Hurtling toward a December ACA cliff
Behind the public scene, a race is on, with red states far more affected than blue by ACA cuts and costs. Republicans are racing towards...something. We'll update here.
Quick overview for all y’all TLDR peeps
When Dems raised the shutdown surrender flag, Rs agreed to “reconsider” ACA subsides by Dec 15.
Rs hate ACA (Obamacare—a clue is in the name). But they haven’t been able to do anything better after 15 years of trying. Now they’re dashing toward an immediate cliff with no easy options in sight.
Americans like ACA, and ACA growth in red states since 2020 dwarfs that in blue states. Worse for Rs: their reliably red rural voters are getting hit more by budget bill Medicaid cuts and huge ACA cost increases than Dem voters. Voters get it and polls consistently show they blame Congress and Trump.
If Rs don’t figure it out, it’s likely to be huge Dem midterm leverage.
Refreshed after a two-month paid shutdown vacation,1 the Senate in particular is looking at possible outs, right now focused on band-aid HSA-like savings accounts, which would have the additional benefit for them of undermining ACA. Democrats so far are holding out for subsidy extension, with a decent rationale. More below.
Bonus points: Cool graphics. Did the super slick dealmaker find yet another way to get us to pay for tariffs? And is he also truly, finally losing it? (Very strong water!)
Stay tuned. We’ll watch it here.
Remember two months ago
…when Democrats brought on the entire, record-setting longest shutdown ever over expiration of ACA pandemic-era subsidies, hitting at least 24 million people? Yes, a couple other issues, but that one stuck. And then they folded when the shutdown started seriously affecting wallets and air travel again, this time for America’s biggest holiday travel season.2
When Dems flew the surrender flag, they forced a reconsideration of the ACA subsidies
—not an extension of the subsidies, but a promise from the Senate to reconsider the subsidies by mid-December. Rs agreed to look at the issue, in no small part due to their constituents actually being hit harder than Dem populations by both the upcoming budget bill hits to Medicaid and the expiration of the pandemic-era ACA subsidies. More than half of ACA enrollees live in Republican Congressional districts. Even more startling, since 2020, ACA enrollment in red states grew much faster than in blue states, accounting for 88% of the total national enrollment growth and increasing by an average of 157% in those states, compared to a 36% increase in states that voted for a Democratic candidate.
Congressional Republicans have definitely been hearing from them about ACA cost increases exceeding $1,000 a month for the average enrollee, and many times that for some. These are not people in top income brackets. Half of enrollees have an individual annual income under $24,000.3
Governing being a taxing endeavor, these days it doesn’t happen until much until polls force an issue, so increasingly negative ratings for both Congress and the White House on healthcare have created consternation in the R caucus. Whoda thunk after their “landslide” 2024 win, right?
The problem with mandate thinking when reality is 50/50
...is that Americans aren’t buying it. Polls4 indicate Americans continue to like the ACA, the reason dozens of Republican attempts to repeal it didn’t fly.5 Another recent poll says about 8 in 10 rate the issue of health care “extremely” or “very” important to them personally. That includes about 9 in 10 Democrats and three-quarters of Republicans, and it puts health care next to the economy among Americans’ top issue priorities. And polling indicates citizens are particularly unhappy with Republicans—not Democrats—about what’s happening on healthcare.
Trump’s approval ratings tanked even more as tariffs hit and the shutdown went on…
..and surprisingly6, Americans are aware of—and very displeased with—what they see as excessive spending and misplaced priorities from this administration.
So, fresh from a two-month paid vacation, the scramble is on in the Senate to fix healthcare in a month
…something no party has been able to do for over a century. You remember “concept of a plan”? It hasn’t even made it to ‘concept’ in the House, and the Senate is focused on band-aids that just move money around to the same insurance companies, but without the detested “Obama” in the name. Democrats have a fixed—if tenuous—goal in mind.
As of today…
Yesterday Trump’s show-and-tell praise of the man the CIA says ordered the murder of Jamal Khashoggi7 was front and center.8 Between that and the post-yowling “we wanted it all along” near unanimous Epstein voting, you may have missed intense action on the ACA subsidies. If the Senate honors their promise to “reconsider” ACA subsidies, the pressure is on. There are less than six weeks before the subsidies expire, with cost-revealing open enrollment underway (and their next paid vaca right around the corner9). Here’s the score so far; we’ll update over the next month as events unfold.
To say Republicans hate the ACA—well, anything including the word Obama—would be an understatement. And while voters may not fully understand it yet, Medicaid and the ACA are inextricably linked; there’s worse coming as the full impact of ACA hits the public. With polls saying their constituents are no longer being successfully gaslighted on the issue, they know a major storm is coming just before midterms.
The House is just getting started. They’re way behind the Senate on this and worried about the Senate rolling them, and some moderate and vulnerable Republicans have already banded together to push for a temporary, possibly one-year, extension to avoid political fallout from the premium spikes. The House meets Thursday morning to start coming up with their…concept. Here’s a good summary of just how badly they’re behind, and what’s ahead.
In the Senate, where several members understand healthcare better and have had longer tenures to consider it, alternatives to extending the subsidies are quickly emerging. Trump is against the subsidies, of course, and says he will only support a plan to “send the money directly back to the people.” At least two senators were immediately ready with dusted-off propoasals for HSA-like savings accounts that have the additional benefit of a potential ACA death spiral.10 Sen. Rick Scott (R-FL)—a long time genius at getting the public to pay for investor profits11—has proposed an HSA-like saving account approach. So has physician Sen. Bill Cassidy (R-LA), the physician who was the final wobbly vote to approve RFK Jr. for HHS, for which he’s had some recent regrets.12 He’s shown flashes of a conscience on occasion in the past—like his vote to impeach Trump—but he’s up for re-election in his deep red state and loves being a Senator.
So far, Democrats remain focused on extending the subsidies. They are banking on several obstacles for Rs: polling, recent double digit election wins, R intransigence on tying everything to abortion, the very short time frame, and the l.o.n.g. Republican history of inability to come up with anything cogent on healthcare. That was a problem two months ago and it hasn’t gone away. We’ll see how the Dem plan flies in the face of organized HSA-like plans from the Senate that follow Trump’s command at a time there are indications Trump’s political grip (and his mind13) may be unraveling.
You knew there would be head-shaking irony in all this somewhere
Here you go. Trump’s directive to Congress health care was actually to pay “large amounts of dollars back to the people.” Specifically, he said “The insurance companies are making a fortune. Their stock is up over a thousand percent over a short period of time. They are taking in hundreds of billions of dollars, and they’re not really putting it back, certainly like they should.”
The obvious irony, of course, is that those same insurance companies are the ones who would benefit from the Senate HSA plans.
But wait! There’s more on this late night special! Reading Trump’s statement carefully, he didn’t say anything about HSAs. He said to send “large amounts of dollars back to the people.” People on ACA are not affluent; there are income limitations for qualification. So, let’s see. If you were a lower income family and received actual cash right around Christmas, would you spend it on a healthcare plan you hope you won’t need in the coming year? Or on an overdue mortgage or rent? Or rapidly escalating utility bills, with electricity up 6% and gas up 14% this year? Or food? Or how about gifts for the kids? In other words, would people use cash to pay, at least in part, for tariff-created inflation? Genius, really…although the Senate was quick to a different translation.
Congressional paychecks continue during shutdowns. 60% kept the paycheck during this one. Check here to see if yours got paid or refused.
Air travel was how the second longest shutdown ended, too. That shutdown—during Trump I—ended after only 10 air traffic controllers stayed home. And this time the impact was going to be much worse, timed just before expected travel records for Thanksgiving, always the biggest travel holiday of the year.
45% of ACA enrollees have individual incomes of 100% to 150% of federal poverty level; 150% is $23,475. Click for more on income levels that qualify for ACA enrollment.
Here are the data sources for graphics in this post: Navigator poll; KFF ACA marketplace growth; KFF ACA public opinion poll.
For a blow-by-blow list of the repeal attempts, click here.
I keep being surprised that voters —well, poll respondents—actually seem to be aware of what’s going on, since the budget bill hits to Medicaid haven’t started yet. They also seemed much more aware of the predicted increase in ACA premium costs before open enrollment showed the reality. In the past, R voters have largely bought into the party line on the horrors of the ACA. Is this the first time we’ve seen R voters turn against the party on healthcare? And the first time voters seemed to understand what was coming before it actually did?
Trivia fact: Jamal Khashoggi was the cousin of Dodi Fayed, the man who died with Princess Diana. How did a conspiracy theory about that not take off?
The MbS visit was originally planned for some time Nov. 17-19 and then finalized for the same day as the Epstein vote. A PR diversion from the Epstein vote, you suggest? How cynical.
Thanksgiving recess is scheduled for November 24-28, with a tentative return date of November 29.
Experts worry the HSA approach is may send current ACA enrollees to cheaper catastrophic plans with no preventive or routine care and extremely high deductibles for severe medical events. Preventive and routine care keep much higher hospitalization costs down, so that would also cause much higher costs later for both enrollees and taxpayers who pay the difference for unfunded care. The HSA-like approach could leave only very sick (costly) people on ACA, ultimately leading to its demise while keeping our current system more firmly entrenched.
Sen. Rick Scott and his family are worth hundreds of millions, stating when he was CEO of Columbia/HCA. Columbia is where Scott, as CEO, led the for-profit healthcare conglomerate to the then-record $1.7 billion penalty to settle federal charges of defrauding Medicare and other government health programs. Scott knows exactly how to make healthcare work for investors at public cost. Buckle up
Sen. Bill Cassidy, a physician, was the concerned but deciding vote to approve RFK Jr. as head of HHS. Since then, he’s experienced some remorse. And it’s clear his medical mind suffers from at least unconscious bias in healthcare, and he is highly skilled at threading the needle to stay on Trump’s good side. But at least he’s a physician (maybe scraping bottom here) and, on occasion, seems to have a conscience—as when he voted to convict Trump on one article of impeachment.
Psychologists and psychiatrists have long speculated on Trump’s mental health—or lack of it. Most frequently mentioned are dementia (which his father had) or [malignant]narcissistic personality disorder. But others also show up in psych literature: antisocial personality disorder (your basic sociopath), paranoid personality disorder, and sadistic personality disorder. As is often the case, whatever is going on is most likely a combination; click here for more. Trump’s niece Mary (a psychologist) and nephew Fred have both recently reiterated the increasing similarity between the president’s behavior and his father ‘s dementia symptoms. Even Epstein apparently weighed in back in 2018 on Trump having early dementia. (More irony: here’s what’s still on our very own HHS NIH website has about all this. Likely not personally approved by RFK Jr. Catch it before it gets taken down.)
Frontotemporal dementia (FTD) symptoms, in particular, are frequently mentioned. Mainstream media, happy to go after Biden’s brain health, aren’t touching that of the retribution-minded current president, but Newsom and Crockett have taken off the gloves very publicly. The denizens of The Bulwark are hardly unbiased, but as former Republicans now followed by millions, they have no difficulty saying what mainstream media won’t. Here’s their post from yesterday. Don’t miss the included video of a Trump’s unhinged ‘speech’ this week.
