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The ACA’s Missing Mandate: Why Costs Keep Rising

Repealing the ACA’s individual mandate destabilized insurance markets, drove premiums higher, and left families paying the price.

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The ACA’s Missing Mandate: Why Costs Keep Rising

By repealing the Affordable Care Act’s individual mandate, policymakers allowed healthy Americans to walk away—leaving insurers with risk pools dominated by those most likely to need care. The result was inevitable: premiums soared, markets destabilized, and families were left paying the price.

When Congress passed the ACA, its most controversial feature was the individual mandate—the requirement that all Americans carry health insurance or pay a penalty. Critics called it coercion. In reality, it was the glue holding the system together.

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A stethoscope, calculator, pills, and cash.

As ACA subsidies expire and Medicaid rolls shrink, millions could face higher premiums or lose coverage, reigniting a national healthcare debate.

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How Expiring Subsidies and Medicaid Cuts Could Reshape U.S. Access to Care

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In the coming year, millions of Americans could see their health insurance premiums rise, or lose coverage entirely, as key federal supports for affordable care are set to expire. The American Rescue Plan Act of 2021 (ARPA) subsidies under the Affordable Care Act (ACA) marketplace, which were later extended by the Inflation Reduction Act, are scheduled to expire at the end of 2025. According to one analysis, if these enhanced subsidies expire, premiums on average could increase by 25-100 percent. At the same time, several states are reducing Medicaid rolls following the end of the pandemic-era continuous coverage requirement. Over 25 million people had been disenrolled from Medicaid and CHIP during this process in 2024. Together, these changes could redefine U.S. healthcare access, reigniting debates about public health and fiscal restraint.

Background

The ACA, passed in 2010, aimed to make health insurance more accessible for millions of uninsured Americans by expanding Medicaid eligibility and creating subsidized plans under the premium tax credit. The ARPA of 2021 significantly increased those marketplace subsidies, eliminating the 400% of poverty threshold for eligibility and reducing the percentage of income that enrollees must pay in premiums. As a result, the number of people eligible for marketplace subsidies increased from 18.1 million to 21.8 million from 2020-2021. Meanwhile, pandemic policies prevented states from disenrolling almost all Medicaid and CHIP enrollees for over three years. When this continuous coverage requirement ended in April of 2023, states began to reevaluate the eligibility of tens of millions of people. The expiration of ARPA temporary subsidies combined with the end of continuous Medicaid coverage set the stage for a contentious healthcare market next year.

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U.S. Healthcare in 2025: Chaos, Costs, and Controversy Without Real Progress
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U.S. Healthcare in 2025: Chaos, Costs, and Controversy Without Real Progress

The year 2025 has been one of the most turbulent years in modern U.S. healthcare. The headlines were explosive, the rhetoric dramatic, and the controversies nonstop. Yet for all the hoopla and upheaval, the medical care Americans receive now, month in and month out, looks no better than what they experienced on January 1 — but far more expensive.

Here are five areas of healthcare that generated chaos, confusion, and conflict in 2025 without meaningful improvement.

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University Roundtable Puts Latino Mental Health Front and Center

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University Roundtable Puts Latino Mental Health Front and Center

“Keep it to yourself. Push it down. Don’t say anything.” That is how Isis Lara Fernandez was taught to live with her status as an undocumented immigrant in the United States.

At 6-years-old, Lara Fernandez fled to the U.S. with her mother and siblings to escape domestic violence in Honduras. From that point forward, Lara Fernandez navigated life with a persistent fear that her secret could be discovered at any point in time.

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