Media Briefing: Health Insurance & the Affordable Care Act

Note: The following transcript is automatically generated and may contain errors. Please cross-reference the audio before quoting.

Ellen Wilson

Welcome, and thank you for joining us today. My name is Ellen Wilson, and I'll be the moderator for this media briefing, which is hosted by the Johns Hopkins Bloomberg School of Public Health.

Today's speakers will discuss the future of health insurance coverage in the United States, with a focus on the Affordable Care Act, the expiration of COVID-era premium subsidies, and proposals to shift support toward health savings-style accounts.

I'd like to briefly introduce our speakers. Gerard Anderson is a professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. Elizabeth Fowler is a distinguished scholar in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.

We will have time for questions following our speakers' answers to questions. We will take some that have been submitted in advance of the briefing and some in the Zoom chat. If you have a question, please enter it in the Zoom chat addressed to panelists and hosts. Please enter your name, media outlet, and question. We hope to cover as many as possible.

Please note that participants are welcome to use images, video, and quotes directly from the briefing, and that the content is for immediate release. Participants will be muted during this briefing, and it will be recorded.

Let's go ahead and start.

Professor Anderson, how is the Affordable Care Act insurance different from insurance provided by large employers?

Gerard Anderson

01:30

So, I'd like to thank all the media and all the people that I've been with over the years, talking about this issue. So let me, jump in. About half of all Americans get their insurance

through their employer. And the cost of that insurance averages about $27,000. So this represents a very large percentage of most people's total compensation. Assume, for example.

that you make $50,000 a year, which is pretty typical, and the insurance costs $27,000. Well, that means that a third of your total compensation is for health insurance.

And that is all tax deductible, so you don't pay any tax on that $27,000, but you do pay a tax on the $50,000 that you earn.

Now assume that the same person is covered by an ACA plan. And these people basically fall into 3 large categories. There are people that retire early.

Because they… and they don't qualify for the Medicare program yet.

They are self-insured.

Or they work for a small employer that does not offer insurance coverage.

So prior to the ACA, they were commonly uninsured, or if they were insured, they often paid a very high premium, especially if they had an existing condition, like cancer or something like that, and so the premium would have been more than $27,000.

But under the ACA, the government pays a portion of that insurance, so the employer, that the employer in most places would pay.

Now, most of those people under the ACA don't have $27,000, and so the debate is how much they should pay so they can afford insurance.

And often, many of these people are living paycheck to paycheck on Social Security, or they're making around $50,000, so even a $1,000 increase in their premium is a big amount that they can't afford.

The COVID subsidies made health insurance affordable to many of them, and without these health, without these enhanced subsidies, it would be very difficult for them to afford even the extra $1,000 or so.

Ellen Wilson

04:02

Great, thank you, Professor Anderson. Now a question for Professor Fowler. Why is giving people money not the same thing as making health insurance affordable?

Elizabeth Fowler

04:13

Thanks, Ellen, and thanks for the chance to be here. So, Congress provided those enhanced subsidies for ACA marketplace plans during COVID, and the enhanced subsidies are the reason that many people were able to afford coverage, and why, without the enhanced subsidies, many are facing steep premium increases or loss of insurance altogether. The President's proposal takes a different approach to addressing affordability, to give money directly to people rather than reducing the rate

Or the cost of insurance itself.

Giving people money through a health savings account, a health reimbursement account, or a flexible spending account is really not the same as providing health coverage. These approaches might work for people with higher means, or people who are relatively healthy and don't incur any health costs in the near term, but for

But for patients undergoing treatment for cancer, which can run tens of thousands of dollars.

Or a patient anticipating surgery, or a child with special health needs, or a patient with a chronic health condition, $1,000 or even $5,000 in a contribution to a tax-preferred savings account, which may grow over time, but not in time to meet current health needs, will not come close to covering the cost of care.

One trip to the emergency room could exceed the amount provided. I think another important point to make here is that a proposal like this is also not operationally feasible in a short period of time.

Important questions need to be addressed. For example, who qualifies? Are the amounts adjusted by geography? Because healthcare costs vary in different parts of the country. Do they vary by age, family size, income, employment status? How are the funds distributed? Through what means?

I think it's also likely to invite, potentially, a level of fraud and abuse, and frankly, waste of taxpayer dollars that will eclipse whatever fraud the proposal is purporting to address.

Looking for ways to address fraud and abuse and waste, and asking questions about why costs are high is the right approach, but costs are going up across the system for all payers, and patients are shouldering an increasing share of that burden.

Ellen Wilson

06:21

Thank you, Professor Fowler. Now we'll take additional questions. A reminder, if you have a question, please enter it in the Zoom chat with your name, media outlet question, and to whom you'd like to address your question.

Let's start with a question from Tammy Luby with CNN for Professor Anderson. Starting out, what is causing premiums to rise among ACA, Medicare, and employer coverage?

Gerard Anderson

06:45

So…

Healthcare costs, that is the amount that hospitals spend, physicians spend, drugs spend, is growing at about 7% or 8% per year. We see that in the latest numbers from CMS. And so, the insurance companies have to pay

the hospitals, physicians, drug companies, and so they have to increase their rates 7 or 8%. Also, they're very concerned that people will drop coverage when you,

when the premiums go up, and so they have to build that into the rates that they do, so it's not surprising that the rates will go up by 10% or 11%,

Because the underlying cost of care is going up by 7%, but then, as people drop out of the ACA plan, it'll be the sick people that'll remain in the plan, the healthy people are much more likely to drop, so insurance companies have to take that into account.

And so, all of us in health economics are very concerned that insurance, especially in the ACA plans, will start being more and more expensive as the sick people remain and the healthy people drop.

Ellen Wilson

08:06

Right, thank you. Professor Fowler, anything to add?

Elizabeth Fowler

08:10

I think it's important to add that this is not unique to ACA marketplace plans. Healthcare costs are rising across the country. If we want to solve the problem of high and rising costs, let's take a step back and start thinking about how to address affordability challenges across the system.

Ellen Wilson

08:29

Great, thank you. Next question from Kylie Kaczynski with NPRWESA FM for Professor Fowler.

Is the U.S. seeing more small companies move toward individual coverage health reimbursement arrangements, ICHRAs, and how does that model compare with the group insurance plan?

Elizabeth Fowler

08:50

So the reconciliation bill that passed last summer, the one big, beautiful bill, included provisions to open a pathway for employers to buy coverage through ACA marketplace plans or other qualifying coverage.

If businesses want to start moving people into these markets, the markets need to be stable. And by not renewing the enhanced subsidies, they are potentially undermining the stability of these markets. For example, by driving out healthier people who can no longer afford coverage. So I think a better path to make sure that ICRAs remain a viable option is to make sure that the marketplace remains

An affordable place to buy coverage.

Ellen Wilson

09:29

Great, thank you. Here's a question from Evan Robinson-Johnson with the Pittsburgh Post-Gazette for Professor Anderson to start us out. What impact do hospitals and medical systems do you anticipate from thousands of people dropping coverage? How much flexibility do hospitals and insurers have on pricing?

Gerard Anderson

09:48

So, that's two questions. The first question is the second one I'll answer, and that is, how much flexibility do they have?

And what we see is large amounts of flexibility around the United States. There are certain places where hospital prices and physician prices are very high, and those are places typically where there's a lot of concentration of hospital and physician services, and other places where it is much lower concentration, and the prices tend to be

lower. So they have a lot of flexibility there.

So I think what we're gonna see is, people trying to pass through these costs of, people becoming uninsured.

The hospitals have to treat people, that's a rule, and so when somebody walks into the hospital in an emergency situation, they need to be treated.

And so, somebody has to pay for it, and that is most likely to be people who have insurance, because the hospitals, the physicians will say, I've got to find somebody to take care of that patient, and that is typically the person who has insurance gets their insurance rates increased.

Ellen Wilson

11:11

Professor Fowler?

Elizabeth Fowler

11:13

Yeah, I think what's critically important here is to remember that this disruption that we're talking about now is happening as the historic reductions in Medicaid funding and other policies to reduce Medicaid coverage are being implemented.

The Congressional Budget Office estimated that the One Big Beautiful bill could potentially result in up to 10 million people losing health coverage.

And that bill could have included a renewal of the COVID ACA subsidies.

But not only did it not include the ACA subsidies, but it also cut nearly a trillion dollars from Medicaid. And taken together, these cuts are only going to place more pressure on hospital costs and hospital, bottom line. Any proposal to give back money to the people will not be able to make up for these gaps.

Ellen Wilson

11:59

Great, thank you. Here's a question from Scott Macioni with WYPR in Baltimore for Professor Fowler.

Why hasn't there been any pressure on insurance companies to eat some of the cost of the ACA premium credit loss? Many are reporting high profitability.

Elizabeth Fowler

12:18

I think that's a good question. I think insurers have done what they can to try to mitigate the potential impact. For example, to try to shift some of the costs to other

levels of coverage. Remember, there's, the silver, gold, bronze, plans, and they've tried to move the way that they think about the distribution of those,

costs and the premiums, to benefit people who are using subsidies,

to offset the cost of their premiums. I think there's only so much insurers can do. I think that, costs and premiums are going up.

across the board, I think this point is worth making again, that this is not unique to ACA plans, and insurers are also struggling to,

meet the higher costs of care. Several insurers, large insurers, we saw them reduce their, earnings estimates as a result of some of these, underlying trends in the market.

Ellen Wilson

13:28

Great, thank you. For Professor Anderson, a question from Garrett Larson with WTHITV in Indiana. What is the impact on those who live in rural areas where access to care is already limited? What can people do to make sure their medical needs are met without going into debt?

Gerard Anderson

13:46

So, I feel for the people in rural areas. I mean, they are having a very difficult time. They typically have fewer choices among ACA plans.

Generally, only one or two options, whereas in urban areas, they might have 4 or 5 options. And, you know, they're often already at the bronze Plan, which is the least expensive plan, so they have nowhere else to go.

Saying that…

It's still very important to maintain your health insurance coverage. Even if you're healthy, you might have an accident, you might have a heart attack, you might have cancer, and so you definitely need to have insurance.

If you can't afford it, there are a number of options. There's federally qualified health centers, which are in many rural areas, and you can, get care at those places.

The Congress just passed $50 billion to help rural hospitals, and every single state got some amount of money, generally, in the $1 billion range.

And those were meant to help rural hospitals, so you need to find out what the rural hospitals are gonna do with this particular money.

You gotta monitor the level of charity care that that hospital actually provides. Some of them provide very little charity care, some provide a lot more charity care.

Somebody's got to take a look at your particular hospital and figure out how much charity care they have. And if you have an emergency situation, there's a law called IMTALA,

which allows you to get care in an emergency situation. It doesn't guarantee that it will be free, but it does guarantee that you will get care. So you do, in fact, need, when you have an emergency situation, to actually go to the hospital and get the care that you need.

Ellen Wilson

15:56

Great, thank you. Here's a question from Joseph Burns with the Association of Healthcare Journalists for you, Professor Anderson, to start us out. What advice do you have for people who may be uninsured in 2026, and how they can pay for care themselves and for themselves and their family members?

Gerard Anderson

16:17

So, the first thing you've got to do is go to the hospital and learn their charity care obligations. And many of them have, written policies which say.

If you will make this amount of money, you will get free care.

The same thing occurs with

pharmaceutical companies, they have patient assistance programs that allow you to get reduced or free care. Now, many of them don't

allow the amount to be very large if you don't have insurance. They're really trying to get you, for people with insurance to get those drugs. So, it is a problem for those people. And many physicians have a certain amount of services that are, free care that they make available, but

I feel for you, and especially feel for you if you have

Multiple chronic conditions or need a whole series of physician services, trying to line up those physician services are really a challenge.

Ellen Wilson

17:30

Professor Fowler?

Elizabeth Fowler

17:33

Yeah, I think also keep in mind there are certain circumstances that provide a second chance, or another bite at the apple to enroll in coverage. For example, if you move to a new area, if you get married, have a baby, have a change in employment status, that means you lose your employer coverage.

Some states also provide programs that aim to address gaps in coverage, so it's worth checking to see if your state has a program that might provide health coverage.

And then people should also take advantage of the health services provided in their community that may be available, and tailored to people who need affordable care, like community health centers and federally qualified health clinics.

Ellen Wilson

18:14

Great, thank you.

Starting with Professor Anderson, here's a question from Richard Payerton with Medical Economics.

Can you comment on the effects of premium increases on access and affordability to primary care? What advice would you give to primary care physicians who may be losing patients due to loss of insurance?

Gerard Anderson

18:36

So, it is a real problem, that if people don't have insurance, or if they have very high deductible health plans, they're going to say, do I really need to make that physician visit, especially to a primary care physician? Maybe I can put off

That primary care visit for another year and not get the checkup, do all sorts of things like that.

That's really important for them to get the service. I mean, if I'm a woman, and I don't get the breast exam.

it's another year that potentially the cancer grows. So you need to go see your primary care physician

And, you know, from the physician's point of view, they may take a hit in terms of their volume of services, basically the routine services. My expectation is that they will

still see the sick patients, because the sick patients need to go there, but it's the more routine services that will, most likely drop in terms of volume. So, you know, in that regard, those are not particularly well-paid services to the physician, so I think that they will do generally okay.

Ellen Wilson

19:56

Great, thank you. Professor Fowler?

Elizabeth Fowler

19:59

Yeah, you're asking about the downstream effects for patients, of potential, high costs and the inability to afford health coverage, or health costs, and I think an important thing to keep in mind is, or point out, is that medical debt is one of the most frequent causes of bankruptcy in the U.S.

an estimated 60-65% of personal bankruptcies are tied to unpaid medical bills, and it's also a cause for reduced credit ratings. So I think there are very real impacts that could happen for people who are unable to pay their healthcare bills.

Ellen Wilson

20:38

Great.

Okay, so, we have covered the downstream effects when people lose coverage and are unable to pay for needed care, particularly once coverage decisions have already been made. Professor Anderson, anything to add to that?

Gerard Anderson

20:58

So, if you,

Don't go to the doctor. If you don't go to the emergency room, what is likely to happen?

Well, you essentially will no longer, get your preventive services. And what we know from many studies over many years is that getting your preventive services are critically important.

If you gotta get your vaccines, and those are critically important. And then just getting checkups

for certain, medical procedures, like mammograms for prostate cancer or other things, are all important. And what we see is when you don't get those.

Not necessarily the same year, but the next year, or maybe 5 years from now, what we will see is a certain medical condition propping up that could have been treated earlier.

that wasn't treated earlier, and therefore, the person has a much larger medical expenditure, and so we need to make sure to prevent those. The United States only spends about 2 or 3% of its…

healthcare dollar on prevention. Other industrialized countries spend a much higher percentage of their healthcare dollar on prevention. And their life expectancy is longer, their health status is greater. So, if we have a system where we really don't provide emphasis on primary care.

We're gonna see a continued decline in life expectancy, as we've seen recently.

And so we need to do something to deal with that particular issue.

Ellen Wilson

22:43

Great, thank you. Here's another question from Joseph Burns with the Association of Healthcare Journalists, starting with Professor Anderson and then Professor Fowler. Do you all have any advice for consumers in the last few states, 7 or 8, that have ACA marketplaces still available through the end of this month?

Gerard Anderson

23:04

Oh, absolutely. You should definitely enroll if you possibly can. You know, I was optimistic two months ago that, in fact, that they would,

provide money for the enhanced subsidies. I think it's still possible that they will, but I'm not as optimistic as I was 2 or 3 months ago that this would, in fact, happen.

But if you do have the option, recognize that only about 80% of the people don't get sick in any given year, but 20% of us

have a major illness or a major expenditures that you probably can't afford to pay for yourself. That would be something more than $5,000.

Typically, $20,000 if you ended up going to the hospital, or more. So.

you know, you can roll the dice and say, I'm gonna remain healthy for this year, but you've got to recognize that you have about a 20% chance

of the dice not going up very well for you, and therefore, I would advise all people in those 7 states

To provide… to get insurance coverage.

Ellen Wilson

24:26

Great, Professor Fowler?

Elizabeth Fowler

24:29

Yeah, as someone who was involved in the drafting and passage of the Affordable Care Act, it pains me to think that we're going in the wrong direction and people are losing coverage, rather than we're continuing to address, health coverage challenges.

I, I think if there's still the opportunity, people should shop around, and they absolutely should try to sign up for a plan that meets their needs. It will be more expensive, but, you know, health coverage is important.

There may be, there may be coverage available in the state, for children, for example, through the Children's Health Insurance Program. It's worth looking to see whether Medicaid coverage, could provide assistance, if, if, people qualify. But, in those states where there's still an opportunity, I would say please keep checking and searching for affordable options.

Ellen Wilson

25:29

Great, thank you. And back to the proposal to give people money to pay for medical services. Anything to add to that, Professor Anderson?

Gerard Anderson

25:39

So, as I said just a moment ago, 20% of us incur 80% of the spending, and 80% of us incur 20% of the spending. So, the concern here is if you're paying for it yourself, because you don't have insurance.

you could end up in that 20%, and that is a very expensive 20%, and as Dr. Fowler said, you're probably going to go into bad debt, and therefore have

To pay off that, or try to pay off that bill of $50,000, or $100,000,

Over many years, and that will

not allow you to do all sorts of things that you'd like to do. Maybe to purchase a house, maybe to get married, maybe to do a whole variety of things that you wanted to do.

So, you know, not having insurance and incurring a bad debt, and as I said, 20% of us incur a large medical expenditure in any given year.

That is a risk that I think many people just do not want to take.

Ellen Wilson

26:54

Great, thank you so much. For Professor Fowler, how do rising insurance premiums and everyday medical costs expose broader structural gaps in the U.S. healthcare system, particularly when it comes to subsidies and affordability?

Elizabeth Fowler

27:09

Well, we've talked a lot about how rising costs are impacting all parts of the system, including employer-sponsored coverage, Medicare, as well as ACA plans, and I think, you know, one thing to keep in mind is, is if we want to solve these problems, we need to step back and look at all parts of the system. I hear sometimes

there's accusations of, you know, people getting ACA subsidies who may be at higher income brackets, and I think, you know, just keeping in mind that we sponsor… the government, covers employer-sponsored health coverage, through tax subsidies.

people with employer-sponsored coverage don't pay taxes on their employer-sponsored coverage. It's not included as income, and that's a very expensive part of the system as well, that could be arguably, called inflationary and also helps drive up costs. So, if we're going to take a look at the system, I think we need to take sort of a whole scale

Top-down look at how we subsidize and pay for health coverage, what's causing costs to go up, and how we can address those challenges.

Ellen Wilson

28:22

Great, thank you. Yes, Professor Anderson, please go ahead.

Gerard Anderson

28:25

One of the things I study is comparative health insurance systems and what's going on in other industrialized countries.

And if we look at it, we spend about 18 or 19% of our gross domestic product on healthcare. They're spending 9 or 10%. So they are a very different, level of expenditure for healthcare, which means that they can spend money on other things. Education, housing, national defense, whatever their priorities are.

And we are spending 18%, which locks us into, not having as much flexibility. So, I think what we're going to have to do at some time is to take a look at that issue.

For people who, compensation is tied to how much the health and premiums that their employer pays.

It's also a huge issue, because, often you don't get a wage increase simply because all the money that the company's gonna give you, your total compensation, goes to health

coverage, health premiums. And so, people, even with good coverage, need to be aware that they're not getting the raises that they might get because of healthcare spending.

Ellen Wilson

29:45

Great, thank you both for answering all the questions. We will now take a few minutes to share brief closing remarks. Professor Anderson, please go ahead.

Gerard Anderson

29:54

So, you know, if people don't have health insurance coverage, they really need to think very carefully about not

buying health insurance coverage. I understand that it's very expensive, I understand that you have other needs, but as I said before, if you get sick.

you're gonna have a very large expenditure, and you're gonna have to try to pay that off for many years in the future. And that's gonna limit what else you can do.

Ellen Wilson

30:27

Thank you, Professor Anderson. Professor Fowler, please go ahead.

Elizabeth Fowler

30:31

Yeah, at the end of the day, health insurance exists to protect people from financial risk that they can't predict or manage on their own, and any proposal purporting to address affordability should be judged on whether it actually delivers the protection when people need it most.

Thank you again for this opportunity.

Ellen Wilson

30:50

Thank you both for your insightful answers, and we will email the links to the resources mentioned today and shared in the chat, and with that, I'd like to say thank you again to everyone for joining us today. A link to this recording and an unofficial transcript will be provided later today.

• How New Federal Legislation Will Affect Health Care Costs and Access for Americans

• What’s Behind Rising Health Insurance Costs? 

• Public Health On Call: The New Reality Facing Medicare, Medicaid, and the ACA 

• The Potential Impacts of Cuts To Medicaid

Contact the Johns Hopkins Bloomberg School of Public Health media team.

Visit the Bloomberg School's newsroom.