What Will the Administration’s Policies Actually Mean for Patients? –

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The Big Picture –
By Glynn Wilson –

The Affordable Care Act changed American health care by making insurance available to millions of people who previously couldn’t obtain or afford it. The second Trump administration is now making changes that appear to be a direct attack on some of the most significant advances of what came to be called “Obamacare,” for good or ill.

President Donald Trump and his administration have made political claims that lowering health-care costs, reducing government spending, fighting fraud and changing the way Medicaid and insurance subsidies work will make America’s health policies work better. Critics disagree.

The most consequential change is no longer merely “proposed.” The 2025 reconciliation law has already been enacted, and the Congressional Budget Office estimates that its health provisions will result in 7.5 million more uninsured Americans in 2034, including a projected 12.9 million reduction in Medicaid enrollment.

This would leave millions of Americans with less coverage, and a smaller government role in paying for health care without making the underlying corporate health-care system any smaller or better.

That distinction may be one of the most important things for patients to understand.

The Biggest Change: Medicaid

The most consequential change is the reduction in federal Medicaid spending and enrollment resulting from the 2025 reconciliation law.

The Congressional Budget Office estimates that the law will reduce Medicaid enrollment by approximately 12.9 million people and increase the number of uninsured Americans by approximately 7.5 million by 2034.

Those changes don’t necessarily mean 7.5 million people suddenly lose all access to medical care. Some people will obtain insurance through employers. Some will move into ACA marketplace plans. Some will become eligible for other coverage.

But millions are expected to lose Medicaid coverage or become uninsured.

That matters enormously for hospitals and physicians.

Why Hospitals Care About Medicaid

Hospitals don’t provide medical care in a vacuum. They have payrolls, buildings, equipment, emergency departments and specialists to pay for.

When an insured patient receives care, the hospital generally receives reimbursement. When an uninsured patient receives emergency care, the hospital may receive little or no compensation for the full cost.

That means reducing Medicaid enrollment could create particular problems for hospitals serving low-income communities.

And that brings us directly back to the corporate-health-care question.

Large hospital systems have the financial reserves and economies of scale to absorb losses better than many small independent practices.

A rural hospital may not. A small physician practice may not. A community hospital operating on thin margins may not.

The unintended consequence of reducing government insurance payments could therefore be more consolidation.

A struggling independent practice closes. A larger hospital system buys it. A rural hospital cuts services or closes all together.

A larger system absorbs the remaining patients.

The government spends less. But the health-care corporation becomes larger.

That is a paradox worth watching.

The Administration’s Argument

The Trump administration argues that Medicaid has become vulnerable to fraud, improper payments and inefficient spending, although no proof has been offered and is not forthcoming, leaving the administration open to criticism and creating a political opening for Democrats.

The administration has launched major anti-fraud efforts involving Medicare and Medicaid and has said the objective is to protect taxpayers while making health care more affordable. In February 2026, HHS announced initiatives including tighter scrutiny of questionable Medicaid claims and a nationwide moratorium affecting enrollment of certain durable-medical-equipment suppliers.

But very little fraud has been identified, and the new so-called work requirements have just become an even more bureaucratic electronic paperwork requirement for patients, something many elderly patients are not equipped to deal with.

Personal Details

This just happened to me. Because of the new federal changes, states are sending out letters to everybody demanding that they prove they are a resident of the state in which they reside, and they are only given 10 days to MAIL a postcard that is being used to PROVE that people are legal residents.

I got such a letter in the mail. I checked the box and sent the card back, but apparently it was lost in the mail. So I received another letter from Sacramento saying that my health care had been canceled, and another letter from Social Security saying that the state would no longer pay my Medicare Part B premium. In fact, it indicated that Social Security was deducting FOUR MONTHS of premiums retroactively, meaning I would not receive enough Social Security to make it through the month of September.

I was able to jump into action and ended up fixing the problem. But I had to first contact Social Security on the phone, file an electronic appeal, and contact the Mariposa County Health and Human Services department to get an agent to help straighten the issue out with the state and feds. The case worker who had been assigned to my case was new and didn’t yet understand all the nuances of the system. So a supervisor had to become involved.

On a followup call with Social Security to let them know that the county and state had fixed the problem, I was told to contact the Social Security office in Merced. But the phone number for that office automatically redirected to a private health insurance outfit called Medicare Advantage. There was no one working in the Merced office to take the call.

When the national Social Security office confirmed this, and I filed the digital appeal demanding a review of my case, the problem finally got fixed.

Imagine how many older people without the technical skills to fight the bureaucratic system are now suffering without health coverage and reduced Social Security payments. Republicans often campaign for office saying they are for reducing federal bureaucracy. But in fact, Trump’s changes only created even more bureaucracy. This proves it.

People are dying all across America right now because of this. Is that the intent?

The ACA Marketplace Is Also Changing

This administration is also changing the rules governing ACA marketplace insurance, and proposed regulations for 2027 they say is intended to increase competition, reduce fraud and improve the operation of the exchanges. The administration says the changes will remove barriers to innovation and help reduce premiums.

But there is another possibility, or perhaps probability. If regulations reduce enrollment or subsidies faster than they reduce the underlying cost of medical care, consumers could simply end up paying more themselves.

That is the central problem with American health insurance. Insurance prices are not the same thing as health-care prices.

You can make an insurance plan cheaper by reducing what it covers or increasing the deductible. That doesn’t make medical care cheaper.

The Subsidy Question

The ACA marketplace became particularly dependent on federal subsidies after the enhanced premium tax credits were introduced during the Biden administration. Those enhanced subsidies have since become a major political battleground.

CBO’s current projections show federal spending on ACA marketplace subsidies declining substantially because of provisions enacted in the 2025 reconciliation law, and estimates that the law reduces projected premium-tax-credit spending by approximately $130 billion over 2026–2035.

From the government’s perspective, that’s savings. From a patient perspective, however, the question is: Who pays the difference?

If the federal government pays less, either insurers, employers or patients ultimately bear more of the cost — unless underlying medical prices fall enough to compensate. That is basic economics no one in Congress or this administration seem to grasp.

The Drug-Price Wild Card

There is another area where the administration could potentially produce benefits for patients: prescription drugs.

In August 2026, the administration announced additional agreements with pharmaceutical companies aimed at bringing certain medicines to Medicaid programs at prices tied to international “most-favored-nation” pricing. The administration estimates substantial future savings, although the actual discounts are not fully public and independent assessments of the ultimate savings remain necessary, but not forthcoming.

It is an interesting question that has been asked by previous administrations, including the Obama administration.

Why should Americans pay substantially more for the same medicine than patients in other wealthy countries?

If the administration succeeds in forcing prices downward without reducing access to innovative medicines, patients could benefit. But that remains to be seen.

Medicare Is a Different Story

Medicare is more complicated.

The 2025 law’s biggest insurance changes primarily involve Medicaid and ACA coverage, while Medicare continues to grow as an enormous federal program. CBO projects Medicare spending at about $1.1 trillion in 2026, with spending continuing to rise substantially over the following decade.

The administration therefore faces a fundamental problem.

America is aging.

Older Americans use substantially more medical care. Cardiovascular disease, cancer, diabetes, dementia and other chronic conditions become more common with age.

Simply cutting the government’s contribution doesn’t eliminate those medical needs.

Someone still has to pay the cardiologist, operate the catheterization laboratory, perform the bypass surgery and provide the hospital bed.

What Happens to the Corporate Health-Care Machine?

This may be the most important unanswered question.

Suppose the federal government spends less on Medicaid, and ACA subsidies are reduced.

Even if Medicare and Medicaid aggressively pursue fraud by providing more digital paperwork, this will not help and most likely hurt patients.

Suppose drug companies are forced to offer lower prices. Does American medicine become less corporate?

No. In fact, some of these policies could strengthen large organizations.

Consider a small physician practice. It has relatively high administrative costs and limited bargaining power with insurance companies. It may have difficulty absorbing patients who cannot pay and can’t afford sophisticated billing departments. It can’t negotiate drug prices.

A giant health system can do all of those things. So when financial pressure increases, consolidation becomes even more attractive.

The irony is that a government attempting to reduce health-care spending could inadvertently encourage more private-sector consolidation.

What Patients Could Lose

The potential disadvantages are significant.

* More uninsured people.

* Medicaid reductions. People who depend on Medicaid could face new eligibility and enrollment requirements or lose coverage.

* Higher out-of-pocket costs. A less expensive insurance policy isn’t necessarily a less expensive health-care policy. Patients can save on premiums while paying substantially more when they actually need medical care.

* Fewer providers. If Medicaid reimbursement becomes less attractive or administrative burdens increase, some doctors may stop accepting Medicaid patients.

* Rural hospital pressure. Hospitals serving poorer communities could be particularly vulnerable to reductions in government reimbursement.

* More consolidation. Financial pressure could cause more independent physicians and smaller hospitals to join large systems. That could make American medicine more corporate rather than less.

The Heart Patient Is a Perfect Example

Consider someone living in the Sierra foothills with heart disease.

Under the ACA, that person gained important protections against being denied insurance because of a preexisting condition.

Under the current Trump-era changes, that person’s experience could depend heavily on income and the type of insurance they have.

If they have employer insurance, little may change.

If they have Medicare, the picture is different again. And if they depend on Medicaid, eligibility changes could be extremely important.

If they buy insurance through an ACA marketplace, changes to subsidies and eligibility could affect premiums and out-of-pocket costs.

Regardless of insurance status, they still have to find a cardiologist, who probably work for a large hospital system.

The hospital may be negotiating with several insurance companies, and the insurer requires prior authorization for procedures.

The doctor may have productivity requirements.

The patient may be sitting in an examination room wondering for a long time, and have to drive two hours to get to an appointment that lasts five minutes.

Changing who pays for American health care doesn’t necessarily change what American health care costs.

The Real Test

Perhaps the Trump administration should be judged by outcomes rather than ideology, although its attacks on science on many fronts is cause for concern on health care as well.

Do patients pay less? Do more people have access to physicians?

Are heart attacks treated faster?

Do cancer patients live longer?

Are prescription drugs genuinely cheaper?

Are rural hospitals staying open?

Are emergency rooms less crowded?

Are unnecessary procedures reduced?

Are doctors spending more time with patients?

Are medical bankruptcies declining?

Are hospitals becoming more efficient?

And most importantly:

Is the health-care system becoming less expensive without becoming less accessible?

Those are measurable questions.

The Coming Collision

The United States is now confronting three enormous forces simultaneously.

An aging population.

An increasingly corporate medical system.

And a political movement seeking to reduce the federal government’s role in financing health care.

Those forces are going to collide.

The ACA expanded the number of people with insurance. The Trump administration is attempting to reduce government spending and reshape the programs that provide that insurance.

Neither approach, however, completely solves the underlying problem of American medicine: The United States spends enormous amounts of money on health care while leaving patients, doctors and hospitals trapped inside a complicated system of competing financial incentives.

The real reform would have to address the prices themselves. The price of a hospital bed, medical procedures, what a prescription drug costs, and of course the price of an insurance policy.

Also the administrative cost of billing, salaries and overhead of the corporate system, as well as the financial incentives that determine what medicine gets delivered.

Until those things are addressed, America may simply continue moving money from one part of the health-care machine to another.

Then the patient will remain standing at the end of the assembly line, still paying the bill with perhaps less than satisfactory outcomes.

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Finally, we write about what the world will be like in 10 years, when there will be nine billion people on a planet devastated by climate change.

Part I – Facts Matter: The State of Health Care in America

Part II – When Medicine Starts to Look Like a Factory

Part III – The Affordable Care Act and the Corporate Transformation of American Medicine

Part V – Nine Billion People on a Warming Planet: Humanity’s Next Great Test

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