Greetings everyone. I asked our good friend Charles Gaba, a well-known health care data analyst, to return to Hopium to update us on what he’s seeing in the data five months into our first year of the huge health care cuts of the Big Ugly Bill. For years, Charles tracked good news about the impact of the ACA and Medicaid expansion - rising enrollment numbers, falling premiums, and expanding coverage. Now he is essentially running the same analysis in reverse, tracking how many people are losing coverage, how much premiums and deductibles are going up, and how many insurance carriers and clinics are pulling out of markets.
On the ACA he estimates that somewhere between four and six million people will lose ACA coverage by the end of the year, driven both by the elimination of enhanced subsidies and by people who initially kept their coverage but simply cannot afford to maintain it month to month. For those who kept coverage, he estimates that costs have gone up roughly $1,500 per person per year between higher premiums and higher out of pocket expenses. As Charles tell us in the discussion:
of those 19 million or so who did manage to hold on to ACA coverage thus far… it’s not just a matter of their premiums going through the roof in many cases. It’s also their out-of-pocket expenses because what happened with a lot of people is they had to buy down… basically where you downgrade your coverage from, you know, a gold plan to silver, from silver to bronze, from a PPO to an HMO. Basically, you’re downgrading your coverage to a worse plan with worse coverage or worse network, whatever, in order to avoid or partially avoid being hit with those massive premium hikes. But now you have higher out of pocket costs, higher deductibles, higher co pays, maybe a worse network, etc.
On Medicaid, he pushes back on the Republican construct of "work requirements," arguing these are really "work reporting requirements" since most Medicaid enrollees already work. The real purpose of these new onerous requirements, he argues, is to make the paperwork so difficult that people give up and fall off the rolls, which is where some of the planned savings Republicans are banking on will come from - by shoving people off the program.
Gaba warns that the ACA may be heading toward what he calls a “half death spiral,” where the individual market does not collapse entirely, but effectively becomes a high risk pool serving only the sickest and most desperate, much like the broken state based high risk pools that existed before the ACA. He also flags that starting around September and October, tens of millions of Medicaid enrollees will begin receiving notices about coming changes that start in January, which he expects to create significant political and human shock in the days heading into the November elections. As reminder that the CBO projects 15 million people currently on Medicaid will lose their coverage in the coming years due to these barbaric cuts. The initial steps in that process will begin this September.
As we discuss, that tens and tens of people will lose their health insurance and tens and tens millions more who keep their insurance will see their costs rise, was a deliberate policy choice made to fund tax cuts for the wealthy. These cuts are falling hardest on farmers, rural communities, older working people, and anyone who is self employed or runs a small business. The weakening of the individual market will also make it harder for people to start new businesses, sapping some of the dynamism out of our economy, which of course benefits large, established corporations.
Republicans cut almost $1 trillion of out American health last summer, and we now have enough data to understand the impact it is having on families across the country this year. As expected it’s ugly, and it is going to get far, far worse in months and years to come. As we discussed with Colette Delawalla last week the willingness of MAGA to do direct material harm to the poorest and most powerless among us can be breathtaking, and very, very hard, when taken together, not to recognize as modern day eugenics.
For more:
Visit Charles’ Main Site, ACA Signups, where he produces fresh analysis most days, and where he has lots of state by state data. Charles has a new Substack, and you can also follow him on Bluesky.
What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles - Kaiser Family Foundation
This conversation is the latest in a series of discussions we’ve hosted here on the impact of Trump’s war on science, academia, and global and domestic public health. Some previous conversation:
Keep working hard all. We have a country to save, and great candidates to elect, together! - Simon
Bio - Charles Gaba, Heath Care Expert, Founder of ACASignups.net
Health care policy analyst Charles Gaba is the founder of ACASignups.net, which has been live-tracking Obamacare enrollments since the exchanges launched in October 2013. His work has been cited by major publications from the Washington Post and Forbes to the New York Times as being the most reliable source available for up-to-date, accurate ACA enrollment data in the country.
You can also find Charles’ work on Substack.
