for the impecunious, and created new “exchanges” where individuals could compare and purchase plans. Even Obamacare’s most fervent advocates acknowledged, in private, that it was an imperfect bandage, particularly for those on the individual market. It was never enough for the likes of Bernie Sanders, a leftist senator who called for a single-payer system. That cause is now being taken up by a new generation of Democrats, such as Abdul El- Sayed, the party’s Senate nominee in Michigan, who has made health-care- for-all central to his campaign. New data explain the urgency: Obamacare’s bandage is unravelling. That’s in part due to cuts to Medicaid. It’s also because the exchanges are in bad health. Obamacare offered some subsidies to defray the cost of individual plans. But the law’s mandate to buy insurance was in effect eliminated in 2019, and uptake on the exchanges was limited until 2021, when Congress made subsidies more generous for those who had already qualified and available to some who hadn’t. Enrolment then nearly doubled by 2025. Democrats sought unsuccessfully to extend the extra financial assistance, which would have cost about $35bn this year—about as much as the direct costs of the Iran war, according to the Pentagon’s estimate. Now that those subsidies are diminished, the individual market looks more frail than ever.
Figures from insurers and state marketplaces show the effect of the rollback. The number of people buying coverage through the exchanges has already fallen to 19.2m from 21.8m last year. The Congressional Budget Office (CBO), a non-partisan scorekeeper, reckons that by the end of this year it is likely to fall below 17m. Of those who dropped off the exchanges, most appear to be going without coverage. The leavers tend to be more healthy than those who remain on the exchanges, making the remaining pool more costly to insure. Combine a sicker patient population and general inflation in health costs, and the result is higher premiums: this year the average payment increased from $113 to $178 per month. Many enrollees are now buying skimpier plans. In the past year the average amount an individual must pay out of pocket before insurance kicks in has jumped by nearly 40%, to $3,800. This has raised fears of a dismal loop, with higher premiums and more limited plans making insurance still less attractive, particularly to healthier customers. As they leave the exchanges, premiums are driven yet higher. Insurers have already proposed a median premium increase of 15% for 2027, according to KFF, a think-tank. If state regulators approve those rates, pre- subsidy premiums will have grown by more than a third since 2025. The KFF imagines a 40-year-old in Indiana earning $65,000. In 2025, with subsidies, her monthly premium was $316. This year it is $477. Next year it will probably be close to $550. Does this threaten the viability of the exchanges? The CBO estimates that by 2028, 10m fewer Americans will get insurance on the marketplaces compared with last year. But the exchanges will probably avoid collapse, with the remaining subsidies convincing enough people to remain. “The changes basically get us back to what the marketplace looked like from 2016 to 2019,” predicts Ben Sommers, a health economist at Harvard University. The exchanges will be smaller, with fewer participating insurers and sicker customers. There will also be more people without insurance. Evidence suggests that they will put off needed treatment, like certain prescription medicines and surgeries. “We know that from a decade or more of research on the Affordable Care Act,” explains Mr Sommers. Hospitals must still provide
emergency care for them, even if they cannot pay. In May unpaid care was up by an average of 16% compared with a year earlier, according to Kaufman Hall, a consultancy. HCA Healthcare, a for-profit hospital group, reckons the new uninsured population will cost the chain at least $1bn in operating profits this year, equivalent to about 15% of predicted net income. Enrolment on the exchanges in recent years shows “people generally want health insurance,” says Cynthia Cox of KFF. “It’s just a question of whether they can afford it.”■ Stay on top of American politics with The US in brief, our daily newsletter with fast analysis of the most important political news, and Checks and Balance, a weekly note that examines the state of American democracy and the issues that matter to voters. This article was downloaded by zlibrary from https://www.economist.com/united-states/2026/08/16/obamacare-is-becoming-even-more- frail
The real covid-19 scandal is still unfolding The failure to reckon with lives needlessly lost will make the next pandemic deadlier Aug 20th 2026 For all the zeal Congress has shown in investigating America’s response to the covid-19 pandemic, it has been strangely uninterested in exploring a basic question: why did so many Americans die relative to the numbers who succumbed to the virus in other rich countries? Understanding the answer would seem relevant to guarding against the next, inevitable pandemic. Many countries were slow to react, but as they learned about the transmissibility of the virus, and as vaccines became available, they rapidly cut their death rates. Not so America. “The death rate is now about eight times higher in America than in the rest of the rich world,” The Economist reported in September 2021. In all, America lost more than 1.1m people to
covid, or roughly 3,500 lives out of every million. This should haunt every official who was in a position to combat the pandemic. Germany’s death rate was about 2,000 per million people and Canada’s fewer than 1,400, notes Donald McNeil in his book “The Wisdom of Plagues”. Had America managed to split that difference, at about 1,700 per million, “We would have lost about 540,000 fewer dead,” he writes. “Who speaks for them?” Not Congress. America’s lethal underperformance once again went ignored when the Senate Homeland Security Committee recently questioned Dr Anthony Fauci, a crucial adviser on covid to Donald Trump and then to Joe Biden. (Mr Trump later turned on him.) The hearing focused instead on the usual obsessions for which Dr Fauci has become the Republican scapegoat —some absurd and others valid but distantly related, at best, to protecting potential victims of a future plague. While Democrats mostly gave speeches rather than ask questions, Republicans pursued theories that the virus leaked from a Chinese lab, that Bill Gates had some nefarious role, that Dr Fauci had been out to enrich himself through awards for his service—an odd complaint when they do not object to the president campaigning for a $1m Nobel prize. Having testified often to Congress during his 54 years at the National Institutes of Health—38 as director of the National Institute of Allergy and Infectious Diseases—Dr Fauci, who is 85, was reduced to repeatedly invoking the Fifth Amendment, including when asked the colour of his tie. In his opening statement, his hands shaking as he read it, Dr Fauci said his lawyers had advised that recourse because the committee’s chairman, Rand Paul of Kentucky, had made clear an intent to see him behind bars despite a blanket pardon issued by Mr Biden. In other words the Senate could not inquire into a health crisis that racked the country because a key witness feared a perjury trap, and rightly so. Why did so many Americans die? High rates of obesity, diabetes, heart disease and elderliness made them more vulnerable. But government bungling meant America was testing 100 people a day in early 2020 when other countries were testing tens of thousands; that masks and lockdowns were deployed erratically; that contact tracing proved too challenging for the country first to the Moon. Most senselessly, so many Americans died
because so many failed to take the vaccines that Mr Trump, in his most constructive act as president, succeeded in rushing into existence. It is, of course, those vexing vaccines that compel Republicans to look away from the basic question about the pandemic, and to hound Dr Fauci instead. Attempting to square the greatness of Mr Trump with the supposed vileness of the vaccines has inspired his party to heroic feats of doublethink. “President-elect Trump’s Operation Warp Speed—which encouraged the rapid development and authorisation of the COVID-19 vaccine—was highly successful and helped save millions of lives,” declared the committee created by the House to investigate covid in 2024, summarising two years of work. The very next sentence reads: “Contrary to what was promised, the COVID-19 vaccine did not stop the spread or transmission of the virus.” Mr Trump has struggled to escape this self-imposed contradiction. Even as he declined to urge the public to get vaccinated, he and his wife, Melania, secretly had the vaccine before he left office in January 2021. But as Mr Biden and other world leaders delivered the shots, Mr Trump wanted the credit he deserved, and in December that year he told supporters that he had received a booster. “What we’ve done is historic,” he insisted when the crowd booed. “Don’t let them take it away.” He has since let them take his glory away, and endangered more Americans, by questioning the efficacy and safety of vaccines for covid, and other illnesses. The latest attack on Dr Fauci, concocted from his private texts disclosed by Republican senators on August 10th, is that he covered up a threat of miscarriage that the vaccine posed to pregnant women. In fact, the record shows Dr Fauci was consistent, publicly and privately, in counselling a weighing of risks and benefits until studies showed the vaccine was safe in pregnancy—which they have since done. His critics have not produced evidence the vaccine causes miscarriages. Dr Fauci made mistakes, including not disclosing early on that some top virologists initially worried the virus might be man-made. He could be arrogant. But he was not responsible for the worst excesses of the covid response. Those endless school shutdowns were the work of local officials and union leaders. Senator Paul’s release of Dr Fauci’s private diary has exposed his vanity, his delight in every gushing appraisal by the media or
some celebrity. But the diary also reveals a conscientious public servant trying to save as many lives as he could, struggling against the constraints that hobbled America relative to its peers. His summons before the Senate committee was surely intended to humiliate if not incriminate him. It should embarrass the entire country. ■ This article was downloaded by zlibrary from https://www.economist.com/united-states/2026/08/20/the-real-covid-19-scandal-is- still-unfolding
The big democracy where lawmakers are mightier than the executive Polo’s lessons for Argentina The South American hipster language cooler than Spanish