Politics: High Cost Of Healthcare And The Political Fallout

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0:22I was paying last year$57 a month premium, and then it jumped up this year to$16.90 a month. When I first saw it, I was surprised. I thought this was a mistake. Americans, as they have been for decades, are struggling with the rising cost of health care. And there's tons of new polling to suggest why and what voters plan to do about it. For the first time in five years, fewer than half of Americans say they can consistently afford the health care that they need. That's according to the latest data from Gallup. Meanwhile, the U.S. pays nearly double per patient what the average industrialized nation pays.

1:03The Affordable Care Act made a big dent in the swelling numbers of Americans without health coverage. But according to a new report from the Department of Health and Human Services, ACA marketplace rolls shrunk by 5 million people this year compared to last year. And why? Because average premiums exploded nearly 60 percent when Republicans refused to renew premium subsidies. All of that, and Americans are now reliving the all-too-familiar stress of health costs on their budgets. And those Americans, well, they're also voters who say that health care is a top priority at the ballot box, and it's an issue that crosses geographic and party lines.

1:45According to new polling from the Century Foundation, they're a progressive think tank, 71 % of Democrats, 66 % of Republicans, 75 % of rural voters all agree that reining in hospital costs should be a top priority for longmakers. At the same time, a majority of Americans in new polling from Ipsos and Axios say that they're more likely to vote for the candidate in November who will lower their health care costs. I'm Todd Zwilligan for Jen White. You're listening to the 1A podcast. Today, we ask, how will the issue of health care shape the midterms? And how are Americans grappling with the cost of their health?

2:23We'll be back with those answers and more after a short break. Stay with us.

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3:12the people making the art that nourishes us and speaks to our times. So listen to the Fresh Air podcast from NPR and WHYY. Are We Doomed helps you understand humanity's biggest threats. Climate change, pandemics, nuclear weapons. Stuff still hits planets. We stand, divided we fall. How worried should you actually be? And what can we do? I'm Ben Bradford. Join me for Are We Doomed? Part of the NPR network. Listen now wherever you get your podcasts. Welcome back to the 1A podcast. We're talking about the rising cost of health care in America and how that shapes Americans voting. Let's get started and meet our panel.

3:52Julie Appleby is here, senior correspondent at KFF Health News. Julie, great to have you back. Thanks for having me. And also with us on the line, Dr. Zeke Emanuel. He's an oncologist and the vice provost for global initiatives at the University of Pennsylvania. He also was a key architect of the Affordable Care Act. Dazeek, great to see you. Thank you for having me too. And we're already hearing from you. This is Belinda Stroud. I'm 64 years old. I live in Penn Valley, California. I have a Blue Shield PPO plan. I pay$2 ,000 a month. I have a$7 ,000 deductible and it increased at 1 ,200 cents by the Obama plan.

4:37And it's outrageous. The deductible, it's not a PPO. It really isn't. Zeke Emanuel, let's talk first about the realities of healthcare affordability right now. I've said it, I feel like this is an old conversation in America, but that doesn't make it any easier. What do we know about the rising cost of ACA marketplace premiums right now? They're substantial. And I think you put it correctly, that they've been rising mostly, most recently because the Republicans refused to extend the added subsidies that were put in place during COVID to ensure that people could get health coverage while we had the pandemic.

5:16And we're seeing a lot of increase just in the premiums. I mean, I don't know what else What else to say? It's about 58 percent increase in the 2026 premiums. And as you point out, that's a five million percent. Five million people have not renewed. We know that buying in the exchanges is quite price sensitive for every one percent premium increase. You get about one point seven percent decrease in enrollment because a lot of those people, They're relatively healthy and they're playing the risks. They're saying, well, what's the chance I will need a lot of health care? Probably low, so I won't go in.

5:59The consequence is that actually sends premiums up even more because you then concentrate the sick people in the pool for the ACA. So when the last person complained about the increase in premiums, that's a large consequence of the fact that the healthiest people are getting out of the system. I can just add one more thing. You know, a state like California that runs its own exchanges, one of the things it does is heavily advertise, have many languages available to try to attract those healthy people into the exchange. So you have this cross-subsidization that more healthy people who could get sick, who could have an accident, actually end up paying and helping people who are sick and use a lot of health care services.

6:46So, Julie, Zeke described it. Congress, in this case, Republicans in Congress, let premium tax credits that were helping people with ACA subsidies expire. Costs exploded. That's the ACA. Congress also made changes in the reconciliation bill, the big, beautiful bill that made other changes to the Affordable Care Act. What happened? That's correct. Remember, the big debate end of last year was, do we extend these subsidies? and Congress did not extend the subsidies. So that was sort of a double whammy for people. Premiums went up. There was a government shutdown over it. And there was a government shutdown over it.

7:21And then so premiums went up and then also the subsidies became less generous. They didn't go away. There's still subsidies. But then, yes, let's talk about the One Big Beautiful Bill Act. It made a number of changes that the Congressional Budget Office expects the law to sort of decrease spending over time by about a trillion dollars, but it could also lead to about 10 million more people uninsured through 2034. So what did it do? Well, among other things, first of all, it eliminated permanently the special enrollment period for low-income people that essentially let them sign up year after year.

7:57So that was one thing. It also made a number of changes in terms of verification of income. If you are, say, below the poverty level according to federal data, but you say, oh, I'm going to be a little bit above the poverty level next year and estimating it, you have to prove that because those are the folks that are eligible for a subsidy. So there's additional income verification requirements. And so there's more paperwork and more things to require. You call them additional income verification requirements, and I hear barriers to entry. I hear making it harder to sign up. That's what some of the policy analysts believe as well, that it does put these burdens on folks to have to prove it.

8:37And so they are expecting lower enrollment as a result of that. So you've got to maybe come up with more explanation. It could be harder to sign up. So part of that lower enrollment that was expected this year, not only because the subsidies expired, but because the one big beautiful bill did a number of different things that made it a little bit harder to enroll or to get a subsidy. They anticipated that there will be lower enrollment this year. So the insurers, in calculating their premiums, look at that, and they added about four percentage points above what they would have raised their rates anyway just because the subsidies expired.

9:13So all of that's kind of going into this mix of why it's getting more expensive. Zeke, as somebody who helped design, there were a lot of cooks in that pot, but as somebody who helped design the ACA, what has been your reaction watching this Congress make changes to the ACA and doing things that Julie is describing that have made it either more expensive or just harder to sign up? Well, the Republicans have tried many times to repeal the Affordable Care Act. They championed repeal and replace, and I think we're way past 40 cases where they've tried to put the repeal in. They could never get it passed.

9:51And I might emphasize for your listeners, every state that has had a referendum for expanding Medicaid to include healthy adults and get more people on. It has passed in every Republican state by a majority. It passed in Utah, Idaho, Missouri. You just can go on and on. Even Florida, a majority of people voted to it. But Florida has a rule that you need a supermajority to change that. So even Republicans want the Affordable Care Act's health care benefits. And what the Republicans have tried to do in the last few sessions is to undercut and repeal in practice the Affordable Care Act, even if they can't do it in actuality and make it just much harder.

10:49Let me just say one point you raised, which is all these added restrictions, proving your income or work requirements, they really are an attempt just to dissuade people from getting on Medicaid. If you go to Texas and look at the application for Medicaid, it's 17 pages. It asks you if you have oil and gas royalties and things like that. I mean, really? So 17 pages of paperwork. Meanwhile, Julie, White House is reading the same polling as everyone else, probably better polling than most of us get. They know healthcare costs in the ACA are a big issue. They've made some moves recently toward premium costs in the ACA.

11:31What changes are they making that they say are going to lower some of these costs? You know, that's quite interesting because polls have shown that people are very worried about what are called out-of-pocket costs, which is what they have to pay towards their health coverage before it kicks in. Out-of-pocket costs, however, are one of the things the Trump administration is looking at doing. So they have finalized a rule that, you know, this is done every year. It's sort of setting standards for the next year for the Affordable Care Act. So in this rule, they are kind of doubling down on increasing out-of-pocket costs.

12:01Interestingly enough, they are going to allow insurers in some cases to offer plans with much higher maximum amounts people would have to pay in order to bring the premiums down because they know people are looking at premiums as well. So they're doing that. And they've also looked at creating plans that have no networks of doctors and hospitals so that people can go anywhere, but then you would have to sort of make sure your plan is going to pay the amount towards that coverage that the doctor or hospital will accept. And that's another way they say that a lower premiums. We have to take a quick break now, but before we go, one member from our text club writes this, my costs have almost tripled from just over$500 a month last year to$1 ,370 this month.

12:45And yes, these costs will influence me to vote for Democrats in November. And another of you writes, even with insurance costs, costs are too high. I know many older people my age who are choosing food over healthcare because they can't afford both. Much more on healthcare, costs, and politics in America. Stay with us.

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14:21Welcome back to the 1A podcast. We're talking about the rising cost of health care in America and how it could affect the November elections. We're here with Julie Appleby, senior correspondent at KFF Health News, and Dr. Zeke Emanuel, provost at University of Pennsylvania and a key architect of the Affordable Care Act back during the Obama administration. Let's bring in Kelly Hooper now, reporter at Politico covering health insurance and the author of the Daily Politico Pulse newsletter. I recommend it. Hi, Kelly. Hi, thanks for having me. Yeah, great to have you. Kelly, we've been talking about changes in ACA costs, how premiums have gone up and shrunk enrollment for millions of people, caused millions of people to lose coverage.

15:07There have also been major changes, major cuts to Medicaid and cuts to what was a major expansion of Medicaid across the country. Give us some details. What were some of the changes and some of the effects that maybe we haven't even seen yet? Right. So Republicans One Big Beautiful Bill Act, that was enacted last July when President Trump signed it into law. And in that bill were a number of changes to both the ACA and to Medicaid to the tune of about a trillion dollars in cuts across healthcare generally. And so we're starting to see that play out this year, and it'll sort of play out over the next few years as well as those changes are being implemented.

15:54The CBO, I think Julia noted, has estimated more than 10 million people could lose coverage over the next decade as a result of those changes. So the impact could definitely be significant. I think one of the most significant changes in the mega bill was the requirement that states have to implement Medicaid work requirements. So that's the Medicaid expansion states will have to do that by the start of next year. Some states are beginning to roll that out now. So it's not super clear yet how that's all going to play out, but health policy experts, analysts have noted that, you know, the additional administrative barrier of having to verify that you're working for Medicaid enrollees could lead to people losing coverage.

16:42There's also going to be more frequent eligibility checks as a result of the mega bill. And so you've all sort of discussed already how that will add additional administrative barriers and how that could discourage folks from enrolling in the program. And so sort of all those changes combined are expected to lead to a pretty big decrease in enrollment over the next few years. That's Medicaid and also the Affordable Care Act marketplace plans. Zeke, what about pressure on premiums? We talk about premium subsidies help tax credits, help paying for your premiums. Put those aside. Is there upward pressure on the overall cost of premiums?

17:24Now, are ACA premiums just going to keep going up by themselves, subsidies notwithstanding? Yes, there are two pressures that we can identify. One is, as I mentioned, fewer healthy people enrolling, and that means that you will have more people who are sick getting insurance, which will increase the cost. And separately, there's what health economists call healthcare trend, which is basically inflation in the healthcare space, which for years before the ACA had been going at much higher rates than underlying inflation in the economy. And in the last few years, since 2023, has really gone up. A large portion of that health care inflation, not all of it, but a large portion really come from two things.

18:18One are hospitals. Hospitals costs have gone up more since 2000 than any other sector of the economy. More than physician salaries, more than education, more than rent. So hospital health care costs are a major driver. And then we have other important drivers of health care costs, like GLP-1s have been a major increase. Those are mostly on the employer side, but not exclusively on the employer side. And we're going to see a lot more pressure from drug costs going up. I would also say the other thing was hinted at here, and I just want to pull it out, all these administrative barriers, they're also administrative costs.

19:05When you have to go and verify someone is eligible for Medicaid, when you have to go and verify that they're working, that just adds administrative costs, which don't improve anyone's health. So the Republicans are always talking about inefficient government programs. They've just made these programs more inefficient by increasing their administrative costs without having them do more in terms of getting more people the health services they need. Julie? So, yeah, we saw premiums in the Affordable Care Act go up on average about 20 percent this year. And we're starting to see some early rate filings, which is where they submit them to the states to say, hey, here's how much we want to charge next year.

19:45And they're in the double digits in some cases. So we'll see what the final numbers are. But I also wanted to add it's not just the Affordable Care Act. Employer costs are going up as well. In fact, a report came out a little bit earlier this year talking about employers having to pay probably about 9 % more this year. It's going to cost about 9 % more to care for folks this year than it did the year before. All right. Let's talk about employer coverage. We have such an awful system in this country. We have these different pots we have to delineate. We have Medicaid and Medicare. federal and state government.

20:17We have ACA, Affordable Care Act, mostly for self-employed people. Then we have where most people get their health coverage, which is at work, employer-sponsored care. That's about 60 % of Americans get their care there. We got this text from one listener who says, we make too much money for government assistance, but can hardly afford even employer-sponsored coverage premiums. Members of my family have forgone doctor's visits or medications when times were tough, which seems like a tragedy in our country that we can surely avoid. Thank you for that comment. Julie, you just hit on employer-sponsored care.

20:53Again, it's where most Americans under the age of 65 get their coverage. You pay part, your employer pays part. What are we seeing in terms of premium costs there? Premium costs are going up there as well. So the average annual premium for employer plan And coverage for a family this year is$26 ,993. That's a lot of money. Yes, the employer picks up a chunk of that, but the worker pays it as well. On average, about$6 ,800 towards their own coverage and their family's coverage, according to this survey from KFF that's done every year of employers. So that's a lot of money. And let's just also say that it's kind of subsidized.

21:33We talk a lot about subsidies in the Affordable Care Act. And some people say, hey, why are we subsidizing people's care in the Affordable Care Act? Well, we're subsidizing it in employer coverage as well. It's through not paying taxes on that coverage. So that's a huge offset. It actually costs more than it would have cost to extend the Affordable Care Act subsidies, the enhanced subsidies, another 10 years. It costs a lot more than that per year. But you don't pay taxes. So that's kind of a subsidy. You don't really see that because you're not really thinking about that. But it's money that's not going into the Treasury.

22:04Kelly, back in the 2000s and even back into the late 90s, you couldn't talk to a lawmaker without them wanting to talk about the cost of employer-sponsored care. Americans were up in arms and they hated their HMOs and Hillary care and Clinton care and Patients' Bill of Rights and John McCain. Oh, it was all such a thing. They don't talk about it anymore. What are lawmakers saying about what Julie Appleby is describing, which is sharp premium cost increases in places where most Americans get their coverage? We're obsessed with Medicaid and ACA, and rightfully so. Does anybody have a bead on employer-sponsored care?

22:44Yeah, I think that's right. I think a lot of the chatter and discussion right now in Congress and within the administration is about cost increases on the Obamacare marketplace and Medicaid coverage losses. And not a lot of the focus has been on the employer market, which, as has been noted, most Americans are insured through their employer and costs in that market are creeping up. premiums are increased more this year than they have the past few years. And that comes as employers are also seeing double digit increases in their healthcare costs. That's mostly driven by prescription drug spending, which we can, you know, look to the GLP-1 boom as partially driving that as more employer plans cover GLP-1s for weight loss and other conditions.

23:30Also, hospital spending is driving that increase as well. And so I've spoken to quite a few employer groups that are frustrated with the focus in Congress on the ACA and Obamacare and sort of a lack of focus in lawmakers talking about the cost of employer-sponsored insurance. And they sort of feel like they're missing the broader point that this is the larger group of people that are enrolled in this type of insurance. And they're also having their health costs skyrocket. And yet the focus seems to be elsewhere. Zeke Emanuel, GLP-1s have come up a couple of times. They're expensive. They're all the rage.

24:07They're worth billions. We all know people who are on them. They are expensive. Is this going to save us a ton of money in the end, though? Lower obesity, maybe lower heart disease, less sleep apnea means less hypertension. If I'm selling these drugs, I'm going to tell you, yeah, it's an upfront cost, but boy, we're all going to save in the long term. Does that ring true? Drew? No, so far none of the analyses show their cost savings. They may be cost effective, but not cost savings. They may turn out to be cost savings, but we don't have any data to suggest that at the moment. That doesn't mean it isn't a good idea.

24:48We just have a recent report that people who are on GLP-1s actually increase their employment, probably because they're both feeling better about themselves. They're able to get a job. So there's a whole mixture in, are they better for people? The answer is absolutely yes. And if we drop their costs substantially so that we were talking about$400 or$500 a year per person, then we're probably in the range where we really will see benefit, not immediately. And this goes back to another problem we have that you mentioned. We have a rigmarole system. Sometimes you're in Medicaid, sometimes you're in the ACA, sometimes you have employer-sponsored insurance and you rotate, and then you get old and you go on Medicare.

25:34The incentive for any insurer or any program to invest in your prevention and get you on GLP-1s when the payoff might be three, four, five years down the line is zilch because of what we call in the turn. And that's a real problem for those kind of system we've created. Long-term investments in your health, keeping you well, is not something that our system incentivizes. It actually disincentivizes it. No one benefits from that. Yeah. If I'm running Aetna, no shade on Aetna per se, but invest hundreds of millions in GLP-1s just to save Medicare a bunch of money. Right, Julie? That's true. And it's also really hard to measure prevention.