The Trump administration's effort to repeal and replace the Affordable Care Act (ACA) broke with Republican health care policies that stretch back more than six decades to the early Eisenhower administration. While Republicans have always opposed Democratic plans, once in office they generally found creative, market-oriented ways to try to extend access to health care. This article summarizes the health policy legacy of past Republican administrations, contrasts it to the Trump administration's repeal and replace effort, and locates that effort in a larger political context: the rise of white nationalism. White nationalism erodes the social capital that fosters social welfare policies; it challenges the basic idea of a right to health care. White nationalism is an old urge that rises with a new twist in the Trump era: the political parties, which historically diffused conflicts about American identity, have for the first time become divided by ideology, by race, and by immigration status. As a result, racialism and nativism may be more difficult to contain, for the parties now amplify questions of national identity. Health policy debate has become connected to something more powerful and fundamental: the definition of America and Americans.