It’s interesting that this chart could only be created in one country on the planet. Probably the only country where the term “medical bankruptcy” exists.
I'm happy to see you're on board with the value of a public option, which is not as politically infeasible as you suggest, assuming that pricing above Medicare rates can be worked through. At least there's a strategy there: simply allow purchases of a public plan, whether Medicare, Medicaid or the VA system, modified to make it financially viable and affordable. How feasible is universal budgeting? Probably only as the public option, which utilizes that budgeting, succeeds. If there's 'mass migration' to the public option, as you suggest it only demonstrates the failure of the current fee for service insurance system. A public option would lead in providing the vision of a preventive and cost-effective system that you call for. And it would contain those principles you articulately call for.
You may do something that has never been done before; you may destroy the Republican Party. I can only imagine what our country would be like without any Republican states, and you may do just that.
Keep going, Trump. Your madness and insanity are becoming more obvious and more blatant, and it will be impossible to ignore. Your MAGA supporters and Republicans in Congress may follow you over the cliff, or they will have to retreat back under the stone where they came from.
Your uncontrollable, constant lying—looking into the camera and telling us that January 6th never happened—will no longer work. I hope you live long enough to see the Republican Party crumble and your MAGA supporters destroyed, and that you do not die before then, because they may make you a saint. At 80, you look weak, nodding and again lying about your health.
I know you are providing your family with corrupt funds, but that will all change after the fall of Rome. Your bizarre personality and your wishes for monuments honoring you will seem ridiculous and wild, even to your loyal supporters.
Remember the fate of Benito Mussolini in Italy, where he and four of his loyal supporters were hung upside down at a gas station; he, like you, was a fascist dictator; he, like you, destroyed the existing government and had his private army kill all his opponents; he was as corrupt as you, and he, like you, was fascinated by other thugs around the world, especially Hitler.
Your time is coming, so keep demonstrating your madness so we can finally have a country without Southern Republicans. I can only dream of our country as fully democratic, so keep it up, Trump.
A quick, standardized picture might be the easiest way politically to get enough people on board, to change the system.
Here is an animated diagram that explains a single-payer. It packs a lot of information. It is proceeded by a short video that explains the diagram symbols:
If you think this works, please send it to others. The point is to show left-wingers and right-wingers why we need BOTH market and non-market together.
Get rid of the private profit insurers by having a public insurer on the DEMAND side (the patients side), which is called a "single-payer."
BUT keep the private profit market on the SUPPLY side, for competition and innovation in supplying the medicines and machines to the doctors.
This is part of a longer work to add cooperation to mainstream economics.
Like our Military Industrial Complex, the Medical Industrial Complex is a corrupt, micromanaged monopoly conglomerate that thrives on legalized extortion - pay me or die. I know this from personal experience because I am a retired Navy Captain and a retired NIH official. I have posted all over the Internet that we already have an up-and-running national health system called Tricare which serves the military. I can go to any private-practice clinic or hospital that accepts Tricare (most do because they are sure to get paid promptly), and members can get all prescriptions for free from a nearby base pharmacy or by mail for the price of delivery. The cost of everything is negotiated and capped. So, I might be billed $350 for a procedure, but they will be paid $195 and consider it paid in full. My point is that there is a national health system with a proven track record of success that is far less costly than the MxIC, and could be implemented very quickly nationwide. If there is a will, there is already a way.
Plopping down here, in the spirit of keeping those interested informed:
The ACA expanded subsidies that were allowed to lapse 1/1/26 at the insistence of Republicans, data has been starting to roll in from non-federal sources showing something like 3 to 5 million people, of 24 million who had coverage on the ACA exchanges in 2025, losing coverage.
(And, detailed below, there is starting to be evidence that Dr. Oz, and his CMS, are delaying reporting on the coverage losses, which have become evident to them internally. And may be planning a misleading propagandistic response, claiming that the drops are due mainly to the administration's successful crackdown on ACA fraud.)
This information available to the public is part of the new data that continuously rolls in from non-federal non-CMS sources, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% enrollment drop for those 24 million.)
(Incidentally, you can find out about all of these coverage losses, information on which is still rolling in, the most quickly if you subscribe to Charles Gaba, ( https://charlesgaba.substack.com/ ), where his posts contain each bit of information usually on the same day it becomes available.)
In any case, after releasing the initial open-enrollment-period data for 2026 showing only a 4.9% drop in enrollment, with the big defect in the data that people who wind not paying the premium are not counted as dropping coverage, I don't believe anything has been released by CMS (Dr. Oz's Center for Medicaid and Medicare Services, which also manages the ACA).
The much larger coverage-drop numbers indicated in the KFF and NY Times reports, counting people not paying premiums as dropping, have come from other sources. (State exchanges, KFF surveys, and a major consulting company report with access to insurance company data.)
So, has the CMS been blocking the release of information on the coverage drops?
Charles Gaba actually caught one case where the data, usually presented as part of a report on Medicare and Medicaid and CHIP, was omitted.
"Until now, the summary report also included a brief mention of total effectuated ACA marketplace enrollment in Qualified Health Plans (QHPs), rounded off to the nearest 100,000. As of December effectuated enrollment was ~21.8 million people.
However, starting this month, this data point is missing...and that’s not by accident; it includes this footnote:
As of the January 2026 data, Marketplace enrollment data are no longer included in this report but will be available separately soon."
So, we may already have a case of data usually made available being suppressed.
Otherwise, on the data within CMS, I don't know if they usually release it and are holding it back, but we know they have it. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
I too have a major criticism of Krugman; he missed the real problem - Republicans played the Dems throughout the legislation development process until they gutted all of the provisions which would have made the ACA far more effective and popular.
The Gang of Six's 3 Republican Senators sliced and diced the proposal until there was no public option, subsidies had a sunset, a robust guideline effort was gutted, insurers got most of what they wanted, and Medicaid expansion was an option, not a requirement.
I'd add that we need a robust and well-designed clinical guideline development, management, and administration process as well - but one which is NOT a checklist, rather a patient-driven one.
A major miss in all these proposals is actually asking patients/members what their health goals are, and structuring their care around that. Instead of treating symptoms, we need to focus on what is important to people - otherwise they have little motivation to participate in, much less help direct, their own health journey.
This makes far more sense than the endless and in many cases pointless list of tests, screens, assessments and the like which are a mystery to the people undergoing them and a huge pain in the ass for providers.
Continuing, to make sure those interested are aware of what we have currently on our health insurance system. For those interested:
I support the ACA, want it improved, and am behind whatever additional minor or major politically possible system changes (going as far as single-payer) can be put into effect.
In the meanwhile, it's kind of been a hobby with me to point out the ACA defects on affordability and sufficiency of coverage, to try and get the problems fixed. (I will do that here, substantially duplicating content on a prior Potter post that was focused on the excessively high out-of-pocket maximums.
My starting point: old Wikipedia insertions by me:
In about 2019, aware of a bunch of the defects, I actually stuck in a Problems section into the ACA article in Wikipedia.
The content was in the article for a month or two, but then, two other Wikipedia "editors" voted against me to remove all the content. (I don't know if they were honest folks trying to keep what they thought was content falsely besmirching the ACA out, or themselves trying to politically manipulate by controlling content. I do know that it was apparent that neither of them understood a thing about the mechanisms around the ACA, and, as well, no one ever found an error in anything in the content.)
Anyway, the 5 issues that I had inserted in 2019 boil down to:
1) “subsidy cliff” (returned start of 2026 with the lapse of the expanded subsidies; people dealing with the returned "subsidy cliff" are those who experience the truly humongo premium jumps--like of $35,000 a year for a couple with an income of $88,000 a year in some cases).
2) Often-unaffordable copays
3) “Family glitch” (fixed administratively by Biden for as long as another president doesn’t reverse it. So far it is in place.)
4) Medicaid estate recovery on the expanded Medicaid part of the ACA. (It depends on the state. Some states still have it. Massachusetts just fixed it in 2024). A person age 55 or older with ACA expanded Medicaid, in certain states, may not have insurance at all, but only a loan, until death, for whatever medical expenses occur.
5) These “coordination between the agencies problems” that I figured had to be happening, in a different way in each of the 50 states + DC. (In my state, I was thrashed up and down between the expanded Medicaid and on-exchange parts with little notice mid-year a few times.)
(1) and (2) are in focus, either in the wonky coverage these days (for (1)), and I think many are aware that ACA out-of-pocket maximums can be over $20,000 a year for a family..
(3) seems to have been fixed.
So, really, I am calling attention to (4) and (5).
(It has enough internet links that you can verify the assertions from that reference without having to trust me.)
The other problem, really a problem-group, classified under (5) will vary by state, and, in particular, many will exist because of that division of ACA coverage at 138% of FPL between ACA expanded Medicaid, and subsidized on exchange coverage.
Back when I used the ACA in my state (Massachusetts; before aging into my Medicare-for-Me plus a Medigap), I had determined that the state had a core principle: find out as quickly as possible when an income change switched the person up or down between expanded Medicaid and subsidized on-exchange coverage, and switch them as quickly as possible. (Don't worry about the complete change of provider network each time, and changing of autopays, etc.!)
My feeling was nothing would stop the state from thrashing a person up and down 26 times a year, with a provider network change each time!
(Note: The new OBBB requirements of at least twice annual expanded Medicaid eligibility checks, up from once a year, will undoubtedly cause thrashing up and down at least twice a year, even in states that technically manage things as well as possible given the new law.)
Whenever health insurance system change is discussed, I like to point out a few things about the system, for the benefit of those who are not aware.
(I have done this before here, and will plop down a few comments today, which are probably redundant with ones on prior Gooz posts.)
I always like to point out to people who don't already know it, that long-term-care--stuff like nursing homes--is beyond the scope of any near-universal program we have in the U.S. (Except for Medicaid, which requires you to spend down by paying the full cost of a nursing home until you are basically dirt-poor in both income and assets.)
Long-term-care is NOT covered by Medicare, nor the ACA, nor most employer health plans. About 10% of people over 65 have private long-term-care insurance, which can be too expensive for many people, is pre-existing-condition screened, and often has coverage limits that can run out on people.
The only discussion of covering long-term-care that I know of, in the U.S., has been as part of Sanders single-payer.
Some of the other developed countries -- not all-- do have much better systems for long term care, where people are NOT required to spend down first. Notably, Canada.
If interested, I tried to get some details about other countries. I was not able to get all of the information I really wanted, but what I got can be found here:
Part III, of this past Sunday, is still behind a paywall. That is where he switches his recommendation from we have to live with the ACA for political reasons, to allowing some gradual changes, with a possible government option.
I think I can get away with quoting the essence on that here:
"Single-payer isn’t a perfect system, but it is a system that has been run effectively not only abroad but in the United States. While I am by no means dogmatic about this, my view is that the next phase in U.S. health reform should involve an effort to transition away from private insurance to single-payer.
Longtime readers may recall that this was not my position in 2009-10, when Obamacare was being put in place. Nor did I support Bernie Sanders’s call for single-payer in 2016. However, like many and probably most supporters of Obamacare, I backed patchwork rather than comprehensive reform not because I believed that it was the best policy but because I believed that it was the only politically realistic way forward in 2010 and in 2016.
But it’s now 2026, and the political landscape has changed in ways that arguably put fundamental reform in reach."
… [and a bit later in the Krugman post]
"This suggests that an attempt to push people into Medicare-for-all would run afoul of concerns about change.
But it would be much less controversial, I believe, to offer a public option — allowing Americans, including employers providing insurance to their employees, to buy into a Medicare-type system. Many people surely would avail themselves of that option. And if they like what they get, which they probably would, we could transition over time to a single-payer system without forcing Americans into it.
Of course, insurance companies would hate this, and campaign furiously against it. But given their current reputation, this might even help the cause of reform.
Now, I am not offering policy specifics, partly because this post is already long but mostly because this is the point at which we need details from real experts. And I am not at all dogmatic about the path forward.
The main point is, instead, that we are approaching a point at which ambitious healthcare reform, well beyond simply repairing the damage to Obamacare, will be possible. And Democrats should be prepared to rise to the occasion."
--
P.S. O.K. "Democrats rise to the occasion." That includes you, Gooz! (Apparently you are aware of that. That is why you did your post today!)
Concentrating on primary care is so important. A recent article in JAMA proposed treating it as a public utility - funded by all, and available to all. What they left obscure was whether the rest of the health care system would be left intact, without change, or how we might manage to change the funding. I also agree with the suggestion that the income cap on social security withholding needs to be eliminated. That seems like a commonsense reform.
It’s interesting that this chart could only be created in one country on the planet. Probably the only country where the term “medical bankruptcy” exists.
I'm happy to see you're on board with the value of a public option, which is not as politically infeasible as you suggest, assuming that pricing above Medicare rates can be worked through. At least there's a strategy there: simply allow purchases of a public plan, whether Medicare, Medicaid or the VA system, modified to make it financially viable and affordable. How feasible is universal budgeting? Probably only as the public option, which utilizes that budgeting, succeeds. If there's 'mass migration' to the public option, as you suggest it only demonstrates the failure of the current fee for service insurance system. A public option would lead in providing the vision of a preventive and cost-effective system that you call for. And it would contain those principles you articulately call for.
KEEP GOING TRUMP
You may do something that has never been done before; you may destroy the Republican Party. I can only imagine what our country would be like without any Republican states, and you may do just that.
Keep going, Trump. Your madness and insanity are becoming more obvious and more blatant, and it will be impossible to ignore. Your MAGA supporters and Republicans in Congress may follow you over the cliff, or they will have to retreat back under the stone where they came from.
Your uncontrollable, constant lying—looking into the camera and telling us that January 6th never happened—will no longer work. I hope you live long enough to see the Republican Party crumble and your MAGA supporters destroyed, and that you do not die before then, because they may make you a saint. At 80, you look weak, nodding and again lying about your health.
I know you are providing your family with corrupt funds, but that will all change after the fall of Rome. Your bizarre personality and your wishes for monuments honoring you will seem ridiculous and wild, even to your loyal supporters.
Remember the fate of Benito Mussolini in Italy, where he and four of his loyal supporters were hung upside down at a gas station; he, like you, was a fascist dictator; he, like you, destroyed the existing government and had his private army kill all his opponents; he was as corrupt as you, and he, like you, was fascinated by other thugs around the world, especially Hitler.
Your time is coming, so keep demonstrating your madness so we can finally have a country without Southern Republicans. I can only dream of our country as fully democratic, so keep it up, Trump.
A quick, standardized picture might be the easiest way politically to get enough people on board, to change the system.
Here is an animated diagram that explains a single-payer. It packs a lot of information. It is proceeded by a short video that explains the diagram symbols:
https://www.youtube.com/playlist?list=PLT-vY3f9uw3AwU-OdsiSOdK1EtAE2rz3J
If you think this works, please send it to others. The point is to show left-wingers and right-wingers why we need BOTH market and non-market together.
Get rid of the private profit insurers by having a public insurer on the DEMAND side (the patients side), which is called a "single-payer."
BUT keep the private profit market on the SUPPLY side, for competition and innovation in supplying the medicines and machines to the doctors.
This is part of a longer work to add cooperation to mainstream economics.
Like our Military Industrial Complex, the Medical Industrial Complex is a corrupt, micromanaged monopoly conglomerate that thrives on legalized extortion - pay me or die. I know this from personal experience because I am a retired Navy Captain and a retired NIH official. I have posted all over the Internet that we already have an up-and-running national health system called Tricare which serves the military. I can go to any private-practice clinic or hospital that accepts Tricare (most do because they are sure to get paid promptly), and members can get all prescriptions for free from a nearby base pharmacy or by mail for the price of delivery. The cost of everything is negotiated and capped. So, I might be billed $350 for a procedure, but they will be paid $195 and consider it paid in full. My point is that there is a national health system with a proven track record of success that is far less costly than the MxIC, and could be implemented very quickly nationwide. If there is a will, there is already a way.
Plopping down here, in the spirit of keeping those interested informed:
The ACA expanded subsidies that were allowed to lapse 1/1/26 at the insistence of Republicans, data has been starting to roll in from non-federal sources showing something like 3 to 5 million people, of 24 million who had coverage on the ACA exchanges in 2025, losing coverage.
(And, detailed below, there is starting to be evidence that Dr. Oz, and his CMS, are delaying reporting on the coverage losses, which have become evident to them internally. And may be planning a misleading propagandistic response, claiming that the drops are due mainly to the administration's successful crackdown on ACA fraud.)
This information available to the public is part of the new data that continuously rolls in from non-federal non-CMS sources, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% enrollment drop for those 24 million.)
There is a nice 5/19/2026 KFF report that summarizes the higher post-open-enrollment-report drops, looking to be 3 to 5 million, here https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/ )
A few weeks earlier (5/1/26), the New York Times also had a nice, similar story, limited by slightly earlier data. (https://www.nytimes.com/2026/05/01/business/obamacare-enrollment-decline.html )
(Incidentally, you can find out about all of these coverage losses, information on which is still rolling in, the most quickly if you subscribe to Charles Gaba, ( https://charlesgaba.substack.com/ ), where his posts contain each bit of information usually on the same day it becomes available.)
In any case, after releasing the initial open-enrollment-period data for 2026 showing only a 4.9% drop in enrollment, with the big defect in the data that people who wind not paying the premium are not counted as dropping coverage, I don't believe anything has been released by CMS (Dr. Oz's Center for Medicaid and Medicare Services, which also manages the ACA).
The much larger coverage-drop numbers indicated in the KFF and NY Times reports, counting people not paying premiums as dropping, have come from other sources. (State exchanges, KFF surveys, and a major consulting company report with access to insurance company data.)
So, has the CMS been blocking the release of information on the coverage drops?
Charles Gaba actually caught one case where the data, usually presented as part of a report on Medicare and Medicaid and CHIP, was omitted.
Charles reports on that here: https://charlesgaba.substack.com/p/cms-posts-january-2026-medicaid-chip
Quoting Charles:
"Until now, the summary report also included a brief mention of total effectuated ACA marketplace enrollment in Qualified Health Plans (QHPs), rounded off to the nearest 100,000. As of December effectuated enrollment was ~21.8 million people.
However, starting this month, this data point is missing...and that’s not by accident; it includes this footnote:
As of the January 2026 data, Marketplace enrollment data are no longer included in this report but will be available separately soon."
So, we may already have a case of data usually made available being suppressed.
Otherwise, on the data within CMS, I don't know if they usually release it and are holding it back, but we know they have it. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
https://www.notus.org/healthcare/aca-healthcare-dropped-insurance-numbers-subsidies
Quoting that:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
(I and other readers of Charles Gaba's substack were pointed to the leaked information in NOTUS by his post: https://charlesgaba.substack.com/p/breaking-cms-admits-over-30-million )
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
https://econjared.substack.com/p/why-are-people-so-damn-mad/comment/261555717
Concur.
I too have a major criticism of Krugman; he missed the real problem - Republicans played the Dems throughout the legislation development process until they gutted all of the provisions which would have made the ACA far more effective and popular.
The Gang of Six's 3 Republican Senators sliced and diced the proposal until there was no public option, subsidies had a sunset, a robust guideline effort was gutted, insurers got most of what they wanted, and Medicaid expansion was an option, not a requirement.
https://thehill.com/homenews/senate/49546-gang-of-six-healthcare-reform-negotiations-on-verge-of-collapse/
Dems got played - as they almost always do.
I'd add that we need a robust and well-designed clinical guideline development, management, and administration process as well - but one which is NOT a checklist, rather a patient-driven one.
A major miss in all these proposals is actually asking patients/members what their health goals are, and structuring their care around that. Instead of treating symptoms, we need to focus on what is important to people - otherwise they have little motivation to participate in, much less help direct, their own health journey.
This makes far more sense than the endless and in many cases pointless list of tests, screens, assessments and the like which are a mystery to the people undergoing them and a huge pain in the ass for providers.
Continuing, to make sure those interested are aware of what we have currently on our health insurance system. For those interested:
I support the ACA, want it improved, and am behind whatever additional minor or major politically possible system changes (going as far as single-payer) can be put into effect.
In the meanwhile, it's kind of been a hobby with me to point out the ACA defects on affordability and sufficiency of coverage, to try and get the problems fixed. (I will do that here, substantially duplicating content on a prior Potter post that was focused on the excessively high out-of-pocket maximums.
My starting point: old Wikipedia insertions by me:
In about 2019, aware of a bunch of the defects, I actually stuck in a Problems section into the ACA article in Wikipedia.
(https://web.archive.org/web/20190829095943/https://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act#Problems )
The content was in the article for a month or two, but then, two other Wikipedia "editors" voted against me to remove all the content. (I don't know if they were honest folks trying to keep what they thought was content falsely besmirching the ACA out, or themselves trying to politically manipulate by controlling content. I do know that it was apparent that neither of them understood a thing about the mechanisms around the ACA, and, as well, no one ever found an error in anything in the content.)
Anyway, the 5 issues that I had inserted in 2019 boil down to:
1) “subsidy cliff” (returned start of 2026 with the lapse of the expanded subsidies; people dealing with the returned "subsidy cliff" are those who experience the truly humongo premium jumps--like of $35,000 a year for a couple with an income of $88,000 a year in some cases).
2) Often-unaffordable copays
3) “Family glitch” (fixed administratively by Biden for as long as another president doesn’t reverse it. So far it is in place.)
4) Medicaid estate recovery on the expanded Medicaid part of the ACA. (It depends on the state. Some states still have it. Massachusetts just fixed it in 2024). A person age 55 or older with ACA expanded Medicaid, in certain states, may not have insurance at all, but only a loan, until death, for whatever medical expenses occur.
5) These “coordination between the agencies problems” that I figured had to be happening, in a different way in each of the 50 states + DC. (In my state, I was thrashed up and down between the expanded Medicaid and on-exchange parts with little notice mid-year a few times.)
(1) and (2) are in focus, either in the wonky coverage these days (for (1)), and I think many are aware that ACA out-of-pocket maximums can be over $20,000 a year for a family..
(3) seems to have been fixed.
So, really, I am calling attention to (4) and (5).
So let me give a reference on (4):
https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing
(It has enough internet links that you can verify the assertions from that reference without having to trust me.)
The other problem, really a problem-group, classified under (5) will vary by state, and, in particular, many will exist because of that division of ACA coverage at 138% of FPL between ACA expanded Medicaid, and subsidized on exchange coverage.
Back when I used the ACA in my state (Massachusetts; before aging into my Medicare-for-Me plus a Medigap), I had determined that the state had a core principle: find out as quickly as possible when an income change switched the person up or down between expanded Medicaid and subsidized on-exchange coverage, and switch them as quickly as possible. (Don't worry about the complete change of provider network each time, and changing of autopays, etc.!)
My feeling was nothing would stop the state from thrashing a person up and down 26 times a year, with a provider network change each time!
(Note: The new OBBB requirements of at least twice annual expanded Medicaid eligibility checks, up from once a year, will undoubtedly cause thrashing up and down at least twice a year, even in states that technically manage things as well as possible given the new law.)
Whenever health insurance system change is discussed, I like to point out a few things about the system, for the benefit of those who are not aware.
(I have done this before here, and will plop down a few comments today, which are probably redundant with ones on prior Gooz posts.)
I always like to point out to people who don't already know it, that long-term-care--stuff like nursing homes--is beyond the scope of any near-universal program we have in the U.S. (Except for Medicaid, which requires you to spend down by paying the full cost of a nursing home until you are basically dirt-poor in both income and assets.)
Long-term-care is NOT covered by Medicare, nor the ACA, nor most employer health plans. About 10% of people over 65 have private long-term-care insurance, which can be too expensive for many people, is pre-existing-condition screened, and often has coverage limits that can run out on people.
The only discussion of covering long-term-care that I know of, in the U.S., has been as part of Sanders single-payer.
Some of the other developed countries -- not all-- do have much better systems for long term care, where people are NOT required to spend down first. Notably, Canada.
If interested, I tried to get some details about other countries. I was not able to get all of the information I really wanted, but what I got can be found here:
https://normspier828307.substack.com/p/paying-for-nursing-homes-and-long
Just letting people know, if they are locked out of Krugman's Part II explainer by the paywall he had on it, it has been released just today outside of the paywall here: https://paulkrugman.substack.com/p/unlocked-repost-curing-us-health-0b3
Part III, of this past Sunday, is still behind a paywall. That is where he switches his recommendation from we have to live with the ACA for political reasons, to allowing some gradual changes, with a possible government option.
I think I can get away with quoting the essence on that here:
"Single-payer isn’t a perfect system, but it is a system that has been run effectively not only abroad but in the United States. While I am by no means dogmatic about this, my view is that the next phase in U.S. health reform should involve an effort to transition away from private insurance to single-payer.
Longtime readers may recall that this was not my position in 2009-10, when Obamacare was being put in place. Nor did I support Bernie Sanders’s call for single-payer in 2016. However, like many and probably most supporters of Obamacare, I backed patchwork rather than comprehensive reform not because I believed that it was the best policy but because I believed that it was the only politically realistic way forward in 2010 and in 2016.
But it’s now 2026, and the political landscape has changed in ways that arguably put fundamental reform in reach."
… [and a bit later in the Krugman post]
"This suggests that an attempt to push people into Medicare-for-all would run afoul of concerns about change.
But it would be much less controversial, I believe, to offer a public option — allowing Americans, including employers providing insurance to their employees, to buy into a Medicare-type system. Many people surely would avail themselves of that option. And if they like what they get, which they probably would, we could transition over time to a single-payer system without forcing Americans into it.
Of course, insurance companies would hate this, and campaign furiously against it. But given their current reputation, this might even help the cause of reform.
Now, I am not offering policy specifics, partly because this post is already long but mostly because this is the point at which we need details from real experts. And I am not at all dogmatic about the path forward.
The main point is, instead, that we are approaching a point at which ambitious healthcare reform, well beyond simply repairing the damage to Obamacare, will be possible. And Democrats should be prepared to rise to the occasion."
--
P.S. O.K. "Democrats rise to the occasion." That includes you, Gooz! (Apparently you are aware of that. That is why you did your post today!)
Concentrating on primary care is so important. A recent article in JAMA proposed treating it as a public utility - funded by all, and available to all. What they left obscure was whether the rest of the health care system would be left intact, without change, or how we might manage to change the funding. I also agree with the suggestion that the income cap on social security withholding needs to be eliminated. That seems like a commonsense reform.