The Trump administration is implementing the most sweeping rollback of social spending in American history. Millions of Americans are being thrown off Medicaid. The president and his Republican allies in Congress refused to extend enhanced subsidies for people buying individual health insurance on Affordable Care Act exchanges, which Democrats have warned since last year will cause millions more to lose coverage while health-insurance premiums spike for those still enrolled. Last week, as Democrats predicted, insurers on the exchanges announced premium increases averaging 14 percent, coming atop a 20 percent hike the previous year.
Yet here is how Bernie Sanders responded to this grim news. “We have a fundamental choice to make,” the senator wrote on X. “We can maintain a broken healthcare system that allows insurance companies to make billions by raising premiums by 14%-35% next year. Or we can enact Medicare for All and save the American people $650 billion a year.”
Sanders claims that the only alternative to soaring premiums is to replace all private health insurance with a government-run, single-payer health-care system. But there is, in fact, a much simpler alternative: Restore the subsidies that Democrats enacted under the Biden administration. Before the ACA passed in 2010, nearly 20 percent of Americans under 65 were uninsured. By 2023, that number had been cut in half.
Sanders’s message did not mention that Democrats had done anything at all on the issue. Nor did it mention the Trump administration or the Republicans, who have caused the problem.
[Read: Americans are in denial about elder care]
American politics is, to a very substantial degree, a fight over health care. Democrats believe that all Americans should have access to medical care, even if that requires government subsidies to help them afford it. Republicans don’t. One of the biggest obstacles Democrats face is that they have adversaries on both their right and left flanks who each, for different reasons, wish to obscure this basic fact.
Health insurance is becoming a crisis again because Republicans decided to make it one. Other than occasional vague promises, such as making Obamacare “much better, strong, and far less expensive,” Donald Trump rarely mentioned health care during his most recent presidential campaign. His 2024 convention speech ran for more than an hour and a half without ever referring to his plans to cut the Affordable Care Act.
Yet health care ranks among his most consequential legacies. Nearly 3 million Americans lost their health-care coverage last year. Hundreds of rural hospitals are at risk of closing. The Congressional Budget Office projects that by 2028, the number of uninsured Americans will have risen by a third, with almost 10 million Americans losing coverage.
Republicans have not acknowledged the straightforward effect of their subsidy cuts. Trump and his allies prefer to discuss almost any other subject. To the extent that they have bothered to address the consequences, they have insisted that their cuts do not deprive people of insurance but instead eliminate fraudulent claims. Mehmet Oz, the former celebrity doctor now serving as the administrator for the Centers for Medicare and Medicaid Services, said at a press conference last month that the administration is cutting benefits for “millions of people, literally, who are getting insurance that they don’t want; they don’t even know they have it.” The point of Trump’s subsidy cuts, he argued, was not to throw people off the program but to strengthen it. “If you care about the ACA, then you’ll want us to take the fraud out,” he said.
Oz is repeating a conclusion from the Paragon Health Institute, a conservative think tank, which has claimed that the ACA has given benefits to “improper” beneficiaries. The group’s findings are very questionable, however. Paragon extrapolates, from the number of recipients who don’t file any claims on their insurance, that the program is handing out subsidies to people who either don’t exist or don’t want to have coverage.
But not everybody who gets insurance through their employer files a claim, either. Just because you don’t file a claim doesn’t mean you don’t want the plan. That is the nature of insurance. I’ve never filed a fire-insurance claim, but I do have a policy that I very much wish to keep.
Matthew Fiedler, a health expert at the Brookings Institution, examined the number of Obamacare policyholders who did not file claims and concluded that “these data do not provide persuasive evidence that ‘phantom’ enrollments are widespread.”
Oz misinterprets Paragon’s study, which asserts that there are 6 million “improper” recipients this year, including a million and a half people who are ineligible to receive subsidies. Most of those ineligible recipients are not pretending to be poor—they are inflating their income in order to be eligible for coverage.
They’re doing this because of a perverse, Republican-imposed policy. The Affordable Care Act split the task of covering the uninsured into two programs. The poorest (households below 138 percent of the poverty line) would be enrolled in Medicaid, and those above that threshold would get subsidized coverage on the new exchanges, where insurers would be prevented from charging higher rates to people with preexisting conditions.
[Annie Lowrey: Children’s health care is in danger]
A Supreme Court ruling, however, allowed states to opt out of the Medicaid expansion. Many red states did so, creating a hole in the program: The subsidies for people above the income cutoff were intact, but in certain states (of which nine remain) no programs covered those below it. In many of these Republican-led states, people desperate for coverage have pretended to have more income in order to get insurance. Those payments might not be legal, but the people getting them are very real.
Yet Oz is treating the 6 million figure as if it describes phantom enrollments by people who do not exist. “We believe that 35 percent, roughly, of the people that are using the Affordable Care Act, Obamacare exchanges—because they’ve never used the program once they’ve never filed a claim—may not be legit,” he said.
Whether and to what extent the Trump administration and its allies believe they are merely eliminating fraud is difficult to say. In general, Republicans outsource their social-policy expertise to a handful of conservative wonks who, in most cases, argue that it just isn’t the government’s business to help people who are too poor or sick to cover their own medical expenses. Republicans insisted that the Affordable Care Act was a train wreck that couldn’t work. Those predictions failed, but Republicans haven’t rethought their opposition to it, presumably because they not only thought Obamacare couldn’t work; they didn’t want it to work.
Democrats were wrong about the long-term fate of the Affordable Care Act, too, but in a different way. They assumed that once the public experienced the benefits of Obamacare, Republicans would be unable to take those benefits away. That calculation has proved mostly false. Nearly the entire Republican caucus voted to repeal the law in 2017 (falling just short when a handful of senators defected). In 2025, the GOP sat on its hands and allowed a portion of health subsidies to expire, then voted to claw back Medicaid.
Those votes, and the consequences that are only beginning to be felt, are politically toxic. This is a social catastrophe for people who are too poor and sick to afford health insurance, but it’s also a political advantage for the party committed to helping them. The challenge for the Democrats now is to turn Republicans’ flouting of public opinion into maximal levels of electoral defeats.
That task, however, has become more difficult because progressive activists, and especially those associated with the Democratic Socialists of America, are blaming the wrong party for the crisis that socialists say they are fighting to solve.
The DSA has set itself up in opposition to the Democratic Party, selling itself to progressive voters by promising to do what Democrats will not. Its candidates and advocates routinely say that one of the group’s primary goals is to ensure that everybody can get health care, as if this is the thing distinguishing democratic socialists from the Democratic Party.
The Wall Street Journal recently surveyed the four DSA-affiliated congressional candidates, and all of them cited universal health care as one of their core beliefs. “The Democratic Socialists of America platform calls for universal health care, an idea long since implemented by their counterparts in Europe,” Jia Lynn Yang argued in a laudatory essay in The New York Times Magazine.
There are two very odd things about defining the group this way. The first is that support for universal health care is probably the least controversial element of the DSA’s official platform. The group supports government ownership of major corporations, ending all immigration enforcement, and “abolishing the carceral forces of the capitalist state,” among other things. Its members can be expelled merely for defending Israel’s right to exist.
The second odd thing is that the Democratic Party also supports universal health care. It is, in fact, one of the party’s deepest and most consistent causes. Forming a competing organization that is primarily dedicated to the same goal to which the Democrats are currently dedicated makes little sense.
The Democratic Party’s commitment to giving all Americans access to health insurance dates back to the New Deal. Franklin D. Roosevelt considered it, but settled for a more limited Social Security program centered on old-age pensions. Other Democratic presidents pushed through incremental expansions, such as Medicare and Medicaid under Lyndon B. Johnson, and the Children’s Health Insurance Program under Bill Clinton (who had spent much of his first two years in office trying and failing to establish universal health care).
Under Barack Obama, Democrats finally did establish a universal health-care program. Obama’s plan relied on regulation of the individual health-care market, plus subsidies and expansion of Medicaid, to make coverage available to all Americans. (Undocumented immigrants, who make up about a fifth of the uninsured population in the U.S., remained ineligible.) This effort drew a ferocious right-wing backlash and probably cost many congressional Democrats their careers.
A conservative-controlled Supreme Court nearly overturned Obama’s Affordable Care Act. The Court’s final ruling was a partial rollback that made the Medicaid expansion optional for states. This ruling, not any decision by Democrats, made Obamacare a non-universal program. (About 40 percent of uninsured Americans live in the states that have not expanded Medicaid.)
Since then, Democrats have continued to fight to extend coverage to more Americans. They have campaigned relentlessly to get red states to accept Obama’s Medicaid expansion—it is, indeed, their best issue in those states. They have won ballot initiatives in seven states supporting Medicaid expansion and have elected governors in Kansas, Kentucky, Louisiana, and North Carolina by emphasizing the issue. Just 25 states and D.C. were enrolled in the Medicaid expansion after the Court’s ruling, but 15 more have since joined.
A major weakness in the Affordable Care Act was that the subsidies were too stingy for middle-class people at the higher end of the income spectrum. When Democrats regained control of government in 2021, they fixed that problem, expanding the subsidies and, within two years, bringing the uninsured rate down from 9.7 percent to 7.7 percent. Republicans have since let those higher subsidies expire, causing the uninsured rate to rise again.
When many progressives say “universal health care,” they actually mean universal government provision of health care. That is not the same thing—some universal health-care systems in Europe and elsewhere rely on private insurance, whereas others do not.
But even this narrower definition does not do much to distinguish the DSA from the Democrats. The Democratic Party is roughly divided on the practicality, not the morality, of government-provided health care. Many Democrats favor single-payer health care. More than half of the House caucus has endorsed Medicare for All. The remainder favor universal coverage by building on Obamacare. Nobody in the Democratic Party opposes universal coverage.
[Jonathan Chait: Obamacare changed the politics of health care]
The American health-care system was built around private, employer-provided coverage, which has made transitioning to a fully public system difficult. Even people who dislike the current system tend to resist new taxes or policy changes that would cut off their existing coverage. Obama has said that if he were starting from scratch, he would design a single-payer system; he settled for a hybrid model to avoid having to disrupt care for the majority of working adults who get coverage through their jobs.
Advocates of single-payer health care in particular, and the left in general, have directed the bulk of their efforts into pressuring Democrats to accept their preferred measures, rather than supporting the programs Democrats have fought to enact and expand. Sanders’s decision to condemn the consequences of Republican health-care policy without blaming the Republicans for it is typical of how the left has communicated on the issue. Decades of the left refusing to credit Democrats for advocating for universal health-care coverage has helped lead many Americans to genuinely believe that the party doesn’t care about the policy. About a third of Americans trust the Democrats to do a better job on health care than the Republicans, according to polls, but that leaves two-thirds of Americans feeling otherwise.
Meanwhile, congressional Democrats have prioritized the provision of health care to such an extent that they recently shut down the federal government in an effort to defend health-insurance subsidies.
Young people often say they are let down by the Democratic Party. One source of their disillusionment is their belief that the party lacks a commitment to health care. That belief has been instilled through endless repetition, but is completely mistaken.
Health care is probably the issue that least differentiates the DSA from the Democratic Party. If you favor public ownership of the means of production or believe forming coalitions with communists is important, then joining the DSA makes a lot of sense. But deciding to be a democratic socialist because you care about universal health care is like ditching a Toyota for a Rolls-Royce because you want your car to have a steering wheel.
The post You Don’t Need to Vote for Socialists to Get Universal Health Care appeared first on The Atlantic.
