Pros of expanding public coverage

Cons

+ Medicaid expansion linked to lower death rates

+ Uninsured rate fell from about 16% to 8%

+ Medical debt protection

– About $94B a year in improper payments (CMS FY2025)

– Brokers enrolled people without their consent for subsidies

– Medicare hospital fund runs out in 2033

Bottom line: The US spends about twice the OECD average per person and gets shorter lives. The main reason is higher prices (hospitals, physicians, drugs, administration), not more care. The ACA cut the uninsured rate sharply but didn’t control prices. The 2025 rollbacks are reversing some of its coverage gains. Medicare’s hospital fund runs dry in 2033.

US health spending, 2023

$4.9T; 17.6% of GDP

CMS National Health Expenditure data

OECD average health spending

About 9% of GDP

OECD Health Statistics

US life expectancy, 2023

78.4 years (OECD peers mostly 81–84)

CDC NCHS

ACA Marketplace effectuated enrollment

22.3M (2025) to about 17.5M projected 2026

KFF

Enhanced premium tax credits

Expired Dec 31, 2025

ARPA/IRA sunset

Average net Marketplace premium payment

$113 to $178 a month (+58%), 2026

KFF

Medicare HI trust fund depletion

2033 (2026 Trustees)

Medicare Trustees, June 2026

Medicare enrollment / spending, 2025

69.3M; about $1.2T

Medicare Trustees

2025 reconciliation law Medicaid changes (work requirements etc.)

10M more uninsured in 2034 (7.5M Medicaid/CHIP, 2.4M Marketplace); about 15M including subsidy expiry

CBO, Aug 2025

Affordable Care Act (2010)

Medicaid expansion to 138% FPL (optional after NFIB v. Sebelius; 40 states plus DC have expanded), subsidized Marketplaces, guaranteed issue and community rating, and an individual mandate (penalty zeroed in 2019).

Medicare

Federal coverage for 65+ and disabled people. Part A is funded by payroll tax. Parts B and D are about 75% general revenue. Medicare Advantage now covers about 51% of enrollees. The IRA (2022) introduced drug price negotiation, starting in 2026.

Medicaid

Joint federal-state coverage for low-income people. The 2025 law (OBBBA) adds work requirements for expansion adults (from 2027), more frequent eligibility checks, limits on provider taxes, and cost-sharing.

Employer coverage

About half of Americans, subsidized by the tax exclusion for employer premiums, the largest tax expenditure in the code.

Stated reasons

Underlying drivers

+ Cover the uninsured and people with preexisting conditions

+ Cost control (ACA ‘bending the curve’; GOP: entitlement reform)

+ Medicare: seniors’ security since 1965

+ 2025 cuts: fiscal savings and ‘able-bodied’ work norms

– Hospitals, insurers, pharma and physician groups shaped the ACA in exchange for support (2009 industry deals)

– Price regulation is blocked by provider lobbies; health care is among the top lobbying sectors

– Medicare Advantage overpayment from coding intensity, estimated at tens of billions a year by MedPAC

– 2025 Medicaid cuts helped offset the cost of the tax cuts in the same bill

Coverage

The uninsured rate fell from about 16% (2010) to about 8% (2023, Census). Medicaid expansion is linked to lower mortality in several quasi-experimental studies (e.g. Miller, Johnson and Wherry, QJE 2021).

Big gain

Costs

Spending growth slowed in the 2010s but share of GDP stayed near 17–18%. Anderson et al., ‘It’s the prices, stupid’ (2003, updated 2019): US use of care is near OECD levels, and prices drive the gap.

Not controlled

Outcomes

The US is strong on cancer survival and specialty care. It’s weak on life expectancy, maternal mortality, and avoidable deaths. Part of the life-expectancy gap is guns, drugs and car crashes, not medical care alone.

Poor value

2026 reversal

Enhanced subsidies expired, and Marketplace enrollment is dropping. 2.2M fewer by Feb 2026 (CBPP), with deductibles at a record $3,786 (KFF).

Coverage falling

Fiscal

Medicare and Medicaid are the main drivers of long-term federal deficits in CBO projections. HI turns to deficit in 2027.

Unsustainable

Medicare fee-for-service improper payments, FY2025

6.55%, $28.83B. Improper means not properly paid or documented; it is not all fraud.

CMS FY2025 fact sheet

Medicare Advantage (Part C), FY2025

6.09%, $23.67B, mostly diagnoses that plans’ records failed to support (upcoding risk)

CMS

Medicaid, FY2025

6.12%, $37.39B; 77% was insufficient documentation, which CMS says is generally not a sign of fraud

CMS

ACA advance premium tax credit (APTC) improper rate

0.89%, $657M (benefit year 2023). This measures payment errors, not identity fraud.

CMS

2025 National Health Care Fraud Takedown

324 defendants, including 96 licensed professionals; $14.6B intended loss alleged

HHS-OIG / DOJ

Duplicate enrollment, 2024

Each month, 1.2M people were in Medicaid in two or more states and 1.6M in both Medicaid and subsidized ACA plans

CMS press release

Broker enrollment fraud

Cory Lloyd and Steven Strong convicted (Nov 2025) for ACA enrollments without consent: $233M sought, at least $180M paid. CMS cut off subsidies for about 1.5M ineligible or unauthorized enrollees in 2025.

DOJ; Paragon citing CMS

Phantom enrollees

35% of 2024 enrollees (about 11.7M) filed no claims. Paragon estimates 6.4M improper enrollees and $27B in 2025. Paragon is a market-oriented think tank; zero claims alone don’t prove fraud.

Paragon Health Institute (contested)

Minnesota Housing Stabilization Services (Medicaid)

Program shut down after widespread fraud; 8 charged (Sept 2025), with guilty pleas following

MPR News; KARE 11

Verdict: The US system is bad value: world-leading spending, middling results, and a price problem that both parties avoid because providers fight back. The ACA was a net good on coverage and mortality. Revised: the enhanced subsidies did fuel real broker fraud, so verification reforms are justified. But letting the subsidies lapse entirely, plus the 2025 Medicaid cuts, removes far more eligible people than fraudulent ones (CBO: 10M more uninsured). The fix that would work is price discipline (site-neutral payment, all-payer or reference pricing, MA coding reform) plus means-tested coverage.

Strongest defense of the US system

Strongest critique

+ Innovation: most new drugs and devices are developed and launched in the US

+ Short waits for specialists and elective surgery compared with Canada and the UK

+ Consumer choice, and high quality at the top end

– About twice the OECD cost per person, for shorter lives

– Medical debt and coverage gaps that peer countries don’t have

– Lobbying keeps prices high, a textbook case of capture

Who

Party / level

Position

Evidence

Ref

Sen. Bernie Sanders (I-VT); Rep. Pramila Jayapal (D-WA)

Democrat/Ind.

For

Lead sponsors of the Medicare for All Act

[1]

Asm. Ash Kalra (D-CA)

Democrat

For

Authored AB 1400 (CalCare single-payer); pulled without floor vote Jan 2022

[2]

Gov. Gavin Newsom (D-CA)

Democrat

For

Signed SB 770 (2023) to pursue federal waiver toward unified financing; 2018 campaign backed single-payer

[3]

House Democrats (219)

Democrat

For

Passed ACA 219–212 (Mar 21, 2010); 34 Democrats and all Republicans voted no

[4]

Sens. John McCain, Susan Collins, Lisa Murkowski (R)

Republican (defectors)

For (qualified)

Voted no on 2017 "skinny repeal," which failed 49–51

[5]

Republicans; President Trump

Republican

Against

H.R. 1 (2025) added Medicaid work requirements and cuts; no Democrat voted yes

[6]