Post Reports – The Health Care Debate Behind the Government Shutdown

Date: October 1, 2025
Host: Elahe Izadi
Guest: Paige Winfield Cunningham (National Health Reporter, The Washington Post)

Overview

This episode of Post Reports delves into the policy disputes at the heart of the October 2025 government shutdown, focusing particularly on debates over Affordable Care Act (ACA) subsidies and Medicaid funding. Elahe Izadi interviews national health reporter Paige Winfield Cunningham to explain what’s at stake, break down partisan positions, and explore the broader implications for health insurance affordability across the U.S.

Key Discussion Points & Insights

1. Root Cause of the Shutdown: Health Care Funding Stalemate

• The immediate cause: Congress failed to reach a deal to extend funding, leading to a shutdown affecting multiple federal agencies.
• The heart of the dispute: Disagreement over whether to make pandemic-era ACA subsidies permanent and restore recently cut Medicaid funding.
  • Quote: “The shutdown has had immediate impacts... But today we want to focus our attention on the policy debate at the heart of the shutdown. And it's about health care.” (Elahe Izadi, 00:52)

2. Democrats’ Objectives

• ACA Subsidies:
  • Democrats want to make enhanced, pandemic-era subsidies for ACA (Obamacare) plans permanent.
  • These subsidies have greatly reduced premiums and expanded coverage to more Americans.
  • Quote: “They’re refusing to vote on a government funding bill unless Republicans extend those subsidies.” (Paige Winfield Cunningham, 02:08)
• Medicaid Funding:
  • Democrats seek to restore $1 trillion in Medicaid cuts from the summer’s “one big beautiful bill.”
  • Cuts introduce stricter enrollment checks and work requirements, likely reducing future Medicaid rolls by 7.5 million over 10 years.
  • Quote: “Basically, the changes to Medicaid don't change the benefits themselves...7.5 million fewer people will be enrolled in Medicaid 10 years from now.” (Paige, 02:55 & 03:25)

3. Republican Position and Reasoning

• GOP’s main 2025 legislative achievement was the $1 trillion Medicaid cut and stricter verification and work requirements.
  • These are framed as “restoring integrity” and combating fraud.
  • Quote: “For Republicans, this was their big legislative accomplishment this year. It's what President Trump wanted.” (Paige, 04:37)
• On ACA subsidies, Republicans remain opposed to expansions, citing both ideological objections to strengthening Obamacare and the increased federal cost.
  • Quote: “For Republicans who have long been opposed to the Affordable Care Act, building on that law is the last thing they want to do.” (Paige, 10:19)

4. What Are ACA Subsidies and Why Do They Matter?

• Explanation: Subsidies are federal payments that help individuals purchase private insurance on healthcare.gov, based on income.
• Pandemic-Era Enhancements: Expanded subsidies capped premiums at 8.5% of income and allowed some middle-class families to qualify.
  • Enrollment doubled—from 11 million to 24 million, with around half able to get a plan with no monthly premium.
  • Quote: “Those are really steep costs for a family that, yes, they're not poor, but they're not, you know, wealthy by any measure...Now, under these expanded premiums, those people can be eligible and are eligible for subsidies.” (Paige, 07:09)

5. Potential Consequences If Subsidies Expire

• Up to four million fewer people could retain insurance in ten years, largely in higher-income brackets.
• Premiums are already increasing as insurers anticipate a lapse in subsidies for 2026.
  • Quote: "Premiums are going up. Insurers have assumed those extra subsidies aren’t going to continue. And so when people go and look at those costs, they're going to be a lot higher..." (Paige, 10:02)
• A likely rise in the uninsured rate after historic lows.

6. Medicaid Cuts: Technical Stricter Rules & Work Requirements

• More frequent eligibility checks (twice annually).
• Work or volunteer requirements for some higher-income recipients (80 hours/month).
  • Quote: "...they have to work or volunteer for 80 hours a month. And if they don't show...they can be dropped from coverage." (Paige, 04:07)

7. Republicans’ Cost Argument

• The expanded ACA subsidies raised federal spending from $60 billion/year to $90 billion/year—a 50% increase.
  • However, still a relatively small slice of federal health spending.
  • Quote: “The government was spending about 60 billion a year...that’s up to about 90 billion a year...The subsidies are really a piece of the pie.” (Paige, 12:59)

8. The Role of President Donald Trump

• Trump has accused Democrats of trying to fund healthcare for undocumented immigrants—a claim refuted by Paige and current law.
  • Quote: “Democrats, while they're drawing a line in the sand on health care, it's not over coverage for undocumented immigrants. Undocumented immigrants are specifically banned from the marketplaces.” (Paige, 13:44)

9. Outlook & The Limits of Reform

• Potential for post-shutdown compromise: Some Republican leaders may consider a partial subsidy extension, especially with looming midterms and expected premium hikes.
• Deep partisan divides make substantial or structural reforms nearly impossible.
  • Attempts to make bigger changes to health insurance are unlikely.
  • Quote: "...you know, it's really hard to see going forward how we get any more substantial changes to the health insurance landscape because of how partisan the issue has been." (Paige, 16:11)

10. Broader Trends in Health Insurance Costs

• Health insurance costs continue their long upward trend, driven by high pharmaceuticals and chronic disease—contrary to ACA's promise to “bend the cost curve.”
  • Quote: “It...turns out that didn’t happen. We still see health insurance costs going up, and there are a lot of reasons for that.” (Paige, 17:10)

Notable Quotes & Memorable Moments

• On the Broken System:
  "One would never construct a health insurance system like the one we have in the United States if you were starting from scratch."
  (Paige, 15:52)

• On Insurance Market Dynamics:
  “When you have a scenario where health insurance is just too expensive. Who drops off? It's not the sicker people...It's the healthier people.”
  (Paige, 14:53)

• Historical Parallels:
  “There was a whole shutdown fight in 2013 when Senator Ted Cruz...filibustered over trying to defund the law...”
  (Paige, 10:55)

Timestamps for Key Segments

• 00:52 — What shuts down, what stays open, focus on health care debate
• 02:03 — Origin of the fight: ACA subsidies & Medicaid cuts
• 03:49 — Details of Medicaid eligibility rules & work requirements
• 05:26 — How ACA subsidies work and their impact
• 08:53 — CBO estimates on future uninsured rate if subsidies expire
• 10:19 — Deeper Republican resistance to ACA expansion & past efforts to repeal
• 12:56 — Cost implications: expanded subsidies and GOP framing
• 13:37 — Trump’s public statements and the myth of coverage for undocumented immigrants
• 14:48 — Adverse selection: who drops insurance when costs rise
• 15:48 — Is a structural U.S. healthcare reform even possible?
• 17:08 — Premiums continue to rise despite ACA promises
• 17:50 — Show wrap-up

Takeaway

The current government shutdown spotlights the enduring divide over health care funding and reform in the United States. Democrats are fighting to entrench pandemic-era ACA subsidies and undo sweeping Medicaid cuts, both measures that would keep millions more Americans insured and premiums lower. Republicans, however, remain united against further ACA expansions and consider recent Medicaid changes a signature accomplishment. With premiums rising and next year's elections looming, compromise is possible but unlikely to amount to major reform. Health insurance affordability may remain a persistent, unresolved issue—reflecting the intractable politics of the American healthcare system.