Congress Races to Find Obamacare Subsidy Solution: Reporters Examine the Efforts

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Mark (00:04)
2026 is almost here, and the new year promises to bring skyrocketing healthcare premiums unless lawmakers in
Washington can reach a compromise. We're talking with reporters who cover Congress and the federal health
insurance programs.

Robert King (00:19)
But right now, there's not been any indication from Speaker Johnson that he is going to be, advocating for an-
either- any of the compromise legislation that's being discussed in the House.

Margaret Flinter (00:33)
Our guests today are Robert King, who reports on Medicare, Medicaid, and the Affordable Care Act for
Politico, and Sandhya Raman, a healthcare reporter for CQ Roll Call.

Sandhya Raman (00:44)
I think affordability and, you know, the forms of that will be a big thing, whether or not we get any sort of deal
on ACA or, or some of the other things that have been in the mix. I mean, Congress has been very interested in
PBM reform and things like that to, to bring down health costs. So, I think going into next year, regardless of
what happens in the next couple weeks, that'll be, definitely something big to, to watch here.

Margaret (01:08)
This is Conversations on HealthCare.

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Mark (01:21)
Well, Sandhya, welcome back to Conversations on HealthCare. And Robert, thanks for joining us for the first
time.

Sandhya (01:27)
Thanks for having us.

Robert (01:28)
Yeah, thank you.

Mark (01:29)
Absolutely. Yeah, absolutely. well, here we go again. The Obamacare subsidies are set to expire at the end of
the year, and Congress is really facing another budget deadline of January 30th. Wonder if we could ask both of
you to assess where things stand and what the chances are for a compromise.

Sandhya (01:47)
Sure. I feel like right now, we have a lot of different moving pieces, but not a real sense that any of these things
are gonna make it across the finish line. we're gearing up towards two votes in the Senate, one from each party
on Thursday, on their plan for how to deal with this crisis. looks like both of them are gonna just be party line
votes, not move forward. And in the House, we're kind of waiting to see what, House Republicans are gonna
share with us that they're trying to do. But I think the main thing is that there are a lot of different plans bubbling
up and none of them have enough support to really like, be- make it into law.

Robert (02:26)
Yeah. so yeah, that's definitely the case, I think. Right now, there's, there's not a lot of, consensus on the Senate
side. it seems like, Republicans and Democrats are barreling towards a side-by-side vote that was agreed to by
Senate-majority leaders soon, as part of a deal to reopen the government, I think last month. And so, but there
wasn't a de- a guarantee that a subsidy extension would pass. So right now, what I think is kind of interesting is
that there's more compromise on House side, I think. There have been rep- some Democrats and Republicans,
primarily more vulnerable Republicans- Uh-huh. ... those in tough races next year are getting together and
forming proposals, kind of formulating proposals, like a, an extension of the sub- enhanced subsidies, but with

some reforms. But right now, there's not been any indication from Speaker Johnson that he is going to be,
advocating for an- either- any of the compromise legislation that's being discussed in the House.

Mark (03:35)
And the White House has provided no guidance at all. Is that right?

Robert (03:40)
Well, yeah. There was the... President Trump did float a two-year extent- an, an extension with, an income cap
among some other changes. but that was quickly scuttled after opposition from a lot of rank-and-file
Republicans. And right now, we haven't seen really any endorsement from, President Trump. he did interview
with, Politico's Dasha Burns, an interview that released today. Shameless plug, you can catch it on our
homepage, where she asked him about this issue. And he basically reiterated the push for a direct payment, that
he wants the subsidy to be instead a direct payment to Americans rather than what he calls a bailout to insurance
companies. so, nothing new right there in that interview.

Margaret (04:33)
Well, it seems like wait and see and maybe compromise are the three operative words of the day with maybe on
the compromise. But thank you for that. And, and, this question maybe picks up on that, Sandhya. we have been
hearing that some Republicans want to avoid sending the subsidy funding to the insurance companies, but their
alternative is to put it in individuals' health savings accounts. So, what's the status of that idea at this point?

Sandhya (05:00)
So I guess as of just, you know, maybe less than an hour now, we had Senate Majority Leader, John Thune kind
of tee up that what the Republicans are gonna vote on this week is a proposal from Senators, Bill Cassidy and
Mike Crapo that is kind of similar-ish to one of the things that, that Trump has talked about putting money in
those accounts. And so that legislation was, you know, formally unveiled yesterday. You would get, if you were
eligible for this, between $1,000 and $1,500 per person on the plan per unit, with some different reforms
attached to that. the issue, I think, is that, you know, we haven't really seen... There are no Democrats that have
said that this is something that they want. even among some of the Republicans that you talk to, it might not be
their ideal plan, but they're planning to vote for it. So that's what we're kind of watching there.

Mark (05:56)
You know, Robert, you, ta- talked earlier about the President with his HSA, H- HSA idea, th- the one he'll
support. But the practical reality of setting that up... ... s- seems like something that will take, quite a time to
implement, right? I mean, that- that's not easy to do when all of the negotiations around that seem like that's
almost dead on arrival.

Robert (06:22)
Well, it's- it's interesting. I've talked to several state-run exchange- insurance exchanges, and it's important to
note that o- open enrollment for the ACA 2026 coverage year has started. It started for most states- Right. ... on
November 1st. And a lot of, a- a lot of the state-run exchanges, have told me that they can get a clean extension
of the subsidies implemented within about two weeks. They plan for, they... Most states have, kind of allowed
insurers to offer two sets of rates, one with the subsidies and one without. They obviously approved the rates
with the subsidy- without the subsidies, but they have the, they have the rates, you know, that, with- with the s-
enhanced subsidies inc- calculated, in the hopper if they need to go. They've told me that anything like an HSA
would take longer, and because it's just more complicated. And also, it's important to note that under Cassidy
and Crapo's plan to get an HSA, an ACA customer would have to buy a bronze tier plan, which is different from
a silver or gold tier- ... option. A bronze tier plan has, much lower premiums but they have higher deductibles,
and they also have higher copays than, the other options.

Margaret (07:51)
Makes it very difficult for consumers to actually use the health insurance that they have. Although, I guess the
preventive measures would still, would still be upfront covered. but Sandhya- ... you've reported that a
bipartisan group of House lawmakers also is talking about extending the Affordable Care Act tax credits for,
two more years. Does this have any legs? Do you think that's gonna garner support?

Sandhya (08:15)
So, we have a few different bipartisan groups trying to do this now. I think the, one of the earlier ones was a
group of four that was doing a two-year, with some of these different guardrails, you know, capping, how much

income you could have to be eligible, minimum premiums, things like that. But since that original one, we've
had two more. We had one at the end of last week, with about 30 some members, from- from both parties in the
House that, you know... there's like s- minor details in between each of them, and I think the problem that we've
had is each time, we've not gotten a strong sense from House leadership that they would take this up. And then, I
think interestingly enough, we have another one today that came out with, from Representatives Fitzpatrick,
Suozzi and- and others, which is a little bit of a, kind of in the sweet spot in that it kind of combines the two-
year extension with parts of the HSA, proposal. and so, I think that'll be interesting just, what the reaction is to
that as the House comes in this evening, just because it is a little bit in the middle, and a lot of the other ones
have been a little bit more firmly in one camp or the other. But no kind of strong sense that- that we would even
get a vote on any of these even if, there's support or not.

Margaret (09:33)
You know, Mark, I can't help but think back to when the ACA first came into, being, and these kinds of
questions were being debated in town halls, in high school auditoriums, and- That's right. ... reported on daily,
but we really don't have any kind of, major public ongoing communication in a very palpable way- Yeah. ... I
think out in the communities.

Mark (09:54)
No, that's absolutely right. Sandhya, you know, the other part of this really tricky situation involves abortion,
and Republicans want stricter abortion limitations in order to extend Obamacare funds. That seems like a
nonstarter for Democrats. Is it?

Sandhya (10:09)
It is. I think that it has come up a little bit more and more as we've, you know, get in these conversations. If you
talk to some of the, at least from the Senate side, some of the Senate Democrats that have been part of the
bipartisan negotiations with certain Republicans on, you know, can we come together, can we find some sort of
compromise? That's the thing that they've been saying over the last couple weeks that, you know, this keeps
being a nonstarter, that they absolutely want language that would, prevent if you have a plan that would cover,
abortion from being eligible for the tax credit, and that complicates things given that there are several states
where all coverage, private coverage is going to have that, in some ways, part of their plan. So I think we've
seen a lot of more lobbying on that in the last couple weeks too from, you know, abortion rights groups, anti-
abortion groups, all just kind of, you know, saying that if you don't go one way or the other, that's- that's a
nonstarter, and I think that's been making it a little bo- more complicated in sort of finding a middle ground.

Margaret (
Well, we've been talking about deal-making and, Robert, we all like Washington to reach deals, when that's
possible, seems to move things, forward. But you've also reported that some in the conservative moment-
movement believe that the Obamacare fears are overblown, and I'm curious, what groups like the Paragon
Institute are saying about this.

Robert (11:35)
Sure. So, Paragon Institute has been a think-tank that, has gotten a lot of, influence, over the past couple years,
especially when it comes to conservative health policy. They trumpeted some of the changes that you saw in the
One Big Beautiful Bill, including, provider taxes and state-directed payments, and they have noted that, they
believe that the ACA, enhanced subsidies, which has, increased the amount of $0 premium plans, has increased
ACA fraud.... on the exchanges, because there's more zero dollar, more of these zero-dollar plans where people
may not know that they've signed up for a plan, may not know that they're even on Obamacare. And brokers
would do this so that they could get a, a commission. And, but I've, I've talked with some, other experts and, and
backers of the ACA that note that while there ha- this has been a problem, on the exchanges in CMS in the past
couple years, and CMS has taken action to address it, it hasn't been as much of a problem with the states. And
the reason is, is that the states have state-run exchanges of which there's 20 and the District of Columbia. the
states have a, a more, like a stricter sign-up protocol. They, they, you know, require, consumers to call in to the
marketplace to confirm or require more documentation in order for a broker to get their commission. So, you
know, there's some, you know, critics that are pushing back on that assertion, but it has taken root among a lot
of Republicans this, this idea about that the enhanced subsidies have, increased fraud on the exchanges. And that
is one of the reasons why, they should be expiring, or they should, they should let them expire I should say.

Margaret (13:39)
Wildly popular. (laughs) As far as I can tell, they're pretty wildly popular with consumers.

Mark (13:43)
I, I think we know, polls are opinions and Election Day is judgment. But Robert, I'm, wondering the flip of, of
this is that polling shows Democrats at least now winning on the healthcare issues after the government
shutdown. Wondering if you can give us an overview of where the broader public opinion sits right now.

Robert (14:04)
Sure. So, there's been, I think some, some polling I believe from K- from KFF. which is a nonpartisan,
nonpartisan, health policy research that shows that a majority of both Democrats and I believe also Republicans,
have been in favor of extending the subsidies. it's been harder I think for conservatives to manage and get that
message across that these subsidies are a net negative for, consumers. And it's been an issue that has plagued
conservatives for a while when it comes to healthcare policy, including whether or not they wanted to make cuts
to the Medicaid expansion during Obamacare repeal in 2017. it's, it's kind of a question of whether or not
conservatives... how much will this hurt conservatives. it, you know, remains to be seen. I think that it's
important to note that what I said earlier that ACA open enrollment has started, and there's been, a lot of auto-
enrollment that is still occurring. But some experts say we need to wait and see until January when people will
see their first premium payment- Right. ... and be like, "Wow, I don't wanna pay this, and then I might..." That's
when you might start to see some shifts. But states have already been telling me that they are not seeing as
much, newer enrollees. These are people that are not on the exchanges and would not auto-renew. They are
seeing fewer in, new sign-ups this year compared to, prior open enrollments.

Mark (15:39)
But not fewer people, right? It's just that it hasn't grown? Is that what it... Or there was-

Robert (15:44)
Yeah, yeah, like, like, they, they, there's a certain portion that will auto, auto-renew every year and then there's,
they also have a certain portion that will come in and want to get coverage for one reason or another. either they,
you know, are, have changed jobs or they've, you know, recently decided or recently been able to gain access to,
you know, gain access to subsidies or something like that. But they, what they, what I- I believe I talked with
one state that said that they are seeing, fewer of these new sign-ups so far this year.

Margaret (16:23)
Which may translate to more uninsured people-

Mark (16:25)
That's right.

Margaret (16:25)
... period. Yeah. Well, I'm gonna turn away from, the Affordable Care Act and Obamacare for just a minute.
Sandhya, we'd love for you to tell us about your reporting on the new number two person at the Centers for
Disease Control and Prevention. he's an outspoken critic of mass vaccination. That obviously is troubling, to
many, but what are, what are you hearing and reporting on?

Sandhya (16:48)
I think the timing of them kind of rolling out this, this, you know, number two at CDC is interesting. So, the
former Louisiana Surgeon General Ralph Abraham is, you know, now the number two at CDC. They announced
this shortly before they had the ACIP meetings to, you know, discuss all sorts of vaccination things just last
week. And I think, given his past comments, you know, as, you know, he's a former member of Congress but
he's also in his role as Louisiana, surgeon general, you know, he's amplified a lot of, like, vaccine skepticism.
He's opposed, you know, max vac- ma- mass vaccination for like the flu and also been a pretty strong prom-
proponent of ivermectin, as a COVID treatment which has, you know, been debunked. And so, I think that as
we see a little bit as what he's gonna be doing, that'll be interesting. He's also, criticized, Bill Cassidy who holds
the Health Committee, and that sort of, you know, aligns a little bit with the back and forth that there's been
between Health Secretary RFK Junior and, and Cassidy. So, I'm, I'm kind of curious, you know, what we'll see
from him, especially since now we know-

Mark (18:09)
So, it's not a Senate conf- confirmed position then, I assume?

Sandhya (18:13)
Yeah.

Mark (18:13)
For making those attacks? (laughs)

Sandhya (18:15)
And we don't...We don't have a CDC director, at present, after Susan Báñez was, was fired earlier this year. And
so, I guess in the wait for someone to be nominated by Trump, for that to kind of go through that process, it's,
there's less control from, from Congress and just, you know, less oversight in terms of what's gonna be done
then. But it, it, it seems like it's going to be more on this MAHA agenda. Abraham has spoken pretty frankly
about being a proponent of MAHA, and so I think those are the kind of things that I'll be kind of eyeing, and just
seeing, at CDC in, in terms of how they're gonna address, communicable diseases, but especially on, on
vaccines.

Margaret (18:58)
And, and very interesting, I think we're seeing, states taking things much more into their own control with their
departments of health around their recommendations, what they'll pay for, what they'll provide, to communities,
so it's gonna be very interesting to see how this shakes out.

Mark (19:12)
Senator Cassidy have any buyer's remorse in terms of, the secretary's position or is he just, being, held down by
his conservative base?

Sandhya (19:23)
I think he's a little cryptic in, in kind of how he responds when he's asked on some of these things. I mean, he
will go after specific comments, like after ACIP last week, he said, you know, he was disappointed in some of
the, the things related to hepatitis, especially given his background, you know, working on that issue for many
years as a physician. but I think he's kind of stopped short of just, saying anything too strong. I mean, he's still
also up for reelection coming up, and I, I think it's, it's a tough position to be in when, some of the things that
you might be looking for are not kind of playing out. Is he fa- facing a primary or not? I forget. there have been
people that, yeah, have expressed interest in primarying him.

Mark (20:07)
Yeah, absolutely. Robert, another big change in 2026 is the adjustments to the Medicare physician fee schedule.
Basically, highly paid, physicians are getting a bit of a cut in their reimbursement rate, and primary care doctors
are getting a boost. But to the rescue, the AMA is really fighting back. tell us about their initiative and how
succes- successful it might be.

Robert (20:30)
Sure. So, this is, an issue surrounding the physician fee schedule, which, sets the physician payment rates for
Medicare for the coming year. And this is the first one that has occurred under the new administration, and it
makes some interesting changes to, kind of how the payment rates for certain types of physicians are calculated.
for a while, the, and still going, the American Medical Association relies on, has a committee of doctors, and
that includes se- several different specialists that offer, that offer kind of these payment rates. And there's been
concerns among physicians that the payment rates for primary care has lagged behind that, changes to that has
lagged behind, other more higher-paying specialties. And it has filtered down to whether there, this will, limit
primary care as a desirable, as a desirable type of field to go into, especially since it's very expensive to go into
medical school, and a lot of doctors won't go into one of these specialties 'cause they have student loans to pay
off. So, CMS really tried to make a change to this where it bumps, payments for family medicine and general
practices by about 3%, and at the same time, it lowers the payments for some specialties. like for instance,
neurosurgeons will have a 5% pay cut, but, in some s- in some respects, that specialty could, get a higher pay
cu- pay increase. Like an allergist will take home an extra 7%. So, this is part of a, this action done by Dr. Oz,
who is actually a doctor, is, part of a, a larger examination, I would say, that the RFKs HHS wants to take on the
AMA. They are concerned that the AMA has too much power when it comes to setting, rates and policy for,
Medicare. For instance, there's been concerns about the diagnosis codes, which is the code that a doctor will
submit to Medicare to, essentially get reimbursed for a service. These codes have been, created by the AMA as
well. So, there's concerns whether or not the codes have been properly, you know, developed over time, and
that's, I think, another fight that we should look for on the horizon surrounding this. 'Cause this is s- this is a
issue that RFK in particular has, has championed in addition to many, many others.

Mark (23:32)

Margaret, Robert just mentioned student loans. (laughs) And I think the whole prof- profession, the whole
healthcare industry was taken by surprise when nurses were sort of relegated to a much lower level in terms of,
healthcare, coverage, in terms of, student loans. I'm wondering, d- is this, wh- where did this sort of arise from?
I think, the nursing world's, certainly very concerned about the change that happened. I- any sense of what was
the motivating force to make those changes?

Robert (24:04)
I believe that that was a, I think, something that the Department of Education had created, and it's part of a
larger reform, effort that they're doing to be d- that they're looking to do over there. They're looking to,
um...You know, it's, it's creating the “what is the definition of a professional degree”, and they want to reclassify
graduate nurses as graduate instead of professional, which could limit the amounts, student loan amounts that
nursing students could get. nursing organizations have really been pushing hard against this. They think that it is
a harmful policy for the profession. So, we'll see where this goes.

Margaret (24:48)
We'll have to do another show on that, sometime 'cause it has a potential very adverse impact on the pipeline,
certainly in terms of primary care as well as acute care, settings. But I wonder, if I could just, get us to focus for
a moment on the fact it's also open enrollment season, for the Medicare Advantage plans. And generally, I think
almost since Medicare Advantage plans were created, the Republicans were big supporters, but that, there
started to be some cracks in that facade. tell us where you think things stand in terms of continued support for
the Medicare Advantage plans.

Robert (25:23)
Sure. So, I, I, I think that Republicans still love MA. I think that Democrats, well, more centrist Democrats, I
think progressives are not fans of MA, but I think that Republicans still love Medicare Advantage. But there is a
growing course of concerns surrounding the program. They, Republicans are concerned about the high amount
of, prior authorization care denials which require a doctor to, get insurer approval before delivering a
prescription or delivering care. It's become a source of frustration for doctors, and, and Republicans have, have,
have generally seen and heard that frustration. There's also concerns about spending. Republicans have wanted
Medicare Advantage spending to be in line with traditional Medicare, and it, that's just not the case. And they've
been very critical of that. There's been a bipartisan bill called the UPCODE Act, which, new UPCODE Act,
which is, co-sponsored by Jeff Merkley and Bill Cassidy, that would clamp down on some of these, some of
these issues that they say are driving a higher spending in the Medicare Advantage program. So, I think that
Republicans are still very, in favor of Medicare Advantage, but there are definitely targeted reforms that they
want to make to the program.

Mark (26:56)
I know we only have a few minutes left, but let's ask each of you what you think the big healthcare story of 2026
will be.

Sandhya (27:03)
I think, to, to put it all under one umbrella, I think affordability, and, you know, the forms of that will be a big
thing, whether or not we get any sort of deal on ACA or, or some of the other things that have been in the mix. I
mean, Congress has been very interested in PBM reform and things like that to, to bring down health costs. So, I
think going into next year, regardless of what happens in the next couple weeks, that'll be, definitely something
big to, to watch here. And I would just also add in, you know, after we got the, One Big Beautiful Bill passed
into law this year, a lot of those things start getting implemented next year. So just in terms of how those play
out or if there are things teed up for 2027, just how states are figuring out that they will implement those things.
So, I think those will both be very big.

Robert (27:50)
Yeah. I, I ... Yeah, definitely. And two things that I'm really looking for are, the implementation of the Rural
Health Transformation Program. Right. It's a $50 billion fund passed with the One Big Beautiful Bill Act, which
I'm trying to make as OB3 as the acronym to be used. I don't know if it'll work. but that money, there, you
know, c- CMS is going to decide which states get a slice of that money literally in a couple weeks. And there's
already ... Politically we had a, a story about how some plans, some states are chaffing that they have to adopt
certain MAHA policies, in order to qualify for that funding. So, where that money goes and how it's spent is
something I'm really taking a look at. I, as a CMS reporter, I'm also looking into, you know, concerning what
changes that Dr. Oz has been making or wants to make, to physician, to physician pay and to value-based care,
especially, several new models that they are rolling out and they're implementing. I think the other thing I'm

really looking into is how states implement the work requirements program- Right. ... for the, under OB3,
which, goes into effect in 2027. So, states have about a year to set up this whole program and ensure that people
don't get, inadvertently lose coverage, which was a concern that some states had, with work requirements, is
that, you know, some people will drop off coverage even if they meet the requirements. So those are, kind of
three things that I'm keeping an eye on. And of course, we have the midterms and also, you know, MAHA,
within HHS, what could be the n- the next, change that we could see for the agencies?

Margaret (29:42)
Well, we'll be keeping an eye on both of you and on your reporting, and we wanna thank you, Sandhya and
Robert, for joining us. And thank you to our audience for being here. Remember, subscribe to our videos on
YouTube, find us on Facebook and X, and please share your thoughts and comments about this program. Take
care and be well.

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Margaret (30:04)
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
retransmitted in whole or in part without the expressed written consent from Community Health Center Inc. The
views expressed by guests are their own, and they do not necessarily reflect the opinion of Conversations on
Healthcare or its affiliated entities.

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