November 21, 2025 • 21 mins
In this episode of One Thing Trump Did, We talk with KFF Health News Chief Washington Correspondent Julie Rovner about Obamacare subsidies, which are set to expire at the end of the year. Many in Congress want to see them extended to that insurance premiums don't skyrocket, but President Trump says he has no interest in spending more money on the Affordable Care Act. Instead, he wants to send that money directly to Americans. #ACA #Obamacare #healthcare #subsidies #Trump #DrOz
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Episode Transcript
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Speaker 1 (00:00):
The system is not working. Well, I don't really think
it's the fault of the ACA, which is what Republicans say,
it's the fault of not fixing our healthcare system.
Speaker 2 (00:18):
Welcome to one thing Trump did, available exclusively on The
Middle podcast feed. I'm Jeremy Hobson, and each week on
this podcast, we pick just one thing coming out of
the Trump White House and break it down in a
non partisan way with someone who knows what they're talking about.
And this episode, the one thing is the Affordable Care
Act subsidies that are set to expire at the end
(00:39):
of this year. You know, the ones the Democrats wanted
extended in order to reopen the government when it was
shut down, and then they backed off that demand and
settled for a vote on the subsidies in the Senate. Well,
what I'd like to do in this episode is understand
what exactly is going on with the subsidies, how they're
going to affect healthcare for people who are on Obamacare
and people with private insurance, and what might happen now.
(01:02):
President Trump, for his part, has urged lawmakers not to
waste their time with the Affordable Care Act and that
the only healthcare he will support is sending the money
he would have used to extend the subsidies directly back
to the people. Meanwhile, Mehmet Oz, who is Trump's head
of Medicare and Medicaid Services, set on CNN that the
subsidies could be extended.
Speaker 3 (01:21):
There are ways for us to continue to cover Americans
without allowing the widespread fraud. And I don't want to
underplay this. Four point four million people right now we
believe are getting full insurance coverage with the Obamacare. Many
of them don't know they have that coverage. Their dually
enrolled both in Medicaid.
Speaker 4 (01:36):
And these you fix that. It's the middle of November.
Can you fix that in the next five weeks.
Speaker 3 (01:41):
Well, we can definitely put an incentive to remove that
as a possibility. I'll give you a good example. Get
people to pay five dollars five dollars is that too
much to pay a month? Paying five dollars a month
means at least you have to opt into the program.
You can't get falsely put on the program by some
broker without you knowing.
Speaker 4 (01:55):
Are there conversations about doing things like you just said
with the Republicans in Congress, maybe even with Democrats in
order to get these subsidies at least extended in the
short term.
Speaker 3 (02:07):
There are discussions around extending the subsidies if we deal
with the fraud, waste, and abuse.
Speaker 4 (02:12):
Well.
Speaker 2 (02:12):
For more on how this could shape up, we're joined
by KFF Health News Chief Washington correspondent Julie Robner Hi,
Julie Hi, Jeremy Okay. So, first off, what is the
deal with these subsidies, How much do they cost taxpayers
and how many people do they help? Right now, so there's.
Speaker 1 (02:29):
About twenty four million people who buy their insurance on
what now the individual market through the Affordable Care Act.
There were interestingly, only twelve million people who were buying
this insurance before the subsidies were increased in twenty twenty
one during COVID. As it turned out what people really wanted,
what people really needed in order to buy health insurance
(02:50):
was not a mandate which was in the original Affordable
Care Act. It was just insurance that they thought they
could afford. So when they made insurance much cheaper by
you know, making the subsidies much larger, many more people
signed up. So we're talking about roughly twenty four million people.
The subsidies. The Democrats originally only did them for I
(03:11):
think it was two years, and then they managed to
extend them again through the end of twenty twenty five.
That was all they could find the votes for. It
wasn't that they didn't want to make them permanent, it's
that they didn't have the votes to make them permanent,
and they were hoping that the Republicans would join them
in extending the subsidies. Because, as it turns out, most
of that additional twelve million people who signed up are
(03:32):
in Republican states, and a lot of them are Republicans.
They are small business owners, farmers, and ranchers. They live
in states like Florida and Texas and Georgia. So these
are Republican constituents who are about to see their premium's
skyrocket if these subsidies expire as scheduled at the end
of this year. That's not what happened, which I assume
(03:53):
we'll get into.
Speaker 2 (03:54):
Yeah. Well, and just on the issue of the number
of people who are getting these subsidies and who are
on the Affordable Care Act marketplace is doubling in the pandemic,
what did the pandemic have to do with adding more
of these substanties just because the economy was in rough
shape and more people needed it well.
Speaker 1 (04:12):
And also because we had a pandemic and it was
important that more people have health insurance, right, And that
was mostly it was, you know, there were so many
people without health insurance that they extended the subsidies to
make it easier for people to get health insurance so
that if they got COVID, their bills would be covered.
That was basically the idea behind it.
Speaker 2 (04:31):
So in the situation that we're in right now and
the deadline that's coming up later this year, is this
only about people who are on Obamacare or is this
about all people are going to see their premiums rise.
Speaker 1 (04:41):
Yes, and no, it's mostly about people who are on Obamacare.
And I should mention that of the twenty four million
people roughly who buy their own insurance on the exchange,
it's about ninety percent of them get some size subsidy.
Some you know, some subsidies are bigger than others. It
depends how much you earn, it depends where you live
and how much insurance surance costs where you live, because
that varies. But it's most of those people who will
(05:05):
be impacted, and they will be impacted most directly, but
the Congressional Budget Office estimates that if the subsidies, the
additional subsidies are not extended, about four million people will
end up dropping their coverage, dropping their insurance coverage, become uninsured.
Those people will eventually get health care, they'll eventually need
and get health care, and somebody will have to pay
(05:27):
for it. So if they're not poor enough to end
up on Medicaid and not old enough to end up
on Medicare, it's probably going to get loaded onto other
people's health insurance premiums. Either that or we're going to
see providers close. So eventually, when there's a large number
of people without insurance, people with insurance end up paying
the bill one way or the other.
Speaker 2 (05:48):
Right, I mean, you're not allowed to refuse somebody at
the emergency room. But by the way, what emergency lands
them in the emergency room would probably be could be
a lot cheaper if they actually went to the doctor
regularly in advance of that and dealt with the things
that needed to be dealt with earlier. On how much
would it cost if Congress just came in and said,
we're going to extend the subsidies, so it's.
Speaker 1 (06:10):
About thirty five billion dollars a year to extend these
additional subsidies, or three hundred and fifty billion dollars over
ten years. Although it doesn't seem to be we.
Speaker 2 (06:17):
Should know, by the way, that is less than what
Elon Musk is worth right now. It is three hundred
and fifty billion. Yeah, I think he's four hundred and
fifty and on his way to a trillion. So just
just to put that in perspective, it's.
Speaker 1 (06:27):
Also less way less than the you know, the Republicans
cut taxes back in the summer, so it's not you know,
compared to sort of other things. It's actually not all
that much money. But as I was about to say,
Republicans seem to now be using this to launch another
full scale attack on the Affordable Care Act. It's not
about the money they would like. They say they would
(06:49):
like to take the money and give it to people,
to individuals, rather than give it to insurance companies in
the form of subsidies for insurance.
Speaker 2 (06:57):
Let's talk about that for a second. This is what
President says he wants to do, give the money to
people directly. How would that work.
Speaker 1 (07:04):
Well, they're already things called health savings accounts and flexible
spending accounts. They're already ways for people to get money.
They get it either tax free on the front end
or tax free on the back end, or both in
some cases. So these are, you know, tax sheltered accounts
that you can use to pay for medical expenses. Now,
in most cases they are in addition to insurance. In fact,
(07:24):
you're not allowed to use this money to pay insurance premiums.
You're allowed to use it to pay things like deductibles
and co payments and co insurance, and for things that
aren't covered or that you don't have insurance for, like
eyeglasses and dental care. Those are fairly typical ways that
people use these accounts. They also use them if they
(07:44):
have what's called catastrophic insurance, so insurance with very high deductibles.
They can use it to meet their deductible. The problem
is if you just give people a couple of thousand dollars,
which is essentially what would happen here, and they don't
have insurance to back it up, or they have insurance
that has many, many thousand dollars deductible, there's going to
be a big gap if they need healthcare I fell
(08:05):
and broke my wrist earlier this summer. I needed fairly
simple outpatient surgery. It costs thirty thousand dollars. I'm really
glad I have insurance to pay a good chunk of
it myself. But you know, a couple of thousand dollars
is not going to help somebody who has an accident
or is diagnosed with a chronic or serious disease.
Speaker 2 (08:25):
So what about that point? And this is something that
some Republicans have brought up, is the costs of these
things are so high and how are we ever going
to push down the costs of medical care if nobody
really sees the price tag because the government is subsidizing
and the insurance companies are driving up the costs. And
is there an argument there? And is there a solution
(08:46):
if that's what your problem with it is?
Speaker 1 (08:48):
There is an argument there, but fixing it. You're not
going to fix it by saying individuals, you go out
and negotiate, you know, lying on your gurney in the
emergency room. You know already we have people lying on
the gurney in the emergency room saying are you in
my network? You know, when they have insurance, which is
problem enough, But they're not going to say, gee, could
(09:09):
you take me down the street where I could get
this for twenty thousand dollars instead of forty thousand dollars.
That's not really the way you know, health insurance works.
I mean, Republicans absolutely do have a point that third
party payment is definitely driving up costs. It's just that
there needs to be a more systematic way to go
about figuring out how to do it. I will say
(09:30):
that most other countries, you know, it's kind of a
myth that most other countries have single pay our health
insurance where the government pays it. Most other countries have
kind of a hybrid system like we do. They have
government doing some things and private insurance doing some things.
But most of those other countries very very stringently regulate
the prices of things, including drugs, including other medical care.
(09:51):
We in the United States do not. That's a big reason.
It's not just the fact that you know, we use
about the same amount of medical care as people in
other countries, we pay a lot more for it.
Speaker 2 (10:01):
Now, if Trump were to somehow get his way here
and start handing out money to people to pay for
their own health care, would that destroy the Affordable Care
Act because the healthy people would just pull out of
the marketplaces, and then it doesn't work.
Speaker 1 (10:18):
It could I mean it depends. You know, people say,
what happens if the additional subsidies expire? Well, what happens
if they expire is we go back to twenty twenty
when there was a you know, a fairly workable Affordable
Care Act marketplace. It had about twelve million people in
it who had no other good way to get health insurance.
What would draw many more people out is if they
(10:38):
are suddenly allowed to buy you know, what we call
bare bones insurance. Democrats call it junk insurance. Republicans call
it real insurance. But basically it doesn't cover very much.
It's for people who are basically healthy and think they're
not going to need to spend very much on medical care,
and they have lower premiums because they cover fewer things.
So if you have something serious, you may be in
(10:58):
real trouble. And that's why most of these plants were
outlawed when the Affordable Care Act passed. But if people say, oh, well,
I can get you know, this insurance that's called insurance
for twenty bucks a month, I'm going to do that.
If all those healthy people then leave the Affordable Care
Act exchanges, then you could have a real problem with
the Affordable Care Act falling apart. I should add sort
of an in passing, although it's a whole lot more
(11:20):
than in passing. The Trump administration is doing a lot
of other things to undermine the Affordable Care Act, some
of it just by regulation. They're making it harder to
what's to re enroll, to renew your coverage automatically. They're
shortening the open enrollment period. They've cut by ninety percent
the budget for people who help people sign up, who
help people figure out what their best option is for
(11:43):
health insurance. So they're already going, you know, four square
after the ACA. They're just not kind of advertising it.
Speaker 2 (11:49):
Well and they're not giving us any plan to replace
it yet after all these many years. And we're going
to talk about that in a moment, and what are
some of the options on the table. One thing Trump
did with KFF Health News Chief Washington correspondent at Julie
Robner will be right back. Welcome back to One Thing
(12:25):
Trump did on the Middle podcast feed. I'm Jeremy Hobson.
In this episode, we're talking about the looming deadline for
some key Obamacare subsidies and what it all means for
healthcare in this country. My guest is KFF Health News
chief Washington correspondent Julie Robner. Julie, you heard doctor Oz
say there that he thinks some extension of the subsidies
is possible, that discussions are happening if waste fraud and
(12:49):
abuse is dealt with. What do you hear in that.
Speaker 1 (12:52):
Well, there actually is a compromise that could be workable,
and there has been an issue with waste fraud and abuse.
When they extended the subs they made the basically health
insurance free for people under I think about one hundred
and fifty percent of poverty, which is not very much money.
It's like twenty thousand dollars a year in income. What's happened, though,
(13:13):
is that some unscrupulous insurance brokers, you know, would then
enroll people in these zero premium policies. Sometimes the people
wouldn't even know that they had insurance. The insurance companies
would collect the premiums from the government, the brokers would
collect their commissions for signing up the people. People didn't
get any medical care because they didn't know they had insurance.
(13:33):
Sometimes they would have insurance and the brokers would switch
to them around. One of the proposed solutions to that
is charging a deminimus premium for those people at the
lower end of the income spectrum, maybe five or ten
dollars a month. That way they would know they have insurance.
That democrats have no problem with that, they would be
happy to do that. The other thing that the expanded
subsidies did was there had been a cap that you
(13:56):
could only get subsidies if you were up to a
four hundred percent of poverty a little over one hundred
thousand dollars a year for family of four, and then
if you were just slightly over that, you got nothing.
If these subsities expired, they'll go back to getting nothing,
which is why some people will see, you know, dramatic
increases in their premiums. But there's been talk of don't
let people, you know, with unlimited income collect these subsidies,
(14:19):
although you only do collect the subsidy if the premium
is more than ten percent of your income. So obviously
the bill Gates of the world are not going to
be able to get subsidies. But if there's a concern
that it goes too high up the income scale. Democrats
have said that they would be willing to cap it
just at something higher than four hundred percent of poverty.
So that is a potential compromise. But right now, at
(14:39):
least judging from what I've seen the last week, Republicans
are sort of retreating back to their corners of you know,
we don't want to have any part of this then,
as is the president. So I don't know how you
would actually get that compromise.
Speaker 2 (14:53):
What about an extension of the subsidies, like for a
year and then they figure it out later. They love
that in Washington, they do.
Speaker 1 (14:59):
That's the the old kick the can down the road.
That doesn't seem likely either, though, As I say, the
Republicans seem to be stiffening their spines against any extension
of these subsidies. What will happen in January when they
get their own voters who are coming to complain to them.
I don't know, you know, perhaps the heat will get
too hot and they will change their mind. But the
(15:20):
later it goes, the harder this is going to be.
I mean, they could insurers could turn the subsidies back
on because they knew that that was a possibility. But
if Congress decides to tinker with them, and you know,
let's have let's change the upper limit, let's make people
pay at the lower That's a lot more complicated and
would take a long time. And we're into open enrollment.
(15:41):
It ends January fifteenth in most states.
Speaker 2 (15:44):
Julie, do the other things that are happening in the
political world right now, the elections in New Jersey and
in Virginia, the Epstein files release, Do these things play
into what might happen with healthcare just because of the
political dynamics.
Speaker 1 (16:00):
Do you think you would think so? But as I say,
it seems that Republicans are retreating rather than trying to
find compromise. Here, I'm a little bit surprised. The last
time we had a full scale healthcare debate was in
twenty seventeen. It did not end well for the Republicans.
The Democrats swept the midterms in twenty eighteen. But a
lot of the people in Congress have changed since twenty seventeen,
(16:22):
and they may not remember.
Speaker 2 (16:24):
That was the time when John McCain did a thumbs
down and ended the Trump plan to repeal Obamacare. Speaking
of which, It's now been fifteen years since the ACA
was passed, and there's still really no plan from Republicans
on what they would want to do instead. Keeping in
mind asterisks that Obamacare was originally a Republican plan from
(16:44):
Massachusetts and Governor Mitt Romney.
Speaker 1 (16:47):
Yes, thank you very much. I usually say that, but
you managed to say that before me this time. Yeah,
I mean the Republicans. The only other plan the Republicans
have had besides what became Obamacare is this idea of
let's just give money to individuals and see if they
can negotiate and bring the prices down. You know, there's
been a lot of work, and this is bipartisan. There's
(17:08):
been a lot of work on price transparency so people
at least know how much things are going to cost.
It hasn't worked very well, but that is something that
both Republicans and Democrats have worked on, and that is
something that Trump did in his first term that you know,
the Democrats applauded, but we've not really seen that sort
of transparency translate into people being able to more effectively
(17:28):
shop for medical care at better prices.
Speaker 2 (17:32):
Julie, I'm going to ask you a question. I don't
know if you've been asked. Maybe you have, But I
was wondering about it as I was getting ready for this,
which is, if there had been a so called public
option in Obamacare, which a lot of Democrats had pushed for,
and in fact, Obama had a sixty seat majority in
the Senate when they passed Obamacare, and it was Democrats
like I think Joe Lieberman who said, no, we're not
(17:52):
going to do the public option. But if there had
been one, would this situation have been avoided that we're
in right now?
Speaker 1 (17:59):
Boy, that's a good question. No one has ever asked
me that before. I would need to think about that.
I don't know. I mean, there is a concern. And
you know I said this when the Affordable Character first passed.
There was an awful lot in that bill that said,
you know, the Secretary shall or the Secretary may all this,
all this authority to the HHS secretary. And I said,
you know, the HHS secretary isn't always going to be
(18:20):
a Democrat in favor of this. And so we are
now seeing So I don't know what the Trump administration
would have done with a public option. I don't know
what they would have done with the public option in
the first Trump administration when they wanted to get rid
of the ACA. It's a good question, it's a good
what if. And I'm going to go ask some experts myself.
Speaker 2 (18:38):
Yeah, Well, the HHS Secretary is Robert F. Kennedy Junior.
He hasn't it doesn't seem like been on the front
lines of this conversation about subsidies yet or has he?
Speaker 1 (18:47):
No, he has not. He's left most of this to
doctor Oz, who, in addition to being in charge of
Medicare and Medicaid, is in charge of the ACA for
the federal government that that also lives within the centers
for Medicare and Medicaid services. So he's he's actually the
appropriate person to be assessing this.
Speaker 3 (19:02):
Uh huh.
Speaker 2 (19:03):
So what do you think is going to happen in
the next month.
Speaker 1 (19:06):
I do not know. I keep you know. I didn't
know how the shutdown was going to end. The only
thing I'm fairly confident of is that we are well
into yet another round of debating healthcare reform, which I
think is a good thing. I think everybody, Republicans and Democrats,
and consumers and people who are healthcare professionals, agree that
the system is not working well. I don't really think
(19:27):
it's the fault of the ACA, which is what Republicans say.
It's the fault of not fixing our healthcare system, being
not having the votes in Congress of the administration to
really do anything you know, transformative that would fix it,
and things have continued to get worse. And it's a
good thing that we have the debate. But I have
no idea where we're going to end up.
Speaker 2 (19:49):
But other than like turning the United States into a
single payer system, which I'm sure there are some people
listening to this right now going, well, obviously that's the solution,
just like all the other countries do. Is there another
transformational thing that could happen to our healthcare system that
would fix this?
Speaker 1 (20:06):
As I said, it's not single payer or nothing. It's
not single payer or what we have now. We could
fix what we have now with a private insurance system,
you know, with government involvement. Also, what we are lacking
that other countries have is price regulation, and it's you know,
Lena conn at the Federal Trade Commission was kind of
working around that a little bit during the Biden administration,
(20:28):
and she was sort of summarily sent on her way
when Trump took back over. But it's going to take
people looking at prices and how the system is structured
and how the system is regulated. States have a lot
of power both over the insurance industry and over the
healthcare industry, which also makes things a little bit more
difficult than some you know, smaller countries have it. But
(20:49):
that's not to say that it couldn't be fixed without
going to a single payer system.
Speaker 2 (20:54):
All right, Well, I don't think that's going to happen
in the next month, but we'll check in with you
to see what does happen with these subsidies. Julia Robner,
chief Washington correspondent for KFF Health News. Thank you so much.
Happy Thanksgiving. I have a great holiday season. You'll be
working very hard.
Speaker 1 (21:07):
I will thank you, Jeremy, and.
Speaker 2 (21:09):
Thanks you for listening to one thing Trump did. It
was produced by Harrison Pattino. Our next Middle episode is
coming to your podcast feed later this week. It is
a repeat because it's Thanksgiving, but we're going to bring
you one of the most downloaded episodes, which was the
one about the philosophical Middle. If you like this podcast,
please rate it wherever you get your podcasts and write
a review. Our theme music was composed by Noah Haidu.
I'm Jeremy Hobson. Talk to you soon.
The system is not working. Well, I don't really think
it's the fault of the ACA, which is what Republicans say,
it's the fault of not fixing our healthcare system.
Speaker 2 (00:18):
Welcome to one thing Trump did, available exclusively on The
Middle podcast feed. I'm Jeremy Hobson, and each week on
this podcast, we pick just one thing coming out of
the Trump White House and break it down in a
non partisan way with someone who knows what they're talking about.
And this episode, the one thing is the Affordable Care
Act subsidies that are set to expire at the end
(00:39):
of this year. You know, the ones the Democrats wanted
extended in order to reopen the government when it was
shut down, and then they backed off that demand and
settled for a vote on the subsidies in the Senate. Well,
what I'd like to do in this episode is understand
what exactly is going on with the subsidies, how they're
going to affect healthcare for people who are on Obamacare
and people with private insurance, and what might happen now.
(01:02):
President Trump, for his part, has urged lawmakers not to
waste their time with the Affordable Care Act and that
the only healthcare he will support is sending the money
he would have used to extend the subsidies directly back
to the people. Meanwhile, Mehmet Oz, who is Trump's head
of Medicare and Medicaid Services, set on CNN that the
subsidies could be extended.
Speaker 3 (01:21):
There are ways for us to continue to cover Americans
without allowing the widespread fraud. And I don't want to
underplay this. Four point four million people right now we
believe are getting full insurance coverage with the Obamacare. Many
of them don't know they have that coverage. Their dually
enrolled both in Medicaid.
Speaker 4 (01:36):
And these you fix that. It's the middle of November.
Can you fix that in the next five weeks.
Speaker 3 (01:41):
Well, we can definitely put an incentive to remove that
as a possibility. I'll give you a good example. Get
people to pay five dollars five dollars is that too
much to pay a month? Paying five dollars a month
means at least you have to opt into the program.
You can't get falsely put on the program by some
broker without you knowing.
Speaker 4 (01:55):
Are there conversations about doing things like you just said
with the Republicans in Congress, maybe even with Democrats in
order to get these subsidies at least extended in the
short term.
Speaker 3 (02:07):
There are discussions around extending the subsidies if we deal
with the fraud, waste, and abuse.
Speaker 4 (02:12):
Well.
Speaker 2 (02:12):
For more on how this could shape up, we're joined
by KFF Health News Chief Washington correspondent Julie Robner Hi,
Julie Hi, Jeremy Okay. So, first off, what is the
deal with these subsidies, How much do they cost taxpayers
and how many people do they help? Right now, so there's.
Speaker 1 (02:29):
About twenty four million people who buy their insurance on
what now the individual market through the Affordable Care Act.
There were interestingly, only twelve million people who were buying
this insurance before the subsidies were increased in twenty twenty
one during COVID. As it turned out what people really wanted,
what people really needed in order to buy health insurance
(02:50):
was not a mandate which was in the original Affordable
Care Act. It was just insurance that they thought they
could afford. So when they made insurance much cheaper by
you know, making the subsidies much larger, many more people
signed up. So we're talking about roughly twenty four million people.
The subsidies. The Democrats originally only did them for I
(03:11):
think it was two years, and then they managed to
extend them again through the end of twenty twenty five.
That was all they could find the votes for. It
wasn't that they didn't want to make them permanent, it's
that they didn't have the votes to make them permanent,
and they were hoping that the Republicans would join them
in extending the subsidies. Because, as it turns out, most
of that additional twelve million people who signed up are
(03:32):
in Republican states, and a lot of them are Republicans.
They are small business owners, farmers, and ranchers. They live
in states like Florida and Texas and Georgia. So these
are Republican constituents who are about to see their premium's
skyrocket if these subsidies expire as scheduled at the end
of this year. That's not what happened, which I assume
(03:53):
we'll get into.
Speaker 2 (03:54):
Yeah. Well, and just on the issue of the number
of people who are getting these subsidies and who are
on the Affordable Care Act marketplace is doubling in the pandemic,
what did the pandemic have to do with adding more
of these substanties just because the economy was in rough
shape and more people needed it well.
Speaker 1 (04:12):
And also because we had a pandemic and it was
important that more people have health insurance, right, And that
was mostly it was, you know, there were so many
people without health insurance that they extended the subsidies to
make it easier for people to get health insurance so
that if they got COVID, their bills would be covered.
That was basically the idea behind it.
Speaker 2 (04:31):
So in the situation that we're in right now and
the deadline that's coming up later this year, is this
only about people who are on Obamacare or is this
about all people are going to see their premiums rise.
Speaker 1 (04:41):
Yes, and no, it's mostly about people who are on Obamacare.
And I should mention that of the twenty four million
people roughly who buy their own insurance on the exchange,
it's about ninety percent of them get some size subsidy.
Some you know, some subsidies are bigger than others. It
depends how much you earn, it depends where you live
and how much insurance surance costs where you live, because
that varies. But it's most of those people who will
(05:05):
be impacted, and they will be impacted most directly, but
the Congressional Budget Office estimates that if the subsidies, the
additional subsidies are not extended, about four million people will
end up dropping their coverage, dropping their insurance coverage, become uninsured.
Those people will eventually get health care, they'll eventually need
and get health care, and somebody will have to pay
(05:27):
for it. So if they're not poor enough to end
up on Medicaid and not old enough to end up
on Medicare, it's probably going to get loaded onto other
people's health insurance premiums. Either that or we're going to
see providers close. So eventually, when there's a large number
of people without insurance, people with insurance end up paying
the bill one way or the other.
Speaker 2 (05:48):
Right, I mean, you're not allowed to refuse somebody at
the emergency room. But by the way, what emergency lands
them in the emergency room would probably be could be
a lot cheaper if they actually went to the doctor
regularly in advance of that and dealt with the things
that needed to be dealt with earlier. On how much
would it cost if Congress just came in and said,
we're going to extend the subsidies, so it's.
Speaker 1 (06:10):
About thirty five billion dollars a year to extend these
additional subsidies, or three hundred and fifty billion dollars over
ten years. Although it doesn't seem to be we.
Speaker 2 (06:17):
Should know, by the way, that is less than what
Elon Musk is worth right now. It is three hundred
and fifty billion. Yeah, I think he's four hundred and
fifty and on his way to a trillion. So just
just to put that in perspective, it's.
Speaker 1 (06:27):
Also less way less than the you know, the Republicans
cut taxes back in the summer, so it's not you know,
compared to sort of other things. It's actually not all
that much money. But as I was about to say,
Republicans seem to now be using this to launch another
full scale attack on the Affordable Care Act. It's not
about the money they would like. They say they would
(06:49):
like to take the money and give it to people,
to individuals, rather than give it to insurance companies in
the form of subsidies for insurance.
Speaker 2 (06:57):
Let's talk about that for a second. This is what
President says he wants to do, give the money to
people directly. How would that work.
Speaker 1 (07:04):
Well, they're already things called health savings accounts and flexible
spending accounts. They're already ways for people to get money.
They get it either tax free on the front end
or tax free on the back end, or both in
some cases. So these are, you know, tax sheltered accounts
that you can use to pay for medical expenses. Now,
in most cases they are in addition to insurance. In fact,
(07:24):
you're not allowed to use this money to pay insurance premiums.
You're allowed to use it to pay things like deductibles
and co payments and co insurance, and for things that
aren't covered or that you don't have insurance for, like
eyeglasses and dental care. Those are fairly typical ways that
people use these accounts. They also use them if they
(07:44):
have what's called catastrophic insurance, so insurance with very high deductibles.
They can use it to meet their deductible. The problem
is if you just give people a couple of thousand dollars,
which is essentially what would happen here, and they don't
have insurance to back it up, or they have insurance
that has many, many thousand dollars deductible, there's going to
be a big gap if they need healthcare I fell
(08:05):
and broke my wrist earlier this summer. I needed fairly
simple outpatient surgery. It costs thirty thousand dollars. I'm really
glad I have insurance to pay a good chunk of
it myself. But you know, a couple of thousand dollars
is not going to help somebody who has an accident
or is diagnosed with a chronic or serious disease.
Speaker 2 (08:25):
So what about that point? And this is something that
some Republicans have brought up, is the costs of these
things are so high and how are we ever going
to push down the costs of medical care if nobody
really sees the price tag because the government is subsidizing
and the insurance companies are driving up the costs. And
is there an argument there? And is there a solution
(08:46):
if that's what your problem with it is?
Speaker 1 (08:48):
There is an argument there, but fixing it. You're not
going to fix it by saying individuals, you go out
and negotiate, you know, lying on your gurney in the
emergency room. You know already we have people lying on
the gurney in the emergency room saying are you in
my network? You know, when they have insurance, which is
problem enough, But they're not going to say, gee, could
(09:09):
you take me down the street where I could get
this for twenty thousand dollars instead of forty thousand dollars.
That's not really the way you know, health insurance works.
I mean, Republicans absolutely do have a point that third
party payment is definitely driving up costs. It's just that
there needs to be a more systematic way to go
about figuring out how to do it. I will say
(09:30):
that most other countries, you know, it's kind of a
myth that most other countries have single pay our health
insurance where the government pays it. Most other countries have
kind of a hybrid system like we do. They have
government doing some things and private insurance doing some things.
But most of those other countries very very stringently regulate
the prices of things, including drugs, including other medical care.
(09:51):
We in the United States do not. That's a big reason.
It's not just the fact that you know, we use
about the same amount of medical care as people in
other countries, we pay a lot more for it.
Speaker 2 (10:01):
Now, if Trump were to somehow get his way here
and start handing out money to people to pay for
their own health care, would that destroy the Affordable Care
Act because the healthy people would just pull out of
the marketplaces, and then it doesn't work.
Speaker 1 (10:18):
It could I mean it depends. You know, people say,
what happens if the additional subsidies expire? Well, what happens
if they expire is we go back to twenty twenty
when there was a you know, a fairly workable Affordable
Care Act marketplace. It had about twelve million people in
it who had no other good way to get health insurance.
What would draw many more people out is if they
(10:38):
are suddenly allowed to buy you know, what we call
bare bones insurance. Democrats call it junk insurance. Republicans call
it real insurance. But basically it doesn't cover very much.
It's for people who are basically healthy and think they're
not going to need to spend very much on medical care,
and they have lower premiums because they cover fewer things.
So if you have something serious, you may be in
(10:58):
real trouble. And that's why most of these plants were
outlawed when the Affordable Care Act passed. But if people say, oh, well,
I can get you know, this insurance that's called insurance
for twenty bucks a month, I'm going to do that.
If all those healthy people then leave the Affordable Care
Act exchanges, then you could have a real problem with
the Affordable Care Act falling apart. I should add sort
of an in passing, although it's a whole lot more
(11:20):
than in passing. The Trump administration is doing a lot
of other things to undermine the Affordable Care Act, some
of it just by regulation. They're making it harder to
what's to re enroll, to renew your coverage automatically. They're
shortening the open enrollment period. They've cut by ninety percent
the budget for people who help people sign up, who
help people figure out what their best option is for
(11:43):
health insurance. So they're already going, you know, four square
after the ACA. They're just not kind of advertising it.
Speaker 2 (11:49):
Well and they're not giving us any plan to replace
it yet after all these many years. And we're going
to talk about that in a moment, and what are
some of the options on the table. One thing Trump
did with KFF Health News Chief Washington correspondent at Julie
Robner will be right back. Welcome back to One Thing
(12:25):
Trump did on the Middle podcast feed. I'm Jeremy Hobson.
In this episode, we're talking about the looming deadline for
some key Obamacare subsidies and what it all means for
healthcare in this country. My guest is KFF Health News
chief Washington correspondent Julie Robner. Julie, you heard doctor Oz
say there that he thinks some extension of the subsidies
is possible, that discussions are happening if waste fraud and
(12:49):
abuse is dealt with. What do you hear in that.
Speaker 1 (12:52):
Well, there actually is a compromise that could be workable,
and there has been an issue with waste fraud and abuse.
When they extended the subs they made the basically health
insurance free for people under I think about one hundred
and fifty percent of poverty, which is not very much money.
It's like twenty thousand dollars a year in income. What's happened, though,
(13:13):
is that some unscrupulous insurance brokers, you know, would then
enroll people in these zero premium policies. Sometimes the people
wouldn't even know that they had insurance. The insurance companies
would collect the premiums from the government, the brokers would
collect their commissions for signing up the people. People didn't
get any medical care because they didn't know they had insurance.
(13:33):
Sometimes they would have insurance and the brokers would switch
to them around. One of the proposed solutions to that
is charging a deminimus premium for those people at the
lower end of the income spectrum, maybe five or ten
dollars a month. That way they would know they have insurance.
That democrats have no problem with that, they would be
happy to do that. The other thing that the expanded
subsidies did was there had been a cap that you
(13:56):
could only get subsidies if you were up to a
four hundred percent of poverty a little over one hundred
thousand dollars a year for family of four, and then
if you were just slightly over that, you got nothing.
If these subsities expired, they'll go back to getting nothing,
which is why some people will see, you know, dramatic
increases in their premiums. But there's been talk of don't
let people, you know, with unlimited income collect these subsidies,
(14:19):
although you only do collect the subsidy if the premium
is more than ten percent of your income. So obviously
the bill Gates of the world are not going to
be able to get subsidies. But if there's a concern
that it goes too high up the income scale. Democrats
have said that they would be willing to cap it
just at something higher than four hundred percent of poverty.
So that is a potential compromise. But right now, at
(14:39):
least judging from what I've seen the last week, Republicans
are sort of retreating back to their corners of you know,
we don't want to have any part of this then,
as is the president. So I don't know how you
would actually get that compromise.
Speaker 2 (14:53):
What about an extension of the subsidies, like for a
year and then they figure it out later. They love
that in Washington, they do.
Speaker 1 (14:59):
That's the the old kick the can down the road.
That doesn't seem likely either, though, As I say, the
Republicans seem to be stiffening their spines against any extension
of these subsidies. What will happen in January when they
get their own voters who are coming to complain to them.
I don't know, you know, perhaps the heat will get
too hot and they will change their mind. But the
(15:20):
later it goes, the harder this is going to be.
I mean, they could insurers could turn the subsidies back
on because they knew that that was a possibility. But
if Congress decides to tinker with them, and you know,
let's have let's change the upper limit, let's make people
pay at the lower That's a lot more complicated and
would take a long time. And we're into open enrollment.
(15:41):
It ends January fifteenth in most states.
Speaker 2 (15:44):
Julie, do the other things that are happening in the
political world right now, the elections in New Jersey and
in Virginia, the Epstein files release, Do these things play
into what might happen with healthcare just because of the
political dynamics.
Speaker 1 (16:00):
Do you think you would think so? But as I say,
it seems that Republicans are retreating rather than trying to
find compromise. Here, I'm a little bit surprised. The last
time we had a full scale healthcare debate was in
twenty seventeen. It did not end well for the Republicans.
The Democrats swept the midterms in twenty eighteen. But a
lot of the people in Congress have changed since twenty seventeen,
(16:22):
and they may not remember.
Speaker 2 (16:24):
That was the time when John McCain did a thumbs
down and ended the Trump plan to repeal Obamacare. Speaking
of which, It's now been fifteen years since the ACA
was passed, and there's still really no plan from Republicans
on what they would want to do instead. Keeping in
mind asterisks that Obamacare was originally a Republican plan from
(16:44):
Massachusetts and Governor Mitt Romney.
Speaker 1 (16:47):
Yes, thank you very much. I usually say that, but
you managed to say that before me this time. Yeah,
I mean the Republicans. The only other plan the Republicans
have had besides what became Obamacare is this idea of
let's just give money to individuals and see if they
can negotiate and bring the prices down. You know, there's
been a lot of work, and this is bipartisan. There's
(17:08):
been a lot of work on price transparency so people
at least know how much things are going to cost.
It hasn't worked very well, but that is something that
both Republicans and Democrats have worked on, and that is
something that Trump did in his first term that you know,
the Democrats applauded, but we've not really seen that sort
of transparency translate into people being able to more effectively
(17:28):
shop for medical care at better prices.
Speaker 2 (17:32):
Julie, I'm going to ask you a question. I don't
know if you've been asked. Maybe you have, But I
was wondering about it as I was getting ready for this,
which is, if there had been a so called public
option in Obamacare, which a lot of Democrats had pushed for,
and in fact, Obama had a sixty seat majority in
the Senate when they passed Obamacare, and it was Democrats
like I think Joe Lieberman who said, no, we're not
(17:52):
going to do the public option. But if there had
been one, would this situation have been avoided that we're
in right now?
Speaker 1 (17:59):
Boy, that's a good question. No one has ever asked
me that before. I would need to think about that.
I don't know. I mean, there is a concern. And
you know I said this when the Affordable Character first passed.
There was an awful lot in that bill that said,
you know, the Secretary shall or the Secretary may all this,
all this authority to the HHS secretary. And I said,
you know, the HHS secretary isn't always going to be
(18:20):
a Democrat in favor of this. And so we are
now seeing So I don't know what the Trump administration
would have done with a public option. I don't know
what they would have done with the public option in
the first Trump administration when they wanted to get rid
of the ACA. It's a good question, it's a good
what if. And I'm going to go ask some experts myself.
Speaker 2 (18:38):
Yeah, Well, the HHS Secretary is Robert F. Kennedy Junior.
He hasn't it doesn't seem like been on the front
lines of this conversation about subsidies yet or has he?
Speaker 1 (18:47):
No, he has not. He's left most of this to
doctor Oz, who, in addition to being in charge of
Medicare and Medicaid, is in charge of the ACA for
the federal government that that also lives within the centers
for Medicare and Medicaid services. So he's he's actually the
appropriate person to be assessing this.
Speaker 3 (19:02):
Uh huh.
Speaker 2 (19:03):
So what do you think is going to happen in
the next month.
Speaker 1 (19:06):
I do not know. I keep you know. I didn't
know how the shutdown was going to end. The only
thing I'm fairly confident of is that we are well
into yet another round of debating healthcare reform, which I
think is a good thing. I think everybody, Republicans and Democrats,
and consumers and people who are healthcare professionals, agree that
the system is not working well. I don't really think
(19:27):
it's the fault of the ACA, which is what Republicans say.
It's the fault of not fixing our healthcare system, being
not having the votes in Congress of the administration to
really do anything you know, transformative that would fix it,
and things have continued to get worse. And it's a
good thing that we have the debate. But I have
no idea where we're going to end up.
Speaker 2 (19:49):
But other than like turning the United States into a
single payer system, which I'm sure there are some people
listening to this right now going, well, obviously that's the solution,
just like all the other countries do. Is there another
transformational thing that could happen to our healthcare system that
would fix this?
Speaker 1 (20:06):
As I said, it's not single payer or nothing. It's
not single payer or what we have now. We could
fix what we have now with a private insurance system,
you know, with government involvement. Also, what we are lacking
that other countries have is price regulation, and it's you know,
Lena conn at the Federal Trade Commission was kind of
working around that a little bit during the Biden administration,
(20:28):
and she was sort of summarily sent on her way
when Trump took back over. But it's going to take
people looking at prices and how the system is structured
and how the system is regulated. States have a lot
of power both over the insurance industry and over the
healthcare industry, which also makes things a little bit more
difficult than some you know, smaller countries have it. But
(20:49):
that's not to say that it couldn't be fixed without
going to a single payer system.
Speaker 2 (20:54):
All right, Well, I don't think that's going to happen
in the next month, but we'll check in with you
to see what does happen with these subsidies. Julia Robner,
chief Washington correspondent for KFF Health News. Thank you so much.
Happy Thanksgiving. I have a great holiday season. You'll be
working very hard.
Speaker 1 (21:07):
I will thank you, Jeremy, and.
Speaker 2 (21:09):
Thanks you for listening to one thing Trump did. It
was produced by Harrison Pattino. Our next Middle episode is
coming to your podcast feed later this week. It is
a repeat because it's Thanksgiving, but we're going to bring
you one of the most downloaded episodes, which was the
one about the philosophical Middle. If you like this podcast,
please rate it wherever you get your podcasts and write
a review. Our theme music was composed by Noah Haidu.
I'm Jeremy Hobson. Talk to you soon.
Host
Jeremy Hobson
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