Tag: ACA

It’s Only a Subsidy If You’re Poor

Jan 15, 2026

By KIM BELLARD

Even though most ACA enrollees/would-be enrollees have made their 2026 enrollment decisions assuming the expanded premium subsidies are not going to be renewed, the renewal of those subsidies is not entirely dead. Last week the House narrowly passed an extension, relying on a discharge petition and 17 Republican Congressmen willing to go against their leadership. Meanwhile, in the Senate, Senator Bernie Moreno (R-OH), of all people, is leading an effort to come up with a bill to expand them as well.

Whether it will eventually get passed is uncertain, as is how/when it might be reconciled with the House bill, and the President might just veto whatever extension might manage to emerge. The expanded subsidies aren’t dead yet, they’re just “mostly dead,” as Miracle Max would say.

The seeming indifference to the concerns of over twenty million ACA enrollees is appalling, but in character. This is an Administration and a Republican Congress that doesn’t like SNAP, Medicaid, school lunches, or aid to starving people in Third World countries, among other things. If you’re poor, they think, too bad; get a job, or a better job, and pull yourself up yourself. No handouts.

If they were against federal subsidies generally, out of fiscal prudence or other guiding principles, I could respect it. I wouldn’t agree with it, but it’d at least be intellectually honest. The trouble is, they’re not against subsidies per se; they just don’t like them going to poor people. I.e., the ones who need them most.

What set me off on this was a ProPublica/High Country News investigation into grazing on public lands. If you live in the East you probably don’t think much about either grazing or public lands, but if you live in the West you are probably very familiar with both. Almost 50% of land in Western states is federally owned. It ranges from 85% in Nevada to 4% in North Dakota. Almost half of California is federal land. You might be forgiven if you assume federal lands must be national parks, but they are small relative to land managed by the Bureau of Land Management (BLM), the U.S. Fish & Wildlife Service (FWS), and the U.S. Forest Service (USFS).

According to ProPublica: “The federal government allows livestock grazing across an area of publicly owned land more than twice the size of California, making ranching the largest land use in the West.” Well, you might think, that’s not inherently bad; we might as well use the land for something, maybe even make a little money from it. That’s the problem; the federal government is practically giving it away. Its analysis found that the grazing fees charged amount to a 93% discount relative to the market rate. You read that right: ninety three percent. That’s not a discount, that’s a giveaway.

OK, that’s eye-opening, but if it helps a bunch of ranchers who are struggling to survive, maybe that’s not so bad; ranching goes back to frontier days and has a certain cowboy appeal. Unfortunately, that stereotype isn’t quite true.

Let’s Check the Math on Health Subsidies

Dec 3, 2025

By KIM BELLARD

It’s December 3, and, to no one’s surprise, Congress still has not acted on extending the expanded health care premium tax credits for ACA. To Congress, the subsidies don’t expire until the end of the year, so they figure they have until at least then to act, or maybe sometime after that, given the way they handled the recent government shutdown.

On the other hand, consumers who are renewing or shopping for ACA plans face a more immediate deadline; they have until December 15 to enroll for January 1^st. They’re already seeing huge increases that result from a normal renewal increase plus the loss of the generous subsidies; Kaiser Family Foundation estimates that their premiums will more than double without them. They can’t wait while Congress plays politics.

There seems to be agreement that something will be done about the subsidies, but less clarity about what that something is. Some centrists argue to extend the enhanced subsidies but with some tweaks, such as lowering the upper income levels and/or requiring everyone to pay at least some minimum premium. To me, that’d be a reasonable compromise. But some Republicans, including President Trump, are calling for a more radical change: instead of giving the expanded premium tax subsidies to those “fat cat” insurers, give them directly to consumers through health savings accounts (HSAs). Put individuals over insurers, they argue.

I’m here to tell you: the math does not work.

I am not an actuary, but long ago I was a group underwriter, setting rates for employer groups’ health insurance, and, also long ago, I was involved in the early days of so-called consumer directed health plans (CDHPs), including HSAs and high-deductible health plans. I don’t disagree that HSAs and high-deductible plans can play a role, but one has to understand the math that drives health care spending.

The central fact of health care spending is that it isn’t evenly distributed. It is a perfect example of the Pareto principle: 80% of spending comes from 20% of people. The flip of that is that about 15% of people have no healthcare spending in any given year. What insurance does is take money from everyone and use it to fund the spending of the high cost people. That’s what all insurance does.

OK, I’ve avoided doing the math as long as I could, but here goes. One proposal has called for $2,000 to be deposited in each enrollee’s new HSA. Let’s keep it simple and say there are 1,000 such people, and that their average annual health care spending is $2,000 (which, of course, is way low). So we have 1,000 x $2,000 = $2 million in both subsidies and spending. It works out perfectly, right?

Not so fast.

Trade Ya Subsidies For a Government

Oct 13, 2025

By KIM BELLARD

As you may have heard, the federal government is currently shut down, although for many federal workers – those deemed “essential” – that just means they keep on working but don’t get paid (and, in fact, some might never get paid). The cause is the now-standard failure of Congress to pass a budget. As it often does in these instances, the House did pass a continuing resolution (CR) to keep the government open (for seven weeks), and Senate Republicans are willing to go along, but Senate Democrats are balking. Even though they’re usually the ones who advocate “clean’ CRs, this time they’re holding out to include some other legislative fixes. Their key demand: continuing the expanded ACA premium tax credits.

I am a little puzzled why this is the hill upon which they’re willing to keep the government shut down.

Let’s back up. When ACA was passed in 2010, a crucial component was subsidies to help low- income people afford ACA coverage (along with subsidies for cost-sharing features like deductibles). Subsidies were, and are, crucial for the ACA marketplace to survive. These subsidies came in the form of premium tax credits.

If you recall the dismal individual health insurance marketplace pre-ACA, individuals couldn’t get coverage unless they passed medical underwriting, and, even then, preexisting conditions exclusions applied. As a result, few qualified and everyone complained. ACA did away with medical underwriting and pre-existing conditions exclusions, but the only way to ensure that enough healthy people would join the risk pool was to generously subsidize their coverage, much as employers do with employment-based health insurance. Thus the premium tax credits.

The trade-off worked for almost ten years. About ten million people got coverage through the exchanges. Then the pandemic hit. People needed coverage more than ever, yet many people’s incomes crashed. So in 2021 Congress passed “enhanced” premium tax credits as part of the American Rescue plan Act. They increased the amounts of the credits and made them available to some higher income families. Those expanded credits were extended to the end of 2025 as part of the Inflation Reduction Act.

It is those expanded premium tax credits that are expiring. The original credits would remain. Things would go back to the way they were pre-pandemic (although, of course, premiums are now higher due to inflation). It’d be more of a setback than a catastrophe.

The expanded tax credits did have a dramatic impact. Enrollment went from about ten million to over 24 million – 22 million of whom had the expanded credits. So it certainly is a non-trivial matter if they expire. KFF estimates that average premiums would double in 2026.

Still, though, CBO estimates loss of the expanded credits would result in about 3.8 million people losing coverage, which is a far cry from the 14 million whom gained coverage since they were implemented.

I’m not sure if the CBO is being overly optimistic, or if ACA has taught people to appreciate their coverage.

Everyone in Congress knew, or should have known, that these tax credits were expiring this year.

When is Preventative Care not Preventative? Let’s get Labcorp to join in! (Part 2) (with UPDATE)

Aug 13, 2025

By MATTHEW HOLT

To join in the fun I am having with Blue Shield of California & Brown & Toland Physicians IPA being unable to tell me why I have a $34.94 bill for lab work (see image) that should either be covered as preventable under the ACA, or have co-pay of $50 (see image of the BS of CA screenshot for the $50), I called Labcorp.

After 6 minutes I got a very confused person. BTW there is NO way to communicate with Labcorp on the website, and if you put your invoice number into their IVR system there is NO way to get a human. The only way to do that is to hang up and start again, NOT put in your invoice number and hit 0. Then wait on hold with muzak to get a human. They then ask your DOB and phone number. The call center is in the Philippines BTW.

I explained that I wanted information on which test was not covered under the ACA. Brown and Toland/Blue Shield’s EOB says I have a $0 co-pay (see image).

The Labcorp rep told me that of the 5 tests done (with CPT code and price), 3 were not covered. The Lipid (85027 $107.10), the A1C (80061 – $81.90) Uric Acid (84550 $43.05). 2 of those 3 clearly are covered under the ACA. The Uric Acid one may not be according to my reading of the CMS site. Labcorp submitted that bill to Blue Shield. The rep consistently told me the claim was sent to Blue Cross Blue Shield of CA, which doesn’t exist.

At that point — 15 minutes in — the call dropped. I don’t know if they just hung up but they had asked for my phone number. They didn’t call me back.

But I am a pain in the ass, and I called them back. After roughly 4 mins on hold, I got another rep. She told me ALL of the CPT codes/lab tests were subject to copay. She told me that Blue Shield (NOT Brown & Toland Physicians) has bundled all of these codes and there is a co pay for all of them. Which is what the bill says.

So the only thing I can do is to send an email with the screenshot of the EOB, which is from the IPA not Blue Shield. So I did that and may get a response in 3-5 business days.

I know you are on tenterhooks. Let’s see what happens next but the complete absence of anything resembling consumer transparency or access to the relevant information makes a mockery of everything Paul Markovich says on stage.

UPDATE. Labcorp both emailed me back AND asked me to contact them on Linkedin. See what they asked for! Yes even though they have sent me a bill and I sent them the invoice number, they want every detail possible about the claim they ALREADY have!

Full email below just for giggles

Oh and when I went to DM them on Linkedin as they requested their account was not accepting DMs!

2nd UPDATE: A very nice man from the Blue Shield of California corporate office called me up. We discussed whether the care I got was preventative or not and why I was being charged the $34.94. Of course he didn’t know. He agreed with me that it was a shit show, and actually started to complain that sometime HE had been charged for preventative stuff he thought should have been free.. He didn’t have any solution other than calling Brown and Toland to cancel the charge, but I told him I didn’t want any special treatment (at least not yet!). I told him I wanted no special favors, but I wanted the claim reprocessed and an explanation.

And there’s a part 3!

Matthew Holt is the founder and publisher of THCB

The Art of Political Jiu-Jitsu: Project 2025 and Donald Trump

Sep 13, 2024

By MIKE MAGEE

Funny think about that Project 2025’s “Mandate for Leadership.” Trump declared in this week’s debate, “I know nothing about it.” But in addition to the vast majority of authors and editors of the document having served in the prior Trump administration, the former President’s name is mentioned in the 887 page document over 300 times.

Described by Pulitzer Prize winning economics columnist, Carlos Lozada, the work itself is an “off-the-shelf governing plan.” It’s packed with conservative fan favorites, not simply “militarizing the southern border” and reversing what they call “climate fanaticism”, but especially placing DEI (diversity, equity, inclusion) efforts in the waste bin, banning abortion nationally, and pushing deregulation and tax cuts for the richy rich.

None of that is surprising if you’ve run into these characters on K street and beyond. This is who they are, and largely who they have always been. Over the years, I’ve bumped elbows with them in Washington and in corporate C-suites galore. What makes this effort a bit unique is, of course, the presence of a cooperative headliner who will clearly endorse “the elevation of religious beliefs in government affairs” and actively diminish “the powers of Congress and the Judiciary.”

This is political jiu-jitsu practiced at its highest level. Rather than dismantling the “deep state,” these operators are fast at work “capturing the administrative state” for their own self-serving purposes.

Understanding jiu-jitsu takes one a long way toward understanding the Heritage Foundation and Freedom Institute’s puppet masters. The word “Jū” means “gentle, soft, supple, flexible, pliable, or yielding.” It’s companion, “jutsu” is the “art or technique.” Combine the two, and you have the ”yielding-art.” The intent in bodily (or political) combat is to harness an opponent’s power against himself, rather that confronting him directly.

Political jiu-jitsu may be deceptive and confusing in the absence of visible weaponry, but it is anything but gentle. In the physical version, you are instructed in joint locks and chokeholds of course, but also biting, hair pulling, and gouging. Kevin Roberts, the President of the Heritage Foundation and editor of Project 2025, is a master of the political version. While he and Trump outwardly employed a “nothing to see here” stance, demographic realities were cued up in the document. The solution to the growing minority status for Republicans? “Voter efficiency” and a rigged census. Or in the Project’s words: “Strong political leadership is needed to increase efficiency and align the Census Bureau’s mission with conservative principles.”

Robert’s language is soft, but its impact hard indeed. In the introduction he suggests that the Declaration of Independence’s words “pursuit of happiness” were better understood to be “the pursuit of blessedness” while providing corporations a market free hand “to flourish.” Career civil servants are recast as “holdovers” without “moral legitimacy.” And the Justice Department suffers this put-down – “a bloated bureaucracy with a critical core of personnel who are infatuated with the perpetuation of a radical liberal agenda.”

Majority rules and demographic changes being what they may, alternative facts and voter suppression have been added to the tools of “political jiu-jitsu” artists. But Kelly Anne Conway was nowhere to be seen this week, and their headliner was long-winded, boring, and tired. As for voter integrity, the Democrats are fully funded and lawyered up. Finally, good Republicans everywhere have begun to recognize that towing the MAGA line much further puts their down-ballot hopes in the direct line of fire. Those 300 mentions are beginning to look like a liability instead of an asset.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

The Money’s in the Wrong Place. How to Fund Primary Care

Feb 5, 2024

By MATTHEW HOLT

I was invited on the Health Tech Talk Show by Kat McDavitt and Lisa Bari and I kinda ranted (go to 37.16 here) about why we don’t have primary care, and where we should find the money to fix it. I finally got around to writing it up. It’s a rant but a rant with a point!

We’re spending way too much money on stuff that is the wrong thing.

30 years ago, I was taught that we were going to have universal health care reform. And then we were going to have capitated at-risk entities. then below that, you have all these tech enabled services, which are going to make all this stuff work and it’s all going to be great, right?

Go back, read your Advisory Board Company reports from 1994. It says all this.

But (deep breath here) — partly as a consequence of Obamacare & partly as a consequence of inertia in the system, and a lot because most people in health care actually work in public utilities or semi-public utilities because half the money comes from the government — instead of that, what we’ve got is this whole series of massive predominantly non-profit organizations which have made a fortune in the last decades. And they’ve stuck it all in hedge funds and now a bunch of them literally run actual hedge funds.

Ascension runs a hedge fund. They’ve got, depending who you believe, somewhere between 18 billion and 40 billion in their hedge fund. But even teeny guys are at it. There’s a hospital system in New Jersey called RWJ Barnabas. It’s around a 20 hospital system, with about $6 billion in revenue, and more than $2.5 billion in investments. I went and looked at their 990 (the tax form non-profits have to file). In a system like that–not a big player in the national scheme–how many people would you guess make more than a million dollars a year?

They actually put it on their 990 and they hope no one reads it, and no one does. The answer is 28 people – and another 14 make more than $750K a year. I don’t know who the 28^th person is but they must be doing really important stuff to be paid a million dollars a year. Their executive compensation is more than the payroll of the Oakland A’s.

On the one hand, you have these organizations which are professing to be the health system serving the community, with their mission statements and all the worthy people on their boards, and on the other they literally paying millions to their management teams.

Go look at any one of these small regional hospital systems. The 990s are stuffed with people who, if they’re not making a million, they’re making $750,000. The CEOs are all making $2m up to $10 million in some cases more. But it also goes down a long way. It’s like the 1980s scene with Michael Douglas as Gordon Gecko in Wall Street criticizing all the 35 vice presidents in whatever that company was all m aking $200K a year.

Meanwhile, these are the same organizations that appear in the news frequently for setting debt collectors onto their incredibly poor patients who owe them thousands or sometimes just hundreds of dollars. In one case ProPublica dug up it was their own employees who owed them for hospital bills they couldn’t pay and their employer was docking their wages — from $12 an hour employees.

Republican Health Policies Disproportionally Harm White Citizens in Their States

Jun 10, 2022

BY MIKE MAGEE

“As I’ve said before, I believe Dr. Ladapo is an anti-science quack who doesn’t belong anywhere near our state’s Surgeon General office, let alone running it. But now that he’s been confirmed, it’s my sincere hope that he and Governor DeSantis choose to focus on saving lives and preventing unnecessary illness instead of continuing their absurd promotion of conspiracy theories and opposition to proven public health measures — but I’m not going to hold my breath.”

If you identified these as the words of the former governor, and now Congressman Charlie Crisp, currently running to retake the office he once held, you’d be wrong. These are the words of another state Democrat who is running a distant 2nd in the Democratic primary battle set for this summer.

Simple Bills are Not So Simple

Jan 5, 2022

By MATTHEW HOLT

I went for an annual physical with my doctor at One Medical in December. OK it wasn’t actually annual as the last time I went was 2 & 1/2 years ago, but it was covered under the ACA, and my doc Andrew Diamond was bugging me because I’m old & fat. So in I went.

I had a general exam and great chat for about 45 minutes. Then I had blood work & labs (cholesterol, A1C, etc) and a TDAP vaccination as it had been more than 10 years since I’d had one.

Today, about one month later, I got an email asking me to pay One Medical. So being a difficult human, I thought I would go through the process and see how much a consumer can be expected to understand about what they should pay.

Here’s the email from One Medical saying, “you owe us money.”

What Will Shape Joe Biden’s Health Care Agenda?

Nov 7, 2020• 7

I’m thrilled to have health futurist Jeff Goldsmith back on THCB, and given Biden was only confirmed as President-elect this morning, his article on what to expect is extremely timely!–Matthew Holt

By JEFF GOLDSMITH

The Trump administration’s health care journey began with a trillion dollar near miss–the failed Repeal and Replacement of ObamaCare- and ended with a full-on train wreck, the catastrophically mismanaged COVID epidemic that will have claimed 300,000 lives by the time he leaves office. After four years of posturing and lethal incompetence, it will be a relief to see caring and professionalism return to the White House health policy under President-Elect Joe Biden.

Like Inheriting a Badly Managed World War

Like Barack Obama, Joe Biden will be saddled at the beginning of his regime with a damaged national economy. He will also walk in the door to the immediate need to manage the greatest public health catastrophe in a century as well as its economic consequences–a deep and enduring recession. Biden will be inheriting the equivalent of a badly managed World War we are presently losing.

Public health professionals who were marginalized by Trump will be challenged not only to craft coherent policy to contain and extinguish COVID but also to sell it to a frightened and polarized general public, many of whom reject the need for basic public safety measures.

Controlling COVID and rebuilding the critical public health agencies–CDC and FDA–that have damaged by political meddling will consume the lion’s share of the administration’s health policy bandwidth in its first year. It will be pressed to address a huge readiness gap–from critical PPE supplies to the development and deployment of testing and tracing capability to public health co-ordination and messaging–for the next pandemic. Increasing the presently inadequate level of public health funding (less than $100 billion a year in a $21 trillion economy) seems inevitable.

The inability of Congress to produce a fall round of COVID relief will create pressure on Biden to take immediate action to help struggling sectors of the economy, like airlines, restaurants and hospitals, as well as further help for the long term unemployed. Only a little more than half of the 22 million jobs lost in the spring have returned by November. Twenty million Americans were stranded by the July expiration of supplemental unemployment benefits as well as countless millions more “free agents” and contractors not eligible for traditional unemployment that are losing coverage at the end of the year. Mortgage, credit card and consumer loan forbearance are ending, and unless Congress acts, acres of rotten credit will turn rapidly into a banking and bond market crisis which the Federal Reserve cannot fix by itself.

State governments face FY21 deficits equaling $500 billion over the next two years , against a current annual spending base of about $900 billion. Further assistance to state and local governments will almost certainly include an additional increase in the federal match for Medicaid (FMAP), beyond the 6.2% temporary increase passed in March). Medicaid enrollment will likely top 80 million by mid 2021, almost one-quarter of the US population. Some states will have upwards of 40% of their population on Medicaid by mid-2021.

States laboring under severe revenue shortfalls will be unable to afford the expanded Medicaid program that was part of ObamaCare without a further increase in the FMAP rate. President Trump and Senate Republicans blamed the state and local government fiscal crisis on profligate Democratic mismanagement, and blocked aid to them during 2020. But Texas, Florida, Georgia and other red states have the same problems New York and California do.

Serious Fiscal Limitations Push the Health Policy Agenda Away from Coverage Expansion

Barack Obama entered office with a FY08 federal deficit of $420 billion. Joe Biden enters with a FY20 deficit of $3.1 trillion and a baseline FY21 deficit of $1.8 trillion, before adding the cost of the likely additional trillion dollar-plus stimulus package early next year. It will be passed over the dead bodies of Republican Congressional leadership suddenly recommitted to deficit reduction after racking up $8 trillion in deficit spending during the four years they controlled the federal government.

Coverage Expansion via Medicare and Public Option Unlikely

That deficit will significantly constrain a further expansion of health coverage. Not only will “Medicare for All” be off the table. Severe fiscal pressures will cause the new administration to “slow walk” a public option (which would require federal subsidies to implement) and Medicare expansion to people over age 60. These expansions were going to be controversial and politically costly because they would be fiercely contested by hospitals and other care providers concerned about the erosion of their commercial insured customer base (the source of perhaps 130% of their bottom lines) as well as the use of Medicare as a de facto price control lever.

By the time Biden addresses the first two problems–COVID and the economic crisis–he will probably have expended his limited stock of political capital and be weakened enough to be unable to take on the large messy issues of health coverage expansion and cost control. The Affordable Care Act exhausted Obama’s store of political capital, by early 2010. His administration’s failure to turn the economy cost the Democrats control of the House of Representatives and 20 (!) state legislatures in 2010.

What Can Biden Do in Health that Does Not Require Federal Spending?

Thus, the focus of Biden health policy is likely to be on items not requiring fresh spending.

THCB “SPOOKY” Gang: Episode 30 10/29

Oct 29, 2020

Episode 30 of “The THCB Gang” was live-streamed on Thursday, October 29th! Watch it below!

Matthew Holt (@boltyboy) was joined by some regulars and this episode was a spooky be a COSTUME PARTY! On this episode were data privacy expert Deven McGraw (@healthprivacy), writer Kim Bellard (@kimbbellard), health economist Jane Sarasohn-Kahn (@healthythinker), CTO of Carium Health Lygeia Ricciardi (@Lygeia), MD & hospital system exec Rajesh Aggarwal (@docaggarwal), policy & tech expert Vince Kuraitis (@VinceKuraitis), and me, THCB’s Editor-in-Chief (@zoykskhan). The conversation had a more spooked tone to it as many of us are worried about the safe transition of power, the safety of voters, the misinformation about herd-immunity, the rising COVID-19 cases, and everything happening in the Senate. What will the results of November 3rd bring for this country?

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan, producer