Talking With Jonathan Cohn

The coming premium apocalypse, the shutdown, and more

Thanks in part to enhanced subsidies, more than 24 million Americans now get health insurance through the exchanges established by the Affordable Care Act. But those enhanced subsidies expire Dec. 31, which will be apocalyptic for many people; and Democrats have made extending them their key demand in the shutdown fight.

So this seemed like a good week to talk with Jonathan Cohn, who has been following the ACA and its ramifications since the beginning, and wrote a terrific piece about Republican lies regarding what’s at stake now. Transcript follows:

. . .

TRANSCRIPT:
Paul Krugman in Conversation with Jonathan Cohn

(recorded 10/1/25)

Paul Krugman: Hi everyone, Paul Krugman again. We’re recording this on Wednesday, October 1. The government has shut down and I’m here to talk to Jonathan Cohn, who’s writing for The Bulwark now. He’s also been a long-time go-to person on healthcare, which is suddenly playing a big role here. So hi, Jonathan. Welcome to my non-studio.

Jonathan Cohn: It is great to be here. And you have been my go-to for about 10 different subjects and we share this interest in healthcare, so I’m very excited to be on here, even if the circumstances are, you know, what they are.

Krugman: Yeah, it’s pretty wild. We want to talk about the shutdown and all of that in a bit. But first, let’s talk about the Affordable Care Act, which I know you and I both cheered on a lot when it was in process. So why don’t you describe the Affordable Care Act, then we can talk about it a bit.

Cohn: Yeah, kind of a quick 101 on the Affordable Care Act. So, remember, it was passed in 2010 after a very long debate. Its goal was to get us closer to a universal coverage system, really to put the principles in place to get to a universal coverage system; but not to blow up the system and create something new, mostly because that would be really hard politically. Harry Truman tried it, didn’t work. Democrats were like, “Okay, we’re gonna work with what we got here.”

The easiest way to think about it is sort of to divide it. First of all, if you’re elderly, you’re on Medicare, great, we’re just gonna leave that system. We’ll make some improvements, but we’re not gonna touch Medicare. And we’re not gonna touch employer insurance, mostly. You know, we’ll try to shore that up a little bit, give you some new guarantees, like you can’t have a lifetime limit or anything like that.

Most of the work was for people who fell into one of two categories. First, people who were low income, so below the poverty line or just above it. And we said, Okay, we have a program already called Medicaid that exists. It’s a sort of joint federal-state program. It looks different in every state. We’re gonna kind of try to make a uniform version of it. And instead of having complex categories of who qualifies and based on what demographic, we’re just gonna say, look, if you’re here legally and you’re a citizen and your income is below the poverty line or even just a little bit above the poverty line, you can get onto Medicaid. Full stop, you get Medicaid, that’s your insurance.

And that left the second group of people, people who are too wealthy for Medicaid, not old enough to qualify for Medicare, and they don’t have access to an employer insurance policy. And that could be anybody from a small business owner to a farmer, somebody working part time, someone working at a fast food restaurant that doesn’t offer insurance. A lot of working poor people, but also a lot of middle-class people, shop owners, things like that. And these are traditionally the people who had trouble buying private insurance because, in the way the system used to work, if you couldn’t get it through an employer, then insurers could block you from coverage if you had a preexisting condition or they could charge you a lot more or they could not cover certain benefits.

So they created the Affordable Care Act. This is a system created for those people where they could choose from a set of private insurance plans. And the idea was that it would be kind of like you worked for a big company that offered a number of different plans and you’d get to pick how generous your coverage was, what kind of networks it had and so forth. But all of them kind of met minimum standards. They had to cover preventative care. There could be no limit on how much you could spend in a year. And crucially two things. Number one is it’s available to anybody, regardless of preexisting condition. You didn’t get charged more if you were diabetic or something.

And this is where we’re going to get into the shutdown fight. They said, look, a lot of people can’t afford these plans. You know, you’re making $40,000 a year. Insurance in America is expensive for everybody. You’re probably going to need some, so we’re going to give you some financial assistance in the form of a tax credit. If you make less money, you get more assistance. If you make more money, if your salary is higher, you get less assistance. And again, kind of like it is for employer insurance where your employer contributes, you’re going to get a contribution from this program and you’re going to get your insurance that way. And as a practical matter, if you use that today, and more than 20 million Americans do, you’re buying it online, usually through a website. In most states, you use healthcare.gov. It’s a federally run website run by the Department of Health and Human Services. A handful of states run their own versions. Like if you’re in California, you’re on Covered California. And that’s how it works.

Krugman: Yeah, originally it was supposed to also be a requirement that you buy insurance: a mandate, which I think is still there on the books except the penalty if you don’t buy insurance is zero dollars and zero cents. We thought that was crucial, but it has turned out to be, I guess, less crucial than we thought. Right?

Cohn: Yeah, it’s a weird thing, right? I mean, we spent so much time debating it in 2008 and it went to the Supreme Court. And then, there are interesting arguments about whether it mattered. If you talk to some of your economist friends—John Gruber and people like that—did it matter that we had it originally with a penalty? Did that, like, set a pattern of behavior? Who knows? I think it’s a really interesting question for anyone who’s in economics to kind of research that.

Krugman: Right. But when Republicans basically wiped out the mandate, which was always unpopular, the system did not collapse. There was a lot of fear about a death spiral, but because of the way the subsidies are constructed, which limits your premiums as a percentage of your income, the death spiral just couldn’t get going. And so we’re here. We have this system.

By the way, I do know a couple of people who are out buying insurance through the exchanges. They’re basically small business people, real estate brokers and so on and they could not get insurance previously. They had to work for larger firms. Now they can be the American ideal, the small business person, thanks to the Affordable Care Act. And by the way, I don’t know how much you’ve looked at international comparisons, but I just spent some time in the Netherlands and they have a system that’s not that different. They appear to have private insurers with, again, sort of no discrimination on medical history and substantial government subsidies. And although they do have a mandate, which is effective and has been enforced, it’s not as if this is a completely unprecedented system.

Cohn: No, not at all. I mean, I remember very distinctly when this was first percolating up. And as you know, the sort of prototype for this was a state version in Massachusetts, which was signed by Mitt Romney. The Netherlands model was very much in the minds of people who were sort of trying to construct the system. And I actually remember going there at the time as a reporter to research it. And you’re absolutely right. Conceptually, it’s very similar. It’s probably got more in common with some of the more truly national systems overseas because it’s pretty well regulated, pretty heavily regulated. And it’s been a while but my recollection is, there were four or five insurers. It’s a small country, so it’s a little different. They couldn’t make a profit on the basic benefit package, it all had to be the add-ons. So they were pretty closely regulated, and of course, it’s different. But conceptually, it’s delivering universal coverage through private insurance that you choose.

Krugman: At first it was kind of underpowered. The subsidies were not big enough. I mean, they were big enough that lots of people did get coverage. But then Biden came along and increased the subsidies so that there’s no longer a cap at when the subsidies end. Subsidies are bigger. And I hadn’t realized until we started to reach this point that there’s been a doubling of the number of people buying through the exchanges, right?

Cohn: Yeah, it sounds right. I have to look at the exact numbers to see if it’s actually doubled, but it’s either close to doubled or more than doubled. But it’s at record levels now. I mean, it’s over 20 million, which is a massive increase from where it was.

Krugman: And almost everybody buying on these exchanges is subsidized. Very few people are making enough money that the subsidies aren’t relevant. But the legislation that did this was actually part of the Inflation Reduction Act, which is the Holy Roman Empire of legislation. Which is to say, it was neither holy nor Roman nor an empire. But whatever the Inflation Reduction Act was about, it wasn’t about inflation reduction, but included these enhanced benefits, but with an expiration date, which is December 31st, 2025. Right ahead of us. And this looks kind of catastrophic for a lot of people.

Cohn: Yeah, it’s going to be a big price jump if nothing happens. I know KFF did some calculations. I think they had it as an average increase of $700 per person. I think they recently revised it in the last two days. I didn’t have a chance to dive into it. I actually think the number turns out to be even higher now because there was a separate change that was made. And you know, $700 a year. That may or may not sound like a lot to you, but two things to remember are: this is across the income spectrum. Some of these people are making $30,000 - $40,000 a year for a small family. They’re just barely getting by and hitting them with $400, $500 more a year is a big bump in their lives. But you know, it’s an average. So for some people, the increase will be in the thousands.

And there’s a couple variables here. It depends on things like where you live, because prices are different around different parts of the country. It depends on how old you are, because insurers, even in the new system, are allowed to charge you more if you’re older. It matters where your income is. I’m generalizing here, but the two groups who really seem to take it hard

are the ones who are at the low income end of the scale because they benefited the most. The sort of topping off effect of that extra assistance really made a difference for a lot of them. It was enough to get them over the hump to get health insurance. And then on the other end of the spectrum, especially if you’re older and depending on what part of the country you are, there are some just shockingly high premium increases that are gonna hit some people. That might be if

making just a little too much money to qualify for a subsidy and say they’re in their late 50s, early 60s. You’re going to have people who literally are going to see their insurance premiums rise by more than $10,000 a year and it’s just not gonna be affordable.

Think about Charles Gaba. He’s sort of this cult hero because he was a web designer who’s good at numbers and when the ACA first rolled out, he started following it as a kind of hobby.

And he was really good. Now he’s an analyst that does this full time. He broke down the numbers and figured out which states would be the hardest hit by this. So, if you’re older and a store owner or a small business owner in West Virginia, you could just get hammered by these increases. And again, that’s an extreme case. But you’re looking at a lot of people having to pay more for their healthcare which, I don’t know. Didn’t we have a campaign about lowering the price of living or something like that?

Krugman: Yeah, one of the things I puzzle over is, this was sort of obvious and the One Big Beautiful Bill actually sort of puts off the savage cuts to Medicaid until after the midterms, but this expiration hits before that. It’ll be showing up in people’s mailboxes where their insurers say, “Here’s what it will cost you to renew your policy.” Why weren’t there at least some cynical politicians saying, “OK, you know what? We’re going to keep the enhanced subsidies until we’re past the midterms.” I have a theory about that, but I’m curious. Have you thought about why this has been allowed to just sort of come crashing down on the heads of, as it turns out, probably a lot of loyal Trump voters?

Cohn: Yeah. And actually Charles Gabba and KFF have done analysis and actually it does look like it hits red districts and states disproportionately for obvious reasons that we can get into in a minute. But I have two theories. The first is, there’s the true believers, right? You have people in the Republican party and conservatives who don’t like this. They are against government spending on health care. They don’t want to spend more. They definitely don’t want to spend money on Obamacare. And so I think they may have had a sense, like, “This is what we got elected to do. This is what we believe. We’re going to do it.”

In the same way, you have liberals who sometimes want to do things that may not be popular, but they figure this is what they want to do. So I think there are definitely some true believers out there. I think the bigger reason, to be honest with you, is that they haven’t thought a lot about it. I mean, this is the Republican Party of today. When it comes to health care, there’s just not a lot of there there. We were talking a minute ago about Mitt Romney, the Republican governor. He was kind of a throwback to a sort of earlier generation. You know, whatever you think about Mitt Romney and people know him now as, like, the anti-Trump Republican, but I know him and maybe you remember him as this sort of technocratic, very serious policy guy. He was a business conservative, but he knew his stuff. And there were a lot of Republicans like that. And that has atrophied over the years. You’ve documented that as well as anybody. But even as recently as 10 years ago, you had a stronger bench on the Republican side of people who knew what they were talking about. And it’s just, they’re gone. As the party has become kind of more nihilistic and more extreme, the people who would be on that side, who would be advising the smart economists, either abandoned the party or, in some cases, started talking to people on the left because they seem more reasonable. So, there’s just not a lot of policy infrastructure, not a lot of policy thinking going on on that side.

And when you’re not thinking about the policy and you’re just throwing this stuff at the wall, you don’t always know what’s coming down the pike. And I just think they listen to Fox News, they’re in their bubble, they’re not having policy [discussions]. People say, “Hey! Yo! This is coming down the pike and you’re gonna get caught.” So those are my theories. I don’t know if they’re right, but those are my theories.

Krugman: Yeah, I’m actually pretty much in the same place. I mean, Chuck Schumer came out of the shutdown meeting with Trump saying that his impression was that Trump was not aware of this issue. It’s been all over everything you and I read, but not all over Fox News and so who was going to tell him? You know, big strong men with tears in their eyes coming out saying, “Mr. President, do you know what’s about to happen to health insurance premiums?”

And now people are asking me, “Who’s devising these policies? What’s the policy process on multiple issues?” And I keep on saying there is no policy process. There are no such people. And it’s kind of systematic that people who actually do know what they’re talking about are sort of persona non grata in general. The Heritage Foundation people might be evil but they’re not stupid. You’d think they would have said something.

Cohn: Yeah, well, as you know, Stuart Butler used to be at Heritage way back in the day. He was the original author of one of the original versions of that individual mandate we were talking about.

Krugman: Yeah, Stuart Butler. Basically the father of Obamacare, probably not how he wanted to be remembered, but yeah.

Cohn: That’s right. Look, there are a handful of people who I talk to, but again, I think in some ways they’re true believers. And I think the problem is, in any coalition, if you’re smart, if you’re in politics, [you want to have a debate]. I think you saw this a lot in the Obama administration, whatever their flaws and strengths. You tended to have different camps of people who were independent minded and were smart, who also knew their stuff, but also sometimes had different perspectives. And there was a tension, there was a real debate. And that’s when you’re having the internal debate in the Roosevelt Room, or if you’re in Capitol Hill, in the committees. I mean, you remember the ACA fight, right? It was a year, right? And there were so many debates and there were hearings…

This stuff, if it gets hashed out in public, I mean, it can be messy, it can get distorted. God knows how much time we spent back then talking about death panels. But when you’ve gone through weeks and weeks of committee hearings, most of the key issues do come up naturally, even if you’re not raising them. The press will raise them, the opposition will raise them. And the Republicans aren’t doing any of that anymore. They’re setting up a situation where only a limited universe of people advise them. There’s a handful who I think know what they’re talking about, but if it’s that one perspective, and there just isn’t a lot of pushback from people who have the knowledge to say, “Hey, wait a minute, I don’t think this is gonna work out so well politically.” Or, “Hey, wait a minute, I know you think this is a good idea, but I’m coming from a different place. I think it’s a bad idea.” But that’s how you get bad policy and bad politics too.

Krugman: I interviewed Nancy Pelosi a few years ago at the 92nd Street Y in New York. Trump had basically tried to create a death spiral for Obamacare during his first term, which failed to happen because the subsidies are very cleverly designed. They’re not a certain amount of money. They cap your expenditures. It was a cleverly designed bill, whatever you think about it. And I asked her, “How did political types like you interact with the policy wonks to produce such a cleverly designed bill?” And her answer was, “I am a wonk.”

And that’s probably to some extent true, but I’m not sure who in Congress you would say that about on the Republican side now. So, yeah, they may have just stumbled into this. It’s pretty amazing that you could get to this point. And really, here we are just months ahead of the premium apocalypse, and apparently the president hears about it for the first time from Chuck Schumer.

Cohn: I think this says a lot about Trump, right? I mean, it’s not like nobody wrote about this in the New York Times or various publications. There was probably even some coverage in the Wall Street Journal. The news pages certainly had coverage about it. You have to sort of genuflect the whole culture, the cultish culture of Trump. And here you are.

Krugman: Right. You were going to tell me why you think red districts are hit harder by this cutoff.

Cohn: So this gets a little weedy, but I’ll try to not get too weedy. But so we were talking before about how the ACA was set up, right? And the idea was kind of like a layer cake, if you want to think about it that way. Medicaid for low income people and then ACA exchange coverage for people who were above 135% of the poverty line and didn’t have employer insurance. And when they wrote the law, the assumption was every state was going to expand Medicaid, because it was written in such a way so that every state would do it. The Affordable Care Act had this complex structure, but the assumption was every state would do it. And because of that, the money that’s available to people in the exchanges sort of stops below 100% of the poverty line.

And as some of your viewers and listeners may know, in 2012, there was a really big Supreme Court case about the Affordable Care Act. If you believe what’s been reported, John Roberts actually at one point was ready to nuke the whole thing and then kind of pulled back from the precipice and they ended up upholding most of the law. But the one really important part they struck down was where they said, “Hey, states, you can reject the Medicaid expansion.” So as a result, lots of states initially did not opt into the Medicaid expansion. Over time, more and more have, but we still have 10 holdout states. And politically, it’s exactly what you expect. It’s Florida, it’s Texas, it’s Georgia, it’s mostly Southern red states that don’t want to expand Medicaid because there is a state contribution. And so the states have to opt into it. And the elected officials in these states are against it, even though I think, from the standpoint of even a red state, it’s a great deal, but whatever.

Krugman: Yeah, I guess the federal government contributes 90% now. And the tax revenue from the extra health care that gets provided almost certainly covers the state contribution. So it’s weird.

Cohn: Yeah, and it props up rural healthcare. It’s a really essential source of funding. And a lot of these red states—Mississippi, Alabama, Texas—I don’t know, are there any rural areas in those states? Because those states haven’t expanded Medicaid, you have a very large uninsured population that if they lived in Colorado or they lived in Massachusetts or even West Virginia, which did expand Medicaid, they would be eligible for Medicaid.

In those states, where the funding levels are, some of those people, only some, are able to get coverage through the Affordable Care exchanges. So as a result, you have a proportionally higher number of low income people on ACA exchange policies in those 10 states relative to other states. And again, these are some pretty big states. I mean, Florida, Texas, Georgia—we’re talking a lot of people there. And if you do the math, it turns out that on a state by state basis, and it works out to some extent on the district level too, in part for complex reasons, it tends to be disproportionately red districts, red state voters. It’s not so overwhelming that you can say it’s only those states. Believe me, plenty of people are gonna feel it in blue states, swing states. I’m in Michigan. It will be a big deal here certainly.

Krugman: Now, Democrats have chosen to make this their demand for keeping the government open. What do you think of that choice of ground? And then let’s talk about what we think might actually happen.

Cohn: Yeah, yeah, so I’ll preface this with a caveat. I’m the world’s worst strategist. People always like to play poker with me because I lose. But I would say as a substantive matter, I think there’s a solid reason. I’m an institutionalist and I like to work through normal procedures and negotiations. I’m not a fan of shutting down the government as a way to get policy ends. I didn’t like it when it happened before. But we’re in a world now where all the norms have been blown up. All the procedures have been blown up. They’re passing laws without committee hearings. This sort of feels like 10 years ago, because things are happening so fast, but one of the many truly, I thought, egregious parts of this bill that they passed over the summer was there was no time for scrutiny. They pushed it through. You remember, they were voting on stuff before the text was out, before the CBO scores were out. The Affordable Care Act took a year of debate and deliberation. And [with the OBBBA,] they basically squeezed a major bill that was going to cut taxes, change healthcare, by the way, get rid of a generational investment in green energy.

And that’s not to even say anything about the fact that they’re not doing committees, they’re not negotiating, they’re just pushing stuff through. There’s the whole other element, which is the way the Trump administration is not following the law. And I’m not even talking about the weaponization of the Justice Department. I’m talking about Congress appropriating funds and the Trump administration not spending those funds, even when the courts are ordering them to. They’re finding ways to fight. So as far as I’m concerned, if that’s the world you’re in, then you need to play in that world. So you use the political leverage you have when you have it.

It seems to me there are three demands Democrats have put forward. The first is that they want some guardrails so that money will actually be spent. I don’t know how effective those will be, but it seems completely reasonable to me to do that. And then they want to undo these healthcare cuts, which I think you can argue were pushed through in a way that was fundamentally contrary to the process. And their answer was always, “Well, we can, so we will.” All right, so we can hold up the government spending then to do this. I mean, that’s fair game. And then on the subsidies, same thing. Democrats had a bill back in January. They’ve had proposals to extend these extra subsidies that have made the program so much more affordable and Republicans didn’t want to answer it.

You know, substantively speaking, I think those are fair grounds for going outside the normal process because at this point, the normal process does not exist. Trump and the Republicans have blown it up. So you’ve got to do it. In terms of the strategy question, I don’t know. But to me, it’s something where it’s friendly issue territory to the Democrats. And I think that explains a lot. We’re seeing these lies from the Republicans because they know they’re on the losing side of those debates. It’s something concrete they can do. It’s something they believe in. I mean, either they win and they can say, “Hey, we fought and got you this help,” or they lose and say, “Hey, we did the best we could. These people will not help you. Come vote for us next time and we’ll make something happen.”

Krugman: Yeah.

Cohn: There is a separate argument that they should be standing their ground more. Trump and the Republican party are destroying democracy. So I’d be all for that. My hesitation there is I worry that would require a level of coordination among the Democrats and leadership skills they may not have. I wish they did.

And I don’t have insight into what it’s like inside the caucus, but it may be that this is the ground where they are most confident they can hold together. And it is. I mean, this unites the caucus— the conservative Democrats, liberal Democrats, they’re all on the same page.

Krugman: Some people said they should be going after the Trump tariffs, as well. Those are wildly unpopular, but on the other hand, people don’t understand tariffs at all. And so it might be a little bit hard to argue. A new, elevated bill from the insurance company is really concrete. This should be kind of simple. But how Republicans are trying to frame this is really quite extraordinary. And you had a really good piece on this.

Cohn: So I mean, as we were just saying, Democrats have moved the playing field over to healthcare, which is an issue on which they have the advantage. And they have the advantage because people like Democratic policy on healthcare. They think it’s good. In general, people like Medicare. And it turns out they really like Medicaid. They like the Affordable Care Act now. They don’t want to cut these programs. They want to keep these programs going, if anything, and they want them to be more generous with less bureaucracy and more organized, all of which Democrats have lots of proposals to do. Republicans don’t believe in it, which again, I think that’s why we have politics. We should debate that. And if they want to go out and say,
“We think it’s bad. We think the money is better spent on our tax cuts,” or, “This is causing healthcare quality to go down,” which they said, we can have that argument, but they don’t want to have that argument because they know they’re going to lose that argument.

So they are trying to plant the flag somewhere where they have an advantage. Immigration is an issue. So they’ve come up with this argument that “what Democrats really want is free care for illegal immigrants.” And I use that phrase deliberately because it’s the phrase the Republicans are using. And you can see why they like it because immigration, if the polls are right, tends to be an issue more favorable to Republicans. I don’t know how much that’s changing now, to what extent people don’t like what they’re seeing in the streets, but in general, right? That’s a favorable issue to Republicans.

You could see this narrative bubbling up in the places where these things bubble up—in the conservative media here and there. But it was very prominent a week ago. JD Vance went on Fox and said, “Democrats want to spend a trillion dollars on free care for illegal immigrants.” And Speaker Johnson said something almost exactly the same, which is ludicrous.

And in fact, actually, when I was gonna write about this, my initial thought was, don’t even write about it because this is what they do is they make up this crazy lie. You get sucked into this debate about it and now you’ve spent half your time giving voice to this crazy thing and giving it credence. But of course, they just kept pounding away at it and it’s kept going. So I did write about it.

The single most important thing to remember when you hear this repeated is that by law, undocumented immigrants cannot get Medicare. They cannot get Medicaid. They cannot get federally subsidized insurance through the exchanges. They are not eligible for these things. Federal dollars cannot provide direct insurance under those three programs for undocumented immigrants with a tiny, tiny little asterisk I’m going to get to in a second.

The second thing to realize is that not only can undocumented immigrants not get those programs, many people who are here legally cannot. So for example, if you’re on your way to get a green card for permanent residency, there’s a five-year waiting period in general before you can get on these programs.

Now, there are some people who are here lawfully. They might have protected status. They might be asylum seekers. These are people we’ve said “you get to be in this country.” And under some circumstances—and it gets real complicated fast because it depends on what your status is and what program we’re talking about—there are some circumstances where those people can get federally subsidized insurance. They’re not illegal aliens, though, right? I mean, they are people here lawfully.

Krugman: Yeah.

Cohn: So that is the big lie they’re telling. JD Vance was out on TV this morning and then he was at the White House just before we got on to record this. And I noticed they’re kind of walking it back a little bit. They’re trying to narrow it down to something where they feel it’s more defensible. I would say JD Vance is the most enthusiastic proponent of administration lies. And so he’s out there constantly saying this. So he kind of retreated back to saying, “Well, actually, you know, when we say ‘illegal aliens,’ we meant all these people that Biden let into the country that he shouldn’t lawfully.” OK, but they’re not illegal, they’re legal. I mean, you may want to change policy and that’s fine, that’s an immigration debate, but they’re not illegal.

And number two, that’s still a really small portion of what we’re talking about here. Most of the dollars that are up in this debate about the Medicaid cuts and Obamacare, that’s all going to US citizens or people here legally. Remember I said there was an asterisk? So there’s this tiny piece, and I mean tiny, it’s literally less than 1% of total funding in Medicaid. The federal government does reimburse hospitals when they provide emergency care to people who are here and would qualify for Medicaid if not for their immigration status. That’s a very complicated explanation, but I wanted to get it technically correct. Basically, if you’re a hospital, you cannot turn somebody away if they show up at your doorstep with a heart attack or they’re delivered by ambulance. And when hospitals provide that care, it costs them money. And as a way to sort of offset some of those losses so they don’t have to lose so much money, the federal government will reimburse that care to the hospitals. And in some states, they’ve sort of expanded it a little more broadly to include things like prenatal care, chemotherapy, dialysis. Again, this is a tiny amount of money and even in that small portion of money, only a portion of it is for undocumented immigrants. Remember I said before, if you’re applying for a legal permanent residence, that’s a five-year wait. So if you’re one of those people who show up at the ER, this program would reimburse the hospital. The funny thing was, Vance got up today, and I don’t know if he said it at the White House, because I didn’t see the White House, I didn’t see the whole White House press conference, but he was on Fox this morning. He said, these were Biden era programs.

Well, actually, emergency Medicaid has been around since the 1980s. It was part of a budget act signed by Ronald Reagan. And then 10 years later, when they did welfare reform, which was passed by Newt Gingrich and the Republicans, all the liberals hated it. And one of the things that the liberals hated was it actually restricted access to benefits for immigrants, very much in the vein of what Trump and Stephen Miller want to do now. Even those Republicans said, “OK, we’ll keep this emergency Medicaid thing.”

I don’t know how much it was compassion, though I would like to think most of us would think if someone’s got a heart attack and we can save them, we should. We can worry about the money later. You know, that’s a debate to have later. But I think there was some realization that, if you’re a hospital in Arizona or California where, whatever the immigration policy at the time, there’s always gonna be some of these people, but if we don’t help these hospitals out, they’re gonna close. Guess who’s not going to be able to get care? It’s going to be American citizens.

And I suspect that was part of their thinking. Maybe JD Vance, Trump and Stephen Miller don’t like that. I suppose they probably don’t, given the way they think. Fine, they should argue that number one. And number two, let’s just go back to the first point: this is a morsel of the money that’s being made. And so to suggest that because of that 1% of spending, Democrats are out to give free care to illegal immigrants. It’s just a lie. It’s a lie in the sense that it is fundamentally untrue. They know it’s untrue. They are trying to create a misperception and distract from what the real issue is, which is that they don’t want to spend the money on Medicaid and Obamacare that would help millions of people get insurance.

Krugman: You basically have to have a social security number to get on these programs, right? It’s basically impossible to fraudulently enroll. Whether there’s some fraud on the part of healthcare providers is another question. But basically you cannot fake your way into coverage under Obamacare.

Cohn: No. And in fact, you’ll probably appreciate this. You remember when healthcare.gov rolled out and the website crashed? I sometimes think it was the lowest point for the program. The point where I most questioned whether it would survive. It was such a fiasco.

Krugman: We mentioned Charles Gaba. Let me give him a shout out. He first got all of our attention because there were all these stories about how the program was doomed. The website crashed. And then, like in January, he was actually crunching the enrollment data. And he said, you know, millions and millions of people are signing up for this thing. This thing is actually going to be a success. I wrote it, but for the most part, the legacy media didn’t cover it at all. Unless you were reading Charles Gaba’s blog, you didn’t know about any of this.

Cohn: Yep, no, he was like a one man show back then. Well, one of the reasons that the website was struggling, and there were a lot of reasons, and it was a big failure and a case study on how not to govern. But one of the design challenges for the website was it had to cross check all this different information. And checking immigration status, that was very much on people’s minds. By that point, it had already become a really politicized issue in the way it is now. From around 2010, 11, 12. They were wired into that at the White House and the HHS. They didn’t want stories popping up in a year or two that all these undocumented immigrants were getting on the program. So healthcare.gov, had to be able to do a real time check of social security and tax data or whatever documents people were filing with the Department of Homeland Security. And technologically, it was really hard. It was a big deal. And it was among the complications they did not deal with successfully that contributed to the whole thing going down. So if they weren’t trying so hard to check for citizenship status and create a system that was so rigorous, they might not have had such a hard time making a website that works.

But they did and the website does work and it does now check the documents. It’s a really rigorous check. I’m sure there are people out there who figured out a way around it. It happens. It’s a big country. But the idea that this is like a rampant fraud going on, it’s just, it’s very far-fetched.

Krugman: It’s kind of like Elon Musk’s kids claiming that there are tens of millions of dead social security recipients. It just isn’t there.

Cohn: It’s just not there. Yeah.

Krugman: Do you think there’s any chance that Republicans will in fact make a deal to keep this alive? I don’t know how any of this plays out.

Cohn: It’s funny, I was talking to some people about that. These days I’m so focused on the policy, I’m not talking as much to people on Capitol Hill. It’s hard to know. However, I was struck by the fact that there seemed to be more uncertainty about how this one’s gonna go. We’ve had shut down fights or big standoffs over policy and people are generally uncertain because there’s so many wild cards here.

I do kind of think at the end of the day, there will be a deal that gets at least some of the money, primarily because I think for what you were talking about at the very beginning, this is in their self-interest. I mean, that’s the weird part about this. Republicans are going to be better off heading into the midterms. If I’m a Republican member of the House of Representatives or Republican senator and I’m running for reelection, I’d rather not be running in an environment where I have lots of angry constituents because their health insurance premiums went up.

And I don’t know about you, but I feel like watching the ACA evolve has been an incredible learning experience for me and lots of times I’ve been wrong about things and it’s helped me to sort of hopefully become a better thinker and writer and reporter. When it comes to political dynamics, something I did not appreciate until the rollout of ACA and some associated issues, is that you can have a world where 80% of the people are better off and 20% of the people are worse off. That 20% is gonna be really loud and angry. And the angry people are the ones who will dominate the conversation. It’s just human nature.

And the number of people affected by premium hikes now because there’s so many people on the exchanges, it dwarfs the number of people who had to face higher premiums when Obamacare first came online. And that was a huge backlash. So my theory is that Republicans may have come to this late, but I think they’re seeing it now. And actually Trump’s pollsters a while ago were kind of warning about this.

So my theory is, this is in their best interest to do. That doesn’t guarantee anything, because there are enough pitfalls here, and there’s enough true believing economic conservatives on healthcare who just don’t want this to happen, so that could stop it. But my theory is that this can end in some kind of extension. And I actually think it’s gonna be a hard question for Democrats at some point, what are they willing to settle for? Because to be honest with you, I’m in favor of people getting healthcare. That’s my bias. But from a political standpoint, there’s ways to do this that basically gets the Republicans off the hook politically for now without dealing with the problem in a long-term way. And you could argue, well, if Democrats don’t get more political power, it’s gonna be harder for them to really secure this in the long run. So, I mean, it’s gonna get complex. I do think, however, that there’s a path to some more money there.

Krugman: Well, I’m not sure whether that’s hopeful or not given all the other dynamics, but I personally know at least one person where basically the coverage that she got through Obamacare saved her life. So I’m really big on, as you say, getting people healthcare.

Cohn: That’s right.

Krugman: We’ve had this program now for 10 years and it’s done more than that. I think it’s done a tremendous amount of good. But I guess nothing lasts forever. Anyway, thanks. Thanks so much for talking to me.