The Price of Care: Fixing The ACA

Summary

What A Day — "The Price of Care: Fixing The ACA"

Host: Jane Coaston
Guest: Mark Shepard, Associate Professor of Public Policy, Harvard Kennedy School
Date: October 28, 2025

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Episode Overview

This episode centers on the looming expiration of enhanced Affordable Care Act (ACA) subsidies, which—unless extended—will sharply increase premiums for millions of Americans. Host Jane Coaston and guest Mark Shepard dissect the politics and policy behind healthcare affordability, why U.S. health insurance costs so much, and practical reforms that could make American healthcare more accessible. The conversation is especially timely as the government shutdown drags on due to party-line disputes about continuing these crucial subsidies.

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Key Discussion Points & Insights

The State of the ACA & Shutdown Stalemate

• Government Shutdown Tied to Healthcare Subsidies
  • Enhanced ACA subsidies, in place since 2021, are set to expire this year unless Congress acts ([00:48]).
  • Sharp premium spikes are expected if the subsidies vanish: Illinois could see an 80% increase, New Jersey up to 175%.
  • Democrats want to extend subsidies. Republicans resist, risking both public fallout and their own prospects in the 2026 Congressional elections.
• Political Maneuvering
  • House Speaker Mike Johnson claims Republicans have been working on healthcare, but actions such as proposed Medicaid cuts contradict those assertions ([01:53]).
  • Jane’s tone is sharply critical of political spin, emphasizing policy over posturing.

Who Benefits from ACA Subsidies and Who Pays ([02:46])

• The “Missing Middle”
  • Shepard explains: "America doesn't just have one form of health insurance. We have a complex system. And these subsidies are for people who we might call the missing middle..." ([03:00])
  • Target group: not poor enough for Medicaid, not old enough for Medicare, and lacking employer insurance.
  • Without subsidies, roughly 25 million Americans on ACA exchanges would struggle to afford coverage.
• Spillover Effects
  • If more people go uninsured, costs don’t vanish: "They don't stop getting sick. They still show up at hospitals ... someone has to pay the cost." Often it’s hospitals or taxpayers ([04:14]).

Why Is U.S. Healthcare So Expensive? ([05:11])

• Higher Prices, Not Higher Usage
  • Shepard: "America is expensive because we pay higher prices for similar amounts of healthcare..." ([05:20])
  • Unlike national health systems (e.g., England), U.S. lacks centralized cost controls. Many insurers, weak bargaining power, aversion to government price-setting.
  • The U.S. values competition and innovation, but this allows costs to spiral.

What Can the U.S. Learn from Other Countries? ([06:28])

• International Models: Switzerland as a Case Study
  • Switzerland offers universal health insurance through regulated private insurers: "It's been described as Obamacare for all." ([06:38])
  • Key reasons Switzerland’s system is cheaper:
    • 1. Universal Mandate: Everyone must enroll, pooling risk and keeping costs down.
    • 2. Government Regulation: The state negotiates drug prices and regulates payments, using bargaining power to reduce provider costs.
  • In the U.S., fragmented government makes such centralized negotiation difficult.

Could These Reforms Work in America? ([08:33])

• Federalism Is a Barrier
  • Shepard: "They really rely on having an effective government that's centralized. In America, we have a federalist system, 50 state governments..." ([08:57])
  • Unlike Switzerland, U.S. insurance regulation is split among states and the federal government, complicating major reforms.

Potential Reforms Within the ACA ([09:36])

• 1. Public Option Plans
  • Designed by state governments but implemented by private insurers. Could create downward pressure on prices through competition.
  • "Washington state has tried out a public option plan with some success. Colorado has had versions of this." ([10:32])
• 2. Pro-Competition Subsidy Reform
  • Current subsidies rise as insurer prices rise, removing incentive for insurers to compete.
  • "If insurers raise their price, they get bigger subsidies from the government and that weakens competition." ([11:04])
  • Proposals: introduce fixed subsidies or arrangements that reward cost-saving behaviors to promote price competition.

Practical Advice for ACA Shoppers ([12:06])

• Open Enrollment Begins November 1
  • Without congressional action, plan prices may rise dramatically.
• Shepard’s Advice
  • "Health insurance is really important. The costs are going to hurt if enhanced subsidies are not expanded, but the cost of going uninsured could be even higher." ([12:21])
  • Contact your representatives to urge for extension of subsidies, as they are key to affordable coverage and healthy marketplaces.

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Notable Quotes & Memorable Moments

• Jane Coaston:
  • “Apparently cutting Medicaid by 15% now constitutes working on healthcare since day one of this Congress…” ([02:07])
  • “There are other countries with private insurance options, where healthcare doesn’t cost so much that people risk going without it. So what’s going on here—and what could America be doing about it?” ([02:29])
• Mark Shepard:
  • “American healthcare—very expensive. That’s not unique to Obamacare’s health insurance exchanges. It’s true everywhere.” ([03:36])
  • “America is expensive because we pay higher prices for similar amounts of healthcare, because ultimately there is less desire to keep costs low.” ([05:20])
  • “In Switzerland, there’s a central program to negotiate the price of drugs that helps keep costs low because the one national government can negotiate low prices with pharmaceutical companies. We don’t do that in America.” ([07:54])
  • “They really rely on having an effective government that’s centralized. In America, we have a federalist system, 50 state governments. Each has their own power…” ([08:57])
  • “Health insurance is really important. The costs are going to hurt if enhanced subsidies are not expanded, but the cost of going uninsured could be even higher.” ([12:21])

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Key Timestamps

• 00:48 — Stakes and impact of expiring ACA subsidies
• 02:46 — Who gets ACA subsidies & why they matter
• 04:14 — Potential consequences if subsidies expire (uncompensated care)
• 05:11 — Why US healthcare is more expensive than Europe
• 06:38 — Swiss model: how private insurance can support universal care
• 08:57 — Why US political structure complicates reform
• 09:44 — Realistic reforms under existing US system
• 12:21 — Advice for Americans shopping ACA coverage during open enrollment

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Conclusion

This episode offers a nuanced, critical analysis of why U.S. healthcare costs remain stratospheric, even with private insurance, and explores potential (but politically challenging) reforms. The expiring ACA subsidies are just one battle in a larger policy war—one that affects millions of Americans directly and indirectly. Mark Shepard’s expertise provides vital grounding for listeners faced with tough coverage decisions as open enrollment looms and the prospect of higher costs becomes all too real.

Recommended for anyone navigating the ACA marketplace or seeking to understand why American healthcare remains such a stubborn policy knot.

Transcript

[Jane Coston]

It's Tuesday, October 28th. I'm Jane Coston and this is Whataday, the show asking why did President Donald Trump get an MRI at his last physical at Walter Reed National Military Medical Center?

[Donald Trump]

I did. I got an mri. It was perfect.

[Jane Coston]

Yeah, you know, typically one does not get an MRI at a physical, but maybe I'm just not achieving the same levels of stupendous health as our 79 year old president. On today's show. Like many of us, the president gets mad at a Canadian ad he saw during the World Series. Not like many of us, it's informing his statecraft and a ragtag group of former USAID workers band together to fund some of the shuttered agency's most critical programs. But let's start with healthcare, because the main issue keeping the government closed is healthcare. Specifically the enhanced Affordable Care act subsidies that have been in place since 2021 and further lowered premium costs. Democrats want the enhanced subsidies extended. Republicans don't. Without them, folks who rely on health care plans they bought on the exchange will see their premiums skyrocket. For example, the Chicago Tribune reported on Monday that Illinois residents could see their ACA plan costs increase by about 80% if the subsidies expire. And in New Jersey, health care costs on the exchange could rise by 175%. Some Republicans are starting to worry that doing absolutely nothing while millions of Americans either pay more for health care or lose it entirely MAA make it tougher to hold onto Congress in 2026. But what to do about it? Of course, Republicans could negotiate with Democrats to extend the subsidies and end the shutdown, but obviously they won't do that. House Speaker Mike Johnson tried one tested tactic to handle the issue on Monday. Lying.

[Doug Ford]

What we're doing right now, what we have been doing, what we were already doing because we knew we were coming up to the end of the year. And we know that health care is a major burden for the American people. We've been working on it since day one of this Congress. We worked on it in the years prior.

[Jane Coston]

Apparently cutting Medicaid by 15% now constitutes working on health care since day one of this Congress. And let's not even get into the in the years prior thing before I get too mad online. But health care really is a major burden for millions of Americans, especially the ever rising cost. There are other countries with private insurance options where healthcare doesn't cost so much that people risk going without it. So what's going on here and what could America be doing about it? To find out, I spoke to Mark Shepard. He's an associate professor of public policy at the Harvard University Kennedy School of Government. Mark, welcome to what a day.

[Mark Shepard]

Thanks for having me.

[Jane Coston]

So from the very beginning of the shutdown many moons ago, we have been hearing a lot about these enhanced Affordable Care act subsidies that expire at the end of the year. So to start, what are these subsidies and who gets them?

[Mark Shepard]

It's a great question. And to answer that, you have to realize that America doesn't just have one form of health insurance. We have a complex system. And these subsidies are for people who we might call the missing middle of the American health insurance system. So they're not low enough income to get Medicaid, they're not seniors, so they can't get Medicare, but they don't work in jobs that provide health insurance coverage. And so if they want health insurance, Obamacare health insurance exchanges are what they need. That's the only form of coverage that's really viable. And what the subsidies are trying to do is they're trying to make sure that that coverage is affordable. So American healthcare are very expensive. That's not unique to Obamacare's health insurance exchanges. It's true everywhere. But because healthcare is so expensive, that coverage isn't going to be affordable unless the government steps in to provide some help to lower and middle income households.

[Jane Coston]

So in short, the enhanced subsidies keep more of Americans in that missing middle that you referred to insured. But why would that matter to individual people who don't need to get their health insurance through the aca? What would happen if these subsidies expired?

[Mark Shepard]

So I think the first answer is that there's no direct effect on people who get coverage, say through Medicaid or through employers. The main effect of this policy is on the 25 million people who get coverage in the ACA health insurance markets. There is, though, some indirect effects when people are uninsured, as more people will be if the enhanced subsidies expire. They don't stop getting sick. They still show up at hospitals, at emergency rooms, and someone has to pay the cost. And if they can't afford it, it's often hospitals, local governments, state governments who bear that cost. And ultimately that gets passed on in different forms to taxpayers and to others in the community. So it's not free. Subsidies for health insurance are designed to make sure people can afford access to healthcare. If you don't do it directly, you're going to end up providing some assistance for health care through indirect mechanisms.

[Jane Coston]

So it seems like the main issue here is just how expensive it is to pay for health insurance in the US Why is it so expensive?

[Mark Shepard]

I think there's no one simple answer. You can certainly look internationally. You can look at our healthcare costs compared to European countries, which tend to spend 50% or less compared to us. And when you do those types of comparisons, what you find is that America is expensive because we pay higher prices for similar amounts of healthcare, because ultimately there is less desire to keep costs low. So if you look at a place like England, England has a national health insurance program. They have government budgets that set how much funding there will be for the National Health Service. And ultimately that keeps the cost constrained because hospitals know that their budget is fixed. In America, we don't have fixed budgets. There are many different health insurers. None of them really has the power to be able to constrain healthcare costs, nor is there necessarily appetite to do so. I think in America, there's a greater emphasis on free competition, on innovation, and a concern that any type of cost control will ultimately result in lower quality of care.

[Jane Coston]

So what, what do other countries that have private health insurance systems do differently that make those systems less expensive than ours? And could those things work in the.

[Mark Shepard]

US So this is a great question, and what's important to first note in the question is that there are countries that have universal health insurance, universal access to healthcare through private health insurance systems. A great example is Switzerland, which is a system in which it's been described as Obamacare for all. Everyone in the country gets access to health insurance. They can choose among a set of competing health insurance plans. There are subsidies to ensure it's affordable, but ultimately there's choice and competition in the way it works. But there's really two important details for why what you would call private health insurance in Switzerland looks so much different and so much more affordable than in America. I think one detail is that it's mandatory and universal. We're not talking about a type of coverage that you can opt out, not talking about a coverage that needs to be free. It's financed by taxes. And so people ultimately have to be enrolled. That ensures that both healthy and sick people enroll, which keeps the overall average cost down. Right. If you don't have healthy people participating and only the sick participate, costs tend to be higher. Difference number two is that even though it's private health insurance, behind the scenes, the government still does a lot to regulate that health insurance, including regulating the prices that health insurers pay. Hospitals, doctors, drugs. So, for instance, in Switzerland, there's a central program to negotiate the price of drugs that helps Keep the costs low because the one national government can negotiate low prices with pharmaceutical companies. We don't do that in America. We ask each individual insurer to negotiate their own prices. And because no one has the bargaining power that a central government has, you're not going to get the same deals. And as a result, prices will be higher.

[Jane Coston]

Now, there's a lot of differences between the United States and Switzerland, but what are the reasons why that kind of negotiation between the government and private insurers or any of these other factors that we see in Switzerland or in other countries that have that mix of private public healthcare, are there reasons why those would not work in the United States?

[Mark Shepard]

I think they really rely on having an effective government that's centralized in America. We have a federalist system, 50 state governments. Each has their own power. Medicare is a federal program, but Medicaid, the second largest program by spending, is a state run program. The states regulate some health insurance, the federal government regulates other types of health insurance. It would be very challenging unless there were major reforms in our regulatory structure to implement that type of program in America. So I think ultimately we're kind of stuck with what we have. And the question is, how do you make it work as well as possible?

[Jane Coston]

So to your point, what we have right now is the Affordable Care Act. Is it possible to lower health insurance premiums within our current system?

[Mark Shepard]

You know, I think there's two policies that come to my mind. One is to introduce more public option type plans into exchanges. So imagine that you took a plan whose parameters were designed not by a private health insurance company, but designed by the state government. Those plans are still operated by private health insurers, but their parameters, including some of the prices that they might pay hospitals and doctors, are set by the government. That's why we call it a public option plan. It's a public plan, but it's just another option that you could choose and that could compete against private plans, potentially driving down the costs of healthcare. So Washington state has tried out a public option plan with some success. Colorado has had versions of this.

[Jane Coston]

And you mentioned that there was another potential reform that could work. What was that?

[Mark Shepard]

So if public option plans are more associated with the left, you might think about pro competition subsidies that would be associated more with reforms proposed on the right. And this is an area where Republicans, I think, have a point, that subsidies today are designed in a way that doesn't promote maximum competition among insurers. Today, health insurance subsidies in the ACA are set up in order to cover the full difference between the total cost of health insurance, what insurers set, and whatever amount is deemed affordable for households to pay. So, for example, say the full cost of health care is $6,000 a year. That's a typical number. If it's affordable for a household to pay $1,000, then the government covers the full difference. Well, what happens if insurers raise their prices? Still the government covers the full difference. What does that mean? It means that insurers, when they raise their price, they get bigger subsidies from the government and that weakens competition. So if you were thinking about reforming that, what you'd want to do is to shift more towards types of subsidies that encourage insurers to keep prices low, that don't have this link between subsidies and prices. You might think about fixed subsidies. You might think about shared savings schemes that encourage insurers and states to keep costs low. The ultimate goal is to make subsidies structured in a way that encourages competition as opposed to weakening competition.

[Jane Coston]

In the meantime, open enrollment starts this Saturday, November 1st. And unless there is a miraculous deal coming our way, Americans are going to see much higher prices in the ACA marketplace. As someone who thinks about this all the time, do you have any advice for them?

[Mark Shepard]

I think the first advice would be that health insurance is really important. The costs are going to hurt if enhanced subsidies are not expanded, but the cost of going uninsured could be even higher. So it tends to be worth it to find money to continue your health insurance coverage if you can possibly do so. Maybe step two would be encourage your representatives to vote for enhanced subsidies. These really have done a tremendous amount to protect lower and middle income households, to keep the cost of coverage more affordable, to ensure that younger and healthier people participate in the marketplaces. All of these things have gone up dramatically since enhanced subsidies were passed in 2021. And you know, Republicans often argue that the subsidies were meant to be temporary and just a Covid era protection. I don't think that's really correct. The enhanced subsidies are a way of ensuring that the coverage is truly affordable, given what households feel that they can pay. And if they go away, households are going to face more pain. Many of them will drop out of coverage, even though I would advise them not to. And ultimately, we're all going to pay the costs.

[Jane Coston]

Mark, thank you so much for joining me.

[Mark Shepard]

You're welcome. Thanks for having me.

[Jane Coston]

That was my conversation with Mark Shepherd, Associate professor of Public Policy at the Harvard University Kennedy School of Government. We'll get to more of the news in a moment, but if you like the show. Make sure to subscribe, leave a five star review on Apple Podcasts, watch us on YouTube and share with your friends. More to come after some ads what a day is brought to you by Deleteme. Right now the headlines are chock full of data breaches and regulatory rollbacks, making us all vulnerable. But you can do something about it. Deleteme is here to make it easy, quick and safe to remove your personal data online. Deleteme does all the hard work of wiping you and your family's personal information from data broker websites. And Deleteme sends you regular personalized privacy reports showing what info they found, where they found it and what they've removed. DeleteMe isn't just a one time service. DeleteMe is always working for you, constantly monitoring and removing the personal information you don't want on the Internet. The New York Times Wirecutter has named Deleteme their top pick for data removal services. I have been really thrown by all of the data breaches we keep hearing about in the news lately. In a recent Coinbase data breach, a hacker obtained names, addresses, phone numbers and the last four digits of users Social Security numbers plus masked bank account numbers. Data brokers can vacuum up a lot of that data, create a searchable profile about you and sell it to whoever wants it. Thankfully, Deleteme can help remove it from those sites and keep your info from falling into the wrong hands. Take control of your data and keep your private life private by signing up for Deleteme now at a special discount for our listeners. Get 20% off your DeleteMe plan when you go to www.joindeleteme.com wad and use promo code wad at checkout. The only way to get 20% off is to go to www.joindeLeteme.com wad and enter code wad at checkout. That's www.joindeleteme dot com wad code wad@designer.

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[Jane Coston]

Here's what else we're following today. Head of Lines.

[DSW Announcer]

People are going to.

[Doug Ford]

Be lined up out here to get food and we're talking about a damn ballroom. Don't lose the plot.

[DSW Announcer]

Don't lose the plot of what's going on here.

[Jane Coston]

Minnesota Democratic governor Tim Walz spoke at a food bank in the city of Eagan Monday, announcing $4 million in emergency funding for participants in the Supplemental Nutrition assistance program, or SNAP. Amid the government shutdown, the U.S. department of Agriculture posted a notice on its website saying SNAP or food stamps will not go out to the roughly 42 million Americans who rely on the program on November 1, and recipients may soon have to find other ways to feed themselves and their families. And in case you're wondering, isn't there a contingency plan for this? The USDA issued a memo Friday that the $5 to $6 billion in SNAP contingency funds can only be used for unforeseen disasters like hurricanes, contradicting a since deleted September 30 shutdown plan that claimed Congress intended those funds to sustain SNAP benefits during a shutdown because, of course, Virginia Republican governor Glenn Youngkin declared a state of emergency in anticipation of the cutoff. And California Democratic governor Gavin Newsom announced plans to call up the National Guard to support food banks. The US Extended its trade deal deadline with Mexico by several weeks. The deal covers a range of imports, including aluminum, the key ingredient in the can Trump's been kicking down the road most of this year. Trump set a Nov. 1 deadline to boost tariffs on some Mexican goods from 25 to 30%, targeting products not covered by the U.S. mexico Canada Trade deal. But Mexican President Claudia Sheinbaum said that she and Trump agreed that talks between the US And Mexico were going, quote, very well. Even on Trump sensitive topics like security and migration. Things were much frostier to the north, where President Trump said on Saturday that he plans to hike tariffs on imports of Canadian goods by an extra 10% because grandpa is yelling at the TV again. An anti tariff television ad aired by the province of Ontario during the World Series sparked Trump's Ireland. The ad used the words of former President Ronald Reagan to criticize U.S. tariffs. Trump spouted off about it on Air Force One on Monday.

[Donald Trump]

They shouldn't have done it. They've apologized and they said we're going to take the ad down. Well, they did it, but they did it very late. They let it play for another two nights and now they took that ad down. So I don't know when it's going.

[Jane Coston]

To kick in again. This is about an ad using the words of Ronald Reagan. Trump has reportedly terminated all trade negotiations with Canada because the mean ad hurt the president's feelings. On Monday, the Canadian premier of Ontario, Doug Ford, spoke of the debacle on cnn.

[Doug Ford]

It was an ad to inform the people in the US and mission accomplished.

[Jane Coston]

Mission accomplished, indeed. The Red Cross is joining members of Hamas in the search for the bodies of the roughly 12 remaining Israeli hostages in Gaza. Hamas officials say the remains have been difficult to find due to the mass destruction caused by nearly two years of Israeli airstrikes in the region. A mass burial was held in Gaza Monday for more than 40 of the 195 deceased Palestinians that Israel has returned to Gaza. The Gaza Health Ministry has opened an office to help identify the bodies, but doctors and aid workers say doing so is difficult. Many of the bodies reportedly show signs of torture, execution, possible organ theft, and being run over by tanks. Israel said the bodies belonged to combatants, though they provided no evidence to support that claim. The fragile ceasefire between Israel and Hamas continues to hold for now, but Trump posted on Truth Social over the weekend demanding that Hamas move faster to recover the bodies of the remaining Israeli hostages and implying he'd allow Israel to restart the war if they don't. Despite President Trump gutting USAID earlier this year, a network of former officials, nonprofits and private donors found ways to keep critical foreign aid programs alive. Folks, there is no bad news after the sentence. That's the headline. The Associated Press reports that after the Trump administration froze roughly $64 billion in U.S. assistance overnight, former USAID staff worked off the clock to identify about 80 high impact programs that could still be saved within eight months. Their ad hoc initiative, Project Resource Optimization, helped mobilize more than $125 million in emergency donations from major philanthropies and new donors alike. They fully funded all 80 programs. The effort's backers say the funding won't fully replace what was lost, but it's preserved programs in nutrition, disease prevention, and anti poverty work across the world. That is what good news feels like. Sit in it, breathe it in, and that's the news. That's all for today. If you like the show, make sure you subscribe Leave a Review Welcome Iceland, to our Mosquito Hell and tell your friends to listen. And if you're into reading and not just about how the island nation was reportedly one of the few countries to never have a confirmed sighting of a wild mosquito until last week. Like me, Water Day is also our nightly newsletter. Check it out and [e-mail] subscribe I'm Jane Coston and on behalf of Everywhere With Mosquitoes, Sorry. Iceland Whataday is a production of Crooked Media. It's recorded and mixed by Desmond Taylor. Our associate producers are Emily Foer and Chris Allport. Our video editor is Joseph Dutra. Our video producer is Johanna Case. We had production help today from Greg Walters, Matt Berg, Sean Ali, Gina Pollack and Caitlin Plummer. Our senior producer is Erica Morrison and our Senior Vice President of News and Politics is Adrienne Hill. We had help today from the Associated Press. Our theme music is by Colin Gilliard and Kashaka. Our production staff is proudly unionized with the Writers Guild of America east as.

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