Bulwark Takes - Yes, They’re Coming for Obamacare (AGAIN!)

Episode Date: May 28, 2025

Jonathan Cohn and Andrew Egger break down how Republicans are quietly gutting Obamacare through a sweeping new bill. From Medicaid cuts to sabotage of ACA marketplaces, they explain what's at stake and who stands to lose coverage.

Rural communities are being squeezed from every side. From rising health care costs to crumbling hospitals, from attacks on public schools to the fight for paid family and medical leave, farmers and small businesses are reeling from the trade war. And now, Project 2025 is back with a plan to finish what Elon Musk started. Trump and the Republicans won rural votes, then turned their backs on us. Join the One Country Project for the Rural Progress Summit, July 8th through the 10th.

This free virtual event brings together leaders like Senator Heidi Heitkamp, Secretary Pete Buttigieg, Governor Andy Beshear, and others for real talk and real solutions. Together we'll tackle the most urgent issues facing rural America. Register today or learn more at ruralprogress.com. Hey, it's Jonathan Cohn from The Bullwork here

with my colleague, Andrew Egger. We are here to talk about healthcare today, public health, RFK, vaccines, and then government healthcare programs and what the Donald Trump and the Republicans want to do to Obamacare. Before we begin, if you like what we're doing here at The Bulwark, please follow us on YouTube, subscribe to our podcast, subscribe at thebulwark. Please follow us on YouTube. Subscribe to our podcast. Subscribe at thebulwark.com. Andrew, you wrote this morning a very real call to arms, I think about some news that came out late last week from RFK at the Department of Health and Human Services about vaccines. Before we get into what your argument was, what was the news?

I hadn't even realized until I read your newsletter this morning that we're really getting it with both barrels right now, right? I mean, we've got this stuff that I wrote about happening in the White House at Health and Human Services, kind of like the destruction from within. And then on the other side of things, we've got congressional Republicans gearing up to make all these sort of cuts from outside, cuts to the money going in, changes to the programs in various ways. We're going to talk about all that.

So let's start with what I wrote about, which is the RFK stuff. I don't think it's blowing anybody's mind to hear that Robert F. Kennedy Jr. is not a major fan of vaccines. That's been basically a through line of his political project for decades. I mean, for going back long before he was ever on Donald Trump's radar as Health and Human Services, this was kind of the first thing he and Trump bonded over way back in the day was their shared suspicion that vaccines were, childhood vaccinations were related to autism, which has been thoroughly debunked many, many times. Since he got into HHS, he has been sort of laying the groundwork for a number of these

things. He's been mostly working in the messaging realm and the personnel realm. He's been saying a lot of things about vaccine injury and making a lot of claims about supposed insufficient safety testing for vaccines. And he has also been shedding top vaccine officials at the FDA and CDC, people who are resigning, basically saying they can't work with this guy. Communications, high-ranking HHS communications staff and the FDA's top vaccine official both

resigned back in March. And meanwhile, he has been bringing on some real cranks, some anti-vax types, in order to spearhead some of these quote, unquote, just asking questions type research efforts that he seems pretty confident are going to get the stamp of HHS approval to supposedly buttress this non-existent link between vaccines and childhood autism.

All of that was kind of preliminary. So that's all big throat clear to what has happened in the last couple of days, which is that we are finally starting to see kind of the first real putting into practice of this posture from RFK. Last week, it was the removal of FDA authorization for COVID booster shots for most healthy adults under 65. So if you're over 65, if you have one of a number

of conditions that, in theory, put you at higher risk or that the data has shown put you at higher risk for COVID, you are still authorized to get those shots. But for most healthy adults who are not seniors, that authorization is being pulled off of the table for boosters. So if you've previously had the shots, the annual kind of refresher shots

to keep immunity topped off. That was last week. That was on Friday, or maybe Thursday. Today, or what I wrote about today, just yesterday, what RFK announced was kind of the second tranche of the same sort of thing, where he this time came out and said that the CDC would be removing the same shot, the COVID vaccine, from its recommended vaccine schedule for healthy pregnant mothers and

for healthy children. So essentially, what you're getting there is, formerly, even under the scheme laid out just last week by the FDA, pregnant women would still be able to receive that shot because pregnancy is correlated with a higher risk for COVID, as well as COVID being still somewhat dangerous and at an elevated risk relative to other populations for very young children. So the idea was a pregnant mother would get the shot.

It would protect her, and it would give some antibodies to that child in the opening months of their lives before they're eligible to get their own COVID shot starting around six months. That's now off the table. RFK has pulled that in a video that he put out yesterday where he called it, what exactly did he call it? He said it was another step toward making America healthy again. So this is kind of dangerous and frightening and alarming kind

of on two tracks here. One is just what it is. I mean, one is just that the news itself, right? If you are a healthy adult, if you are a pregnant mother, if you have very young children, you have less choice and less access to these vaccines, or you're likely to have less choice and less access with regard to these vaccines than you did a week ago. We can get into some of the technicalities. Obviously, it's not like they're completely off of the table. You could make the argument,

and we don't know exactly how this is going to shake out. But one could note that if you are a healthy pregnant mother, you still technically qualify under the FDA authorization from last week. But now the CDC has taken it off the schedule, so maybe you can still get the shot, but maybe your insurance won't cover the shot. That's all the stuff that needs to be kind of worked out in the days ahead here. But at a base level, there's just less access to these vaccines than there has been in the past. The other track on which this is sort of alarming and should alarm us, like we should

see where this is going, is that a lot of the arguments that RFK Jr. is making here are not at all constrained to this shot. I mean, I think what I wrote this morning was this is kind of low-hanging fruit, COVID boosters, right? There's not enormous uptake for these shots already in the American population. About a quarter of the population is up to date on their COVID boosters. There's a wide kind of for these shots already in the American population. About a quarter of the population is up to date on their COVID boosters. There's a wide public perception that COVID is this thing that happened and it's over now and maybe you already had some shots, maybe you already had COVID, maybe you feel like you're basically covered.

For RFK to start here, it's like he's establishing a beachhead. The arguments that he is making about this shot, where he is saying it wasn't sufficiently tested, you know, we don't know what the harms are, we need to go back and do placebo testing on this stuff and, you know, really kick the tires on these authorizations and make sure they're legit. These are arguments that he has made for years about all vaccines, and specifically lots of pediatric vaccines that every kid gets today. The MMR vaccine is the measles, mumps, and rubella vaccine being a particular target of his, where he has made identical arguments, basically saying, oh, it's never been placebo tested.

It's never, how could we know? How could we know how safe it truly is? And so there really isn't a limiting principle. I'm sorry, I'm talking forever here, but I'll just end with this. There really is no limiting principle on what RFK is saying about vaccines and what he is likely to do with vaccines. If he would do this for the COVID shots, there's really no limiting principle against him taking similar action with regard to all kinds of other shots on the childhood vaccination schedule, except for perhaps a perceived greater political cost.

If RFK is saying, here we're doing this with the COVID vaccine for kids, that's already really amazing that he's monkeying with the pediatric vaccine schedule here. But it is the latest shot to be added to the vaccine schedule. We've only been vaccinating kids against COVID for a few years. We've only had the COVID shots for a few years. So you can see in his mind this being kind of like a trial balloon.

We'll see how they take this one. In theory, this one should go over a little smoother than other ones would. So let's see how we do here and then proceed from there. But again, that is really the only thing between us and a future where we're talking about these exact same kinds of decisions for a whole wide variety of shots that RFK has criticized in the same terms as he has used to criticize this shot that he is removing from the schedule today.

Yeah, well, and one of the things that you put in your article, which I would recommend to everybody, by the way, but I thought was such a tell, was that when he presented this on YouTube, he didn't phrase it as, you know, he didn't say the, he phrased it as, well, you remember the exact phrase, but you know, this is the latest advance in making America healthy again, and just framing the COVID vaccine as a threat to American health, which is just a mind blowing. I mean, I know we're used to that from Kennedy and we're used to that kind of talk from people who are anti-vax, who have more and more purchase in our conversation. But the idea that this vaccine that has saved millions of lives around the world and would have saved even more here if more people had taken it and now being presented as a threat to American health. Just really, it shows you how upside down

this whole conversation has become. One thing I wanna ask, because I wanna go right to this issue of sort of, you know, this sort of him testing the waters, which is what you argue in the piece. And I think that is so important. Just before we get to that real quickly, this was sort of weird, right?

I mean, the process here was kind of odd. We haven't gotten full details yet in writing. I mean, the sort of CDC announcement came, was the FDA announcement. One of them came in the New England Journal of Medicine. One of them is done on a video on social media. We haven't gotten fully fleshed out paper on this from the, or digital equivalent of paper, I guess is

what we use now. But it's not as if the HHS has put out detailed guidance. As you said, there's some contradictions between what one set of recommendations or another. This does not appear to have been done in consultation with the normal boards of experts who advise the secretary. There isn't even, it's not even clear who's in charge of this CDC right now. Am I correct that we don't, there's,

as far as we can tell, it might just be in a facto Robert Kennedy. I mean, is this, is this a, should we be alarmed by this at all? Does that, I mean, you know, that doesn't seem like exactly the way we should be making these decisions. Yeah, so this is one of those things where any different surface that you choose

to scratch this surface on, you're uncovering something else that's like, oh, gosh, what's going on here. You are correct to note that last week's announcement had more official trappings on it. It was a couple of top HHS doctors with this op-ed in the New England Journal of Medicine kind of laying out the case for it, whereas this most recent change, the change that was just announced yesterday, was just this social media video and in fact seems to have been

rolled out so quickly that there is still accessible or was still accessible as of when I was writing this morning, guidance on the CDC website that seemed to contradict the new rollout where they were talking about how pregnancy presents an elevated risk for complications and hospitalizations with COVID and pointed to the different CDC meta-analyses that demonstrated that. So we're in this bizarre kind of no man's land where obviously RFK is the guy who's making these calls, like his word kind of goes, but we're sort of outside of official channels

to a certain degree. The one other thing that I would say about that is the role that the CDC's Advisory Committee on Immunization Practices usually plays here. Ordinarily, you would see a recommendation like this come after consultation with that committee. That's what that committee is for, is to kind of give HHS and the CDC guidance on vaccine policy rollout. And usually, that committee is very simpatico with the Department of Health and

Human Services, obviously, because that's their work and hand in glove to push forward the best science. When RFK Jr. was confirmed, one of the key pledges that he made to the last Republican holdouts against his confirmation, specifically Senator Bill Cassidy, was that he was not going to monkey with that committee, that he was going to let them do their work and move forward. That has not happened. I mean, RFK back in February postponed, and now it appears to have just been canceled, that committee's first meeting of the year.

Usually they meet three times a year. So they did not meet the one time that they were supposed to have met so far under the Trump administration. They are now scheduled to meet next month. But this announcement about these COVID shots preempts that meeting. It predates it, right? It's not coming on the back of some conversation from that meeting. It's going into that meeting, assuming it happens at all. There's been reporting that RFK is planning to fire some members of that committee. So just in that context, I mean, it again just sort of underscores one that he essentially was lying to various members of the Senate in order to sell them on this very thin fiction that they were sort of hoping to be

convinced of. So they weren't that hard to convince that he was not actually going to be a threat to current vaccines currently in circulation. But also just that he is systematically undermining these sort of regulatory, not regulatory, these sort of advisory bodies behind the scenes, as well as just making these sort of top level changes at the level of policy. And can we just pause for one second to note the irony here?

I mean, the whole energy behind the sort of skeptic, you know, the more popular skepticism of the COVID shots and the anger at Fauci and the anger at the scientific establishment, so much of that was about supposedly decisions being made in ways that were not transparent, that didn't take full account of the science made by a few handful of people sort of superimposing their own views on the available data. And whatever you think of those arguments, and I think among reasonable people there's a spectrum for, did the public health community make some bad decisions? Did they not consult widely enough?

You know, I think there's room for some debate there. But wherever you are in that debate, what we are seeing now is a version of that on steroids. I mean, this is just, this does appear to be Kennedy imposing his will on, in exactly the ways, as you said, that he promised he wouldn't. As you say, and let's go to the other part of your article, which is, this feels like a test. When I was reading your piece about this, my mind, this is quite the pop culture reference,

but my mind flew right to Jurassic Park, the movie when the raptors are testing the vulnerability of their pen. It felt that it does. You make the argument that, in effect, Kennedy's trying to test. How far can I go? Talk about that. There was an analogy used that I thought was quite good.

The contrast here, I think, and I think it holds up, is essentially with how Elon Musk was running Doge in the early days of the White House. He was very emphatically moving according to this move fast and break things sort of strategy where they just turn random things off across the federal government and just see what happened. If they turned off anything that turned out to be load bearing or really important, no big deal. We'll just turn that back on. No harm, no foul. What that ended up doing was provoke a massive backlash far

in excess to what you likely would have seen if they had gone more carefully and less ham-fistedly and fired fewer nuclear scientists and cancer researchers and all those sorts of things, and veterans at the Department of Veterans Affairs, all of which built into this public backlash that tanked Elon Musk's popularity and did end up pretty directly leading to Trump choosing to sideline him as part of his project. Trump is not going to sideline himself.

Trump is going to follow the things that he wants to do, kind of come what may, but he is softer on the people around him. If he sees specific advisors of his or specific ancillary parts of the MAGA project as starting to be a drag, starting to reflect badly on him, he has shown a willingness to pivot off of them. And I think that that is, badly on him. He has shown a willingness to pivot off of them. And I think that that is, we're kind of at that moment here with RFK, where he is operating more cannily than Musk did. He is going more carefully. His aims are no less radical, certainly. I mean, more radical. I would say more radical if anything. Yeah.

Yeah. Yeah. But he is not sort of blundering around in the same kind of just like bull in a china shop doofus kind of way that Musk was. And that makes it harder to marshal public opposition, in a way that Musk was kind of like a perfect figure to become a focal point for protest because it was also ham-fisted and because his personality is so large and his brand is so strange and because he has these car dealerships all over the nation that are just an obvious place to show up and protest at. All of those things made it really easy to focus public protest against Elon Musk. I think what we're going to see now, well, I think it's an open question what we're going to see now, because I think that we are entering a moment where RFK is sort

of whipping the tablecloth off of his anti-vaccine project here a little bit at a time, right? And the question is, will we be able to see absent the shock and awe stuff and absent all those factors I just talked about that made it easy to protest Musk, will we see the same kind of public backlash against Kennedy? Because I think you will have to see that kind of public backlash if there's to be any hope of getting Donald Trump to yank this guy's chain and say, OK, all right, let's not get carried away here.

Let's slow roll some of this stuff. Because again, that's the only thing that's keeping us from seeing what's happened with this shot rolled out across a bunch of other shots. Because the same arguments that he has rolled out against this one are arguments he has made for years against a whole bunch of others. Yeah. And look, there are ways vaccine companies can sue. It does seem like they are. The process that is being used at FDA and CDC,

I'm going to bet based on what I know about those processes, what I know about the Trump administration, they are probably not going through the proper legal channels, which means that companies that want to challenge this probably be able to find pretty solid legal grounds. The problem is this isn't just about companies getting permission to develop these vaccines and sell them.

They have to find it profitable. Vaccines are frequently not profitable. And if HHS makes it difficult and if it throws up these, they're just not going to make these vaccines. Until we get to another knock on wood, let's hope we don't, true crisis situation where suddenly we're scrambling and then who knows what happens if we have Secretary Kennedy in charge. People forget as ham-fisted as the first response was to COVID under the first Trump administration. A lot of people in his administration

were quite skilled and smart. And he had a lot of people on top of things working for him. And the idea that instead of an Alex Azar or some of the other former officials in the Trump administration, we would have Kennedy managing a pandemic response now is one of the scariest thoughts I can imagine. Yeah. All right.

Let's leave Kennedy there. We're doing a whole massive, this is a double stuff episode because you also wrote about a whole different thing also on the subject of healthcare getting demonstrably worse probably in the near to immediate future or maybe not. Who knows? Who knows whether they're going to pass this thing? But let me sort of grab the wheel from you here and talk to you about your newsletter, which also up today. And I had no idea of a bunch of the stuff that was in this. I think a lot of

people have no idea of a bunch of the stuff that you were writing about today because what you have done is basically pull together a bunch of little changes to the healthcare sort of policy apparatus that Republicans are putting forward in this big beautiful bill that just passed the House and stitching it together into a full picture that I found very informative. Can you just talk me through a little bit about what are some of the things that Republicans are putting forward in this big beautiful bill as far as specifically changes to the Obamacare policy regime.

And why is it that these sorts of things have not been a bigger part of our conversation about this legislation? Yeah. So the big picture here, just to remind our viewers, the big, beautiful bill is a bill with trillions of dollars worth of tax cuts. To offset part of that cost, and I emphasize the word part because this is a huge tax cut that's not going to be remotely paid for and it's

going to add to the deficit. But to offset part of the cost, the Republicans in Congress are looking to cut spending primarily on social programs, primarily on health care. Now, until this point, most of us who have followed this, most of this, we've been talking about the cuts to Medicaid, which is the big programs that covers medical bills for 70 million low-income Americans.

We've been talking about Medicaid because those cuts are really big. It would be the largest cut in the program's 60-year history. If they go through as written in the bill that passed the House last week, 10 million, more than 10 million people could lose Medicaid. And because most of those people will

not find alternative sources of insurance, the projections suggest that the number of Americans without health insurance would go up by seven million people. That by itself is a huge deal. I mean, if there was nothing else in this bill, we would be focused on that as a major change and something, a source of major controversy. But it turns out that's not all what they're doing. In addition to the changes to Medicaid,

this bill that passed last week has changes to the Affordable Care Act, a.k.a. Obamacare. And when I say Obamacare, I mean very specifically the part of Obamacare that reordered and rewrote the private insurance market. And if you remember, if you go back in time, back for the Affordable Care Act, if you didn't have insurance through your job and you didn't qualify for Medicaid because you weren't poor enough in your state to fit, then you had to buy insurance on your own and you probably couldn't get it or you couldn't get a good policy if you had a preexisting condition. And even if you didn't have a preexisting condition, the policies were pretty darn expensive

and a lot of people, even middle-class people just couldn't afford them. So Obamacare, Affordable Care Act, set up, you know, sort of set up these marketplaces that were kind of designed to, to mimic a, a, an employer plan, basically, or a set of employer plans where basically anybody could get coverage, if you had a preexisting condition, you got charged the same amount, all the benefits, you know, at least met a standard to cover comprehensive benefits. And if you couldn't afford a policy on your own, depending on your income, you've got financial subsidies, which were worth quite a lot of money,

hundreds of dollars, even thousands of dollars a year. These programs are set up today. If you wanna buy a policy through one of these marketplaces, you know it as healthcare.gov in many states, or if you're in some states run their own. So if you're in California, it's called covered California. There's a state run exchange in some other states like Kentucky, Massachusetts, et cetera. This program, this was the part of Obamacare. Again,

if you know your history, it was pretty rocky start. The website didn't work. There really was kind of underfunded for the early years, but over time, they were able to sort of streamline it. They put some more money into it. And because of that enrollment reached record levels last year, 20, more than 24 million Americans now get insurance through these marketplaces, these Obamacare marketplaces.

Now, back when Trump was president last time, they tried to repeal Obamacare, including getting rid of these marketplaces, getting rid of a lot of the financial assistance, rolling back those regulations. You may recall that did not go well for the Republicans. It blew up in their faces. It was a real political liability. Ever since then, they've been not talking about repealing Obamacare.

If you remember the campaign just a year ago, Trump once or twice, he put out a post on social media, well, I'm thinking of doing something on Obamacare. He actually got a lot of flack for it and he kind of backed off from it. And if you asked Republicans in Congress, like, we don't want to touch Obamacare, we're not going to do anything. Well, narrator, they touched Obamacare. And the thing is, as you said, it's a little bit hard to see because unlike last time, there's not one big change. It's a bunch of little changes. Many of them are technical. They're hard to parse.

They're hard to explain, even for somebody like me, who like, this is my job, right? I mean, this is job description number one for Jonathan Cohen. Explain complicated healthcare things in ways that, you know, make sense. And I find this challenging. I had to get on the phone with five different people.

In part, because the language is confusing. Again, we'll have a little bit of a call back to the earlier part of our show where we're talking about the hasty way these decisions are being made at HHS. Well, this legislation was written hastily. And so as you know, there are provisions that contradict one another and they're not clear what they mean. And in addition, this whole thing got put together, the language, in about a week. So the Congressional Budget Office is still trying to figure out what it all means and what it would all do. But just broadly speaking, and then we can dive into the details

if you want, or we talk about something else. But there's sort of three categories of changes. One is the piece that I think the Republicans are most upfront about. There's no deception here. They wanna take assistance away from people who are immigrants, legal, not illegal, legal immigrants here who previously were able to get coverage through the marketplaces and get subsidies, and now they won't be able to. And that, you know, look, that's part of the brand, right? We don't want, we wanna cut support for people who are coming to this country. You like that, you don't like that, you know, look, that's part of the brand, right? We don't want, you know, we want to cut support for people who are coming to this country.

You like that, you don't like that, but that's pretty straightforward. Second category is where things get complex. There's a whole set of changes to the procedures for signing up for coverage, when you can sign up, under what circumstances, what kind of documentation you have to provide. And each one of these is complex and they overlap with each other and they interact. But the best way to describe it, there's a think tank called the Center for Budget on Policy Priorities. They call it SLUG and I thought that was a pretty good description. It just throws up, it just makes the process of getting onto, buying one of these

policies really cumbersome, really difficult in a way that's almost that is not almost that I do think is designed to discourage people from signing up. So that's the second piece. And then the third piece is just a straight up cut to the amount of money that people are going to get in financial assistance and the kind of protection and a reduction in the kind of protection I'll get from the insurance. Again, you have to kind of dig into the weeds because they don't just say we're cutting it by X percent.

You have to kind of understand what they say when they mean, well, we're going to increase the allowable variance on the actuarial value, and we're going to dial back the sort of assumptions based on we're going to restore funding for the cost sharing reductions. Each one of these is convoluted, but if you run the numbers, you see how it works out. You come out with a world where people are either paying more for their premiums, they are paying more for their out of pocket costs. In a lot of cases, when that is the case, you're going to have some people who are just going to say, look, I'm just not going to get insurance altogether because I can't

afford it. I don't think I can afford it. I don't want to get it. And so the number of people without health insurance is going to rise. So you're kind of in a situation here and people should just go to thebullwork.com to read your piece. They are in fact coming after Obamacare to go kind of chapter and verse through some of this stuff. We don't need to necessarily belabor that here. But I think that the point you make that is the key one is the cumulative effect here is a couple things. One is to essentially just make the product somewhat worse in some respects, somewhat

less favorable to the consumer in terms of dollar in to dollar back out ratio. But the other of which is sort of just turning the crank to make these procedural hoops a little tighter, a little smaller, a few more of them to have to jump through such that more and more people are likely to fail to do this or that or the other thing to qualify at all or to get insurance at all, just to make it logistically more complicated to get health insurance. Obviously, there's a big debate always on these sorts of things where Republicans are saying, well, you have to throw up these barriers in order to reduce fraud, in order to make

sure everyone who qualifies for it really qualifies for it. And Democrats tend to say, well, you have to, like, can we also please try to make sure that the people who are qualifying for it, who do deserve this under the terms we've laid out, are not just getting tossed to the side because they have failed to do all the paperwork correctly or whatever. That's a whole debate.

One point that I wanted to really drill down on here that you made, because I thought it was so important, is who you lose when you make health insurance really hard to get and the difficulty that the extra financial strain that puts on the whole system. So can you talk about that a little bit? Yeah, for sure. As you said, there is a real tension whenever you have a program where you're limiting eligibility in some ways between successfully narrowing that group of people to who you want to target,

and narrowing it so much that you overcompensate and that you make it harder. And one of the things we know from reams of academics say this is not like a hypothesis that's untested. We know this for sure. Is that in the very specific case of healthcare, if you make it harder for people to enroll or if you make it more expensive, that not everyone is going to react the same way.

And the reaction will be somewhat predictable once you think about it, which is that people who have chronic illness, people who know they're going to have serious medical bills, they're going to jump through the hoops. They're going to go over the obstacles, partly because they know they need that health insurance. They know they need to pay for their medication for their diabetes. They know they need the high blood pressure. They know they need that health insurance. They know they need to pay for their medication for their diabetes. They know they need the high blood pressure. They know they need, they have the,

whatever their ongoing medical needs are. They know those bills are coming. So they are very motivated, as an economist would put it, to get that insurance. And probably if you know the world, if you know this world, if you know anyone who has a serious chronic medical problem,

a few of yourself do, it kind of part of life is learning to deal with bureaucracies. You're always dealing with insurance companies. You're always dealing with government programs. So you're probably not gonna be quite as daunted by it. You probably have the documentation. You're more likely to know where your documentation are. You're more likely to know who to call

when the thing doesn't upload properly. That sort of skill sets. So those are the people who are going to get to it. They are going to be much more likely to get insurance even if it's difficult. On the flip side, the people who are healthier, people who aren't used to this, people who are that sort of more marginal customers like, yeah, it'd be nice to have health insurance. It's probably a good idea. I'll do it tomorrow.

I'll do it next week. What? The upload didn't happen right? What's going on? I got to make a phone idea. I'll do it tomorrow. I'll do it next week. What? The upload didn't happen right. What's going on? I got to make a phone call. Now I got to make another. Maybe. Those are the people you tend to lose. And the problem is, in an insurance system, for private insurance, any kind of insurance pool, the whole principle of insurance is that you're spreading medical expenses among a broad, broad group of people. And so what you want, we've talked about this as what we call the 80-20 mix, is sort of the ideal platonic ideal in health economics, where in any sort of

group of people, 80% of the healthcare expenses are concentrated among 20% of the people. The theory is that for the remaining 80% of the people is that they are premiums that they're paying in that covers the medical expenses of the people who have them. And the idea is that this is a fair arrangement, because over time, we all run the risk of getting sick. We could all get in an accident, whatever. We fall in and out of the 20% at different times in our lives. Exactly.

So you want to get that sort of a healthy risk pool, as we would call it, where you that that sort of healthy risk pool, as we would call it, where you're getting plenty of healthy people in. Well, if you start to lose those healthy people, now you're in a situation where the insurance company is saying, wait a minute, we're not getting enough in premiums from the healthy people to cover the bills from the people who have serious medical needs. What do you do? You raise your premiums or you lower your benefits. Okay, well guess what happens when to do that?

Well now the people who are healthy are even less likely to sign up because selling insurance has gotten more expensive. This creates a cycle. Sometimes it gets called a death spiral, which is a little bit of an exaggeration. Typically it doesn't really result in the end of these insurance arrangements, although sometimes insurers do pull out of markets. More commonly what happens is just premiums get very high and to a point where really it's only a good deal for people who are in bad health.

And here's the irony about all of this is that that world I just described where you're not getting enough healthy people because the insurance is hard to get, we experienced that when the Affordable Care Act first came online. It was a big reason why the program was not popular in its early years. One of the things that we learned over time, as is often the case with these large programs, is to make the program work better. You tweak the system in terms of how people enroll, in terms of the way the amount of financial assistance that comes in, to get that healthy in terms of how people enroll, in terms of the way the amount of financial assistance that comes in to get that healthy risk pool.

We're finally there. It's working pretty well right now. Not coincidentally, the program is pretty popular. What this bill would do is it would effectively turn back the clock to that period where it didn't work so well and where it was less popular. And you can draw your own conclusions about whether that's a virtue or a bug in the minds of the people who wrote this bill. All right. Well, I'm sure we'll be watching all that going forward. Again, it's remarkable to me that this has not been a bigger part of the conversation around this bill. I guess that's

one of the problems with a bill that is this big and this beautiful is is there's just so much to talk and argue about that's so beautiful. So beautiful. We're going to get missed. Yeah, right, exactly. But I imagine we're going to be hearing more about it. And thank you for doing the reporting to push that forward. I think we can leave it there.

We've talked a long time. This has been, like I said, a big old double wide. People yell at Sam Stein for being the interviewer who interrupts and all those sorts of things. But now, you get a couple of yakkers like Jonathan Cohn and myself on to just let one another go crazy. We've had these things out to two and a half hours.

So we'll stop there. We'll cut it out. Thanks, Jonathan, for coming on to talk through some of this stuff. Thanks you all for watching, for listening. Hope you head to thebullwork.com and subscribe. Subscribe to the YouTube channel. Thanks for all. Thank you all for watching, and we'll see you next time.