Talking points for an electoral death march

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A man may smile, and smile (sort of)...

Multiple Republican senators and House reps, psyching themselves up for electoral suicide, are sharing this messaging from the Koch-funded Paragon Health Institute, where virtually all their ACA-related talking points originate:

There are of course lies, damned lies, statistics, and Koch-funded talking points designed to strip Americans of healthcare access to help fund tax cuts for the wealthy.

Look at the mid-section of this chart, from 2018 to 2025 (there should be a sharp spike from 2017 to 2018, but never mind). There is barely any premium increase in that long stretch, during which average premiums for employer-sponsored insurance rose far more quickly. Here is the comparison in the National Health Estimate Accounts, published in June of this year (see Table 17 in NHE Projections - Tables, here)

From 2018 through 2023, the last year for which the NHE has data, premiums in the individual market (“direct purchase” above) were up 13% — while premiums in the employer-sponsored market rose 29%. From 2023-2025, average ACA benchmark silver premiums rose 9% (from $456/month to $497/month), while average ESI premiums rose 11% (from $8,435/year to $9,325/year) for single coverage according to KFF’s annual employer benefits survey. As of 2025, ESI premiums remained considerably higher than marketplace premiums, though the difference is probably in line with differences in network quality and actuarial value (a measure of the level of out-of-pocket exposure).

An icy reception for visitors to the immigrants detained at Delaney Hall in Newark

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The, um, visitor reception center at Delaney Hall

Please excuse a departure from our usual usual programming here at xpostfactoid, as I want to report on an ongoing, intentional, sustained abuse of physical and mental health imposed on New Jersey (and really, the entire nation) by our federal government.

On Saturday afternoon, I joined my wife Cindy to visit a detained young man at Delaney Hall, the Geo Group-run immigrant detention center opened this past spring in Newark’s most insalubrious industrial region. As readers here probably know, Geo Group’s treatment of visitors to Delaney detainees is designed to be abusive: Visitors are forced to wait outside, under an open metal canopy with cold metal benches, before being ushered through the gate to again line up outside to be processed through security.

Yesterday, as part of a group of 50-60 visitors, including about ten children and babies, we waited outside for 100 minutes in 35-degree weather.

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Cindy and I are among the volunteers who regularly set up and staff a sort of comfort station for Delaney visitors on the sidewalk outside-- more on that ad hoc enterprise at bottom. We have witnessed what the visitors endure and gotten to know to some of them, but yesterday we had the chance to experience the abuse first-hand (Cindy has visited before, but not in freezing weather or at a crowded time). I am focused here only on the visitor experience at Delaney, respecting the privacy of our friend inside.

Where the 100 minutes went

We arrived for our visit one hour prior to the scheduled 4:30 visiting hour (as Geo Group requires) and joined a line then about 30 people long. The guard worked his way down the line, checking that people were there to visit a detainee scheduled for visiting in that hour. Every time a van or car arrived to go through the gate, he had to interrupt himself and walk back to manually open the gate. This particular guard was civil, which is not always the case.

At 4:15 we passed through the gate and lined up again in front of the security check-in area, a grim cubicle maybe 20 feet square. We waited there, still outside, while the door was opened at intervals and small groups were let in for processing. Each person had to be checked again against the visitor list, hand in their i.d., remove jackets and shoes, and pass through a metal detector. There were 3 Geo employees in the security box, but only one was checking people in. We waited out there for 55 minutes for our turn (and people behind us waited longer), entering security at 5 :10 pm.

Our group included one baby, a toddler and at least ten elementary school-aged children and young teens. After the first group (and largest) group was admitted, the guards did ask the visitors to allow the babies and children and their caregivers to go to the front of the line, which everyone did willingly, but most of those children waited outside as long as we did, as subsequent groups were only about 5-10 people. An elderly person who had to leave the security room to pass off her phone asked to be let in but was made to wait outside again.

The visit itself is not too restrictive. The visiting area is like a crowded school lunchroom, with benches running on both sides of long tables. Visitors are supposed to sit opposite detainees, but people are allowed to touch, and children went to sit with their detained fathers (or other detained relative). There was a fair amount of crying, and of laughter. We visited a young man who has seen too much and has no clear path to a better life, or even a safe life. We will be visiting him again.

The young man we visited told us that Senator Andy Kim was coming to Delaney the next day, and that turned out to be the case. Among New Jersey elected officials, Kim is truly the moral leader, on this as on many fronts.

New Jersey elected officials must act

Despite the federal government’s preemptive powers, New Jersey leaders must make it a priority to stop this abuse of their constituents. The pressure on Geo Group and DHS must be ramped up. Surely this abuse of wives, children, parents, and other loved ones of those detained at Delaney must violate multiple laws and civil rights.

About the volunteer effort at Delaney

Present throughout all visiting hours at Delaney (setting up at 6 a.m. on Saturdays and Sundays for the first visiting hour, which starts at 7:30), an ad hoc coalition of volunteers offers hats, gloves, scarves, blankets and handwarmers; coffee, hot chocolate and donuts; toys and art materials for children (though it’s now usually too cold for the latter); diapers and supermarket gift cards for those who have a breadwinner inside; a listening ear when needed; and information about more in-depth support services, along with a list of vetted immigration lawyers. Several nonprofits as well as individuals are involved in the effort, though I think they would not want me to name them here. Originally, as there was no seating, we set up rows of camp chairs, and we still have those on hand for those who can’t manage on the cold metal benches Geo Group has now set up outside, beneath an open metal canopy.

Delaney Hall, like the next-door Essex County Correctional Center, is located in a truly forbidding industrial region of New Jersey, surrounded by energy storage tanks, warehouses, trashy vacant lots, and industrial facilities. Across the street, a narrow freight railroad track is lined with yards-deep trash. The air often stinks. Behind it all, miles to the east, the Manhattan skyline stands like a vision of a different world. None of this matters directly to the detainees, who, according to our friend inside, have no outside view, though they do exercise outside and so get to breathe the insalubrious air. Delaney is within a mile of Newark’s Liberty International Airport, facilitating deportation. I will never fly into Newark again without seeking a glimpse and thinking about the barbarity we have institutionalized at Delaney and the prison next door.

Update: Via Pax Christie, video footage of the visitor line at Delaney on an even colder evening: https://www.instagram.com/p/DSEPgEKDbs9 

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Bill Cassidy and the Sundowning Kid

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That shit-eating grin will eat your health coverage

I never set up to be a prophet of healthcare policy, or anything else. But when Senator Bill Cassidy floated a plan in early November to extend and modify the enhanced ACA marketplace subsidies that are funded only through 2025, I made a prediction that’s shocked me by its rapid fulfillment:

…if Cassidy reverts to form, he may well embrace plans far more toxic than his current sketch. In 2017, as noted above, he co-sponsored the first and least-bad ACA repeal/replace plan, in March. In September 2017, he co-sponsored the last and worst such plan, Graham-Cassidy, which would have liquidated both the ACA marketplace and the Medicaid expansion, replacing both with inflation-capped block grants to states, inequitably distributed to favor red states (penalizing blue states for expanding Medicaid). Then as now, Cassidy unctuously claimed he was advancing a “nonpartisan” approach— which likely would have increased the uninsured population by more than 30 million, with losses increasing over time as per capita caps on block grants bit progressively deeper.

The plan Cassidy announced last month, which never made it into a bill, would have ended the enhanced premium tax credits (ePTC) in their current form but used the $26 billion estimated cost to fund Flexible Spending Accounts (FSAs) for subsidy-eligible ACA enrollees — that is, funds to spend directly on out-of-pocket costs.

Well lo, less than a month later, Cassidy, along with Senator Crapo, is out with a far more toxic plan, this time written into legislation, that would end ePTC funding and use multiple channels to push ACA marketplace enrollees into plans with actuarial values in the 50-60% range — while also, inevitably, radically cutting enrollment and adding complexity to a marketplace that already presents prospective enrollees with a numbingly complex set of choices. The bill would

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• Fund HSAs for enrollees in bronze plans (60% AV) or catastrophic plans ( ~ 57% AV) worth $1,000 if they are age 18-49 or $1,500 if they are age 50-64.

• Open catastrophic plans (here co-named “copper” plans) to all enrollees, instead of primarily to enrollees under age 30 as in the original ACA (CMS has already widened access, but retained a cumbersome exemption application process).

• Fund the Cost Sharing Reduction (CSR) subsidies that attach to silver plans for low-income enrollees through direct reimbursement of insurers for its value, as it was funded before Trump cut off those payments in October 2017, instead of pricing it into plan premiums as at present. In most states, CSR is priced into silver plans only, as CSR is available only with silver plans. Since premium subsidies are structured so that enrollees pay a fixed percentage of income for a benchmark silver plan, raising silver plan premiums also increases subsidies, creating effective discounts in bronze and gold plans for subsidized enrollees. The bill would end this silver loading, reducing the value of enrollees’ premium subsidies in addition to the loss of ePTC.

At present, slightly less than half of marketplace enrollees, about 11.6 million are in CSR-enhanced silver plans with an actuarial value of 94% or 87%. Another 13% are in gold plans with an AV of 80% — which, thanks to silver loading, are available below the cost of a benchmark silver plan in 20 states. By ending ePTC and raising silver plan premiums at low incomes, while adding a modest first-dollar benefit to bronze and catastrophic plans, the Cassidy-Crapo bill would push millions of low-income enrollees into bronze plans. Ending silver loading would push millions more from gold into bronze — and likely drive additional millions out of the market entirely, as the advent of silver loading (before the Democrats created ePTC in the Biden years) made zero-premium bronze plans available to millions of prospective enrollees. The marketplace — what’s left of it— would be converted largely, if not all but entirely, into a market in which most enrollees obtain just 57-60% AV, leaving them exposed to thousands of dollars in additional out-of-pocket costs. While that exposure would be mitigated for many in some years by the HSA funding, every year a significant minority of low-income enrollees would be exposed to thousands of dollars in extra out-of-pocket costs.

Low-AV coverage as a default option for low-income people is a perpetual Republican goal, the party’s favored alternative to the ACA marketplace. The House and Senate ACA “repeal/replace” bills of 2017 also would have pushed most enrollees into bronze or sub-bronze coverage. Republicans are wed to the discredited premise that high out-of-pocket exposure will reduce waste in healthcare spending and make smart shoppers of people in need of medical care. In fact, Democrats also bought into this canard enough to expose millions of marketplace enrollees to damagingly high out-of-pocket costs. Republicans’ only consistent healthcare “reform” idea is to make those costs even higher, exposing ever more Americans to ever more medical debt.

The bill also picks up where OBBBA left off by gratuitously penalizing states that have enacted the ACA Medicaid expansion (further radically cutting high-AV coverage for low-income people); penalizes states that use their own funds to provide coverage to select undocumented populations; prohibits federal Medicaid funding for gender transition services and bars states from including gender transition in EHBs; bars CSR funding for plans that cover abortion, as mandated in many blue states (federal funds already can’t be used to fund abortion coverage, which must be offered for a separate, small premium). In other words, in addition to increasing the ranks of the uninsured and the underinsured, the bills takes vicious swipes at undocumented, trans, and female human beings. For a more detailed provision-by-provision rundown, see Charles Gaba.

The etiology of this steaming pile of legislative aggression is somewhat mysterious. On the one hand, the Republican plans diverting ACA funds to HSAs multiplied like hydra heads in response to Trump’s seemingly incoherent babble on Truth Social in mid-November, calling on Congress to “Take from the BIG, BAD Insurance Companies, give it to the people, and terminate, per Dollar spent, the worst Healthcare anywhere in the World, ObamaCare.” The Cassidy-Crapo fact sheet fawningly boasts that the bill “sends money to patients instead of insurance companies” (so much for the fond Democratic dreams of circa 2007-2009 of defanging Republican opposition to reducing the uninsured population by centering their plans on a market of private insurance plans).

At the same time, Trump’s sudden turn on insurers and apparently nonsensical call to make healthcare more affordable neither through government-run insurance nor through private insurance looks like his senile transcription of longstanding Republican plans to fund healthcare through tax-favored individual spending accounts. Specifically, the Cassidy-Crap crap, which the whole Republican party now looks to align behind, is essentially the plan floated by Trump whisperer Brian Blase of the Paragon Institute, originally in 2022 and recently updated. Cassidy’s earlier iteration, as I noticed in the prior post, was essentially Blase lite. Blase’s proposal, like the Cassidy-Crapo bill, would end ePTC funding and instead use the funding earmarked for Cost Sharing Reduction (CSR) in the original ACA to fund HSA accounts linked to bronze plans — ending ePTC and silver loading in one fell swoop, and pushing most of the shrunken ranks in marketplace coverage into bronze plans (Blase specifically looks forward to cutting the ranks of the CSR eligible by more than half — see my prior post on this). As is so often the case, Trump’s policy choices are a debased version of already-debased versions of longstanding Republican policy.

You can’t change how much sleep you need by going to bed earlier, and you can’t change how much medical attention people need by reducing the actuarial value of their coverage. You can choose how much healthcare people access by cutting AV, but faced with wildly unaffordable out-of-pocket costs, enrollees they will cut down on desperately needed as well as unnecessary care — and go into debt to boot. In fact, the relatively slow rise of U.S. healthcare spending from about 2013-2023 was mostly likely driven mainly by Americans’ terror of being saddled with unaffordable medical bills. Republicans would cut federal spending by cutting AV along with premium subsidies — increasing the underinsured as well as the uninsured population. By so doing, they will degrade Americans’ physical as well as financial health. Par for the course for a party of corrupt oligarchic-serving thieves and autocrats.

Cassidy, let us not forget, cast the deciding vote allowing confirmation of RFK Jr. as HHS director and the resulting destruction of public health administration by the federal government. He is a cowardly go-along who purports to care for his constituents and offer nonpartisan solutions while in the end always partnering with party hardliners to undermine public welfare. I’m not happy that he’s made a prophet of me. But he is…predictable.

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Some bitter pills to swallow in Trump's ACA prescription

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Raise that subsidy cap...

It may be a fool’s errand to write about reported features of a now-stayed Trump administration plan to extend the enhanced ACA premium subsidies for two years, with various conditions and haircuts imposed.

Since House hardliners have stayed the plan, it’s likely to get worse if it ever sees light of day. But as outlined in the various media reports, the pending plan is full of poison pills — or, shall we say, enrollment-inhibiting side effects. The features already floated raise a question we may well be confronted with: If Republicans do coalesce round a plan something like what’s been floated, would Democrats (most, some, a handful) get on board? Should they?

Let’s consider the constraints imposed on the enhanced subsidy schedule in the Trump outline.

The HOPE Act, extending enhanced ACA subsidies with a slight haircut, is cause for...hope

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Pandora...don't ignore her

Picture yourself in a boat on a river, with tangerine trees, and a Republican party that grounds genuine fiscal conservatism (the kind that eschews multi-trillion-dollar tax cuts) in fact rather than in lies and fantasy. What might a compromise on extension of the enhanced premium subsidies in the ACA marketplace look like?

Stop presses: It might look like the bill put out by the Problem Solvers’ caucus today. (I mean ‘‘stop presses” literally, as I was sketching out my own compromise here when I came across the bill in question.)

The Healthcare Optimization Protection Extension (HOPE) Act (summary here, bill text here) was introduced today by Problem Solvers members Tom Suozzi (D-NY), Don Bacon (R-NE), Josh Gottheimer (D-NJ), and Jeff Hurd (R-CO). It addresses two legitimate concerns about the enhanced premiums subsidies (eAPTC) created by the American Rescue Plan Act and currently funded only through 2025: that they spend too much money subsidizing high-income enrollees (questionable, but not absurd), and that they opened an easy pathway to fraud (true, but only in concert with other factors that can be addressed to shut the fraud down).

The HOPE bill only lightly increases the premium burden at incomes over 600% of the Federal Poverty Level ($93,900 annually for an individual, $126,900 for a couple, $192,900 for a family of four). The subsidy “cliff” — the cap on eligibility — goes back in place, but rises from the pre-ARPA (and now pending) 400% FPL to 935% FPL. The new cliff will take a substantial bite from some pretty affluent individuals and families, as explored below, but the ranks of those affected are small.

100 Years of ACA Repeal

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Please, Sir, may I have my inadequate calorie ration up front?

In its initial lightly sketched form, Senator Bill Cassidy’s ACA reform plan is the least bad of several Republican proposals, in that it extends funding for the enhanced ACA premium subsidies (eAPTC) that will otherwise expire at the end of 2025, while redirecting them.

As outlined to the Washington Examiner, Cassidy’s proposal would end eAPTC but use the $26 billion estimated cost to fund Flexible Spending Accounts (FSAs) for subsidy-eligible ACA enrollees — that is, funds to spend directly on out-of-pocket costs (or other medical costs, e.g., dental). As Charles Gaba notes, it’s unclear whether each enrollee’s FSA would be funded with the amount of eAPTC she would have been eligible for, or whether the FSA would be flat-rate or allocated by some other formula. (Cassidy emphasizes that HRAs, unlike Health Savings Accounts, are use-it-or-lose it, saving the federal government money from enrollees who access little or no medical care in a year.)

The incentive for most enrollees would be strong to use their reduced premium subsidies to buy a bronze plan (average deductible about $7,400) and use the FSA to cover first-dollar expenses. That’s donut-hole coverage, as the FSA wouldn’t cover all expenses up to the deductible or annual out-of-pocket maximum (as high as $10,600). It would work for a lot of people, while leaving lots more who would otherwise have been in high-CSR silver (actuarial value 94% or 87%, in contrast to 60% for bronze) saddled with thousands more in out-of-pocket expense.

A tincture of gold mitigation in the 2026 ACA marketplace

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Trumpcare 2.0 is also gold-laden

Amidst the carnage wrought by the (still reversible) expiration of the enhanced subsidies in the ACA marketplace, one substantial mitigating factor has emerged: silver loading has reached a milestone. While net-of-subsidy premiums for benchmark silver plans will more than double for the average subsidized enrollee, the average lowest-cost gold plan will be priced below the benchmark (second-cheapest) silver plan for the first time.

That average masks a ton of variation: the average lowest-cost gold plan is priced below benchmark in only 20 states. But those states include Texas and now Florida, which together accounted for more than a third of all enrollees nationally (8.7 million). In total, average lowest-cost gold plans have premiums below benchmark in 20 states with 12.7 million enrollees, 52% of all enrollees nationwide. (In another 12 states, lowest-cost gold premiums average less than 105% of benchmark premiums.)

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CMS spin on the ACA marketplace, threaded through the Washington Post

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To have or have not..or have a lot less

My last post delved into CMS’s spin on the expiring enhanced ACA subsidies — that is, the agency’s focus on a) the comparatively modest increase in subsidized enrollees’ premiums for the lowest-cost bronze plan available in 2026 (up a mere 35%, compared to the 114% increase for benchmark silver calculated by KFF) and b) on a relative reduction in the lowest-cost bronze premium compared to 2020 (seven OEPs ago!).

I am sorry to see this distorted frame adopted in the Washington Post by a veteran ACA reporter, Paige Cunningham. The article is not factually inaccurate (though I can’t quite make some of the premium quotes work), but it downplays the impact of expiration of the enhanced subsidies on those who remain subsidized.

Here are the select facts Cunningham reports through the CMS filter:

CMS: Buy the cheapest plan, and these subsidy cuts will only hurt a little

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Heavy OOP burden 

You may have read KFF’s estimate that the average subsidized 2025 enrollee in the ACA marketplace will pay 114% more* for a benchmark silver plan in 2026, if the enhanced subsidies funded only through 2025 are allowed to expire. True!

You may also have read estimates that base (unsubsidized) premiums will rise 25% (from Charles Gaba) or 26% (from KFF). Also true!

Now, as of today, you may read CMS’s proud assurance (via https://www.axios.com/2025/10/28/trump-open-enrollment-premium-prices-health-care-government-shutdownAxios) that things are not so bad:

These claims are doubtless also true! How can that be? Are premiums for subsidized enrollees going up 114% — or 35%? (i.e. from $37 to $50/month, per CMS**).

It depends, of course, on the plan you’re buying and what percentage of your actual medical claims it will cover. The KFF estimate is for the benchmark (second cheapest) plan — the one for which all subsidy-eligible enrollees pay a fixed percentage of income, which is being sharply reduced. The actuarial value of a silver plan varies with income, but for most enrollees it’s 94% or 87% (ratcheting down to 73% or 70% at income above 200% of the Federal Poverty Level (FPL).

If the ARPA-enhanced subsidies are renewed...other factors affecting ACA enrollment in 2026

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Thanks to a court order, you can still attest to an income over 100% FPL

It’s good to see the fight over renewal or nonrenewal of the expiring enhanced ACA marketplace subsidies sitting at the center of the current political agenda.

The enhanced summaries created by the American Rescue Plan Act (ARPA) in March 2021 are plainly the main driver of a doubling of ACA marketplace enrollment from OEP 2021 to OEP 2025 (from 12 million to 24 million). The enhanced subsidies gave the ACA a credible claim to fulfilling the mission embodied in its name, offering affordable to care to all who lack access to other affordable insurance (excepting perhaps two million in the coverage gap created by red state refusal to enact the ACA Medicaid expansion).*

Renewal or nonrenewal of ARPA subsidies will determine the basic size and shape of the ACA marketplace in 2026 and who-knows-how-many years beyond. Even if the subsidies were renewed without strings today, however, other changes to the marketplace triggered by Trump’s CMS, the Republican Congress, and political uncertainty generated by their assaults on the law are likely to inhibit 2026 enrollment substantially.

To get a working sense of how some (not all) of these restrictions function, it’s important to recognize that the majority of enrollments in the ACA exchanges are executed by brokers. Brokers played an important role in the marketplace from the beginning, but their ranks swelled from 49,000 in 2019 to 83,000 in 2024 (as CMS told me by email) - spurred first by encouragement and facilitation by the first Trump administration, and then by the increasing attractiveness of offerings and ease of enrollment when the ARPA subsidy schedule kicked in. By OEP 2024, brokers accounted for almost 80% of active enrollments in the states using HealthCare.gov, which account for about three quarters of all enrollment — up from 44% in OEP 2019. Brokers execute a large share of enrollments in most state-based exchanges as well (e.g., 56% of California’s 2 million enrollments in 2025).