The Trump administration is carrying out what The Atlantic describes as the most sweeping rollback of social spending in American history, with millions of Americans being thrown off Medicaid and the president and his Republican allies in Congress refusing to extend enhanced subsidies for people buying individual health insurance on Affordable Care Act exchanges.
Who Pays for Power
Last week, insurers on the exchanges announced premium increases averaging 14 percent, after a 20 percent hike the previous year. That’s the bill ordinary people get handed when the people at the top decide coverage is expendable. Democrats warned since last year that the move would cause millions more people to lose coverage while health-insurance premiums spiked for those still enrolled. The machinery of “choice” keeps running. The costs land on the sick, the poor, and everyone forced to buy into a system built to ration care.
Bernie Sanders responded on X: “We have a fundamental choice to make. We can maintain a broken healthcare system that allows insurance companies to make billions by raising premiums by 14%-35% next year. Or we can enact Medicare for All and save the American people $650 billion a year.” Sanders said the only alternative to soaring premiums is to replace all private health insurance with a government-run, single-payer health-care system. The Atlantic says a simpler alternative exists: restore the subsidies that Democrats enacted under the Biden administration.
Before the Affordable Care Act passed in 2010, nearly 20 percent of Americans under 65 were uninsured. By 2023, that number had been cut in half. Sanders’s message did not mention that Democrats had done anything on the issue, and it did not mention the Trump administration or Republicans, whom The Atlantic says caused the problem. That omission matters. The fight isn’t abstract. It’s about who gets care and who gets left to fend for themselves.
What the State Took Away
Health insurance is becoming a crisis again because Republicans decided to make it one. Other than occasional vague promises, such as making Obamacare “much better, strong, and far less expensive,” Donald Trump rarely mentioned health care during his most recent presidential campaign. His 2024 convention speech ran for more than an hour and a half without referring to his plans to cut the Affordable Care Act.
The article says health care ranks among Trump’s most consequential legacies. Nearly 3 million Americans lost their health-care coverage last year. Hundreds of rural hospitals are at risk of closing. The Congressional Budget Office projects that by 2028 the number of uninsured Americans will have risen by a third, with almost 10 million Americans losing coverage. That’s not a policy debate. It’s a social wrecking ball.
Republicans have not acknowledged the straightforward effect of their subsidy cuts. Trump and his allies prefer to discuss almost any other subject. When they do address the consequences, they say the cuts do not deprive people of insurance but instead eliminate fraudulent claims. Mehmet Oz, the former celebrity doctor now serving as the administrator for the Centers for Medicare and Medicaid Services, said at a press conference last month that the administration is cutting benefits for “millions of people, literally, who are getting insurance that they don’t want; they don’t even know they have it.” He said the point of Trump’s subsidy cuts was not to throw people off the program but to strengthen it. “If you care about the ACA, then you’ll want us to take the fraud out,” he said.
Who Gets Labeled ‘Fraud’
Oz is repeating a conclusion from the Paragon Health Institute, a conservative think tank, which has claimed that the ACA has given benefits to “improper” beneficiaries. The group’s findings are described as very questionable. Paragon extrapolates from the number of recipients who don’t file any claims on their insurance that the program is handing out subsidies to people who either don’t exist or don’t want coverage. The article says that is not persuasive, because not everybody who gets insurance through an employer files a claim, and not filing a claim does not mean a person does not want the plan. Matthew Fiedler, a health expert at the Brookings Institution, examined the number of Obamacare policyholders who did not file claims and concluded that “these data do not provide persuasive evidence that ‘phantom’ enrollments are widespread.”
Oz misinterprets Paragon’s study, which asserts that there are 6 million “improper” recipients this year, including a million and a half people who are ineligible to receive subsidies. Most of those ineligible recipients are not pretending to be poor, the article says; they are inflating their income in order to be eligible for coverage. The article says they are doing this because of a perverse, Republican-imposed policy. The Affordable Care Act split the task of covering the uninsured into two programs. The poorest households, below 138 percent of the poverty line, would be enrolled in Medicaid, and those above that threshold would get subsidized coverage on the new exchanges, where insurers would be prevented from charging higher rates to people with preexisting conditions.
A Supreme Court ruling allowed states to opt out of the Medicaid expansion. Many red states did so, creating a hole in the program: the subsidies for people above the income cutoff remained intact, but in certain states, of which nine remain, no programs covered those below it. In many of these Republican-led states, people desperate for coverage have pretended to have more income in order to get insurance. The article says those payments might not be legal, but the people getting them are very real.
Oz said, “We believe that 35 percent, roughly, of the people that are using the Affordable Care Act, Obamacare exchanges—because they’ve never used the program once they’ve never filed a claim—may not be legit.” The article says whether and to what extent the Trump administration and its allies believe they are merely eliminating fraud is difficult to say. It says Republicans outsource their social-policy expertise to a handful of conservative wonks who, in most cases, argue that it just isn’t the government’s business to help people who are too poor or sick to cover their own medical expenses. Republicans insisted that the Affordable Care Act was a train wreck that couldn’t work. Those predictions failed, but Republicans haven’t rethought their opposition to it, presumably because they not only thought Obamacare couldn’t work; they didn’t want it to work.
The Reform Trap
The article says Democrats were wrong about the long-term fate of the Affordable Care Act in a different way. They assumed that once the public experienced the benefits of Obamacare, Republicans would be unable to take those benefits away. That calculation has proved mostly false. Nearly the entire Republican caucus voted to repeal the law in 2017, falling just short when a handful of senators defected. In 2025, the GOP sat on its hands and allowed a portion of health subsidies to expire, then voted to claw back Medicaid.
Those votes, and the consequences that are only beginning to be felt, are politically toxic. The article calls this a social catastrophe for people who are too poor and sick to afford health insurance, but also a political advantage for the party committed to helping them. It says the challenge for Democrats now is to turn Republicans’ flouting of public opinion into maximal electoral defeats. That’s the reform game in a nutshell: wait for the next election while the damage keeps piling up.
The article says that task has become more difficult because progressive activists, especially those associated with the Democratic Socialists of America, are blaming the wrong party for the crisis that socialists say they are fighting to solve. The DSA has set itself up in opposition to the Democratic Party, selling itself to progressive voters by promising to do what Democrats will not. Its candidates and advocates routinely say that one of the group’s primary goals is to ensure that everybody can get health care, as if that is what distinguishes democratic socialists from the Democratic Party.
The Wall Street Journal recently surveyed the four DSA-affiliated congressional candidates, and all of them cited universal health care as one of their core beliefs. Jia Lynn Yang argued in a laudatory essay in The New York Times Magazine that “The Democratic Socialists of America platform calls for universal health care, an idea long since implemented by their counterparts in Europe.” The article says there are two odd things about defining the group this way. First, support for universal health care is probably the least controversial element of the DSA’s official platform. The group supports government ownership of major corporations, ending all immigration enforcement, and “abolishing the carceral forces of the capitalist state,” among other things. Its members can be expelled merely for defending Israel’s right to exist.
Second, the Democratic Party also supports universal health care. The article says it is one of the party’s deepest and most consistent causes. Forming a competing organization primarily dedicated to the same goal makes little sense.
The Democratic Party’s commitment to giving all Americans access to health insurance dates back to the New Deal. Franklin D. Roosevelt considered it but settled for a more limited Social Security program centered on old-age pensions. Other Democratic presidents pushed through incremental expansions, such as Medicare and Medicaid under Lyndon B. Johnson, and the Children’s Health Insurance Program under Bill Clinton, who had spent much of his first two years in office trying and failing to establish universal health care.
Under Barack Obama, Democrats finally did establish a universal health-care program. Obama’s plan relied on regulation of the individual health-care market, plus subsidies and expansion of Medicaid, to make coverage available to all Americans. Undocumented immigrants, who make up about a fifth of the uninsured population in the U.S., remained ineligible. The effort drew a ferocious right-wing backlash and probably cost many congressional Democrats their careers.
A conservative-controlled Supreme Court nearly overturned Obama’s Affordable Care Act. The Court’s final ruling was a partial rollback that made the Medicaid expansion optional for states. The article says this ruling, not any decision by Democrats, made Obamacare a non-universal program. About 40 percent of uninsured Americans live in the states that have not expanded Medicaid.
Since then, Democrats have continued to fight to extend coverage to more Americans. They have campaigned relentlessly to get red states to accept Obama’s Medicaid expansion, and the article says it is their best issue in those states. They have won ballot initiatives in seven states supporting Medicaid expansion and have elected governors in Kansas, Kentucky, Louisiana, and North Carolina by emphasizing the issue. Just 25 states and D.C. were enrolled in the Medicaid expansion after the Court’s ruling, but 15 more have since joined.
A major weakness in the Affordable Care Act was that the subsidies were too stingy for middle-class people at the higher end of the income spectrum. When Democrats regained control of government in 2021, they fixed that problem, expanding the subsidies and, within two years, bringing the uninsured rate down from 9.7 percent to 7.7 percent. Republicans have since let those higher subsidies expire, causing the uninsured rate to rise again.
The article says that when many progressives say “universal health care,” they actually mean universal government provision of health care. That is not the same thing. Some universal health-care systems in Europe and elsewhere rely on private insurance, whereas others do not. Even this narrower definition does not do much to distinguish the DSA from the Democrats. The Democratic Party is roughly divided on the practicality, not the morality, of government-provided health care. Many Democrats favor single-payer health care. More than half of the House caucus has endorsed Medicare for All. The remainder favor universal coverage by building on Obamacare. Nobody in the Democratic Party opposes universal coverage.
The American health-care system was built around private, employer-provided coverage, which has made transitioning to a fully public system difficult. Even people who dislike the current system tend to resist new taxes or policy changes that would cut off their existing coverage. Obama has said that if he were starting from scratch, he would design a single-payer system; he settled for a hybrid model to avoid disrupting care for the majority of working adults who get coverage through their jobs.
Advocates of single-payer health care in particular, and the left in general, have directed the bulk of their efforts into pressuring Democrats to accept their preferred measures, rather than supporting the programs Democrats have fought to enact and expand. Sanders’s decision to condemn the consequences of Republican health-care policy without blaming the Republicans for it is described as typical of how the left has communicated on the issue. The article says decades of the left refusing to credit Democrats for advocating universal health-care coverage has helped lead many Americans to believe the party doesn’t care about the policy. About a third of Americans trust the Democrats to do a better job on health care than the Republicans, according to polls, but that leaves two-thirds of Americans feeling otherwise.
Meanwhile, congressional Democrats have prioritized the provision of health care to such an extent that they recently shut down the federal government in an effort to defend health-insurance subsidies.
Young people often say they are let down by the Democratic Party. One source of their disillusionment is their belief that the party lacks a commitment to health care. The article says that belief has been instilled through endless repetition, but is completely mistaken.
Health care is probably the issue that least differentiates the DSA from the Democratic Party. If you favor public ownership of the means of production or believe forming coalitions with communists is important, then joining the DSA makes sense. But deciding to be a democratic socialist because you care about universal health care is like ditching a Toyota for a Rolls-Royce because you want your car to have a steering wheel.