Passing along the breaking news that CMS has finally released the data that it had kept out of a report where it usually is on coverage drops from the expanded subsidies that lapsed 1/1/26.
(As Jonathan documented, there was info that CMS was planning a false attribution of the coverage drops, when it did finally release data, to the administration's successful reduction of fraud.
and Charles caught that the drop, of enrollment is down to 19.2 million, with the important detail that he had to really look for, that that number is as of Feb 2026. (A lot more people can be expected to drop coverage due to the lapsed subsidies as the year goes on.)
Charles worked it out that that’s a 2.63 million drop from the 21.8 million of the same time in 2025. And Charles also worked out that the expected losses just from the 90-day grace period for non-payment kicking in would not have happened by Feb, 2026, as they expire on April 1st 2026.
Maybe folks that are living below the poverty level are fudging their income to qualify for subsidies, but that means they are also paying income taxes on wages they didn’t make. So Fed govt is taking money that is not owed.
While Trump and his plan to give everyone a check to buy whatever insurance they want, claiming that “They will all feel like entrepreneurs!”, is a huge insult to the intelligence of just about everyone, he is not the head of the snake. That is Mike Johnson, a cowardly little weasel from a state where ignorance is a required course.
When they didn’t renew the subsidies — something all but eight senators already predicted would be the result of ending the shutdown — Mike Johnson’s nasty, hapless retort to critics was “It’s not good policy.”
This moron must go! First of all, I will continue to raise the clarion call that we have been overcome by poorly educated people who nonetheless believe they are the smartest people in the room. Really? You mean someone like Chip Roy? Really. If you zero in on Mike, you get a fellow who was educated in the second to last state with a deplorable education system. He went on to what is at best a middling college and an inauspicious law school. His first foray into practicing law was to open his own law school. (It attracted not a single student!). Let’s also remember that the job he now holds is one that he literally begged for 15 times before the caucus gave it to him. I suspect they just didn’t have the stomach to watch him grovel a sixteenth time. But he knows good policy? So does my dog.
We have no time to waste. Trump and his miserable party of sycophants and liars have made it clear that they will settle for nothing less than the complete dissolution of the ACA. They’ve waited 15 years for the power to deprive people of even their health, and just to prove they can. The Republicans are drunk with power for which they have waited, in their minds, far too long. So poor and borderline poor people have no choice but to drop their coverage. But take heart: Argentina got a $40 Billion revolving line of credit, and with your money.
Perhaps the Republicans believe that their rank incompetence demonstrated by their multiple failures to come up with a health plan is actually something they can now turn to their advantage. Make enough people miserable and unhealthy, and they’ll take whatever they are offered, however meager. Mike Johnson and his evil minions must go!
The absurdity of culling the rolls of ACA subscribers is that while people who need the coverage will loose it the fraudsters will continue to defraud the system. They aren’t going away just because premiums increase and enrollment is harder. They will continue to game the system no matter what the rules.
For us the aca was a life saver. Changing ages of how long children could be on your policy and no longer holding illness against you for future policies. Also meaning many states could expand Medicaid.
All this to say at the time ACA was the miracle many of us with sick children needed.
Now we are at a place where republicans do not really care if you or your children are sick. They see us all as frauds and want to eliminate our costs not theirs.
The sad thing about all of this is that those of us in the admin side of the insurance industry know all this. And if you are old enough (as I am) you saw the medical insurance business transition from the old fashioned indemnity plans to major medical and then the PPOs and HMOs.
And we also know that for the average middle class family with kids over 5 years old and parents under 50 they rarely need medical care. So not seeing a doctor or having a claim is meaningless.
And then there are the high deductibles - these cause low paid workers to avoid care.
Again, all well known.
The GOP simply wants to gut any spending they can - and keep taxes low in the robber barons.
Jonathan, Superlative reporting on an issue that affects every ordinary Joe. The most fraudulent President and administration in our history has the audacity to claim they do their injustices to curtail fraud, only dummies and loyalists could by this malarkey. It fits their pattern, they cater to the rich at the expense of everybody else and they could care less what happens to people. Ultimately, however, too many Americans are just not capable of making decisions even in their own best self-interest, this is the tragedy of our time. States like Florida and Texas are prime examples where the elected officials bend over backwards for the the wealthy and conceal their contempt for the poor and the vulnerable. Of course, with this egotistical manic in the oval office, anything having to do with Obama must be vilified and destroyed.
I myself pay some $1,700 per month in premiums, so with deductible and cost of appointments and medications I spend well over $25,000 per year for one person. (The Republican cuts this year caused the premiums to increase by nearly $8,000 compared to last year.)
I am all for responsible policy decisions, after spending decades reading WSJ opinion pages, but with Republicans in the past decade turning essentially into thugs, it's all incredibly discouraging.
"...officials like Oz frequently cite data showing that a little more than one-third of enrollees filed zero claims last year—proving, they say, that millions of people on the program are there unwittingly, and in some cases illegitimately"
Whut?? That makes as much sense as saying people who complain about not getting their Social Security "checks" are likely fraudsters.
Sheesh. There's no end to the stooopidity.
Informative article. The subsidy issue has at least temporarily fallen of most media radar so very much appreciate the update. Thank you!
I would like to provide an example of how skewed government audits of healthcare "fraud" can be.
I used to work in a hospital clinic which treated people who had histories of severe and complex trauma as well as addictions. These people were usually on medicaid. We applied group and individual treatment using scientifically proven therapies such as DBT, ACT, Motivational Interviewing, EMDR, and other therapies.
The government stepped in to train us on their paradigm of treatment planning. 9 months later, they revised those directives & taught us a totally different way of composing treatment plans.
Within a year, they came in and audited our charts (which were still handwritten at that time). They cited us for fraud because the treatment plans were not all written according to their second set of directives.
The government gave us very confusing instructions. They did not audit us on outcomes. They cited us for fraud because our paperwork didn't meet their haphazard standards. The hospital had to give up an extraordinarily huge amount of money because of this audit. The government cited fraud, but this fraud had nothing to do with the high quality of treatment provided.
I wish audits and assessments by the government were not politically biased & instead came from a place of encouraging better health care for all of us.
I worked in state social services for a number of years, and also within social security disability. There was, and will continue to be, a certain amount of fraud in any social services program. The issue is that what I saw over 20+ years in two different states is not even close to what the Trumpers & Sean Hannity claim.
Steve, I do not claim that there is no fraud. I simply wonder if the ways in which fraud is investigated are effective, or if many means of policing fraud get sidetracked by those who want political gain.
Which federal agency was providing the directives?
The Social Security Administration provided the detailed instruction when I worked in disability. The two states provided their own directives and eligibility criteria for general social services work. Within vocational rehabilitation, the federal Rehabilitation Services Administration provided general guidance as well as funding. I did not see a lot of political influence.
I worked around Medicaid and that program, however, was full of fraud.
A few weeks ago, my husband — our sole income this past decade I’ve been disabled — lost his job, leaving us to sort out health insurance for my very significant medical needs. I’m still that teenage conservative in my heart, I guess; I’m so allergic to the idea of being on the dole when I don’t have to be that I (idiotically) never got the formal Social Security disability designation that could qualify me for Medicare.
So when this all happened, I wrote this on my Substack feed at https://substack.com/@treyharris/note/c-266751014 and got some fascinating responses. That and an update below, but first, some of what I wrote:
—
*It’s honestly _bonkers_ to me* to discover that — because of what Congress did — the most cost-effective health care option available to us, now that my husband has just lost his job, is… _COBRA_.
COBRA was virtually never the best option _before_ the ACA. It was what you did as a bridge, or — in my case — because “preexisting conditions” were still legal grounds for excluding you from a new plan.
Sure, there were continuity-of-care and provider-network reasons to bear the full cost of your former employer’s plan. But _cheaper_? The fact that this is even a possibility is staggering.
[…]
I was righteously indignant before because I could run the numbers and imagine this circumstance. Now that I’m in it, I am _pissed_.
—
I got a lot of responses, public and private, and they told me a few things:
1. I’m not crazy, and — much more likely, so my true fear — I hadn’t made a mistake by missing something obvious in my calculations. Brokers responded saying they were seeing exactly this again and again — *this* year, many for the first times in their career. Some with fiduciary duty to do the best things for clients told me they had been forced to recommend COBRA, and this had really just started over the past few months. They said they had no clue what people who remained unemployed for longer than the 18 months allowed on COBRA (extendable, for the disabled awaiting an SSA determination and in a few other arcane situations, to 29–36 months) would do at that point if they hadn’t found new employment and Congress still hadn’t restored subsidies.
2. We now have a generation of post-ACA adults — much like JVL talks about with our coarser kayfabe politics for kids growing up with Trump — who have likely never heard the words “preexisting condition” and known what it really *meant*. The people who were most grossly impacted by those policies pre-ACA are mostly on Medicare now. And people usually don’t start to pay attention to the details of how health insurance works until they really *use* it.
As a result, even young folks with chronic conditions are much more amenable to getting a cheaper underwritten policy, unaware it can exclude treatment or outright cancel them as Jonathan wrote in the story. Older adults are more willing to accept completely unsuitable high-deductible or catastrophic plans — even knowing their family histories — because at least the premiums are something they can stomach. They’re optimizing for the monthly bill, not for what happens when they actually need it. For both groups, the ACA’s success is working against them: it protected people so effectively from the worst outcomes that nobody remembers what those outcomes looked like.
Across the board, the ACA worked well enough, for long enough, that nearly everyone it protected has spent fifteen years developing *exactly the wrong* instincts for the world Republicans are now busy rebuilding.
3. More responses than I expected were simply asking what COBRA even *is* — which, fair: even people who’ve heard of it assume it must stand for something like “Continuation Of Benefits and Related Arrangements,” which at least would make sense. It’s actually just a line item in a mid-80s federal budget bill: the Consolidated Omnibus Budget Reconciliation Act of 1985 included a provision requiring employers to keep offering health coverage to departing employees — at the combined employer-and-employee full cost, which is inevitably *much* larger than anything they ever saw coming out of their pay stubs.
As for those who did know what COBRA was and tried to suggest alternatives: the only actionable suggestion came from someone who’d just asked AI and pasted the answer without checking — it doesn’t exist.
4. There were others recently in the same situation who have come to the same conclusion; there are some who enrolled in a Marketplace plan without ever pricing out COBRA — and only realized afterward how far short it fell of a standard employer plan.
I discovered something else indirectly from a response: what will my husband and I do after 18 months if he doesn’t find new employment and I haven’t yet qualified for health care through disability? Maybe use the “waiting for status” extension I mentioned earlier, yeah?
Unfortunately, we’re going to burn through our savings so much more quickly that we only have about that much saved up anyway, even with cost-cutting. But what do we cost-cut? We do rent in Manhattan, in an apartment much nicer than we’d live in if we hadn’t been a two-income family when we started the lease. Downsizing (not really — we live in under 700 square feet — but, something less nice)? Unfortunately, in the NYC area it’s nearly impossible to start a lease unless you have income or a co-signer — proof of annual income of roughly 40 times the monthly rent is a near-universal requirement. (Luckily, NYC has laws meaning they can’t just eject us or demand to see paystubs so long as we’re keeping up with our rent.)
Move? We’ve lived here because my husband has always lived here and he and his brother have to take care of their mother, who lives here. And moving somewhere cheaper when you don’t have a job lined up isn’t easy anyway. So the next step will be to start using up retirement funds (yes, there are many ways more or less painful, but they all have quite a bit of pain).
This isn’t a sob story — we are so, so *so* blessed to have over a year’s savings plus money in retirement, and almost everyone in a similar health care situation is in much more dire straits. My husband’s work was very specific, as some media tech jobs in NYC can be, but he could find a new job soon — he’s certainly looking. Maybe my writing could help out — though how many middle-aged men have said that and ended up with 80,000 words of unfinished fiction? (At least I know that’s not — *quite* — my problem.)
So, no, not a sob story — but it is a distress story. And an anger story. And it feels connected to everything else: We had a society that wasn’t working very well for most — and then in anger, we elected a government that’s now burning down every bit that worked at all.
Trey - my heart goes out to you & your husband. This being a comment board, I realize I don't 'know you" know you... but I virtually know you to be a person of deep thinking & wide knowledge. That you haven't found one weird trick to solve medical insurance is a sign our incoherent "system" really is forked. Bad. Which I sorta know too from people whose stories I've heard at the food bank, church, etc. I sincerely wish you the best in this challenging journey. From things you've shared in your posts, I know this isn't your first canoe ride on the Wide Wide River. Pretty sure we don't share the same beliefs about any cosmic order; not sure about all that meself but I got nothing better to offer tonite... sending you my best - j
Canadian observer here. I was arguing in the comments at the WSJ with a MAGA: he was on a tear about how horrible Europe was. I pointed out the their life expectancy is 3-4 years longer than in the US.
He didn’t like and started bragging how wonderful American healthcare is. And it is: if you can afford it.
Universal healthcare isn’t perfect either: there are waits for non-emergency surgery for example. And our taxes are noticeably higher.
But your problem would not exist in Canada. We’ve had single payer since the 1960s.
COBRA was a cruel joke disguised as a law to preserve insurance, by requiring companies to extend the same policy coverage for 18 months, after the termination of employment. Back in the day, I knew of no one, starting with myself, who could afford the premiums, once the employer half was gone. Today, we're witnessing a similar slashing of effective insurance. Through an unvarnished kind of direct assault on the despised "Obamacare."
Shelfie - in my family, several of us have had a month or two using COBRA (gratefully, many years back). Can't imagine how middle class working families could handle that for any extended period since the whole reason for it is "you lost your job!"
Yes — as someone who lived and worked for a while in states that had the “continuing coverage” safety rule (that a new insurer couldn’t deny coverage for a preexisting condition provided you didn’t allow yourself to be without insurance for even a day) — my disability is degenerative, so it was a diagnosed preexisting condition long before the ACA, so I actually did have a real need to use COBRA a couple times for a month between jobs — it truly took me by shock.
The spreadsheet I’d written had a column for “difference from COBRA” that presumed COBRA would be more expensive than any other plan fully-loaded. When the spreadsheet broke, I figured it was either the Platinum plans or the Bronze plans, but then I saw the numbers and I was so astonished that I wrote a Python program to do the calculations observably.
It truly is a “cruel joke” — both words entirely accurate. I’d laugh if I didn’t cry…
I'm confused. The republicans are all crying Fraud, but if you are signed up for the ACA even if it's only for a month and you try to e file a tax return without reconciling your payments to any assistance you received, the e-file is rejected by the IRS and can't be refiled until you obtain the proper forms. Although I don't prepare any paper returns from my office, I have to assume that the taxpayer would receive a similiar form if they file on paper.
It’s also a bit weird to think that it’s a bad thing for *an insurance program* if you have a lot of people paying into it and not using it. I mean, it doesn’t hold water as either a smoking gun for fraud *or* a type of “waste, fraud and abuse” sucking our government dry.
Yes, in the (mostly red) states that have allowed brokers in, there are opportunities for fraud by obtaining insurance never used. But ordinarily in state insurance cases, that’s handled by state prosecutors, whose incentives theoretically align. The insurance commissioner has stewardship reasons to ensure applicants are legitimate. But Dr. Oz isn’t acting like any insurance commissioner in this, and obviously Congress isn’t, either.
Since I'm never shy about plopping down something I feel might be useful as a comment, I just want to add a little stuff I have lying around related to the Cohn text in today's post:
' Stories like that used to be a lot more common in the days before the Affordable Care Act, when insurers selling individual coverage routinely subjected buyers to medical underwriting, as well as those retroactive reviews that frequently lead to rescissions like the one Williamson described to me. Putting a stop to those practices was one of the big motivating reasons to pass “Obamacare” in the first place. '
So, the topic is the old pre-ACA system with the "medical underwriting" and "those retroactive reviews that frequently lead to rescissions".
1) Jonathan has at least one link allowing you to verify the issue of the retroactive recissions. I have a few I can add documenting the practice, just in case they help anyone:
(The last one is from Bill Moyers. His good work lives on, but the adobe flash player does not, due to apparent security issues with it that surfaced at some time. So, you don't have a video, and you have to go through the transcript, to pick up that a bunch of insurance executives, in front of a Congressional committee, said they would not be stopping the retroactive recissions.
Also, some might be interested in, if they know of former health insurance executive Wendell Potter, who has long been identifying himself as a repentant former propagandist for the health insurance industry, and who has his own little Substack these days, https://healthcareuncovered.substack.com/ :
Anyway, if you fish through the transcript, you will catch same Wendell Potter (repentant at the time) on the Moyers on that recission topic. (I believe his repentance has been uninterrupted and continues through the current time.)
2) There actually has, pretty recently I'm sure--like in the last year--been some talk by some Republicans of going all the way back to the pre-ACA system. (Thus, with recission problems and the others that went along with the old system.)
I happen to have researched the old system myself, maybe in 2008 or 2009, looking at the systems of whatever high-risk-pools or whatever else each state had to try and cover some of the people who couldn't get an individual insurance policy because of a pre-existing-condition.
I stuck that, at the time, on the web, and it still exists, for anyone interested. Here:
So what I did is, assuming people had never gamed the system by trying to pick up health insurance just when they got sick, (that is always maintained continuous prior coverage), and assuming even they could afford the possibly-very-high premium for any high risk pool that was available, I just looked for problems with the state's system that could keep those people from getting that coverage.
And, I found about half of states had problems that could bankrupt such a person if they never tried to move between states, and about 3/4 did if people dared feel free enough to move between states when they had a pre-existing condition.
(Again, not worrying about the high-risk pool being too expensive.)
As well, I have saved high risk pool rates for Connecticut, which are here:
which has some information on the pre-ACA system, and was designed to help the people in each state at the time. (It's a bit skimpy for many states, and does not really give a person all they would need to know.)
You can click on a state, and then click again, and explore the old pre-ACA system somewhat with it.
(What I really regret is not backing up (on the Wayback link-saving site) each and every link (to the within-state sites on pre-existing-condition protections) that were in my own table.
I did not save them, because I was extraordinarily naive, and did not for the life of me believe that Republicans would continue trying to take us back to the pre-ACA system. As I have indicated, I believe they were doing that as little as just a year ago. That is, in 2025.)
--
Incidentally, I think Charles Gaba has his own separate collection of information on the pre-ACA system.
6/25/26: Oh, I found Charles' stuff.
I can't find that presentation conveniently on his Substack on the moment, but here it is on his other site:
and I note these words from him, which exactly echoes my independent finding:
"Pre-existing condition exclusions – Nearly all state high-risk pools excluded coverage of pre-existing conditions for medically eligible enrollees, usually for 6-12 months. This made coverage less attractive for people who needed coverage specifically for their pre-existing conditions.
(Yes, that's right...even the high-risk pools, designed specifically for those with pre-existing conditions...denied those with pre-existing conditions from enrolling for up to a year. Tough luck if you've been diagnosed with a type of cancer which will kill you in less than a year without treatment)."
(As well, other if his text exactly matches my finding!)
Passing along the breaking news that CMS has finally released the data that it had kept out of a report where it usually is on coverage drops from the expanded subsidies that lapsed 1/1/26.
(As Jonathan documented, there was info that CMS was planning a false attribution of the coverage drops, when it did finally release data, to the administration's successful reduction of fraud.
I have my own post linking to the data that was not released, with a few other items about the fraud stuff here: https://normspier828307.substack.com/p/loss-of-aca-coverage-after-republicans )
Anyway, Charles Gaba caught the data was finally released today 6/26/26, with lots about fraud and stuff, as well. Charles posted about it here:
https://charlesgaba.substack.com/p/breaking-hhs-report-admits-trumpgop
The release of data by CMS is in this report of today:
https://www.aspe.hhs.gov/sites/default/files/documents/f5f29954221d5b5713070ac2541fda8e/aca-enrollment-report-2026-final-version.pdf
and Charles caught that the drop, of enrollment is down to 19.2 million, with the important detail that he had to really look for, that that number is as of Feb 2026. (A lot more people can be expected to drop coverage due to the lapsed subsidies as the year goes on.)
Charles worked it out that that’s a 2.63 million drop from the 21.8 million of the same time in 2025. And Charles also worked out that the expected losses just from the 90-day grace period for non-payment kicking in would not have happened by Feb, 2026, as they expire on April 1st 2026.
Maybe folks that are living below the poverty level are fudging their income to qualify for subsidies, but that means they are also paying income taxes on wages they didn’t make. So Fed govt is taking money that is not owed.
While Trump and his plan to give everyone a check to buy whatever insurance they want, claiming that “They will all feel like entrepreneurs!”, is a huge insult to the intelligence of just about everyone, he is not the head of the snake. That is Mike Johnson, a cowardly little weasel from a state where ignorance is a required course.
When they didn’t renew the subsidies — something all but eight senators already predicted would be the result of ending the shutdown — Mike Johnson’s nasty, hapless retort to critics was “It’s not good policy.”
This moron must go! First of all, I will continue to raise the clarion call that we have been overcome by poorly educated people who nonetheless believe they are the smartest people in the room. Really? You mean someone like Chip Roy? Really. If you zero in on Mike, you get a fellow who was educated in the second to last state with a deplorable education system. He went on to what is at best a middling college and an inauspicious law school. His first foray into practicing law was to open his own law school. (It attracted not a single student!). Let’s also remember that the job he now holds is one that he literally begged for 15 times before the caucus gave it to him. I suspect they just didn’t have the stomach to watch him grovel a sixteenth time. But he knows good policy? So does my dog.
We have no time to waste. Trump and his miserable party of sycophants and liars have made it clear that they will settle for nothing less than the complete dissolution of the ACA. They’ve waited 15 years for the power to deprive people of even their health, and just to prove they can. The Republicans are drunk with power for which they have waited, in their minds, far too long. So poor and borderline poor people have no choice but to drop their coverage. But take heart: Argentina got a $40 Billion revolving line of credit, and with your money.
Perhaps the Republicans believe that their rank incompetence demonstrated by their multiple failures to come up with a health plan is actually something they can now turn to their advantage. Make enough people miserable and unhealthy, and they’ll take whatever they are offered, however meager. Mike Johnson and his evil minions must go!
The absurdity of culling the rolls of ACA subscribers is that while people who need the coverage will loose it the fraudsters will continue to defraud the system. They aren’t going away just because premiums increase and enrollment is harder. They will continue to game the system no matter what the rules.
As always, you are my go to person for the state of and understanding about Americans’ opportunities for health care, Jonathan!
One reality that I find disgusting is that we now have an American trillionaire yet Republicans want to deny adequate healthcare to too many people!
Thank you for sticking with this issue like a dog with a bone, Jonathan.
For us the aca was a life saver. Changing ages of how long children could be on your policy and no longer holding illness against you for future policies. Also meaning many states could expand Medicaid.
All this to say at the time ACA was the miracle many of us with sick children needed.
Now we are at a place where republicans do not really care if you or your children are sick. They see us all as frauds and want to eliminate our costs not theirs.
The sad thing about all of this is that those of us in the admin side of the insurance industry know all this. And if you are old enough (as I am) you saw the medical insurance business transition from the old fashioned indemnity plans to major medical and then the PPOs and HMOs.
And we also know that for the average middle class family with kids over 5 years old and parents under 50 they rarely need medical care. So not seeing a doctor or having a claim is meaningless.
And then there are the high deductibles - these cause low paid workers to avoid care.
Again, all well known.
The GOP simply wants to gut any spending they can - and keep taxes low in the robber barons.
Jonathan, Superlative reporting on an issue that affects every ordinary Joe. The most fraudulent President and administration in our history has the audacity to claim they do their injustices to curtail fraud, only dummies and loyalists could by this malarkey. It fits their pattern, they cater to the rich at the expense of everybody else and they could care less what happens to people. Ultimately, however, too many Americans are just not capable of making decisions even in their own best self-interest, this is the tragedy of our time. States like Florida and Texas are prime examples where the elected officials bend over backwards for the the wealthy and conceal their contempt for the poor and the vulnerable. Of course, with this egotistical manic in the oval office, anything having to do with Obama must be vilified and destroyed.
Americans won't care until their own imidiate family has a real health issue, and their insurance is nowhere to be found.
My fellow Americans, REPUBLICANS DO NOT CARE IF YOU DIE.
REPUBLICANS DO NOT CARE IF YOU DONT HAVE A HOME AS YOU AGE AND OR YOUR PARENTS AGE.
REPUBLICANS DONT CARE IF YOUR CHOLD DIES JUST BECASE YOU CANT AFFORD HEALTH CARE.
REPUBLICANS SIMPLY DONT CARE
I
I myself pay some $1,700 per month in premiums, so with deductible and cost of appointments and medications I spend well over $25,000 per year for one person. (The Republican cuts this year caused the premiums to increase by nearly $8,000 compared to last year.)
I am all for responsible policy decisions, after spending decades reading WSJ opinion pages, but with Republicans in the past decade turning essentially into thugs, it's all incredibly discouraging.
"...officials like Oz frequently cite data showing that a little more than one-third of enrollees filed zero claims last year—proving, they say, that millions of people on the program are there unwittingly, and in some cases illegitimately"
Whut?? That makes as much sense as saying people who complain about not getting their Social Security "checks" are likely fraudsters.
Sheesh. There's no end to the stooopidity.
Informative article. The subsidy issue has at least temporarily fallen of most media radar so very much appreciate the update. Thank you!
I would like to provide an example of how skewed government audits of healthcare "fraud" can be.
I used to work in a hospital clinic which treated people who had histories of severe and complex trauma as well as addictions. These people were usually on medicaid. We applied group and individual treatment using scientifically proven therapies such as DBT, ACT, Motivational Interviewing, EMDR, and other therapies.
The government stepped in to train us on their paradigm of treatment planning. 9 months later, they revised those directives & taught us a totally different way of composing treatment plans.
Within a year, they came in and audited our charts (which were still handwritten at that time). They cited us for fraud because the treatment plans were not all written according to their second set of directives.
The government gave us very confusing instructions. They did not audit us on outcomes. They cited us for fraud because our paperwork didn't meet their haphazard standards. The hospital had to give up an extraordinarily huge amount of money because of this audit. The government cited fraud, but this fraud had nothing to do with the high quality of treatment provided.
I wish audits and assessments by the government were not politically biased & instead came from a place of encouraging better health care for all of us.
I worked in state social services for a number of years, and also within social security disability. There was, and will continue to be, a certain amount of fraud in any social services program. The issue is that what I saw over 20+ years in two different states is not even close to what the Trumpers & Sean Hannity claim.
Steve, I do not claim that there is no fraud. I simply wonder if the ways in which fraud is investigated are effective, or if many means of policing fraud get sidetracked by those who want political gain.
Which federal agency was providing the directives?
The Social Security Administration provided the detailed instruction when I worked in disability. The two states provided their own directives and eligibility criteria for general social services work. Within vocational rehabilitation, the federal Rehabilitation Services Administration provided general guidance as well as funding. I did not see a lot of political influence.
I worked around Medicaid and that program, however, was full of fraud.
A few weeks ago, my husband — our sole income this past decade I’ve been disabled — lost his job, leaving us to sort out health insurance for my very significant medical needs. I’m still that teenage conservative in my heart, I guess; I’m so allergic to the idea of being on the dole when I don’t have to be that I (idiotically) never got the formal Social Security disability designation that could qualify me for Medicare.
So when this all happened, I wrote this on my Substack feed at https://substack.com/@treyharris/note/c-266751014 and got some fascinating responses. That and an update below, but first, some of what I wrote:
—
*It’s honestly _bonkers_ to me* to discover that — because of what Congress did — the most cost-effective health care option available to us, now that my husband has just lost his job, is… _COBRA_.
COBRA was virtually never the best option _before_ the ACA. It was what you did as a bridge, or — in my case — because “preexisting conditions” were still legal grounds for excluding you from a new plan.
Sure, there were continuity-of-care and provider-network reasons to bear the full cost of your former employer’s plan. But _cheaper_? The fact that this is even a possibility is staggering.
[…]
I was righteously indignant before because I could run the numbers and imagine this circumstance. Now that I’m in it, I am _pissed_.
—
I got a lot of responses, public and private, and they told me a few things:
1. I’m not crazy, and — much more likely, so my true fear — I hadn’t made a mistake by missing something obvious in my calculations. Brokers responded saying they were seeing exactly this again and again — *this* year, many for the first times in their career. Some with fiduciary duty to do the best things for clients told me they had been forced to recommend COBRA, and this had really just started over the past few months. They said they had no clue what people who remained unemployed for longer than the 18 months allowed on COBRA (extendable, for the disabled awaiting an SSA determination and in a few other arcane situations, to 29–36 months) would do at that point if they hadn’t found new employment and Congress still hadn’t restored subsidies.
2. We now have a generation of post-ACA adults — much like JVL talks about with our coarser kayfabe politics for kids growing up with Trump — who have likely never heard the words “preexisting condition” and known what it really *meant*. The people who were most grossly impacted by those policies pre-ACA are mostly on Medicare now. And people usually don’t start to pay attention to the details of how health insurance works until they really *use* it.
As a result, even young folks with chronic conditions are much more amenable to getting a cheaper underwritten policy, unaware it can exclude treatment or outright cancel them as Jonathan wrote in the story. Older adults are more willing to accept completely unsuitable high-deductible or catastrophic plans — even knowing their family histories — because at least the premiums are something they can stomach. They’re optimizing for the monthly bill, not for what happens when they actually need it. For both groups, the ACA’s success is working against them: it protected people so effectively from the worst outcomes that nobody remembers what those outcomes looked like.
Across the board, the ACA worked well enough, for long enough, that nearly everyone it protected has spent fifteen years developing *exactly the wrong* instincts for the world Republicans are now busy rebuilding.
3. More responses than I expected were simply asking what COBRA even *is* — which, fair: even people who’ve heard of it assume it must stand for something like “Continuation Of Benefits and Related Arrangements,” which at least would make sense. It’s actually just a line item in a mid-80s federal budget bill: the Consolidated Omnibus Budget Reconciliation Act of 1985 included a provision requiring employers to keep offering health coverage to departing employees — at the combined employer-and-employee full cost, which is inevitably *much* larger than anything they ever saw coming out of their pay stubs.
As for those who did know what COBRA was and tried to suggest alternatives: the only actionable suggestion came from someone who’d just asked AI and pasted the answer without checking — it doesn’t exist.
4. There were others recently in the same situation who have come to the same conclusion; there are some who enrolled in a Marketplace plan without ever pricing out COBRA — and only realized afterward how far short it fell of a standard employer plan.
I discovered something else indirectly from a response: what will my husband and I do after 18 months if he doesn’t find new employment and I haven’t yet qualified for health care through disability? Maybe use the “waiting for status” extension I mentioned earlier, yeah?
Unfortunately, we’re going to burn through our savings so much more quickly that we only have about that much saved up anyway, even with cost-cutting. But what do we cost-cut? We do rent in Manhattan, in an apartment much nicer than we’d live in if we hadn’t been a two-income family when we started the lease. Downsizing (not really — we live in under 700 square feet — but, something less nice)? Unfortunately, in the NYC area it’s nearly impossible to start a lease unless you have income or a co-signer — proof of annual income of roughly 40 times the monthly rent is a near-universal requirement. (Luckily, NYC has laws meaning they can’t just eject us or demand to see paystubs so long as we’re keeping up with our rent.)
Move? We’ve lived here because my husband has always lived here and he and his brother have to take care of their mother, who lives here. And moving somewhere cheaper when you don’t have a job lined up isn’t easy anyway. So the next step will be to start using up retirement funds (yes, there are many ways more or less painful, but they all have quite a bit of pain).
This isn’t a sob story — we are so, so *so* blessed to have over a year’s savings plus money in retirement, and almost everyone in a similar health care situation is in much more dire straits. My husband’s work was very specific, as some media tech jobs in NYC can be, but he could find a new job soon — he’s certainly looking. Maybe my writing could help out — though how many middle-aged men have said that and ended up with 80,000 words of unfinished fiction? (At least I know that’s not — *quite* — my problem.)
So, no, not a sob story — but it is a distress story. And an anger story. And it feels connected to everything else: We had a society that wasn’t working very well for most — and then in anger, we elected a government that’s now burning down every bit that worked at all.
Trey - my heart goes out to you & your husband. This being a comment board, I realize I don't 'know you" know you... but I virtually know you to be a person of deep thinking & wide knowledge. That you haven't found one weird trick to solve medical insurance is a sign our incoherent "system" really is forked. Bad. Which I sorta know too from people whose stories I've heard at the food bank, church, etc. I sincerely wish you the best in this challenging journey. From things you've shared in your posts, I know this isn't your first canoe ride on the Wide Wide River. Pretty sure we don't share the same beliefs about any cosmic order; not sure about all that meself but I got nothing better to offer tonite... sending you my best - j
Canadian observer here. I was arguing in the comments at the WSJ with a MAGA: he was on a tear about how horrible Europe was. I pointed out the their life expectancy is 3-4 years longer than in the US.
He didn’t like and started bragging how wonderful American healthcare is. And it is: if you can afford it.
Universal healthcare isn’t perfect either: there are waits for non-emergency surgery for example. And our taxes are noticeably higher.
But your problem would not exist in Canada. We’ve had single payer since the 1960s.
COBRA was a cruel joke disguised as a law to preserve insurance, by requiring companies to extend the same policy coverage for 18 months, after the termination of employment. Back in the day, I knew of no one, starting with myself, who could afford the premiums, once the employer half was gone. Today, we're witnessing a similar slashing of effective insurance. Through an unvarnished kind of direct assault on the despised "Obamacare."
Shelfie - in my family, several of us have had a month or two using COBRA (gratefully, many years back). Can't imagine how middle class working families could handle that for any extended period since the whole reason for it is "you lost your job!"
Yes — as someone who lived and worked for a while in states that had the “continuing coverage” safety rule (that a new insurer couldn’t deny coverage for a preexisting condition provided you didn’t allow yourself to be without insurance for even a day) — my disability is degenerative, so it was a diagnosed preexisting condition long before the ACA, so I actually did have a real need to use COBRA a couple times for a month between jobs — it truly took me by shock.
The spreadsheet I’d written had a column for “difference from COBRA” that presumed COBRA would be more expensive than any other plan fully-loaded. When the spreadsheet broke, I figured it was either the Platinum plans or the Bronze plans, but then I saw the numbers and I was so astonished that I wrote a Python program to do the calculations observably.
It truly is a “cruel joke” — both words entirely accurate. I’d laugh if I didn’t cry…
I'm confused. The republicans are all crying Fraud, but if you are signed up for the ACA even if it's only for a month and you try to e file a tax return without reconciling your payments to any assistance you received, the e-file is rejected by the IRS and can't be refiled until you obtain the proper forms. Although I don't prepare any paper returns from my office, I have to assume that the taxpayer would receive a similiar form if they file on paper.
It’s also a bit weird to think that it’s a bad thing for *an insurance program* if you have a lot of people paying into it and not using it. I mean, it doesn’t hold water as either a smoking gun for fraud *or* a type of “waste, fraud and abuse” sucking our government dry.
Yes, in the (mostly red) states that have allowed brokers in, there are opportunities for fraud by obtaining insurance never used. But ordinarily in state insurance cases, that’s handled by state prosecutors, whose incentives theoretically align. The insurance commissioner has stewardship reasons to ensure applicants are legitimate. But Dr. Oz isn’t acting like any insurance commissioner in this, and obviously Congress isn’t, either.
Since I'm never shy about plopping down something I feel might be useful as a comment, I just want to add a little stuff I have lying around related to the Cohn text in today's post:
' Stories like that used to be a lot more common in the days before the Affordable Care Act, when insurers selling individual coverage routinely subjected buyers to medical underwriting, as well as those retroactive reviews that frequently lead to rescissions like the one Williamson described to me. Putting a stop to those practices was one of the big motivating reasons to pass “Obamacare” in the first place. '
So, the topic is the old pre-ACA system with the "medical underwriting" and "those retroactive reviews that frequently lead to rescissions".
1) Jonathan has at least one link allowing you to verify the issue of the retroactive recissions. I have a few I can add documenting the practice, just in case they help anyone:
a) https://www.cbsnews.com/news/blue-cross-to-docs-help-cancel-coverage/?index=1
b) https://www.pbs.org/moyers/journal/07102009/watch.html
(The last one is from Bill Moyers. His good work lives on, but the adobe flash player does not, due to apparent security issues with it that surfaced at some time. So, you don't have a video, and you have to go through the transcript, to pick up that a bunch of insurance executives, in front of a Congressional committee, said they would not be stopping the retroactive recissions.
Also, some might be interested in, if they know of former health insurance executive Wendell Potter, who has long been identifying himself as a repentant former propagandist for the health insurance industry, and who has his own little Substack these days, https://healthcareuncovered.substack.com/ :
Anyway, if you fish through the transcript, you will catch same Wendell Potter (repentant at the time) on the Moyers on that recission topic. (I believe his repentance has been uninterrupted and continues through the current time.)
2) There actually has, pretty recently I'm sure--like in the last year--been some talk by some Republicans of going all the way back to the pre-ACA system. (Thus, with recission problems and the others that went along with the old system.)
I happen to have researched the old system myself, maybe in 2008 or 2009, looking at the systems of whatever high-risk-pools or whatever else each state had to try and cover some of the people who couldn't get an individual insurance policy because of a pre-existing-condition.
I stuck that, at the time, on the web, and it still exists, for anyone interested. Here:
https://nasmusicsoft.com/HealthInsuranceUSATable.html
So what I did is, assuming people had never gamed the system by trying to pick up health insurance just when they got sick, (that is always maintained continuous prior coverage), and assuming even they could afford the possibly-very-high premium for any high risk pool that was available, I just looked for problems with the state's system that could keep those people from getting that coverage.
And, I found about half of states had problems that could bankrupt such a person if they never tried to move between states, and about 3/4 did if people dared feel free enough to move between states when they had a pre-existing condition.
(Again, not worrying about the high-risk pool being too expensive.)
As well, I have saved high risk pool rates for Connecticut, which are here:
https://web.archive.org/web/20120606085707/http://www.hract.org/hra/Rates/2012/Individual/IndPPORates.htm , which are quite hefty, for older people.
Wait, you say. Am I choosing the more expensive high-risk-pool plan?
No. The other high risk pool plan had a smaller o.o.p. max, and is this one:
https://web.archive.org/web/20120429071912/http://www.hract.org/hra/Rates/2012/Individual/IndSHCPRates.htm
which was a good bit more expensive, unless you happened to luck out with a very low income.
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I also have this old thing from Georgetown University Law School,
https://web.archive.org/web/20120211114302/http://healthinsuranceinfo.net/guides_map.htm#altList ,
which has some information on the pre-ACA system, and was designed to help the people in each state at the time. (It's a bit skimpy for many states, and does not really give a person all they would need to know.)
You can click on a state, and then click again, and explore the old pre-ACA system somewhat with it.
(What I really regret is not backing up (on the Wayback link-saving site) each and every link (to the within-state sites on pre-existing-condition protections) that were in my own table.
I did not save them, because I was extraordinarily naive, and did not for the life of me believe that Republicans would continue trying to take us back to the pre-ACA system. As I have indicated, I believe they were doing that as little as just a year ago. That is, in 2025.)
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Incidentally, I think Charles Gaba has his own separate collection of information on the pre-ACA system.
6/25/26: Oh, I found Charles' stuff.
I can't find that presentation conveniently on his Substack on the moment, but here it is on his other site:
https://acasignups.net/24/09/30/dead-pool-revisited-jd-vance-wants-concentrate-those-wpre-existing-conditions-separate
and I note these words from him, which exactly echoes my independent finding:
"Pre-existing condition exclusions – Nearly all state high-risk pools excluded coverage of pre-existing conditions for medically eligible enrollees, usually for 6-12 months. This made coverage less attractive for people who needed coverage specifically for their pre-existing conditions.
(Yes, that's right...even the high-risk pools, designed specifically for those with pre-existing conditions...denied those with pre-existing conditions from enrolling for up to a year. Tough luck if you've been diagnosed with a type of cancer which will kill you in less than a year without treatment)."
(As well, other if his text exactly matches my finding!)
How about that!