 gubernatorial campaign on expanding Medicaid. He lost last month to GOP incumbent Tate Reeves, who in his 2023 State of the State address referred to the ACA as “Obamacare, welfare, and socialized medicine,” and urged pushback against what he often calls the “Obamacare expansion.”

Yet there was still a sliver of hope for 2024. The Mississippi lieutenant governor, Delbert Hosemann, has shown interest in expanding Medicaid and has kept the door ajar. The retirement of Philip Gunn, the speaker of the state House of Representatives and an adamant opponent of expansion, removes a major legislative obstacle. State Rep. Jason White, chosen unanimously last week to succeed Gunn, has said expansion will be on the table in 2024.

Their positions led Mississippi Today to wonder in September if Republicans were about to “leave Reeves behind” on Medicaid. That was a long shot both then and now. Expanding Medicaid at this point could be read as tacit approval of the ACA and faith in its future existence. And that would provoke the ire of Dear Leader, who failed to stamp out the health law as president but wants another chance to swing the wrecking ball.

This has not been an easy law to kill, as Trump learned when he was president. Since then it has been a pandemic-era lifeline for the uninsured, and tens of millions of people rely on it for coverage. A record 40 million-plus people were enrolled this year through the ACA’s Medicaid expansion, online private-insurance marketplace, and other provisions it would be hard to pull back. Among them: allowing young adults to stay on their parents’ plans until age 26, protecting people with preexisting conditions against punitive rates, and subsidizing premiums for modest-income families.

Medicaid expansion in particular is one of the most studied health policy issues in the history of public health, says Adam Searing, a research professor at Georgetown University’s Center for Children and Families. “It’s irresistible,” he told me, because “there’s one group of states that has it and one that doesn’t.” It’s a natural experiment: You can look at health and financial outcomes to see whether the expansion is making a difference.

Results are in and the news is good. Coverage in expansion states is saving lives, improving health, stabilizing personal finances, and reducing uncompensated care at struggling hospitals—all without busting state budgets. Nearly half of Mississippi’s rural hospitals are at risk of closing, and Reeves argues that Medicaid expansion won’t fix that. Hospital executives, however, consider it an important step, Searing says: “It’s a necessary thing to do. You’re going to have to do other things, but if you don’t maximize people with coverage, you won’t solve it. Coverage is the first thing that you should be tackling.”

Why reject an infusion of federal cash—more than $1 billion a year in Mississippi’s case—that would generate enough savings and economic activity to more than offset the state’s required share, as other states have found? On top of all that, Medicaid expansion is popular, even in Mississippi and other red states, including successful ballot initiatives in Utah, Idaho, Nebraska, Oklahoma, Missouri, and South Dakota.

And now, with Trump spouting off about his intention to undo Obamacare, this may mushroom into a major issue in both the GOP primary and the 2024 general election. Trump not only failed to get the law repealed when he was president, there is still no trace of the hypothetical alternative he insisted would be far superior. One of Trump’s 2024 presidential rivals, Florida Gov. Ron DeSantis, responded to the new Trump ploy Sunday by claiming he will (someday) have a plan to “replace and supersede” the ACA. “Obamacare has failed,” he said on Meet the Press, while refusing seven times to say if that meant “repeal.”

Whatever Trump and DeSantis say, it’s obvious that the ACA has not failed. Democrats are well past the bad old days when the ACA was a massive weight dragging down the national party. It has grown so popular over the years that they used Republican attacks on the law to make gains in the 2018 midterms. The ACA is still viewed favorably by most Americans—59 percent in a poll in May—and the Biden-Harris campaign, responding last week to Trump’s fusillade, released an ad featuring a pediatric nurse worried about a return to the past.

Continuing to reject the Medicaid expansion is senseless from a policy standpoint, and embracing it carries little risk, at least at the state level. “If you did it, you would be more popular,” Stevens says. Still, in the MAGAverse, there’s no denying the possibility of other repercussions. Fox News bookers might stop calling. And you might not get a job in the next Donald Trump administration. Should there be one.