The Republican assault on Obamacare has created a healthcare bloodbath, with worse yet to come
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Since the Affordable Care Act’s enactment in 2010, the Republican mantra about the law has been “repeal and replace.”
On the surface, the GOP never got what it wanted. The key moment in this campaign arrived in July 2017, when the late Sen. John McCain (R-Ariz.) stood on the Senate floor and issued a thumbs-down gesture to kill repeal.
But that’s misleading. The latest statistics on Obamacare enrollments and pricing show that for millions of Americans, repeal indeed has happened.
A new Affordable Care Act marketplace rule...adds to the burdens of millions of people in the United States who are already struggling to afford their health care costs.
— Center on Budget and Policy Priorities
The expiration of enhanced ACA subsidies as of Jan. 1 prompted millions of Americans to either give up their Obamacare health plans or shift to plan levels with lower premiums but higher co-pays and deductibles.
Although official statistics for the 2026 plan year are not yet complete, expectations are that the number of enrollees could fall to as few as 16.5 million. That would be a decline of more than 26% from the 22.3 million beneficiaries last year, and the first such decline since the ACA marketplaces opened in 2014. The scale of the decline is still unclear, because people’s abandonment of ACA plans isn’t final until they fail to pay their first-month premiums, and statistics on that trend aren’t yet fully available.
What has happened, however, is that average premiums have increased by 58% nationwide this year, rising to $178 per month from $113, according to the healthcare research organization KFF. Average deductibles rose by 37%, or by $1,027 per person, KFF calculated, reaching a record high of $3,786.
That’s “the steepest increase in deductibles ever seen in this market,” KFF reported. The underlying cause was the shift by enrollees from silver-level plans with relatively low deductibles to bronze plans with much higher deductibles.
In California, where the Covered California state ACA marketplace is the largest in the country, a standard silver plan costs roughly $580 per month per person, but a bronze plan can be had for a premium of about $290. (The rates can vary by ZIP Code and age.) But co-pays are higher for bronze plans — $60 for primary care visits versus $50 for silver plan visits. Deductibles also are higher — $5,800 per year per person for bronze plans versus $5,200 for silver plans.
The original ACA subsidies capped premiums on a sliding scale, ranging from 2.07% of income for those earning 138% of the federal poverty line to 9.83% of income for those at 400% of the poverty line.
The ACA’s drafters knew from the outset that these subsidies were inadequate. Especially troubling was the sharp cutoff of any subsidies for families earning even a dime above 400% of the poverty level — the so-called subsidy cliff. But that was a budgetary compromise, and the expectation was that Congress would get around to fixing the cheeseparing subsidy at a later date.
The pandemic forced Congress to act. In the 2021 American Rescue Plan Act, Congress refashioned the subsidies so families with income up to 150% of the poverty level could find decent Obamacare plans for free. The act eliminated the subsidy cliff by capping premiums for families at 400% or more of the poverty line at 8.5% of applicable income.
The benefits were seen almost immediately. ACA health plan enrollments roughly doubled to 19.3 million from 9.7 million in the three years after the subsidies were increased. But Congress failed to extend the enhanced subsidies past their expiration last Dec. 31.
California backstopped the federal subsidies for the lowest-income enrollees — mostly those for households earning up to 150% of the federal poverty level, or $23,940 for individuals and $49,500 for a family of four. That premium support, which was funded out of a $190-million state reserve fund, averaged about $45 per month, Covered California said.
The state subsidies mitigated the damage from the expiration of the federal assistance, says Charles Gaba, the indefatigable private analyst of Obamacare financials. Even so, he calculated, “Covered CA enrollees are paying 36% higher net premiums on average this year, along with a 17% average increase in out of pocket costs.” Put it together, and California enrollees are paying, on average, about $1,100 more in healthcare costs.
It’s almost certain that things will get worse. President Trump’s hostility to the Affordable Care Act has long been manifest. He pushed hard for the repeal act that McCain shot down in 2017 during his first term. He also has implemented changes in ACA practices that reduce access to healthcare and increase paperwork.
Within weeks, insurance carriers will start calculating their premiums for 2027. They’ll be using their current experience to do so, including the higher sickness and death rates they’re seeing thanks to a higher uninsured or underinsured population. In itself, that points to higher premiums next year.
“A new Affordable Care Act (ACA) marketplace rule finalized by the Centers for Medicare & Medicaid Services adds to the burdens of millions of people in the United States who are already struggling to afford their health care costs,” concludes the Center on Budget and Policy Priorities, a progressive think tank.
A rule just made final for 2027 ACA plans will have the effect of reducing access to healthcare and increase paperwork and costs. Among the changes is an increase in out-of-pocket limits for bronze plans, which have been chosen this year by a record 40% of enrollees because of their lower up-front costs. The new limits are $15,600 for individuals and $31,200 for a family, up from $10,600 and $21,200 this year.
That could leave some individuals and families on the hook for all their medical expenses, the CBPP observed. As the organization reports, “$15,600 is about a third of median personal income, and roughly the entire income of a person at the federal poverty level.”
Among other provisions of the new rule is one that would allow “non-network” health plans into the ACA marketplace beginning in 2028. These are plans that don’t maintain a roster of providers who agree to accept the plan’s payments as payments in full for services so that their patients don’t face additional charges. Non-network plans set forth a schedule of fees; providers can charge more, sticking the patients with responsibility for paying the excess — the dreaded “balance billing” effect.
The rule, observed Sabrina Corlette, Jason Levitis and Lindsey Murtagh of Georgetown, the Urban Institute and Brown “would violate minimum requirements of the Affordable Care Act, harm consumers, and significantly destabilize the ACA Marketplaces, leaving consumers with fewer and more expensive coverage options.”
The new rule will eviscerate many patient protections written into the ACA. It says it would allow patients to “negotiate prices among available providers to find a provider who will accept the plan’s benefit amount as payment in full.” This is a familiar chimera offered by enemies of the ACA.
The idea is that patients can shop among doctors to find the cheapest option. But its promoters know full well that patients rarely do this — it’s time-consuming, requires more knowledge about prices than patients generally have, and doesn’t work to protect those needing care that is “not reasonably shoppable, such as non-elective procedures, non-emergent services that must be performed rapidly, or services for which there is limited provider choice,” the researchers noted. And what about patients “who are very sick or otherwise unable to engage in one-on-one price negotiations with providers”? They’ll be on their own.
The White House announced the new rule with a press release bristling with meretricious claims that it “strengthens program integrity, expands consumer protections, promotes plan innovation and consumer choice, and restores greater authority to states.” In truth, it undermines program integrity, eliminates key consumer protections, forces consumers into choices that are not to their benefit and saddles states with higher costs.
The Republican healthcare strategy is now fully rolled out. They no longer feel the need to “repeal and replace” the Affordable Care Act. Instead, they’ll leave it in place while eliminating or hamstringing all the elements that have bolstered its popularity (Americans approved of the act by 57% to 35%, according to a Gallup poll taken in November) and its effectiveness.
The ACA began the process of revolutionizing American medicine, but it left a lot undone. For some reason, the fear that more will be done to make American healthcare more accessible, affordable, efficacious and humane grips Republican hearts. Go figure.
That said, Trump and the GOP have provided Democrats with a road map to reforming American healthcare: Start by looking at all the changes made by the Republicans, and reverse every last one of them.
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Ideas expressed in the piece
The article argues that although congressional Republicans failed to formally “repeal and replace” the Affordable Care Act in 2017, a de facto repeal is underway as Republican leaders and the Trump administration let key supports for the law lapse and adopt rules that make coverage less affordable and less protective.
It contends that the expiration of enhanced premium subsidies at the end of 2025 has forced millions of people either to drop ACA marketplace coverage or to trade down from more protective silver-tier plans to cheaper bronze plans with much higher deductibles and cost-sharing, driving a projected enrollment drop of more than a quarter from last year’s 22.3 million enrollees.
The piece highlights that, according to KFF and other analysts, premiums and deductibles have spiked sharply in 2026 as a result of this shift, with average premiums and out-of-pocket costs rising to record levels, and notes that this reverses the coverage gains seen after Congress temporarily boosted subsidies during the pandemic.[1][3]
It emphasizes that the enhanced subsidies enacted in the American Rescue Plan Act allowed lower-income families to obtain zero-premium or very low-premium plans and eliminated the “subsidy cliff” for middle-income households, nearly doubling marketplace enrollment over several years; the lapse of those subsidies is portrayed as a deliberate policy choice rather than an accident.[1][3]
The article points to California as a case study, arguing that even though the state temporarily used its own funds to partially backstop the lost federal help for the lowest-income enrollees, consumers there are still paying significantly higher net premiums and out-of-pocket costs, demonstrating how much financial damage the federal pullback has caused.
It criticizes President Trump’s longstanding hostility to the ACA and asserts that recent administrative actions—including a new federal rule for the 2027 plan year—continue this “assault” by raising out-of-pocket maximums on the bronze plans that an increasing share of enrollees are choosing because of their lower monthly premiums.
The article cites progressive analysts who warn that the new rule’s higher out-of-pocket limits—over $15,000 for an individual and more than $31,000 for a family—will leave many low- and middle-income patients effectively uninsured in practice, because they will never be able to meet such large cost-sharing burdens.
It argues that allowing “non-network” plans into ACA marketplaces starting in 2028 would resurrect widespread balance billing and undermine core consumer protections the ACA was designed to provide, with experts from Georgetown University, the Urban Institute and Brown University warning that this could destabilize the marketplaces and leave consumers with fewer, more expensive options.
The piece is sharply critical of the administration’s justification that the rule will “strengthen program integrity” and expand consumer choice, contending instead that it increases paperwork, weakens protections, shifts risk and costs onto patients and states, and relies on a “chimera” of price-shopping that is unrealistic for very sick patients or those needing urgent or non-shoppable care.
Overall, the article argues that the current Republican strategy is to leave the ACA on the books but strip away or constrain the elements—such as generous subsidies and strong network and cost-sharing rules—that made it popular and effective, and it suggests that Democrats now have a clear roadmap: systematically reverse each of these changes to restore and extend the law’s protections.
Different views on the topic
In contrast, some Republican lawmakers and conservative policy advocates argue that the enhanced ACA subsidies were an overly generous, pandemic-era expansion that should not be made permanent, emphasizing that the Congressional Budget Office has estimated that locking them in would add roughly $335 billion to federal deficits over 10 years.[3]
Senator Chuck Grassley and other Republicans contend that the richer subsidies have “left Obamacare, a program already riddled with problems, wide open to new waste, fraud and abuse,” asserting that looser eligibility rules and larger tax credits create stronger incentives for gaming the system.[3]
A report from the conservative Paragon Health Institute, cited by critics of the ACA, claims that the number of people reporting incomes between 100% and 150% of the federal poverty level—thresholds that qualify for zero-premium plans and lower deductibles—may exceed the number of people who actually earn that little, suggesting to these analysts that some enrollees or brokers are mis-stating income to access the most generous subsidies.[3]
From this perspective, tightening oversight, reducing subsidy generosity, or allowing those expansions to expire is framed as necessary to protect “program integrity” and taxpayer dollars, even if it leads to higher premiums for some and lower overall enrollment.[3]
Some Republicans and conservative commentators maintain that the ACA remains structurally flawed, arguing that its regulatory requirements and subsidy design distort insurance markets, drive up underlying premiums, and entrench federal control over health coverage; they see scaling back recent expansions as a step toward a more market-oriented system.[1][3]
Rather than extending temporary subsidies, Republican leaders in Congress have prioritized other fiscal and policy goals, including tax relief and broader deficit concerns, and have declined to guarantee a long-term extension of the enhanced credits—an approach their critics say sacrifices affordability, but which supporters describe as a necessary limit on open-ended federal commitments.[2][3]
Policy analysts interviewed in coverage of the subsidy debate note that there is an inherent trade-off: the enhanced subsidies have clearly increased coverage and lowered premiums for millions, yet keeping them would cost the government a substantial sum; some experts who are not fully aligned with the article’s stance emphasize that weighing these competing priorities is a legitimate policy question rather than simply an “assault” on healthcare.[3]
Supporters of giving states more leeway and of encouraging greater “plan innovation and consumer choice” argue that loosening some ACA rules could spur insurers to offer a wider range of products, potentially including lower-premium options with different cost-sharing structures, and say that individuals should be allowed to select plans that match their own risk tolerance and budget, even if those plans have higher deductibles or more limited networks.[1][3]
Finally, while critics of the new federal rule emphasize the dangers of higher out-of-pocket caps and non-network plans, backers of stricter verification and benefit rules argue that requiring consumers to be more cost-conscious and permitting more varied plan designs could help slow federal spending growth and premiums over time, and they view these steps as corrections to what they see as earlier over-expansion rather than an attempt to dismantle the ACA altogether.[1][3]
