Why It Costs So Much to Get Sick

Summary

Podcast Summary: Chasing Life – “Why It Costs So Much to Get Sick”

Host: Dr. Sanjay Gupta (CNN Podcasts)
Guest: Dr. Elizabeth Rosenthal (Physician, Health Journalist, Author)
Original Air Date: October 17, 2025

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Overview:

This episode tackles the underlying reasons behind the high cost of getting sick in the United States. Dr. Sanjay Gupta is joined by Dr. Elizabeth Rosenthal, a seasoned health journalist and former ER physician, to dissect the U.S. healthcare system’s history, dysfunction, current crisis, and potential paths forward. With the backdrop of a government shutdown threatening Affordable Care Act (ACA) subsidies, the conversation explores how policy, profit motives, and insurance design have contributed to unaffordable and often inadequate care.

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Key Discussion Points & Insights

1. The Dire Consequences of Policy Deadlock

• The episode opens with the context of a government shutdown endangering healthcare subsidies.
• Notably, recent studies (Yale/UPenn, 2023) estimate that cutting federal health spending could lead to “51,000 preventable deaths annually” ([00:53] Dr. Sanjay Gupta), as cited by Senator Bernie Sanders.
• Dr. Rosenthal and Gupta emphasize that these numbers aren't just statistics—they reflect real human lives.

“You take 15 million people off of their health care... what do you think is going to happen to them? ...They will die.”
— Dr. Sanjay Gupta ([00:44])

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2. Why the System Fails Patients: Business over Care

• Dr. Rosenthal explains that U.S. healthcare has become dominated by business interests, with hospitals now run as profit-driven entities, often to the detriment of patient experience ([06:07]).
• She illustrates with personal anecdotes—her husband, suffering from terminal cancer, faced unnecessary delays and suboptimal treatment due to resource-allocation priorities ([06:36]).

“Most hospitals run as businesses now... You try and make an appointment... two, three months out because hospitals want to run as full ships all the time, and the waits are terrible...”
— Dr. Elizabeth Rosenthal ([06:07])

• The rise in “medical debt”—100 million Americans with some form—reflects this harsh financial burden ([05:02]).

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3. How Did We Get Here?

• Dr. Rosenthal traces the “unnatural evolution” of healthcare insurance from simple disability coverage to today’s labyrinthine employer-based and government programs ([08:26]).
• She calls insurance “the original sin” because it distances patients from the real costs, fueling unchecked price increases ([09:24]).

“Insurance... for many years separated the patients from the cost. So... I didn’t really care how much was being charged.”
— Dr. Elizabeth Rosenthal ([09:24])

• The 1990s brought in management consultants who advised hospitals to aggressively “unbundle” and monetize every service and supply, further inflating costs ([10:19]).

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4. Cost-Sharing and Its Pitfalls

• Rising copays, deductibles (now sometimes up to $9,000/year), and coinsurance were supposed to give patients “skin in the game.”
• Instead, she argues, it’s “more like having a kidney in the game” for many Americans ([13:33]), deterring necessary care for fear of bankruptcy.

“A $7,000, $5,000 deductible when most Americans don’t have $500 in their savings account, what’s that going to do? ...I’m going to stay away from the health care system.”
— Dr. Elizabeth Rosenthal ([13:33])

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5. International Comparisons & Possible Alternatives

• Other high-income countries control costs with “nonprofit insurers and more price regulation” (citing Germany and Switzerland) ([15:25]).
• The U.S. system, in contrast, keeps adding complexity rather than simplifying or regulating prices.

“Our system keeps getting more and more complicated by these kind of interventions rather than simpler.”
— Dr. Elizabeth Rosenthal ([15:25])

• Dr. Rosenthal is flexible on solutions: single payer (“Medicare for all”), lowering Medicare age, public option—all would be preferable to current dysfunction ([16:56]).

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6. Physician Sentiment & Systemic Resistance

• More than half of physicians now reportedly favor a Medicare-for-all system ([19:02]).
• Systemic inertia is immense: insurers, hospitals, and pharma industry deploy much stronger lobbying and legal resources than states or patients can muster ([20:24]).

“They are way better lawyered up than states. They have way more lobbyists than states.”
— Dr. Elizabeth Rosenthal ([22:39])

• Hospitals with nonprofit status don’t necessarily act differently than for-profits, often prioritizing financial throughput over patient or community benefit.

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7. The Human Toll and Political Apathy

• Despite large numbers affected, healthcare isn’t a core electoral issue because many people interact rarely and opaquely with the system ([23:48]).
• Dr. Rosenthal shares her discomfort at her work being cited in a recent high-profile, violent incident in New York, which she sees as rooted in real but misdirected public frustration ([24:40]).

“There’s just this deep well of frustration with the health care system that politicians aren’t addressing and aren’t tapping into. And I wish they would.”
— Dr. Elizabeth Rosenthal ([24:40])

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8. Open Enrollment Mayhem Amid Shutdown

• With ACA premium subsidies at risk, millions may lose or be unable to afford coverage:
  • Premiums have sharply increased.
  • Subsidies are expiring, with insurers and exchanges left in chaos ([27:38], [30:19]).
• The technology and bureaucracy cannot keep up, likely causing even more to go uninsured out of confusion or desperation.

“It really is going to be just unbelievable chaos. And, you know, in the end... people are just like, I give up.”
— Dr. Elizabeth Rosenthal ([31:42])

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9. Who Gets Hurt?

• Not the very poor (who qualify for Medicaid), but:
  • Working-class, self-employed, gig workers, small business employees, freelancers—the “missing middle” ([37:48]).
• Without coverage, these Americans risk medical bankruptcy, resorting to GoFundMe for care ([38:55]).

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10. Looking Forward: Fixes and Frustrations

• Rosenthal is both hopeful (doctors organizing, real debate) and pessimistic (systemic inertia, lobbying power).
• If she were to write another book, she’d cover private equity, consolidation, and the limits of patient empowerment—believing real change will only come from systemic, not individual, action ([39:02]).

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Notable Quotes & Memorable Moments

• “I think our health care system is broken. I think it is dysfunctional, and I think it's on the verge of collapse.”
  — Dr. Elizabeth Rosenthal ([01:18])

• “I think I said in my book it’s more like having a kidney in the game now.”
  — Dr. Elizabeth Rosenthal ([13:33])

• “More than half of physicians say they would be okay with Medicare for all. That’s a real sea change.”
  — Dr. Elizabeth Rosenthal ([19:02])

• “Hospitals... are run mostly by business people. The patients are kind of just the throughput of the organization.”
  — Dr. Elizabeth Rosenthal ([21:32])

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Key Timestamps

• 00:44 — The deadly implications of subsidy cuts
• 05:02 — The human impact: medical debt and avoidance of care
• 08:26 — Historical development of U.S. insurance
• 13:33 — Dangers of excessive cost-sharing for patients
• 15:25 — International comparisons and nonprofit insurance
• 19:02 — Physician attitudes shifting on single payer
• 24:40 — Public frustration cresting into dangerous actions
• 27:38–34:46 — Breakdown of open enrollment and coverage crisis amid shutdown
• 37:48–38:55 — Who is most affected by subsidy loss and what’s at stake
• 39:02 — Rosenthal reflects on future directions for reform and research

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Conclusion:

This episode delivers an urgent, wide-ranging discussion of why Americans pay so much—and get so little—for health care. Rosenthal and Gupta expose the system's historical accidents, perverse incentives, and daunting political obstacles, while warning that failure to act will only deepen the crisis. The conversation is rich with data, history, and personal insight, offering both dire warnings and pragmatic hope for change.

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If you want to learn about what's driving America's health care disaster—and what could be done about it—this episode is essential listening.

Transcript

[Dr. Sanjay Gupta]

Welcome to Chasing Life. As you no doubt know by now, we are currently in the midst of a government shutdown. And if you've been tuning in, you know that health care is really at the heart of it.

[Podcast Host]

Senator Sanders, you've said 50,000 people could.

[Dr. Elizabeth Rosenthal]

Die from ACA subsidy cuts, but right now, 1.4 billion.

[Dr. Sanjay Gupta]

Just this week, CNN's Kaitlan Collins moderated a town hall with Representative Alexandria Ocasio Cortez and Senator Bernie Sanders. It was all about the shutdown. And there was this one moment in particular that really gave me pause. What you just said, about 50,000 people dying a year. This is based on studies done from the University of Pennsylvania and Yale. You take 15 million people off of their health care, by and large, low income and working class people, what do you think is going to happen to them? They don't go to a doctor.

[Dr. Elizabeth Rosenthal]

They have chronic problems.

[Dr. Sanjay Gupta]

They will die. So I decided to look into that study that Senator Sanders is citing, and it's pretty legit. In June, researchers at Yale and UPENN sent letters to senators with their findings, which were that an estimated 51,000 preventable deaths will occur annually if all the planned cuts to federal health spending are enacted.

[Dr. Elizabeth Rosenthal]

I think our health care system is broken.

[Dr. Sanjay Gupta]

I think it is dysfunctional and I think it's on the verge of collapse. Look, perhaps we're a bit jaded from the news cycle. Maybe we're just tired of hearing politicians speaking in extremes. But here's the thing. My guest, who is very much not a politician, she sounds pretty alarmed as well.

[Dr. Elizabeth Rosenthal]

You know, I see some things that are hopeful and some things that are not. The question is, will they be addressed before the system just really falls apart? Because I think it's pretty close to doing so.

[Dr. Sanjay Gupta]

Dr. Elizabeth Rosenthal, she's not a politician, as I said, but she's done basically everything else. She was a trained physician and ER doctor before turning to journalism. She was at the New York Times for two decades plus. Now she's senior contributing editor at KFF Health News and also author of a real interesting book on the healthcare industry titled An American How Healthcare Became Big Business and How youw Can Take It Back. That book also has a very strange and tragic connection to Luigi Mangione as well.

[Podcast Host]

It's something we'll talk about later in.

[Dr. Sanjay Gupta]

The podcast, but today we're mostly going to be discussing the US Healthcare system, its complexities, potential solutions, and how the crisis at the center of the shutdown could impact you. And on Tuesday, we're going to bring Dr. Rosenthal back again on paging Dr. Gupta and we're going to talk about how to navigate the open enrollment period. It is complicated. It is confusing even for me. Elizabeth has some great tips for now though. Let's hear from her and find out what's really behind this healthcare debate and its role in the government shutdown. I'm Dr. Sanjay Gupta and this is is Chasing Life.

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[Podcast Host]

Well, Dr. Rosenthal, thank you for joining us. Welcome to Chasing Life.

[Dr. Elizabeth Rosenthal]

Thanks for having me.

[Podcast Host]

The name of the podcast is Chasing Life. Do you feel like you're chasing life every day?

[Dr. Elizabeth Rosenthal]

I feel like I'm Chasing Life, and particularly about this topic that I'm obsessed about. I'm just trying to figure out how to make it better for people, which has kind of been my journalistic mission for decades.

[Podcast Host]

Yeah, well, I do want to get into that background because I find it fascinating and I think you and I share a lot of connective tissue in this regard. But what is the specific topic that you find fascinating?

[Dr. Elizabeth Rosenthal]

Well, you know, generally our healthcare system doesn't deliver to patients in terms of quality of care and in terms of the prices we get charged. So what I worry about right now, and particularly in this season of renewing insurance, is that people avoid going to see doctors and avoid going to the hospital because they're just afraid of the bad experiences they've had. And they don't trust doctors or hospitals because they've had bad and very expensive experiences. We did a podcast and a series of articles called Diagnosis Debt, and it's about 100 million Americans have medical debt now, and that's just going to go up if people don't have insurance. And what we're seeing now threatens to leave millions of more people uninsured.

[Podcast Host]

So when you talk about the bad experience, you're primarily talking about it from a financial standpoint. There's other things, obviously, but the sort of diagnosis debt, as you call it.

[Dr. Elizabeth Rosenthal]

No, I think it's multifaceted, because I think most hospitals run as businesses now. I mean, I think you and I both know that. And one thing I'm obsessed with is ER boarding, how much time people spend in emergency rooms. That's particularly older patients. And, you know, that's largely a financial decision. I think My husband, who died earlier this year.

[Podcast Host]

I heard that. I'm sorry, Dr. Rosenthal, they shared that with me. I'm sorry.

[Dr. Elizabeth Rosenthal]

That's okay. Well, he and his final admission spent three days in the er, and I knew there were elective admissions coming into the hospital. I saw other patients going upstairs. But I think, you know, this is an older guy with stage 4 cancer who's just going to take up a bed and won't generate any revenue and will be a placement problem, you know, if he doesn't happen to die on this admission, which he, in fact, did. And so I think it's really multifaceted. You try and make an appointment for physical therapy or a neurologist or an endocrinologist, and it's, you know, two, three months out because, you know, hospitals want to run as full ships all the time, and the weights are terrible, the phone trees. You know, talk about a bad use of AI assistance. You know, there are multiple bad experiences that go well beyond the cost, but I think they're all related to, you know, what? I wrote my book about how healthcare became big business, and I'm not sure there are good ways to take it back individually, frankly.

[Podcast Host]

Okay, well, that's sort of a little bit of what I wanted to pivot some of this conversation around, which is, how did we get here and how do we get out? So let's start with how did we get here? Because you and I have both evaluated healthcare systems around the world, and I think when you do that, the consensus always is, look, there are things that work well with our healthcare systems, but many, many things that don't. Some of which of you have alluded to. Did we get here through a process of natural evolution, or what were the weird sort of forces that got us to this place?

[Dr. Elizabeth Rosenthal]

Well, I would call it more unnatural evolution. You know, basically, the Idea of insurance goes way back to the turn of the last century where it was really more like disability insurance. It was pay, which you got because you couldn't go to work. And hospital stays were inexpensive. So it really wasn't about that. Then around that time, a teachers union in Texas decided to have insurance for their employees. And some employers developed on site clinics to help their employees. But the big change was really Post World War II, when there was a labor shortage and companies started offering health insurance as a perk, you know, and that was a big thing. So then there were all these people who had insurance which was tied to their jobs, and more people got insurance that was tied to their jobs. And then in 1963, people over 65 didn't have jobs. So they were just like flailing in the wind, unable to bear the costs. So Medicare was started to help them. And I call insurance the original sin. Not because it's bad to have insurance, it's kind of a must have, but because it for many years separated the patients from the cost. So when I had my children in the 90s, I paid nothing. I paid like to have cable TV in my room. So I didn't really care how much was being charged. And of course, what happens kind of organically or evolutionarily is some doctors realize, hey, you know, entrepreneurial doctors, it doesn't matter how much I charge because the patients aren't going to feel it.

[Advertisement Narrator / Dr. Elizabeth Poynter]

Right.

[Dr. Elizabeth Rosenthal]

Another big step was, you know, in the 1990s, there was this era of HMOs, and they were really putting the squeeze on hospitals. And so hospitals called in business consultants like McKinsey at Bain, Boston Consulting Group. They looked at hospital procedures and how they operated. And they said, guys, you're leaving all this money on the table. Like, when I was an ER doctor, I came with the er, but the inside of business was like, wow, you can charge separately for that doctor and for that IV bag and for the nurse who's inserting the needle. And P.S. like, when patients are in the recovery room, why are you giving that away for free? You can charge. And not only that, you can charge in 15 minute intervals. And you. And I know you're a surgeon, like, why are people in the recovery room? Sometimes it's because they need to come out of anesthesia. And sometimes the extra half hour is because their team is having dinner. And so we've gotten to this place where everything is billed, each little, every pill, every interaction. And then as a reaction to that, the insurer said, oh, we've got to Let patients have some skin in the game. And that started kind of slowly. There were co pays which were kind of minimal. And there was a deductible which wasn't very much. But you know, those little bits of change didn't really. Patients didn't feel them enough. So over time the deductibles have gone up. So I think some people have $9,000 deductible plans. In addition to co pays, there's coinsurance, which is 20% often for hospital stays. And you know, man, if you're in the ER for four hours, that's 10,000 probably and your portion is 2,000. And so I think we're at this critical juncture where we put efficiency ahead of patient care. And we've sacrificed a lot of patient care in the name of efficiency. And I say we as a kind of lapsed physician, but we've lost the population in that process.

[Podcast Host]

Let me focus in on something that you brought up a couple times, this idea of cost sharing, of having skin in the game. When you had your kids back in the 90s, it was free. Patients were largely insulated from cost. So they weren't effective negotiators in terms of trying to bring those costs down because they didn't really care. They didn't even see the numbers often. Then you started having more cost sharing, sort of incremental at first in terms of co pays, but higher, higher sort of cost sharing with high cost deductible plans, things like that. Is that a good thing or not to have this increased cost sharing? Does it actually achieve some of the goals you're talking about?

[Dr. Elizabeth Rosenthal]

I don't think so. I think it's gotten so high, you know, it's always a question like with plastic bag fees, is 10 cents enough to get people to bring carrier bags? But if you charge too much, they won't go shopping, they won't eat. That's obviously an exaggeration, but I think that is what's happened now with cost sharing. You know, patient centered, cost effective care. Great idea. But they become kind of slogans that, you know, what does it mean to have skin in the game? I think I said in my book it's more like having a kidney in the game. Now, you know, that's interesting. You know, a 7,000, $5,000 deductible when most Americans don't have $500 in their savings account, what's that going to do? It's going to make them say, except in a dire emergency, I'm going to stay away from the health Care system.

[Podcast Host]

Right. Should it be different for different people depending on your income?

[Dr. Elizabeth Rosenthal]

We've kind of tried to jury rig the finances over and over again the whole time I've been a physician and kind of nothing has worked. The healthcare system is kind of incredibly agile at playing to the newest incentives and doing end runs around them. So yes, that is a concept. It would be really hard to roll out that kind of idea with all the different incomes and all the different changes in incomes. I mean, in some ways that is what Medicaid tries to do. It says if you're below this basic income in 40 states but not the other 10 others, you can get on Medicaid where you will have almost no cost sharing.

[Podcast Host]

Right, right.

[Dr. Elizabeth Rosenthal]

Our system keeps getting more and more complicated by these kind of interventions rather than simpler. And you don't have to have a national health system if you don't want it. I mean, Medicare for all would be fine. Or you could slowly lower the Medicare age as Hillary Clinton had proposed as a candidate. Or you could have a public option which would basically throw down the gauntlet to the insurers and say if you can't do as good as this, people can walk with their feet. Or Germany, Switzerland, they have systems with lots of insurers, but they have a lot more price regulation. And this is going to cause fire to come out of some people's ears. The insurers have to be not for profit. So there you go, you said it.

[Podcast Host]

You said it. Where people seem to be in agreement on is what you started off by saying, which is that we've spent a lot of money, $4.5 trillion on healthcare and we don't have what we should have to show for it.

[Dr. Elizabeth Rosenthal]

Right.

[Podcast Host]

I think regardless of your political party or whatever, I think there's a lot of agreement on that. Even within the medical establish. I don't think anyone is raising their hand and saying this system works perfectly. Not even close. Again, I don't want to get you in any kind of trouble here, but if you could wave a magic wand, what would the system look like? Would it look more like a single payer system?

[Dr. Elizabeth Rosenthal]

It would look more like a system where price was controlled to a manageable point, whether by some kind of government negotiation as Medicare does. I mean, there are a lot of ways to get there. Public option. I'm not dodging the ball, really. I don't think you either would want to say this is what I think we should do because it will ultimately be a political decision which one the American public can support. I think any of them would be fine. You know, when people say, oh, Canada, we could never do that, I mean, you know what happened there? And the provincial minister named Tommy Douglas, who really believed in this idea of a provincial health system and fought and he tolerated doctor strikes. And when that province got a provincial health system, the other provinces all said, wow, we want that too. You know, so will a state figure it out and then we'll all just do what that state did. I just think there are so many things we could choose and instead we all kind of put our head in the sand. And I think part of the reason it's not a big political issue is that patients don't interact with the medical system that much. So they get a bill that's ridiculous, or they're on a phone tree that takes two hours and finally get an appointment and then they're like, you know, I hope I don't need a doctor again for a long time. But, you know, it's the physicians who deal with it every day. So last weekend I was speaking to physicians in Minnesota and I'm like, guys, you're stuck in this system now. More than half of physicians say they would be okay with Medicare for all. That's a real sea change from when I was practicing.

[Podcast Host]

Yeah, I've sort of witnessed this firsthand over the last 25 years as I've seen physicians that are colleagues of mine, friends, who it would have been anathema to suggest Medicare for all. And that's that Bernie Sanders hippie kind of stuff. Right. And those same people now recognize that a large payer like that might have a lot of leverage and might make their lives a lot simpler overall. Like I said, nothing is all good or all bad. I mean, you do have other problems that may come with it in terms of patient experience overall.

[Dr. Elizabeth Rosenthal]

Sure.

[Podcast Host]

But I think even if you go like I interviewed President Obama back around the passage of the Affordable Care act and we talked about what it was like to get it done and what had happened back in 94 with the Clinton healthcare plan, all of that. And he made this comment to me that looks if we could start all over again, go back to Pre World War II time that you're talking about, that's probably where we would have landed on a single payer, largely government run sort of system. But now, in order to transform healthcare, you're trying to change parts on a really, really big and fast moving train and you can't do it. That's sort of the excuse I get. Is that a fair excuse?

[Dr. Elizabeth Rosenthal]

Well, yes, it would take a lot of political will. So many parts of the system now were never meant to be as they are now. I mean, insurers initially were not for profit, right? Then we allowed them to convert to for profit status. So now who's their primary? You and I have probably heard that as a physician, to whom is duty owed? The patient. Well, now, to whom who is duty owed? Your employer who is a hospital or insurer. And I think a lot of people hate that. And I hear from physicians all the time how unhappy they are that they're pushed to meet metrics and economic efficiency and return on efficiency. But they are likewise not for profit hospitals. And the ACA did something about this, but it was kind of a baby step. You know, sorry, I believe you work at one, but they don't run that differently than for profit hospitals. They're run mostly by business people. There's a lot of like, the patients are kind of just the throughput of the organization. And so I think there's going to be incredible resistance unless there's the force of government saying, we got to do this. You know, you don't want this thing we have now where you're negotiating every single literal interaction. And you know, when people worry about a big government system, countries that have a lot of insurers and price setting, it's not like Big Brother comes down and tells you what you can charge. I mean, it's a collaborative thing between economists, physicians and the government. And, you know, almost like the ACA ruck does. But there it's just physicians fighting each other for a piece of the pie. So I think there are ways, but we don't ask, for example, from our not for profit hospitals. They're supposed to have their not for profit status because they do charity care and community benefit. You look at the 990 statements and it's hard to see that as real community benefit, most of what they do to claim that status. And yet, and here's the big problem, when anyone tries to move against insurers or pharma or PBMs or hospitals, they are way better lawyered up than states. They have way more lobbyists than states. I live in New York, you know, the Greater New York Hospital association, who's the biggest contributor to most politicians in the state. So it's really, really hard to move unless there's someone, and I'm not running for anything, who really believes this is an important issue and unless people start voting as if this is the life issue that it is. When I hear people Go. And gas prices and egg prices. I'm like, look at your health care, look at your premiums.

[Dr. Sanjay Gupta]

But this gets.

[Podcast Host]

At your point, I think, again, that it's a black box for people, how healthcare pricing works. They don't vote on this issue. We saw that in the early 1990s. Obviously, we saw what happened with the Affordable Care act got passed, but it wasn't one of these core issues. It comes up again here and there. But for a large percentage of Americans, politicians may not use this as a central wedge issue because they don't think it's going to help them get elected necessarily.

[Dr. Sanjay Gupta]

And people are pissed.

[Podcast Host]

I mean, look, I was surprised after what happened with Luigi Magione assassinating a man on the streets of New York and then having this manifesto which he cited some of your work. And Michael Moore, by the way, what did you think when you saw that? When you saw that you were cited in that?

[Dr. Elizabeth Rosenthal]

Well, of course, I thought that, like, no one should kill someone because they're pissed with the health care system. I mean, that's unconscionable to me. So I did not like seeing my name there. I did feel like, okay, why is this there? Why is this young man so enraged? And I think that there's just this deep well of frustration with the health care system that politicians aren't addressing and aren't tapping into. And I wish they would.

[Podcast Host]

Yeah, I think that's a very responsible and fair way to answer that. I mean, it was shocking to me, and I think equally shocking was the response in some sectors of our population celebrating assassination.

[Dr. Elizabeth Rosenthal]

Right, right.

[Podcast Host]

I mean, but you've done important work. You put good information out there. And I think, you know, it does raise a lot of questions about our healthcare system for people overall. Again, I think most people would concede it doesn't work really well. We spend way too much, twice as much per capita as the next country that spends money on healthcare. And again, our mortality rates, our overall patient satisfaction. There's a lot of things that we need to be doing.

[Dr. Sanjay Gupta]

I'm speaking with Elizabeth Rosenthal. She is author of An American Sickness. After a break, she's going to explain why this government shutdown makes open enrollment especially tricky.

[Podcast Host]

This year.

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[Dr. Sanjay Gupta]

Welcome back to Chasing Life. My guest, Elizabeth Rosenthal, trained physician, author, longtime health journalist. Here she lays out the impasse that Affordable Care act enrollees are going to suddenly be facing.

[Dr. Elizabeth Rosenthal]

The problem is, you know, all of those people who we in the last 10 years directed and encouraged to use the Obamacare exchanges, the ACA exchanges, which have, you know, raised insurance rates in this country by tens of millions of people. But what's happening this year is during the Biden administration, the prices of subsidies were going up and it was during COVID so they issued what are called premium support payments. So there were subsidies that if you had a certain income, you put it into the, the computer system. It's not easy to use, but you could do it and it would say, oh, you know, the normal premium would be $900 a month, but you only have to pay 200. So it tremendously helped a lot of people get on insurance who otherwise might have said, I can't afford that. Two things are happening right now. Those subsidies were meant to expire at the end of 2020. This is what the government shutdown is all about. Right now. The Democrats want the subsidies to continue. The president and his allies have said no way. If those expire, a lot of people will be forced to drop insurance. I mean, the Kaiser Family foundation or kff, estimates that premiums will double on average or the median premium will double. Some people will find premium increases of 70%. And the problem is we already know that will happen because the insurers, this is not like, you know, oh, the sky is falling, the sky is falling. The insurers have already submitted their rates for the new year and they are, you know, increased by sometimes 18%, sometimes 30%. These are big increases. And everyone, you know, in health care, we all go, oh, you know, it's only increasing 10% this year. I mean, if your rent increased 10% every year, there would be upheaval in the streets. But somehow we accept this. And this year, if those premium subsidies aren't extended, patients will feel the full force of that increase. And it's estimated that probably over 20 million people or as much as 20 million people could decide to go without or not have the money to do it. If you care about health care, that's a really bad thing. Right.

[Podcast Host]

So to be clear, two things sort of happening at the same time. Rates going up and subsidies going down or vanishing completely in some cases.

[Dr. Elizabeth Rosenthal]

Well, and they're not entirely unrelated because the assumption of the insurers, who are always playing an actuarial ball game, know that if the rates go up a lot because the subsidies expire, a lot of younger people will just leave the risk pool, and that will leave an older, sicker risk pool to insure. So they're calculating that. But there's also a lot of other things going on. You know, prices have been going up anyway. Staffing costs have gone up. The tariffs may affect how much it costs to buy medical supplies. So they're bundling all this stuff into their assumptions. And the thing that's going to get really tricky, and I can't overemphasize the chaos that this will cause. The government is shut down now. Right. We don't know if there will be subsidies or not. People in Idaho are choosing plans today. They will see a price that will probably make their head explode. Right. Because the assumption is if they're not extended, the subsidies will expire. So they may go without insurance when, if the subsidies are extended, they would have bought insurance. We're getting pretty close to November 1, where the period opens up for everyone else. Will the sites be updated? Will they have time to update with the new calculation of what you owe? It really is going to be just unbelievable chaos. And, you know, in the end, when things get that chaotic, these sites are already hard to deal with. People are just like, I give up. You know, and it's just a terrible moment. If you're me and obsess about this all the time.

[Podcast Host]

Yeah. I mean, people aren't going to know how much ultimately it will cost. But right now they'll see a price that reflects increased insurance rates and little if any subsidies, and it will make their heads explode. We'll come back to that in a second. But going Back to what you said earlier. It's one time a year, in part because you don't want people to say, hey, look, I've gotten a diagnosis, now I'm gonna buy healthcare insurance. That's not a system that works. But there are things known as qualifying life events.

[Dr. Elizabeth Rosenthal]

Yes, of course.

[Podcast Host]

So what are those? What would allow you to buy healthcare insurance at a time outside of open enrollment?

[Dr. Elizabeth Rosenthal]

Yeah, outside of open enrollment, if you get married, you get divorced, you lose a job, you have a baby, there are all these things that obviously would change your ability to have insurance. So at those times, if you experience one of those qualifying life events. Yes, you can go back on the market and buy insurance.

[Podcast Host]

So if these subsidies, everything that we're hearing with these subsidies happens and then we get subsidies again, would that constitute a qualifying life event?

[Dr. Elizabeth Rosenthal]

I don't think anyone has considered that possibility. So that's why I said it's just going to be chaos. Because you may get a notice from your insurance saying, oh, actually, your premium isn't $700, it's $200. Again, if you chose the $700. But maybe if you chose no insurance, you would be stuck with. I mean, you know, because the government is shut down. This seems to be an issue that the Dems and the Republicans are arguing mightily about and intransigently about. I don't think we've thought past the will there be subsidies or not? You could always legislate differently. I mean, as President Biden extended open enrollment during the pandemic, so you could say if you were one of these people, here's your second chance. But, you know, it's hard to be optimistic about good things happening at the moment because, you know, even on this step one of should there be premium assistance or not, or premium subsidies or not. Actually, they're called enhanced premium subsidies. Officially. It's hard to get to step two.

[Podcast Host]

You've been at this a long time. What do you think's going to happen over the next couple weeks?

[Dr. Elizabeth Rosenthal]

I can give you my optimistic view and my pessimistic view, because I really don't know which is right. Optimistically, we've calculated at KFF that 80% of the people who will lose enhanced premium subsidies are in red states. It will hurt the Republicans base to do this. And I'm hoping the optimistic view is, I think a lot of the red state governors have spoken out about this. Some congressmen have, not a lot of senators. But that may, you know, optimistically, that could rule the day because it should hurt Republicans in the midterms if they let this go through without the premium, extended premium subsidies. The pessimistic view is, you know, the Trump administration draws a line in the sand and his friends in Congress back him up on that. I mean, Republican governors have spoken out against this, but, you know, they don't have a vote in Congress, so they can't make this go away.

[Podcast Host]

Is there anything about this that makes sense to you? I mean, this is obviously harming people who just being charitable for a second. Like what does driving this.

[Dr. Elizabeth Rosenthal]

Well, it costs money, right?

[Podcast Host]

It costs money. It costs money.

[Dr. Elizabeth Rosenthal]

That's all that's driving it.

[Podcast Host]

But out of all the places to save money, harming your own constituents by putting their subsidies at risk. Look, maybe I'm just sort of riffing with you here, but is that the place to save money?

[Dr. Elizabeth Rosenthal]

Well, I don't think it is. But again, I think there is an argument that one could make, which I think I agree with. But it's not appropriate to apply to the current situation, which is, you know, we keep putting band aids on a broken health system. So when subsidies go up, we don't say, gee, why are subsidies going up? What can we do systemically to prevent that? Instead, we just say, okay, patients, we're going to give you more money to allow this to keep happening. So I wish our country was more inclined to do more regulation of insurer prices and hospital prices, which are all kind of. They're linked together. And pharmaceutical prices, don't forget that we pay more than twice as much as any other country for the same exact drugs.

[Podcast Host]

Who gets harmed the most by what's going on right now with the government shutdown? I would assume it's people who are poor. That's who always gets harmed the most. But people who are gonna have a hard time if these subsidies don't come through, having healthcare insurance, at least for the next year.

[Dr. Elizabeth Rosenthal]

Well, I think that's not an accurate impression because the poor can go on Medicaid, right? I mean, the poor are gonna be harmed by the shutdown in many other ways, right? The end of some of the Medicaidi mean the work requirements and, you know, the reductions in SNAP and all that kind of thing. So, you know, the people who are going to be hurt most by these subsidies going away are not the very poor. They're people who work for small companies. They're entrepreneurs, they're singers, they're actors, they're, you know, geological engineers who are consultants. They're hardworking people who really need these subsidies to be insured and they want health insurance. You know, someone who will be affected by these subsidies, whoever you are, it's going to be really hard for them. And, boy, you know, you'll see their GoFundMe account if they get sick, if they're uninsured.

[Podcast Host]

If you were to write another book at this point, by the way, are you thinking about it?

[Dr. Elizabeth Rosenthal]

Yes and no. Okay. Well, the problem is most of what I wrote in my first book, which is now eight years old, is still relevant, which is what really disturbs me. So I didn't foresee at the time the incursion of private equity into healthcare. I would write about that. I would write about vertical consolidation. I think the how you can take it back part of my book was lackluster because I don't think patients have much clout. I would write about doctors unionization and the rising politicization of doctors. You know, I see some things that are hopeful and some things that are not. The question is, will they be addressed before the system just really falls apart? Because I think it's pretty close to doing so well.

[Podcast Host]

I would be first in line to read it. I learned a lot from you just talking today, and I really, really appreciate your time. Fingers crossed for what happens over the next couple of weeks. And thank you, Doctor.

[Dr. Elizabeth Rosenthal]

Thank you for having me.

[Dr. Sanjay Gupta]

Of course. Elizabeth Rosenthal is senior contributing editor at KFF Health News and the author of An American How Healthcare Became Big Business and How youw Can Take It Back. That's all for today's episode. In the meantime, I'm gonna talk to you on Tuesday for another episode of paging Dr. Gupta. We are gonna go over the basics of health care, insurance coverage, and your options for open enrollment. This is probably something you need to know. Until then, keep chasing life.

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[Dr. Elizabeth Rosenthal]

100% of women go through menopause. Even if it's natural, why should we suffer through it?

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