This year (2025) could be the last one with record enrollment in Affordable Care Act (ACA) health plans if the Republicans in Congress succeed in letting the tax subsidies expire. Those subsidies led to 24.2 million enrollees (including 3.9 million new consumers) signing up for ACA health insurance plans as of Jan. 17, allowing them to pay less for their insurance premiums each month, federal health officials reported.
This story is the fourth in a series.
If the tax credits expire, the cost of health insurance premiums would rise sharply for millions of Americans leaving many struggling to find affordable coverage and making health care itself unaffordable.
As we reported in part one of this series, the official name of the ACA is the Patient Protection and Affordable Care Act, and unofficially, it’s called Obamacare. In part two and part three, we covered the ACA’s significant features. In this article, we’ll highlight some of its failings and attempts to weaken the law.
Health program cuts
The ACA, which was signed into law on March 23, 2010, has already been hampered under the Trump administration. In January, the Trump administration cut the ACA’s navigators and enrollment days, making ACA enrollment more difficult and going against the Republicans’ stated aim to make America healthy again.
In addition to cutting funding for navigators and enrollment days, Trump also fired two Democratic members of the Federal Trade Commission, as Will Weissert and Christopher Rugaber reported for the AP. Given that two Republican commissioners had recused themselves in September, Trump’s firing of two more members meant the commission lacked a quorum to hear arguments in a lawsuit the FTC filed against the largest pharmacy benefit managers. Those PBMs are subsidiaries and profit centers for health insurers.
On April 2, Ed Silverman reported for STAT that in its case against the PBMs, the FTC accused CVS Caremark, Cigna’s Express Scripts, and UnitedHealth’s OptumRx of creating a “perverse” system of rebates. Those rebates allowed the PBMs to sell insulin at high list prices to “line their pockets” while patients were forced to pay more for this life-saving medication, he added.
The Trump administration and the Republicans control the U.S. Senate and the House of Representatives and are likely to view the ACA as wasteful, explained journalist Jonathan Cohn, a senior writer for The Bulwark who until recently wrote for HuffPost. Cohn also is the author of The Ten-Year War, Obamacare and the Unfinished Crusade for Universal Coverage.
Republicans have never hidden their opposition to the ACA, Cohn said. “When they do things like defunding promotions, defunding the navigators and making all kinds of other changes, that’s in their DNA,” he said in an interview. “If you look in the conservative world today, and you read what the people who advise them on policy write, you’ll see they remain hostile to the ACA.”
In one of his first articles for The Bulwark, Cohn reported on the deep staff cuts at the federal Department of Health and Human Services. “The sheer breadth of the cuts is staggering: The layoffs affected agencies that exist to fight deadly pathogens, to protect the nation’s drug supply, to finance and carry out cutting-edge research — along with countless other divisions and offices that touch everything from rural health to early childhood care,” he wrote.
Addressing the ACA’s flaws
Rather than weaken the ACA, Congress and the states could improve health insurance by fixing defects in the landmark law. If they did so, most Americans would support their efforts, as Gallup reported in December. Among U.S. adults, 54% approve of the ACA, and 62% (the highest percentage in more than a decade) say that the federal government is responsible for ensuring all Americans have health insurance, according to the survey.
Perhaps the biggest weakness of the ACA is that it relies on the nation’s health insurers to pay for care. Many of those companies are among the nation’s largest for-profit corporations, as Rylee Wilson reported for Becker’s Payer Issues last year.
In March, Chris Stanton, a reporter and editor for New York magazine, explained how executives at for-profit health insurers focus more on adding revenue and boosting stock prices than on paying for members’ care.
In that article, “The Confessions of Insurance Executives,” Stanton quoted Wendell Potter, a former vice president of public relations for Cigna, who said, “I’ll assure you that the least important stakeholders are the people who are enrolled in their health plans. They’re at the bottom of the pile.”
Despite health insurers’ focus on profits, Congress and the states are unlikely to replace those insurers in part because Obama and Congress enlisted health insurers to make the ACA work since 2010, Potter told me in an interview.
Reports focus on consumer harm
Between Nov. 20 and Dec. 10, the Commonwealth Fund issued three reports on weaknesses in the U.S. health insurance system that harm consumers as follows:
- About 25% of Americans are underinsured, and most of them are in employer plans.
- Older adults struggle to pay for care and skip care.
- Many workers in small businesses have higher health insurance costs and less financial protection than workers in larger businesses.
Sara R. Collins, a senior scholar and vice president at the Commonwealth Fund who tracks health system performance, noted that despite improvements under the ACA, many Americans lack full coverage. “There are issues that people have in all commercial plans, including the employer group market, and also in the individual market, where deductibles can be very high,” she said in an interview. “In the ACA plans, if you’re not eligible for a cost-sharing reduction, the copays and deductibles can be very high.”
The report on health insurance that small businesses provide showed that those workers and their families pay a lot out of pocket, especially for family plans, Collins added. “When they use their plans, those plans fall short of what we expect from health insurance,” she commented.
“About a quarter of the under-65 population has coverage all year, but has such high out-of-pocket costs and deductibles that we define them as being underinsured,” Collins said.
Resources
- Trump administration begins mass cuts of federal health policy researchers, Bob Herman and Tara Bannow, Stat News, April 2, 2025.
- Republican Proposals Would Raise Taxes for Enrollees in Affordable Care Act Marketplaces, Center on Budget and Policy Priorities, Feb. 7, 2025.
- From Laggard To Leader: Why Health Care In The United States Is Failing, And How To Fix It, Health Affairs, Jan. 22, 2025.
- More in U.S. See Health Coverage as Government Responsibility. Approval of Affordable Care Act also near high point, Gallup, Dec. 9, 2024.
link