Trump now wants what the Democrats wanted on health care. Just one problem: his party.

The president refused to negotiate with the Democrats in the Congress when they wanted to renew Obamacare subsidies in exchange for their support in keeping the government open.

Donald Trump said no, even though renewing tax credits expanded during the pandemic would have been good for GOP voters who buy health coverage through Affordable Care Act insurance exchanges.

Now that the government is open, the White House is reportedly going to propose doing what the Democrats wanted all along. This time, however, the main obstacle isn’t them. It’s the president’s party.

CBS News:

“Speaker Mike Johnson has told the White House that most House Republicans have little interest in extending the Affordable Care Act's enhanced subsidies … Johnson delivered the message in a phone call with senior administration officials as President Trump's advisers were drafting a plan to continue the subsidies for an additional two years.”

I don’t know what’s going on, but I do know time is running out. If the Republicans do not act by the end of the year, people like me are going to see their premiums double, triple and, in some cases, quadruple. Moreover, we must decide before open enrollment ends in January.

Some 24 million Americans are in this jam thanks to the carelessness of Trump and the GOP. However, that’s par for a party that doesn’t seem to understand the realities of health care or health insurance.

Republican Bill Cassidy said government should skip over insurance companies to send money directly so Americans can shop around for the best health care, as if ordinary people know the difference between a good open-heart surgery and bad (we don’t), as if heart surgeons know how much open-heart surgery costs (they don’t).

Republican Rand Paul was dumber. He said people should buy insurance through a “collective.” That’s, yanno, what Obamacare is.

As I often do in these situations, I called on Charles Gaba. He’s the founder of acasignups.net and an authority on health policy. The upside? He said, “the cracks in the Trump takeover of the GOP are finally starting to form.” The downside? His recommendations are “like recommending the best Band-Aid to put on a gaping gunshot wound.”

The White House seemed to be ready to push to renew Obamacare subsidies for two years. Then House Speaker Mike Johnson called to say it ain't gonna happen with his conference. What's going on?

Well, the proposal itself is still just a "framework," according to most reporting, but it seems to be sort of a Frankenstein mish-mash of:

• The "HOPE Act," which is a bipartisan proposal to extend the subsidies for two years with minimal changes and logical measures to crack down on broker fraud (which I wrote about quite favorably);
• US Senator Bill Cassidy's "HSAs for All!" proposal, which would convert the enhanced portion of the tax credits into health savings account funding for deductibles and co-pays, etc, instead of premiums (which I wrote about less favorably a week earlier); and
• The Trump administration’s existing so-called "Integrity & Affordability Rule," which is a collection of regulatory changes put into effect earlier this year, which hurt a lot of marginalized people while also weakening the ACA and making it more cumbersome.

Democrats should be extremely alarmed at No. 2 and No. 3, both of which mostly consist of poison pills. But Republicans are apparently furious about No. 1, because most of them are opposed to extending the enhanced tax credits under any circumstances, whether there's a bunch of horrible stuff attached to it or not.

As for what happened, it sounds like the Trump White House just assumed that his iron-clad control over the entire GOP is still so absolute that he didn't have to bother even informing them about it. Apparently, many of them only found out about his proposal via social media reports from Politico, Axios, CNN, etc, as I did.

To me this sounds like the latest evidence that the cracks in the Trump takeover of the GOP are finally starting to form. Senate Republicans ignored his demand that they kill the filibuster; all but one House and Senate Republican voted for the bill to release the unredacted Epstein files; Marjorie Taylor Greene, who's about as maga as maga can be, breaking very publicly with Trump and going from besties to mortal enemies (how much of that is for show I don't know), etc, etc.

I think (I hope) the GOP is finally starting to realize that he's not gonna be around forever and they're having a seriously rude awakening that he's destroyed their brand heading into next year’s midterm elections.

For those people, like me, who buy their insurance through the Obamacare exchanges, time is quickly running out. We're supposed to make choices in the next few weeks. What are we going to do?

Well, as you know, I'm right there in the same boat with you. Both my wife and I are self-employed, and we and our son are on the exchange as well. I wrote about our own situation.

I've written up a detailed Open Enrollment Guide, which includes more than a dozen important tips. Most of these are important every year but some are even more critical this year, especially assuming the enhanced tax credits do expire (which seems almost certain at this point) and due to other harmful changes made via the same "Integrity Rule" I referenced above.

In most states, I don't have a whole lot of advice other than to shop around because the available plans, networks and pricing change a lot from year to year. However, if you live in any of about a dozen or so states, there's actually some good news:

• There's around 10 states that have their own state-based supplemental ACA subsidies, which will cancel out either all or some of the lost federal tax credits for at least a chunk of enrollees (mostly those at lower income levels).
• There's also around a dozen or so states that have implemented (or newly implemented) robust "Premium Alignment" pricing policies, which have the effect of making Gold plans cheaper than Silver plans and Bronze plans dirt cheap (rather than merely "somewhat" cheaper) compared to Silver plans.
• In particular, if you live in New Mexico, you actually have nothing to fear for 2026, because the state has somehow managed to cancel out 100 percent of the lost federal tax credits for 100 percent of enrollees, which is an astonishing story I've written about before and plan on doing again next week:

For most enrollees, however, I admit that some of the above is more like recommending the best Band-Aid to put on a gaping gunshot wound. As much as I hate to say it, for a lot of people, the least-worst thing they can do is to enroll in the dirt-cheapest Bronze plan they can find so that, at the bare minimum, they have protection against a catastrophic healthcare event (hit by a bus, cancer diagnosis, etc).

One glimmer of hope is that if Congress does manage to cobble together a half-decent compromise, it could potentially be made retroactive. The enhanced tax credits could be applied retroactively to January 1, even if it isn't actually passed until, say, March.

Remember, that's how the enhanced tax credits were originally passed in the first place. The Democratic Congress passed, and President Biden signed, the American Rescue Plan Act into law in March 2021, with the extra subsidies made retroactive to the beginning of the year.

I just wouldn't count on that when shopping for a policy, though.

The Republicans know the easiest thing to do is renew expanded Obamacare subsidies. Marjorie Taylor Greene has made it clear that GOP voters are going to get burned if the party doesn't. The White House knows renewal is the easiest route. What's the problem?

I'm a bit stumped. Throughout the government shutdown I assumed that it was wanting to avoid the Epstein file vote, which was preventing Johnson from bringing the House back (since that required him to swear US Rep. Grijalva into office, and she was the 218th signature on the discharge petition). And I'm still sure that was part of his thinking.

Now that the government is back open, however, I can't understand it. As you say, something like the HOPE Act should be a complete no-brainer. And yet they simply can't accept that the ACA as it currently exists (with the enhanced tax credits, which really just raised them to where they should've been in the first place – and the other improvements made by the Biden administration) is extremely popular and is working pretty damned well.

This doesn't mean there aren't still a lot of major problems with the ACA, of course, or that we should declare healthcare reform over with – we still have a long way to go – but relative to where the ACA was a few years earlier, it's a quantum leap better, and they just can't seem to wrap their minds around that.

But at an even deeper level, the entire concept of "shared risk" is one which, as Paul Krugman recently put it, the Republican Brain just doesn't want to understand.

This clip of then-Speaker Paul Ryan trying to "explain" the ACA while failing to realize that he's talking about the very concept of how health insurance itself works illustrates it in a nutshell.

The way the Republicans talk about Obamacare, and health insurance generally, suggests one of two things. They don't know how they work or they do know but are pretending not to for political reasons. If they don't know, then they're hopelessly detached from the cares of normal people. If they do, then they're playing games with people's lives. What are your thoughts?

I suspect it's a combination of both. Cassidy is the most disingenuous about this, because not only is he a doctor, he actually founded a community clinic to provide low-income uninsured residents with free healthcare. So he knows damned well how risk pools, etc, work

Then again, he also once helped set up a nonprofit health center to vaccinate children against hepatitis B and influenza, but he still was the deciding vote to confirm Robert F Kennedy Jr as Health Secretary, so that tells me everything I need to know about his principles.

On the other hand, there's others like US Rep. Tom Emmer of Minnesota, US Senators Roger Marshall of Kansas (also a doctor) and especially Markwayne Mullin of Oklahoma, the latter of whom appears to be a legitimate mouthbreather, who honestly doesn't have a clue how the ACA, or healthcare in general, works.

The reality is that healthcare is an incredibly complicated topic, especially here in the US, where I've always maintained that the problem isn't so much that we don't have a system as that we have all of the systems at the same time, which is about the worst possible situation, since a lot of those different systems actively interfere with each other as well as complicating things.

So when you add to that the old line about it being difficult to explain something to someone when their livelihood relies on them not understanding it, it sort of starts to make sense.