CHARLESTON, S.C. — Republican presidential hopeful Nikki Haley will learn how her campaign is resonating with voters after the Jan. 15 Iowa caucuses, the first presidential nominating contest of this election year.

Already, the former South Carolina governor — who became well known as one of the Affordable Care Act’s loudest critics during her tenure in office from 2011 to 2017 — has raised questions about what her presidency could mean for the nation’s health care policy.

“I would be very concerned,” said Sue Berkowitz, policy director and special counsel for the South Carolina Appleseed Legal Justice Center. “South Carolina is at the bottom of so many things in rankings in our country because of a number of the decisions she made while governor.”

While politicians from both parties rallied behind Haley when she urged lawmakers to remove the Confederate battle flag from statehouse grounds following the 2015 church shooting in this coastal city, her politics diverged sharply from those of her Democratic colleagues when it came to most health care issues.

Haley’s campaign did not respond to multiple requests for comment, but statements she’s made during recent debates offer clues about her health care positions.

She has criticized the Biden administration for high federal spending on covid relief and for the number of people on Medicaid, a program she has argued the federal government should give states more flexibility in funding and administering.

She has also emphasized the need to find consensus on banning abortions late in pregnancy. And on Jan. 10, during her heated sound-off with Florida Gov. Ron DeSantis in the final debate before the Iowa caucuses, she reiterated her critical stance on gender-affirming care.

“I have always said that boys need to go into boys’ bathrooms, girls need to go into girls’ bathrooms, that we shouldn’t have any gender transitions before the age of 18,” she said. “Just like we don’t have tattoos before the age of 18, we shouldn’t have gender transformation or puberty blockers.”

On the campaign trail, she’s addressed reforming Medicare and Social Security. But her tenure as governor, which overlapped with several tumultuous years of national health care reform, offers an even clearer picture of how a Haley presidency might look.

Former South Carolina Medicaid Director Anthony Keck pointed out that one of her early achievements as governor was fixing a $228 million Medicaid deficit.

“People forget what dire straits the Medicaid program was in when she came into office and how it took us a couple years to right the ship,” said Keck, now executive vice president for system innovation at Ballad Health in Tennessee.

Beyond that, Keck said Haley understood that the cost of health care was “growing faster than most people’s paychecks,” adding that affordability and access were “really important to her.”

As Haley eyes the White House, here’s a recap of her health care record as South Carolina governor, a post she left in 2017 after Trump appointed her as ambassador to the United Nations.

Affordable Care Act

In 2011, Haley convened an advisory committee to decide if South Carolina should build its own health insurance marketplace instead of participating in the federal one established under the Affordable Care Act.

But before the group gathered for its first meeting, Haley wrote in an email to her advisers that the “whole point of this commission should be to figure out how to opt out and how to avoid a federal takeover, NOT create a state exchange,” according to a report published by The Post and Courier.

When that email was made public, then-Sen. Tom Harkin (D-Iowa) requested a federal investigation to find out if Haley had predetermined the outcome of the committee. She was eventually cleared of any wrongdoing.

Throughout her time in office, Haley repeatedly advocated for the repeal and replacement of the ACA, but she has not given a definitive answer on the campaign trail about whether she’d try to repeal the law if elected president, The New York Times has reported.

Medicaid

In 2012, when the U.S. Supreme Court upheld the constitutionality of the ACA and made Medicaid expansion an option for every state, Haley declined to expand it in South Carolina. Christian Soura, one of her former cabinet members, estimated in 2019 that “several hundred” people in the Palmetto State had died because of the decision.

On the presidential campaign trail, Haley’s stance on Medicaid expansion has remained unchanged, even as people who live in nonexpansion states broadly support it, according to KFF polling.

South Carolina remains one of 10 states that have not expanded Medicaid eligibility under the ACA, leaving more than 90,000 residents in a health insurance coverage gap, according to a 2023 KFF report.

Even so, Medicaid enrollment and spending in South Carolina during Haley’s tenure grew substantially, drawing criticism from some conservatives.

In 2012, her administration chose to implement a federal program that automatically issued new Medicaid coverage to children from low-income families based on data from welfare assistance and the Supplemental Nutrition Assistance Program, formerly known as food stamps. A 2013 case study found that the Express Lane Eligibility initiative grew Medicaid enrollment in South Carolina by more than 92,000 children in less than a year and that the simplified process “resulted in large enrollment and retention improvements.”

Haley’s administration was also widely applauded for establishing a coalition of health insurers, hospitals, and health care providers to improve birth outcomes in a state where Medicaid pays for more than 60% of all deliveries. Infant and maternal death rates in South Carolina have long ranked among the worst in the nation.

Recent research suggests, however, that some of the policies Haley’s administration prioritized, such as a home visiting program and a campaign to prevent early elective deliveries, didn’t improve maternal or infant health outcomes.

Abortion

On the one-year anniversary of the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization ruling, which allowed state legislatures to outlaw abortion, Haley called the decision a “victory for life and democracy.”

Her position aligned with a controversial bill she signed into state law in 2016 that banned the procedure in South Carolina 20 weeks after the probable date of fertilization — slightly past the midpoint of a woman’s pregnancy.

When she signed the law, it affected only hospitals because the state’s three outpatient abortion clinics already didn’t administer abortions after 15 weeks of gestation. The bill, which she championed, made exceptions for if the fetus were diagnosed with an “anomaly” and would die or if the mother’s life were threatened. But no exceptions were made for rape or incest.

During the recent debate in Iowa, Haley called herself “unapologetically pro-life.”

“Not because the Republican Party tells me to be, but because my husband is adopted, and I’ve got my two sweet children sitting in front of me, and I had trouble having both of them,” she said. “Our goal should be how do we save as many babies as possible and support as many moms as possible.”

On the campaign trail, Haley has tried to thread the needle between being pro-life and recognizing the difficulty of enacting a national abortion ban. She has spoken of finding areas that are winnable for Republicans, including increasing access to contraception and supporting adoption. That said, Haley indicated she would sign a national abortion ban as president if such a bill reached the Oval Office.

Certificate of Need

During her first term, Haley vetoed more than $1 million from the state budget that had been allocated to administer the health department’s long-standing “certificate of need” program. The program required hospitals and health care providers to apply for permission from the state before building new facilities or purchasing expensive equipment, with the goal of controlling health care costs and avoiding duplication of available health care services.

At the time, Haley called the rules “intensely political” and said they allowed “bureaucratic policymakers” to block health care providers from offering treatment. “We should allow the market to work rather than politics,” she said.

Nevertheless, the state Supreme Court ruled in 2014 that a budget veto wasn’t sufficient to eliminate the regulations.

The South Carolina Legislature ultimately repealed the state’s certificate of need rules last year.

During the Jan 10. debate, Haley said she would eliminate certificate of need across the country. The rules still exist in about two-thirds of states.

Rural Hospitals

During Haley’s second year in the governor’s office, the hospital where she was born in 1972 closed its doors. After a failed attempt to merge with other hospitals in the area, it became financially unfeasible for that hospital in the rural town of Bamberg to remain open.

In 2013, Haley announced her administration would reimburse rural hospitals across the state for all their uncompensated care costs, amounting to tens of millions of dollars over her time in office. The policy is still in effect.

Essentially, hospitals lose money when uninsured patients don’t pay their bills. Federal law offers some support. For example, it requires state Medicaid programs to make “disproportionate share” payments to hospitals that serve large numbers of low-income and uninsured people.

But programs like those don’t necessarily cover all of the losses.

Haley prompted the South Carolina Legislature to support rural hospitals by increasing their disproportionate share payments because, without an infusion of cash, several of them faced the same fate as Bamberg County Memorial Hospital.

“I certainly don’t think it’s a bailout,” Haley told The Post and Courier in 2014. “We’re allowing solid footing for these hospitals to make the changes that they need to make.”

But her plan wasn’t fail-safe. Two more rural hospitals closed during Haley’s tenure as governor.

Vaccine Mandates

As a member of the state House of Representatives in 2007, Haley co-sponsored a bill that would have made the vaccine for HPV, the virus that causes nearly all cases of cervical cancer, mandatory for girls entering seventh grade. It was ultimately killed by evangelical lobbyists, who have historically associated the HPV vaccine with encouraging underage sex, KFF Health News reported.

Several years later, Haley called her support of that bill a mistake.

In 2012, Haley vetoed a bill that would have provided free, voluntary HPV vaccines to seventh graders in South Carolina.

During the pandemic, Haley, whose sister-in-law died from covid, said she received a covid vaccine, though she has said she firmly opposes covid vaccine mandates.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.