Commentary: When health care becomes a choice, something is broken

Recently, a nurse told me she had to choose between paying for her husband’s surgery and putting a new roof on their home. “We’re praying for no rain,” she said. In that moment, the distance between political promises and real life collapsed.

This is what the economy feels like for millions of Americans — not a graph, not a headline, but a quiet calculation of which basic need they can afford to meet. No family in a nation as wealthy as ours should have to rely on the weather to survive.

For years, Americans were promised that the Affordable Care Act (ACA) would be replaced with something better, cheaper, and available to everyone. That promise never became policy. Congress never passed a comprehensive replacement. The closest attempt, the American Health Care Act (AHCA), collapsed under the weight of its own numbers.

The Congressional Budget Office found that it would have left 23 million more Americans uninsured, caused 14 million to lose coverage in the first year alone, cut Medicaid by $834 billion, and raised premiums for older adults to levels many could never pay. A 64‑year‑old making $26,500 a year would have seen premiums jump from $1,700 under the ACA to more than $14,000. Protections for people with pre‑existing conditions would have weakened. That is not “better.” That is not “cheaper.” And it certainly was not “for everyone.”

Despite the AHCA’s collapse, the administration moved ahead on Day 1 with actions that weakened the ACA. It revoked a Biden-era order that had extended enrollment periods and restored funding for Navigators — the trained professionals who help families sign up for coverage. Those supports had been designed to make enrollment easier and more accessible. Removing them made it harder for people to get help, harder to understand their options, and harder to keep the coverage they already had. Families woke up to fewer tools and a more fragile system.

When Congress failed to pass the president’s healthcare plan, it did not stop the administration from weakening the ACA anyway. Key protections were rolled back with no replacement ready — a political victory for those intent on dismantling President Obama’s legacy, but a devastating loss for the people who depended on those protections to survive. Loyalists in Congress allowed it to happen, and now Americans of every party, in every state, are struggling with the consequences.

Then came the consequences. Key ACA protections were eliminated without putting a functioning healthcare plan in their place, leaving families in a system weakened by years of political fighting and offering nothing to replace what had been dismantled. Premiums rose. Protections thinned. Coverage grew more fragile. And the people who were told help was coming were left to fend for themselves.

One of the most persistent misconceptions is that states rejected the ACA because they “couldn’t afford it.” The data show the opposite. Under the ACA, the federal government pays 90 percent of Medicaid expansion costs permanently. States pay 10%. Because Medicaid expansion reduces uncompensated care, mental‑health spending, and emergency‑room costs, states that expanded Medicaid actually saved money. Louisiana saved $199 million in its first full year. Montana saved $28 million in two years. Kentucky projected $820 million in savings over five years. Arkansas saved $444 million between 2017 and 2021.

When protections weaken, people do not lose “coverage” in the abstract. They lose chemotherapy. They lose insulin. They lose the ability to see a doctor before a condition becomes life‑threatening. Uninsured adults are twice as likely to delay care until it becomes an emergency. Hospitals provide more than $40 billion in uncompensated care each year. Rural hospitals in non‑expansion states are six times more likely to close. One in four insulin users reports rationing because of cost. Many families pay $300 to $600 per vial. During the recent Medicaid unwinding, more than 20 million people lost coverage, and 70% of them lost it because of paperwork, not because they were ineligible. After the individual‑mandate penalty was eliminated, premiums rose 7 to 10% in many states. These are not isolated stories. They are the predictable outcomes of policy choices.

Consider Nancy Linder, 47, who lives outside Atlanta. When the enhanced ACA subsidies expired, her family’s monthly premium jumped from $162 to $483 — nearly $3,900 more a year on an income of about $30,000. Nancy has a history of a brain tumor, Parkinsonism, and relies on multiple specialists and medications. “I have to have health insurance,” she said. But like millions of others, she now faces a choice between coverage she cannot live without and costs she cannot afford.

Part of the problem is that we rarely evaluate what works, monitor what doesn’t, or adjust policies based on real‑world results — and families pay the price.

Restoring the ACA would not mean returning to the past and walking away. It would mean restoring what worked and then doing what responsible systems do: reviewing, monitoring, adjusting, and evaluating results on an ongoing basis. Congress could set a clear timeline — annual reviews of coverage rates, affordability, emergency‑room usage, state budget impact, and medication access — and adjust the law as needed. That is what a functioning democracy does. It learns from evidence, responds to real‑world outcomes, and adapts to protect its people. Given the current state of the economy, with families stretched to the breaking point, this is not only a policy choice. It is the human thing to do.

There are solutions. Congress can restore the enrollment supports that worked — extended sign‑up periods, full Navigator funding, and stable subsidies that keep premiums within reach. States can protect Medicaid expansion and the 90/10 federal match that has saved budgets and lives. And policymakers can commit to something we rarely see in health care: ongoing evaluation. If a policy reduces costs and expands coverage, keep it. If it fails, fix it.

None of this is complicated. It simply requires choosing people over politics.

Health care should never force families into impossible decisions. When coverage becomes a choice between survival and sacrifice, something fundamental has broken. We can repair it — not with slogans or shortcuts, but with policies that put people first and protect the dignity of every family. That is the work of a functioning democracy, and it is work we cannot afford to postpone.

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Carolyn Goode is a retired educational leader and former adjunct instructor who writes about civic responsibility, democratic norms, and the human impact of public policy.

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