The bad Exchange replacement nightmare keeps coming back
Say it isn’t so. More talk of an ACA replacement?
Just as 2026 midterm fundraising is heating up, Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz dropped a bombshell recently when he told NBC News that President Donald Trump may have a plan to overhaul and replace the Affordable Care Act (ACA). I emphasize “may.” Dr. Oz referred to the potential hidden plan as he was declaring his opposition to extending the current enhanced Exchange premium subsidies due to expire at the end of this year. “I fully believe the president has a plan,” Oz said. “We’ve been talking about it quite a lot.” He added there is a “full plan,” but Democrats are “hold[ing] the entire country hostage by shutting the government down … the folks who would help this system evolve into a mature model aren’t at work to help do it.” So, there is or isn’t a full plan?
On the issue of enhanced subsidy extensions, I happen to think the current premium enhancements may be too generous, with millions receiving healthcare for no premiums at all. While critics question the data and studies, CMS and the conservative Paragon Institute argue that the enhancements have led to major fraud in the program, an increase in zero claims from enrollees, and what are being characterized as phantom enrollees – those that don’t even know they have coverage as agents and brokers illegally enrolled them to receive commissions.
At the same time, there is no questioning the fact that the enhanced subsidies did lead to a number of benefits. Since they went into effect, enrollment has surged to over 24 million in 2025 – about double what it was in 2020. Many of these folks would otherwise have been uninsured. The enhancements have also made the Exchanges a much less scary financial place for insurers. The enrollment and the better overall risk selection (the enhancements attracted a great deal of young healthy types) has meant more plans, better networks, more access, dropping premiums in some years or reasonable increases in others, and more stability – especially in the roughly half of states that previously had poor coverage.
On balance, I have said that the enhancements should be extended in some form but should be tweaked to prevent fraud and improper enrollments. In a blog here ( https://www.healthcarelabyrinth.com/could-an-exchange-subsidy-compromise-be-in-the-works/ ) I outlined some of the proposed compromises that could see the enhanced subsidies extended. In the end, we know what will happen if the enhancements are not extended – millions will lose coverage, premiums will increase by 114% on average for subsidized folks, and the Exchanges will again be a questionable place in roughly half of all states.
But the Trump administration seems to care little not only about the current subsidy enhancement expiration or the coverage of Americans. They say that they want a better ACA but have never really offered one that didn’t mean millions losing coverage. That applied when the GOP tried to repeal the ACA in 2017. That applied during the most recent 2024 campaign where Trump said he had the “outlines” of a plan to make healthcare better but never unveiled one. That applied during the debate over the One Big Beautiful Bill, where the GOP cut coverage and offered little in the way of true reform. And that applies now with Oz’s remarks – there is no credible plan. Where’s the plan!
Over the years, the GOPers (this is my party) rally around all sorts of possible reforms, such as breaking the hard link between employment and health coverage by promoting individual options. Some of the ideas are not bad, such as expanding ICHRA health accounts to allow businesses to subsidize individual coverage, Health Savings Account (HSA) expansions, and more. I would question their advocacy, though, for short-term, limited duration coverage. It is not comprehensive coverage and has a ton of challenges, including access and true affordability in healthcare. I would say over time, too, that we may need to pull back on some mandated benefits and coverage in the ACA as it is driving costs and making things unaffordable (which also creates access and affordability challenges).
But again, ripping apart the ACA as we know it now with nothing truly comprehensive to replace it would mean millions lose coverage. In my book, The Healthcare Labyrinth (available at this site). I suggest the best way to lower costs and improve affordability and quality is to truly reform price, ensure affordable universal access, and invest in primary care, health, and wellness. The problem is that Republicans generally believe that healthcare is a commodity, one earned and purchased as you move your way up the income latter. Democrats are not any better. Their answer is more and more dollars to expand both covered populations and benefits without regard to long-term sustainability. Neither party will really stand up consistently to entrenched healthcare lobbies (e.g., hospitals, provider groups, health plans, pharmacy benefits managers, and brand drug makers) who staunch reform at every pass.
Oz’s remarks that “I fully believe the president has a plan” are both fascinating and exasperating. I would think the chief healthcare official in government would know about the plan and even have had a hand in developing it. Have we sunk so low that policy comes only from Trump’s supposed ruminations? Perhaps so.
That Trump and Oz would even mention replacement again has to have sent shivers down the spines of a couple dozen swing state House GOPers and a few senators up for re-election soon. Control of at least the House hangs in the balance and history says the deck is stacked against the GOP maintaining conrol as it is. It is really the last thing they need to hear right now – more talk of paring coverage just as premiums for millions will double next year if the enhanced credits expire. In 2018, the 2017 ACA repeal attempt was a leading reason for the Democrats taking back the House. The One Big Beautiful Bill Act, with over $1 trillion in Medicaid and Exchange cuts and perhaps $500 billion more in Medicare because the bill increased the deficit, could be a seminal issue in 2026 midterms.
Oz’s remarks here are undisciplined and naïve – much like the president’s healthcare remarks are at times. They both should stop worrying millions of Americans or put up a true reform plan to be debated – one that preserves coverage vs. taking it away from millions. What neiher official quite understands is that healthcare coverage is popular and, well, politically populist. Trump should bring his instincts on drug price reform to the overall healthcare reform arena. It would not only pay huge political dividends, but right the healthcare ship of state by conrolling costs and improving quality.
#healthcare #coverage #aca #obamacare #exchanges #medicaid
— Marc S. Ryan
