Merchants of Death.

The healthcare system is falling apart, and we now have the numbers to show it.

Part of the UNFTR project is to build the case for Medicare for All. It’s not just a talking point and a throwaway policy position to us—it’s a moral imperative and an economic justice issue. The intent today is not to litigate that position, because we’ve produced a healthy amount of content on the matter and have resources anyone who wants to go deeper. But it is the backdrop here, and it’s the clear way forward.

For now, there’s a lot to cover, because the system is deteriorating rapidly. People are losing coverage. Medical debt is increasing again. The main cost drivers—pharmaceuticals, hospitalization, and end-of-life care—are skyrocketing. This isn’t working, and neither party has a plan. Like, nothing even close to a plan.

There is a silver lining to all of this, or at least a hopeful reading. It’s possible that in their pursuit to kill Obamacare and gut Medicaid, these soulless monsters may very well have opened the door to something better. Necessity is the mother of invention. But desperation is the fuel for revolution.

The American Healthcare Quilt

Let’s start with how we actually get healthcare in this country.

First off, there is no American healthcare system. There’s a patchwork of overlapping, half-built solutions that were never designed together, don’t talk to each other, and leave huge coverage gaps.

You’ve got the ACA exchanges—the marketplaces created in 2010, Healthcare.gov at the federal level, state-run versions like Covered California, all built for people who don’t get insurance through a job and don’t qualify for Medicare or Medicaid. That’s the “last resort” tier—the self-employed, the gig worker, the small-business owner. It was supposed to be the fix. And who could have imagined that a system written and lobbied for by insurance companies wouldn’t ultimately work to our benefit? Huh.

Before the ACA, and still running alongside it, you’ve got employer-sponsored insurance—the dominant model since World War II, when wage controls pushed companies to compete for workers with benefits instead of pay, and it calcified from there into the backbone of American healthcare. Half the country gets coverage this way, which means half the country’s access to medical care is tied to whether they still have a job, whether that job is full-time, and whether their employer eats the premium increase or passes it down.

Layer on union insurance—negotiated benefit plans that used to be the gold standard, gutted as union density collapsed over the last 40 years, but still meaningful for organized labor, especially in the building trades and transit. In fact, it was union coverage that spurred private corporations to build a system in the first place because union health benefits were so highly coveted.

Then the government-sponsored tier—Medicare for seniors, Medicaid for low-income households, CHIP for kids specifically. These are the closest things we have to actual universal, publicly administered coverage, and not coincidentally, they’re also the most efficient parts of the entire system. We’ll come back to that.

And then there’s absence. The uninsured. The strategy is: don’t get sick, and if you do, go to the emergency room, because federal law says they have to stabilize you regardless of ability to pay. That’s the plan for tens of millions of Americans.

Six systems. Zero coordination. And healthy people are constantly getting pushed off one and onto another—losing a job and falling off employer coverage, aging off a parent’s plan at 26, aging into Medicare at 65, falling in and out of Medicaid eligibility as income fluctuates by a few hundred dollars a month. Every transition is a place where people potentially fall through.

Now compare that to every other wealthy democracy on earth. Now, to be clear, there is no single “socialized medicine” model. It’s a spectrum. The UK’s National Health Service is about as close to fully socialized as it gets—government owns the hospitals, employs the doctors. Canada runs single-payer, but delivery stays private—doctors and hospitals are independent, the government’s just the one paying the bill. Germany and Switzerland run tightly regulated, nonprofit, multi-payer universal systems where everyone is required to be covered. France blends public insurance with a private supplemental layer.

Of course, there are trade-offs on things like wait times, choice and funding. I’m not pretending they’re all equally good or free of their own political fights. But every one of these countries made a decision that healthcare access isn’t contingent on your employment status, your income, or your luck. And the results show it—we spend more per capita than any of them, by a wide margin, and get shorter life expectancy and higher infant mortality in return.

The Collapse

This is where we go from abstract to material. The last 12 months have produced some of the worst coverage numbers since before the ACA existed.

Start with the ACA marketplaces. Effectuated enrollment—meaning people who actually paid their premium and are actually covered—dropped 13% between 2025 and 2026, falling from a record 22.1 million people down to 19.2 million, according to KFF’s analysis of federal Health & Human Services data. That is the first enrollment decline on the ACA marketplaces since the first Trump administration. An actual drop of nearly three million people. And KFF’s own projection says it could keep falling, down to an average of around 17.5 million enrollees by the end of the year. In a KFF survey taken during this stretch, 17% of enrollees said flat out they weren’t confident they could keep affording their premiums for the rest of the year.

This is the real world impact of the GOP killing the enhanced premium tax credits. When those expired, the average enrollee trying to keep their exact same plan saw their premium payment jump 114%. Some downgraded coverage, others dropped it. And the impact is already showing up in hospitals. The New York Times reported in July that hospital operators, including Community Health Systems, are seeing a sharp rise in uninsured patients, tied directly to people who lost coverage once those subsidies disappeared.

And this isn’t close to over, because premiums are rising independent of the subsidy fight entirely. Health System Tracker’s nationwide analysis found a median proposed 2027 marketplace increase of 15%, following an 18% median the year before. That’s two straight years of double-digit increases—the second-highest requested change since 2018—and if this holds, premiums will have risen more than a third in two years.

Small businesses are getting hit just as hard. The same research group’s review of small-group plans—companies with 50 or fewer employees—found a median proposed 14% increase for 2027.

These are terrible trends, but the most inhumane, in my opinion, is what’s transpiring with Medicaid, especially when it comes to children.

The One Big Beautiful Bill Act cuts around $900 billion in Medicaid over ten years. The Congressional Budget Office projects that means more than ten million fewer people enrolled in Medicaid by 2034. The American Medical Association estimated that about 11.8 million people would lose coverage.

It’s already happening. Georgetown University’s Center for Children and Families found nearly 2.5 million children have lost Medicaid or CHIP coverage since January 2025. Five states saw enrollment drop 10% or more. And, they’re purging people in such a dystopian bureaucratic way by forcing states to renew Medicaid recipient eligibility every six months instead of annually. Plus, starting next year, certain adult beneficiaries must prove they’re working or volunteering at least 80 hours a month, or enrolled in school, just to keep coverage they already qualify for.

Two Brown University epidemiologists wrote in STAT that getting a “medically frail” exemption from the work requirements is becoming a nightmare scenario. Their example: someone undergoing cancer treatment lacks the right renewal form, gets disenrolled, hits long wait times with no path back in, and somewhere in that maze, stops chemotherapy. Their words: “Paperwork here is not merely an annoyance, it is a matter of life or death for millions with Medicaid coverage.”

So tally where that leaves us. Marketplace enrollment down roughly three million and falling. Premiums up 114% for people keeping their existing plan, rising another 15% next year regardless. Medicaid on track to shed ten million-plus people by 2034, with 2.5 million kids already gone. These are the nails in the coffin, but we must also be honest about how and why the system was failing before the GOP decided to put a pillow over it and suffocate it.

Perverse Incentives

So why has every attempt to patch this system—including the Affordable Care Act—fallen short of actually solving it?

Because you cannot build a for-profit system around a service whose entire purpose is to make itself unnecessary.

In most industries, the profit motive and the stated goal of the business are aligned—a car company wants to sell cars, so it wants you to buy more cars. But a health insurer’s stated goal is a healthy population, except a healthy population doesn’t need insurance. It doesn’t file claims. A genuinely healthy customer base is, on a balance sheet, a customer base with nothing to sell to. The industry doesn’t make money on health—it makes money on the gap between premiums collected and claims paid out. Every dollar spent on your actual care is, structurally, a dollar the company would rather not spend. It’s why we don’t have healthcare in this country. We have sick care—a system engineered to manage illness profitably, not produce health, because health is bad for the topline.

This is the thing our own reporting keeps coming back to: the system isn’t broken. It’s working exactly as designed—designed to generate returns for shareholders, not outcomes for patients. Once you see it that way, every infuriating feature of American healthcare starts making sense. Why insurers fight so hard over prior authorization—every denied or delayed claim is an averted payout. Why deductibles keep climbing—it pushes cost risk onto you before the company touches its own money. Why pharmacy benefit managers (PBM) exist as an entire industry unto themselves, taking a cut between manufacturers and patients—the top three PBMs alone pulled in over $600 billion in a single year, as we’ve reported before, and all they do is push paperwork.

In pure administrative waste, the “efficient private market” argument falls apart on contact. Medicare—the public, government-run program—spends about 2% of its budget on administration, roughly in line with Canada’s single-payer system. Private insurance, excluding Medicare entirely, runs administrative costs around 13%. That’s a six-times efficiency gap because Medicare doesn’t need to spend money finding reasons to deny your claim, doesn’t need armies of underwriters pricing individual risk, and doesn’t need to court shareholders. The private model spends a huge chunk of every premium dollar running the apparatus of profit-extraction before a dollar reaches an actual doctor.

This is also the honest answer to why Obamacare—for all the good it did, cutting the uninsured rate from persistent double digits to around 9% at its best—was always going to hit a ceiling. The ACA didn’t remove the profit motive from health insurance. Instead it regulated around the profit motive. It was always a patch on the incentive structure, not a replacement of it. And patches degrade.

No matter how cleverly you regulate this model, you’re asking a profit-seeking industry to voluntarily underperform its own profit motive in the name of public health. So at an absolute minimum, if we keep any version of this private-market structure, it needs to be subsidized heavily, permanently, and insulated from being a political football a single hostile Congress can gut in a budget bill. But that’s the minimum, and even there, you’re paying the private industry’s built-in inefficiency tax forever. The actual answer is universal coverage that takes the profit motive out of the transaction between a sick person and the care they need.

Mike Johnson, Mike Crapo, Mitch McConnell, Paul Ryan before them, and Donald Trump himself did not just take healthcare away from millions of people. They may have opened the door to real progressive change. Because the only way real change ever happens in this country—the only way we swing the pendulum, for better or worse—is when enough people get crushed. Uninsured, underinsured, buried in medical debt, watching a parent or a kid get denied care over a missed form—that is not a stable political condition. It’s kindling. Their short-term victory in killing access to healthcare may be exactly what sets up Medicare for All for the long-term win.

For now, take heart that there are people out there with the answers—people like Pramila Jayapal, Bernie Sanders, AOC, and Abdul El-Sayed. There is real momentum here. It’s just a shame that we have to watch the GOP burn it all to the ground before we’re able to rebuild again.