Health Reform Review: What’s Breaking, & Breaking Through

June 11, 2025

Note to HJM readers: These are politically trying times. I’m distracted by that turmoil, and I bet you are too. Hence the brief hiatus in recent HJM posts. However, I think health insurance is a critical and integral part of democratic evolution. That’s why I undertook this status report despite, indeed partially in response to, the political struggles. – Jim

A) Proposed funding cuts

Congress’ budget reconciliation bill has morphed, far more than ever before, into an omnibus policy bill – possible because policies need funding. A budget bill is not subject to the Senate’s filibuster rule, which would empower Democratic opposition. There’s another tactical reason: the more sweeping the provisions, the less likely that opposition to specific elements will coalesce. Several health insurance provisions are important:

Medicaid cuts are the highest profile issue. Proposed changes include enrollee cost-sharing, lower federal payments for states covering or helping immigrants, work requirements, limited retroactivity of eligibility, blocking minimum nursing staffing levels, and eliminating participation by Planned Parenthood. Total federal cuts are ~$800 billion over 10 years.

Affordable Care Act (ACA) – failure to extend COVID-era premium subsidies would cut federal contributions to health care for the near-poor by $300 billion over ten years.

Veterans’ Affairs (VA) – the new VA director is eager to cut budgets, with no surgical precision in the process, threatening clinical capacity. Community medical resources are often not up to the task of picking up the slack.

Medicare is not directly affected by the budget bill. However, under the 2010 PAYGO law, rising federal budget deficits (expected with the new bill) would trigger up to 4% cuts to Medicare, totaling $500 billion. This is likely to be taken from payment levels, and thus potentially decrease provider participation.

Federally Qualified Health Centers (FQHC) are a major source of health care for lower income populations. Funding derives 40-45% from Medicaid (which will be heavily cut) and 15-25% from grants (which are currently not targeted, though the funding agency HRSA may be substantially cut).

Estimated changes in coverage & deaths – All of these funding cuts translate to large dips in insurance coverage and increases in mortality. Although many potential program effects can’t be quantified, e.g., for the VA, the Medicaid and ACA changes are likely to lead to 16 million more uninsured (10.9 from Medicaid, 5.1 from the ACA). The Medicaid contraction alone may increase deaths by 2,500 – 5,000 per year.

B) Flaws in the armor

The “armor” is, of course, the broad array of political and rhetorical defenses deployed by defenders of our profit-driven health insurance to retain the status quo – and their immense financial gains. The “flaws” are vulnerabilities: developments that can, in ways both focused and far-reaching, undermine private health insurance defenses. Several of these flaws are now appearing in a potentially synergistic fashion.

Widespread displeasure with Medicaid cuts. Polling indicates that opposition far exceeds support. Only 1 in 6 adults want reduced Medicaid spending; 42% want increases. Most (55-75%) are worried about the impacts on patients and providers. Even among Trump 2024 voters, 2/3 want Medicaid spending protected or increased.

Anger with private insurers. The 2024 murder of the United Healthcare CEO clarified – and galvanized – broad dislike of private insurers. Polling in December found that 7 in 10 adults blame the death at least partly on private insurance care denials and profits.

Stricter regulation of Medicare Advantage insurers. The Center for Medicare & Medicaid Services (CMS) is substantially bolstering oversight of MA plans. Audits of diagnostic upcoding (which bumps MA premiums by $40 billion / year) are being enhanced 50-fold. UnitedHealth (UH) is being investigated. And care denials are being restricted and scrutinized. This clamp-down is surprising with a pro-business White House, perhaps reflecting the industry’s distinct Harris tilt in 2024 election donations.

Slipping profits for MA insurers. The increase in premium rates for 2025 was 3.7%, the same as previewed by the Biden administration, despite expectations of an increase. UH 2025 profit projections dropped by 12–15% from forecasts, due to higher care use in MA and the payment level; stock prices dropped 22% in April. Other insurers also lost value. Alas, still quite profitable … but vulnerable.

Pharmacy Benefit Manager regulation. PBM pricing practices are under new scrutiny from federal agencies. And states are regulating too.

Drug pricing reform. The Trump administration, confounding expectations, is pushing to slash drug costs. But true to form, blaming other countries – for paying unfairly low prices. And demanding a “most favored nation” approach: other nations pay more and we pay less. Pharma doesn’t seem too upset, perhaps anticipating preserved profits There’s no telling where this will go.

Physicians unionizing. In the last several years, unionization level and intentions have jumped up, with a focus on physician welfare such as reducing moral injury. Many unions are pro-single payer.

Ongoing Support for Government Insurance Role. Gallup polling from Dec 2024 found that 65% of US adults say it is the “responsibility of the federal government to make sure all Americans have healthcare coverage” — the highest level since 2007. Support for a “government-run healthcare system” is 46% vs 49% for ”a system based mostly on private health insurance”. Properly described single payer (“government health insurance with mostly private providers”) would poll higher.

C) Advocacy strategy

Breaking the entrenched opposition to single payer will require large doses of determination, creativity, and persistence. With no guarantee of success, but every reason to keep trying, because so much health and peace of mind are at stake. I list a few themes, opportunities, and resources. This is far from a comprehensive strategy – which we will return to in future posts.

Highlight budget bill cuts & their effects: Tell everyone you know what’s at stake if programs are unraveled – millions more uninsured, thousands more lives lost.

Contact your senator, especially if Republican: The budget bill faces an uphill battle in the Senate – the vote margin is narrow, and public sentiment is against it. But Senators need to be reminded constantly of this displeasure, and understand the consequences of going against the will of voters.

Persuade friends and family members. Show them the stark statistics summarized above about what happens with insurance cuts. Remind them of the fundamental humanity of providing health insurance, and the cruelty of taking it away.

Eyes on the prize for Single Payer. Go beyond the critique of program cuts. Single payer is the solution that both saves money and provides universal broad coverage with generous benefits. Dozens of countries use it, with lower mortality, lower spending, and no significant medical debt. Use the cuts to Medicaid and other programs – which people heartily dislike – to offer the vision of permanent, universal public insurance.

Expand your vision to community empowerment. Single payer is essential, but a truly transformative approach should also build public health capacity and not-for-profit community providers (more on this soon).

Participate in Coalition-building. There are many opportunities. The May 31 National Day of Action for Single Payer had events in dozens of cities (full report soon). There’s a one-payer state strategy meeting in Denver (and on Zoom) on August 1-2.

Health Justice Monitor: Check out our new website, HJM 2.0, to be launched in June. Blog posts (of course), data visuals for use in talks, a list of 5-minute daily actions, a glossary, organizational descriptions and links, and to navigate all this – super-charged search capabilities including via an AI bot – ask any question, get a coherent & authoritative answer.