They Are, In Fact, Coming After Obamacare Again
Plus: Billy Joel and the value of medical research.
EIGHT YEARS AFTER TRYING AND FAILING to repeal Obamacare, Donald Trump and congressional Republicans are taking another shot at the seminal health care law. This time, the plans are less ambitious and their work has garnered less attention. But, if successful, the efforts could still have devastating effects.
The attack is buried in the “Big Beautiful Bill” that the House sent over to the Senate for consideration last week. Much of the press coverage of that legislation has focused on the proposed cuts to Medicaid—which makes sense since together they would represent the biggest cuts in that program’s sixty-year history and could leave more than 7 million people without health insurance.
But the Republican legislation would also take a few hundred billion dollars out of the Affordable Care Act. As a result, an additional 4 million people could end up newly uninsured, according to an analysis by the Center on Budget and Policy Priorities. And even among those who do not lose their coverage, millions could end up paying more for their health care in the form of higher insurance premiums, higher out-of-pocket costs, or both.
As with the proposed Medicaid cuts, it can be difficult to wrap your mind around these changes because the GOP legislation calls for not one big transformation but a bunch of smaller ones, many of them technical and difficult to parse.
The bill would rewrite the rules for “passive enrollment” and “provisional eligibility”, for example, and alter the “allowable variation” for calculating “actuarial value” in insurance plans. It would also restore full funding for “cost-sharing reduction” payments that Trump took away in his first term—a move that, paradoxically, would make insurance more expensive in the future.1
But if you can step back and see the full picture, and if you can find your way through the numbers and the wonky language, you’ll see how these shifts would affect millions of Americans. Among them would be clients of Courtney Callaway, an insurance broker in Omaha, Nebraska I first met about eight years ago, who is already thinking of what the changes would mean in her part of the country.
PART OF CALLAWAY’S BUSINESS is selling policies through HealthCare.gov, the marketplace created by the Affordable Care Act. It’s where people without employer coverage can buy reliable, comprehensive insurance even if they have pre-existing conditions, and where they may be eligible for subsidies worth hundreds or thousands of dollars a year depending on their incomes.2
This past winter, more than 24 million people signed up for insurance on HealthCare.gov or one of its state-run equivalents, like Covered California. That was the highest number ever, and contributed to a new record low in the percentage of Americans without insurance.
ACA coverage has been a lifeline for many, despite its well-chronicled shortcomings.3 And Callaway has seen the program’s impact firsthand. Her customer base includes farmers and early retirees, hair stylists and small business owners—basically, the full spectrum of people who have no way to get reliable insurance through a job. During a recent phone interview, she told me she worries people like that will struggle with some of the law’s proposed changes.
As an example, she cited somebody applying for coverage with financial assistance following a layoff or a divorce or the death of a spouse—life-altering events that allow people to get insurance even outside normal open-enrollment periods. When they apply, marketplaces will attempt to verify income, citizenship status, and other key pieces of information by cross-checking with other federal databases. Discrepancies are common and getting the paperwork to document income or status changes can be difficult, Callaway said.
“Maybe your spouse passed away and you had coverage through their work, and so now you’re dealing with losing a spouse and trying to get signed up for your own insurance for yourself and your kids, and get documentation from a job that wasn’t even yours,” Callaway explained. “Suppose you lose your job because the place closes down. So now who are you calling to ask for proof that you had coverage? What if you’ve moved and the documents are being sent by mail?”
The current system allows for that possibility by providing what amounts to a ninety-day grace period, during which the insurance coverage is in full effect and the financial assistance is flowing while people have a chance to sort through their paperwork. The GOP bill would effectively end the grace period so that anybody whose data didn’t match up immediately would have to pay the full premium until they work through the discrepancies.
In reality, Callaway said, some people just aren’t going to be able to keep up with the premiums. In some cases, they will be among those losing insurance altogether.
“It becomes a snowball, where they get behind . . . making their first payment, which backs them into the next payment that’s due,” Callaway said. “And depending on their financial situation, sometimes that’s a really big burden.”
THAT ONE HYPOTHETICAL MIGHT NOT SEEM like such a big deal, because not that many people would fall into that particular gap. But the end of the ninety-day grace period for people with life-changing events is just one of the ways the GOP bill would change enrollment and eligibility procedures.
Others include a provision that would shorten the annual open-enrollment period from two-and-a-half months to one-and-a-half, as well as one that appears to end automatic re-enrollment at the end of the year by requiring people to re-establish their eligibility for coverage and financial assistance.4
“That doesn’t happen anywhere else in the healthcare system—everybody else has automatic re-enrollment for their insurance,” Christen Linke Young, a visiting fellow at the Brookings Institution, said in a phone interview. “And yet here they’re adding this mandatory annual process—and a bunch of additional paperwork—that’s going to snare other people.”
“We have a system today that verifies that income reasonably accurately,” added Young, who as a Biden administration official helped refine and maintain the enrollment system. “They are turning it from a system that is designed to verify income into a system that is designed to catch people and keep them out of coverage because they can’t make it through the hurdles.”
Making matters harder for those using the exchanges, the paperwork requirements would come on top of Trump administration cuts to the very agencies and contractors responsible for processing it. That includes “navigators,” the officially authorized enrollment counselors who specialize in helping people with complex personal circumstances or difficulty finding their way through insurance bureaucracies.
“They’ve slashed navigator funding by 90 percent and they’ve cut the case workers at the marketplaces,” Sabrina Corlette, a research professor at Georgetown’s Center Health Insurance Reform, said in a phone interview. “There may not be the human beings on the other end to do all this manual labor to receive the documentation and to assess it and then confirm it.”
The ostensible rationale the GOP has offered for these changes is to reduce fraudulent enrollment, following media exposés and HHS investigations into instances of agents and brokers exploiting loopholes in the system that made it possible, in some cases, to enroll people or switch their plans without their knowledge. (The agents and brokers would then collect the commissions.)
But the Biden administration took steps to combat these practices, in part by making some technical changes at HealthCare.gov and in part by suspending agents and brokers it accused of improper or unauthorized enrollments. Plan switches made by agents and brokers dropped by 70 percent following these changes, which—as a recent Commonwealth Fund report noted—is likely a sign the reforms were having an impact.
The Republican health care bill would focus its anti-fraud efforts on the behavior of applicants rather than agents and brokers, which is basically the opposite of what the Biden administration tried. That makes it hard not to suspect they are simply out to slash government health care assistance, especially when other parts of the legislation would shift more costs onto people buying marketplace coverage—by, among other things, allowing insurers to sell policies that have higher copayments and deductibles.
“The changes to the maximum out-of-pocket limit are a big deal—and again, that’s just making everybody’s coverage worse,” Young said.
BELIEVE IT OR NOT, THERE’S A WHOLE OTHER set of changes to the Affordable Care Act under consideration outside of the Big Beautiful Bill. It’s the debate about whether to extend a temporary boost in subsidies for people to buy insurance that is set to expire at the end of this year. If those subsidy enhancements lapse on schedule, an additional 4 million people could go uninsured.
If that took place total enrollment in the ACA marketplaces could fall by one-third. “Proportionately, that’s a much bigger enrollment and coverage loss than projected for Medicaid,” Drew Altman, president of the health research organization KFF, noted recently.
But even the numbers of people losing insurance don’t fully capture the impact of what Republicans are considering or proposing. That’s because the people most likely to go without coverage when enrollment gets more difficult—or more expensive—are healthier people who figure they have less to lose. And if they drop coverage in large numbers, insurers could struggle financially, since premiums from people in relatively good health are what cover the costs of people with large bills.
“Sick people will jump through hurdles to get coverage. Healthy people are less inclined to do so,” Louise Norris, a Colorado broker and widely read analyst at the website HealthInsurance.org, told me in a phone interview. “When you’re trimming enrollment like this, you are running the risk that the people you’re trimming across the roles are more likely to be the healthier population. So you do face the possibility of less stability in the individual market.”
“Less stability” in insurance markets translates into more expensive coverage, skimpier benefits and fewer insurance options. And if you know your Obamacare history, then you know this is what the program looked like in its early years.
It was a lot less popular back then, and helped far fewer people. Evidently Trump and the Republicans miss those days and want to go back to them.
Keeping the Faith
Late last week pop icon Billy Joel announced he was suspending concerts through July 2026 in order to get treatment and therapy for a form of hydrocephalus, a neurological condition that can cause physical and cognitive impairment. It’s heartbreaking news about an entertainer who, even at 76, sells out stadiums for shows that stretch beyond two hours as they turn into singalongs for tunes that span the ages.
I was lucky enough to catch one of those performances last summer when Joel wrapped up a decade-long residency at Madison Square Garden, the New York City venue that now belongs to him as much as it does to the Knicks or the Rangers. And like the rest of his most devoted fans—yes, that’s the 1982 Long Island concert bootleg on my running mix—I hope he can perform again. He’s reportedly said he wants that to happen and experts have said that’s possible with early diagnosis and the right treatment—which, thankfully, he appears to be getting.
Interestingly, the scientist who first identified this form of hydrocephalus back in 1964 was a Colombian neurosurgeon who had trained in the United States and made some of his most important discoveries at Massachusetts General Hospital, the teaching institution affiliated with Harvard University.5 Since then, much of the essential research into diagnosis and treatment—into both what’s available already and what might be available in the future—has taken place with the help of funding from the federal government, including the National Institutes of Health.
I know that last part thanks to Michael Williams, a neurologist at the University of Washington who has done some of that groundbreaking research—and who told me about the critical role federal backing has played ever since the NIH convened a workshop on hydrocephalus in 2005. “If we had not had that funding for research since the 2005 NIH workshop, we wouldn’t understand nearly as much as we do now about the basic science and the clinical science of hydrocephalus,” he told me.
The context for our conversation was the cuts the Trump administration has been making to medical research—both through targeted attacks on institutions like Harvard and broad reductions in grants through agencies like NIH. (Oh, and the hostility to foreign-born researchers as well.) Williams didn’t comment on the Trump administration directly. But he did point out that investing in hydrocephalus can pay all kinds of dividends, including a chance to prevent future medical problems and their associated costs.
“Diagnosing and treating hydrocephalus saves health care costs every time an elderly person falls, every time they’re being evaluated for dementia, every time they’re ending up in a nursing home,” Williams said. He’s right, and that logic applies to all kinds of other medical research too.
I’m not trying to appropriate Joel for a partisan argument and I’m certainly not claiming to speak for him. He largely avoids talking about politics, and the most important thing by far is that he gets well. But for those of us who do think about politics and policy, at least when we’re not waving to Brenda and Eddie, the possibility of Joel making a strong recovery should serve as one more reminder of how important medical research is—and what we’d lose without it.
The short(ish) version of this story is that the ACA requires insurers to provide better coverage to lower-income buyers, then gives insurers federal money to cover that cost. Trump in his first term blocked that money, thinking it would undermine the ACA. But insurers quickly figured out how to exploit the ACA’s funding formula to get more money anyway. The net result was more help for insurance buyers—in other words, the opposite of what Trump intended—though it also cost the federal government more money. The Republican bill would effectively reverse the process, thus producing budget savings but also leaving buyers with less financial help.
If you would like a refresher on why getting insurance was so much more difficult before the Affordable Care Act, you can find it here.
The most prominent shortcomings: The premiums and out-of-pocket costs can still be quite high, even with those subsidies, and the provider networks are frequently thin, making it hard to find certain specialists.
I say “appears” because a separate provision in the bill puts new restrictions on re-enrollment. This sort of inconsistency is likely a byproduct of last week’s rush to finalize language and then get a floor vote, before outside analysts—and many lawmakers themselves—could figure out exactly what the bill said.
Correction (May 28, 2025, 2:10 p.m. EDT): As originally published, this sentence mistakenly described the doctor who first identified this form of hydrocephalus as a neurologist; it has been corrected to note he was a neurosurgeon. And while he did first detect the condition in the 1950s, as this sentence originally stated, he did not publish about it until 1964; the sentence now lists that year.
There can be no doubt that the GOP does not have a plan - any plan - any issue. Except cut taxes for the rich. The country deserves leaders that are concerned about the citizens - health, food, housing, retirement earnings.
This GOP Congress is shameful
Magat voters will probably cheer on getting rid of “Obamacare” but will be pissed when they lose their ACA healthcare plans. They really are stupid that way!