The Pill Bottle and the President
Weeks before the midterms, the Trump administration killed the program that was holding down Medicare drug premiums for 25 million Americans. The people about to open the sticker-shock letters this fall are the same people who put him in office — and the arithmetic behind that decision reveals more than politics. It reveals a presidency that no longer knows what it is doing.
On Tuesday afternoon, without hearings, without notice to enrollees, and without any pretense of a public policy debate, the Centers for Medicare and Medicaid Services announced the termination of the Part D Premium Stabilization Demonstration — the Biden-era program that has, for the past two years, been the invisible hand keeping Medicare prescription drug premiums from spiking as the Inflation Reduction Act’s $2,000 out-of-pocket cap phased in. CMS Administrator Mehmet Oz, the former daytime television doctor now running the largest health insurance program on earth, called the subsidy a “bailout” for insurance companies. He posted on X that “premiums will go up by less than $10 for most Medicare recipients.” The Hill and Newsweek reported the announcement within hours. But the Wall Street Journal reporting that preceded it told a different story: roughly half of the 25 million Americans enrolled in stand-alone Part D plans will see monthly premium increases “largely in the $11 to $20 range.” The subsidies cut the average Part D premium by more than a quarter this year. That reduction is now gone.
The framing matters. CMS insists this is a technical wind-down of a “temporary demonstration.” What actually happened is that a policy tool designed to shield 25 million people from the volatility of a privatized drug market has been discarded — and the sticker-shock letters will arrive in seniors’ mailboxes in late September, during the exact stretch of early voting that runs into November. The White House can call it whatever it wants. The elderly woman opening a bill for $54 a month in November instead of $34 in October will not care what CMS called it.
I. What Was Actually Killed
Before we go further, the facts have to be exact — because the administration’s spin depends on them being blurry. Medicare Part D itself has not been eliminated. The $2,000 annual out-of-pocket cap survives. The Inflation Reduction Act’s prohibition on annual base-premium growth above six percent through 2029 survives. What has been ended is the Part D Premium Stabilization Demonstration, a program the Government Accountability Office valued at roughly $9.8 billion across 2025 and 2026, that transferred federal dollars to Part D insurers specifically to prevent monthly premiums from spiking during the IRA’s transition years. In practice, it was the difference between a $36 average premium and something considerably higher.
Juliette Cubanski, vice president and director of the Program on Medicare Policy at KFF, the nonpartisan research group, put it plainly to NPR: this year, the subsidies reduced the average drug plan premium by $16. “That might not sound like a lot of money to some people,” she said. That comment, in a country where the median Social Security check is a little over $1,900 a month and where Senator Ruben Gallego has already warned CMS that “even modest increases in premiums may force [beneficiaries] to make difficult decisions between paying for medications and covering other basic living expenses,” is the entire argument in a sentence.
A Biden-era CMS program that channeled federal support to Part D insurers to blunt premium volatility during the IRA transition. Terminated at end of 2026.
Enrollees in stand-alone Part D drug plans, per KFF. Roughly half will see monthly premium hikes of $11–$20.
Per the Government Accountability Office, cited by NPR. The subsidies reduced the average premium by more than 25% in 2026.
Medicare open enrollment begins October 15. Premium change notices will reach mailboxes weeks before the November midterms, per reporting from MSNBC.
II. The Human Math of a Skipped Pill
To understand why a $12 or $18 monthly premium hike is not a rounding error, one has to understand what happens inside the body of a 74-year-old on a fixed income when the pharmacy total climbs past what she has in her purse. The clinical term is cost-related medication non-adherence. She rations her pills. She takes the blood-pressure medication every other day instead of daily. She stops filling the statin altogether. She splits the diabetes prescription in half. Then, some morning six or eighteen months later, her son finds her on the kitchen floor.
This is not speculation. It is a documented public-health pattern. A West Health Policy Center analysis conducted by Xcenda, the research arm of AmerisourceBergen, projected that high out-of-pocket drug costs would cause approximately 1.1 million premature deaths of seniors in the Medicare program over a ten-year period — an average of roughly 112,000 excess senior deaths per year — while generating an additional $177.4 billion in avoidable Medicare medical costs. The plurality of those projected deaths are cardiac: 354,800 from atrial fibrillation and ischemic heart disease alone. Another 70,400 from chronic kidney disease. 69,300 from chronic obstructive pulmonary disease. 62,700 from diabetes. Every one of those conditions is manageable — routinely, reliably manageable — if the medication is taken. Not taken, they kill.
Peer-reviewed research documents the same relationship at a finer resolution. A Yale School of Medicine study published in the Journal of the American Geriatrics Society found substantial costs related to non-adherence among older adults, and a 2025 analysis in the International Journal for Quality in Health Care found that Medicare-only enrollees were nearly five times as likely as dual-eligible beneficiaries to skip anti-hypertensive medication because of cost. The CDC’s own Preventing Chronic Disease journal has published on the same phenomenon. This is settled science. Raise the price of the pill, and some fraction of the people who need it will stop taking it. Some fraction of those people will die of the preventable thing the pill was preventing.
“Trump and Republicans are making healthcare more expensive for seniors at every turn. In the middle of a GOP-induced affordability crisis, they are eliminating a key program that helps seniors afford their medications, meaning countless seniors will soon pay more just to get the lifesaving prescriptions they need.”
— Leslie Dach, Chair, Protect Our Care
The truly perverse feature of this arrangement is that the federal government does not save money by forcing seniors to skip pills. It spends more. When the woman on the kitchen floor is brought to the emergency room, Medicare Part A picks up the tab for the hospital stay — a stay that averages, for adults 65 and older, well over a thousand dollars for the ER visit alone, with the inpatient deductible for 2026 sitting at $1,676 per benefit period, according to CMS’s own published rates. What is denied on the front end as $16 a month in premium support returns on the back end as multi-thousand-dollar hospitalizations, stroke rehabilitation, dialysis, cardiac catheterization, and, not infrequently, death. The Xcenda modeling put the ten-year figure of avoidable Medicare medical costs at $177.4 billion. This is deferred care as fiscal policy: pay a little now, or pay a lot later and bury some people in the meantime.
III. Who, Exactly, Is About to Pay More
Here is where the political arithmetic collapses into moral incoherence. The demographic most affected by the end of the Part D Premium Stabilization Demonstration is the demographic that put Donald Trump in the White House twice. Medicare enrollees skew older, whiter, more rural, and more Republican than the general electorate. They live in the exit-ramp small towns of Ohio, the mining counties of Pennsylvania, the farm counties of Iowa and Wisconsin — places where the local hospital may be forty minutes away, where the pharmacy is the only pharmacy, where a $20 monthly increase in a fixed-income budget is not an inconvenience but a genuine reordering of the month.
These are not abstractions. Nearly 25 million Americans are enrolled in stand-alone Part D drug plans. Another 31 million are enrolled in Medicare Advantage plans with drug coverage. The majority, in both cases, are seniors on fixed incomes, and a substantial share are also disabled Americans under 65 who qualified for Medicare through Social Security Disability Insurance. Reporting on the CMS decision from Reuters noted that the majority of enrollees in the subsidy program were seniors or people with disabilities. The country’s most reliable voting bloc is about to open its mail and find out that the president they trusted with their vote has chosen to make their medication less affordable — weeks before an election.
The cruelty is not the surprise. The cruelty is the predictability. Every progressive who warned that Trump’s first-term promises on drug prices were rhetorical — that a president whose signature legislative achievement was a $1.5 trillion tax cut skewed toward the top 10% would never, in fact, deliver on prescription affordability — is now watching that warning become policy. Senator Bernie Sanders posted on social media that “Trump said he would cut drug costs by 1,500%. He lied.” The number is characteristic Sanders hyperbole. The core claim is exactly correct.
Get Involved Today
Contribute to our mission and turn your concerns into action.
IV. The Emergency-Room Doom Loop
Consider what a rational, functioning administration would have done here. Faced with the phase-in of a $2,000 out-of-pocket cap that reshaped how insurers priced Part D risk, a responsible administration would have used the stabilization demonstration to extend the smoothing period — or, more ambitiously, would have proposed making the subsidy structure permanent, tied to Medicare drug-price negotiation, and pointed to the Xcenda findings on avoidable deaths and downstream Medicare costs as the fiscal rationale. That is what the math says. Every dollar of premium subsidy averted at the pharmacy counter is measured, in the peer-reviewed literature, against multiple dollars of downstream inpatient care.
What the administration did instead was walk away from the smoothing program, describe it as a giveaway to insurers, and offer no replacement mechanism — no expanded low-income subsidy, no negotiated-price backstop, no reinsurance restructuring, nothing. The Trump-administration official who briefed reporters volunteered, almost as an aside, that if the program had remained in effect next year, more than half of the subsidy money would have flowed to a single company, UnitedHealth Group. That is an argument for redesigning the subsidy — not for scrapping it and letting the premium fall where it will on the pill bottles of a diabetic in Erie or a cardiac patient in Sioux Falls.
The Wall Street Journal also reported that the higher Part D premiums will “push more Medicare enrollees into Medicare Advantage” — the privatized version of the program that the federal government pays more per beneficiary to cover than traditional Medicare. So the administration’s stated concern — that federal dollars were flowing to insurance companies — is answered, on the record, by a policy design that will flow more federal dollars to insurance companies. There is no coherent theory of the case. There is only the reflex.
“Republicans are doing everything they can to make health care unaffordable for Americans, especially for seniors. Trump and Republicans’ massive healthcare cuts have pushed working families to the brink as they grapple with skyrocketing insurance premiums, even bigger medical bills, and rising prescription drug costs. Americans are taking on record amounts of medical debt just to make ends meet — all while Trump and his family get even richer and his wealthy donors rake in tax cuts.”
— Kendall Witmer, DNC Rapid Response Director
V. Timeline of a Preventable Crisis
Inflation Reduction Act is signed, establishing a $2,000 annual out-of-pocket cap on Part D prescription spending and granting Medicare authority to negotiate prices on select high-cost drugs.
CMS launches the Part D Premium Stabilization Demonstration to blunt premium volatility during the IRA phase-in. The program cuts average Part D premiums by more than 25 percent in 2026.
Following a series of increasingly erratic presidential outbursts on Iran, Rep. Jamie Raskin introduces legislation to establish a bipartisan Commission on Presidential Capacity — the mechanism envisioned by Section 4 of the 25th Amendment.
Affordable Care Act premium subsidies are allowed to expire. Nearly a quarter of ACA enrollees tell KFF pollsters they would forgo coverage in 2026 if their premiums doubled.
CMS announces the termination of the Part D Premium Stabilization Demonstration effective end of 2026. Approximately 25 million Part D enrollees now face 2027 premiums set without the stabilization backstop.
CMS will release final 2027 plan premiums. Individualized change notices will reach enrollees’ mailboxes weeks before the November midterm elections.
Medicare open enrollment begins — the same window in which most states conduct early voting for the midterms.
A Question of Capacity, Not Merely of Policy
It is not the position of this editorial board that policy disagreement is a justification for removing a president from office. It is not. A president is entitled to pursue an agenda voters disagree with. But there is a difference between an agenda and a pattern of decisions that no rational operator of the executive branch would make — and the Medicare Part D decision is a case study in the second category, not the first.
What Section 4 says. The 25th Amendment, ratified in 1967 in the wake of the Kennedy assassination, provides in Section 4 that the Vice President and a majority of principal officers of the executive departments — or “such other body as Congress may by law provide” — may declare in writing to Congress that the president is “unable to discharge the powers and duties of his office.” Upon that declaration, the Vice President immediately assumes those powers as Acting President.
Who has already invoked it. In April 2026, Rep. Jamie Raskin, Ranking Member of the House Judiciary Committee, wrote to the White House Physician demanding a cognitive and neurological evaluation of the President and introduced legislation, with 50 co-sponsors, to establish the “such other body” Section 4 anticipates — a Commission on Presidential Capacity. Senator Bernie Sanders publicly described the President’s April Easter posts on Iran as “the ravings of a dangerous and mentally unbalanced individual.” Senator Chris Murphy said that were he in the Cabinet, he “would spend Easter calling constitutional lawyers about the 25th Amendment.” Senator Ed Markey, Rep. Eric Swalwell, Rep. Sydney Kamlager-Dove, and Rep. Yassamin Ansari have all explicitly called for invocation. A February 2026 Reuters-Ipsos poll found that a majority of Americans — including 30 percent of Republicans — say the President has become erratic with age.
How the Medicare decision fits the pattern. A president operating with full command of the machinery of the executive would understand that (a) 25 million people are about to open premium notices, (b) those notices will land during early voting, (c) the affected demographic is his own base, (d) the fiscal savings are illusory because federal spending on Medicare Advantage will rise as enrollees shift, and (e) the downstream medical costs of forgone medication exceed the premium subsidy by orders of magnitude. That an administration proceeded anyway is not evidence of a bold ideology. It is evidence of decision-making unmoored from the ordinary feedback loops that constrain rational governance. The Medicare Part D decision, standing alone, is a policy mistake. Placed alongside the Iran outbursts, the Greenland fixation, the aggressive threats against foreign heads of state, and the pattern of late-night social-media rants that a group of psychiatrists in June characterized as “rapidly worsening, reality-untethered, increasingly dangerous decline,” it is something else. It is a data point in a picture.
Honest Assessment of the Barriers
No serious observer believes the 25th Amendment is about to be invoked. Vice President Vance will not sign such a letter. This Cabinet will not sign such a letter. The Raskin commission bill will not pass a Republican House. Senator Marlin Stutzman spoke for the Republican majority when he called the effort “the TRUE madness.” These are real barriers, and the Editorial Board will not pretend otherwise.
Why the barriers do not settle the question. The framers of the 25th Amendment did not draft Section 4 for the easy cases. They drafted it for exactly the case they feared — a president whose capacity was in question, and a political establishment whose incentives ran against acknowledging it. The barriers do not negate the constitutional argument; they are the argument. Every American who is about to pay more for insulin, for warfarin, for lisinopril, because a president made a decision that no coherent theory of governance supports, is entitled to ask the question the amendment exists to answer: is the person making these decisions capable of making them? The barriers only make the asking more urgent.
VI. What Leadership Would Look Like
Senate Minority Leader Chuck Schumer, quoted by STAT News, called the CMS decision “heartless, cruel, and completely by choice.” The word that matters in that sentence is the last one. Nothing about this had to happen. Nothing about this was forced by budget arithmetic, or by law, or by any external constraint. The stabilization demonstration cost $3.6 billion in 2026 — a rounding error against a federal Medicare budget approaching a trillion dollars, and a fraction of the Medicare medical costs that will now accrue in emergency rooms and inpatient wards as people who cannot afford their pills present in crisis. The decision was, in Schumer’s exact framing, a choice.
A president exercising leadership over a healthcare system he inherited would have made a different choice. He would have looked at the demographic composition of Part D enrollees — his voters — and understood the political cost. He would have looked at the mortality projections and understood the human cost. He would have looked at the Medicare Advantage cost curve and understood the fiscal contradiction. He would have looked at the timing — the September notice, the October open enrollment, the November election — and understood the political malpractice. He would have restructured the subsidy, or reallocated it toward low-income beneficiaries, or negotiated a permanent extension in exchange for expanded price negotiation. He would have done something other than what was done.
He did what was done anyway. That is the story. And the story is, in the end, not about Medicare. It is about whether the person who is supposed to be governing is governing at all.
Editorial Conclusion
The termination of the Medicare Part D Premium Stabilization Demonstration will not, in itself, end American democracy. It will end some lives. It will impoverish some families. It will drive some seniors to skip the pills that keep their hearts beating and their kidneys filtering, and some of those seniors will die of the entirely preventable thing the pill was preventing. It will cost the Medicare program more, not less, in the emergency rooms and inpatient wards where the deferred care of a nation without adequate prescription coverage always ends up.
But the decision matters beyond its human cost. It matters because a functioning presidency does not make decisions of this kind. It matters because a Cabinet exercising its constitutional obligations does not sign off on decisions of this kind. And it matters because the Twenty-Fifth Amendment was written for a country that would, when the moment came, be capable of asking the plain question the amendment exists to answer.
The moment has come. The question is on the table. What is required is not partisan advantage but constitutional seriousness — and the courage of the officers of the executive branch to fulfill the duty the Constitution imposes on them, before more of the people who trusted this president bury the family members he lied to.
Sources & References
- NPR — “An end to Medicare Part D subsidies could raise premiums next year”
- Newsweek — “Trump Scraps Medicare Part D Subsidy: What It Means for Seniors”
- The Hill — “Trump administration moves to end Biden-era Medicare Part D subsidy program”
- Common Dreams — “Countless Seniors Will Soon Pay More”
- STAT News — “End of Medicare drug subsidy gives Democrats new attack line”
- MSNBC / Maddow Blog — “Trump administration eyes end to subsidies in Medicare’s prescription drug plan”
- MSNBC Opinion — “How Trump’s new Medicare cuts could raise prescription costs for seniors”
- Reuters via Detroit News — “Trump administration to end Medicare premium subsidy program”
- Quartz — “Trump administration ends Medicare Part D premium subsidy”
- U.S. News & World Report — “The Trump Administration Is Ending a Medicare Part D Subsidy Program”
- West Health Policy Center / Xcenda — “High Drug Prices and Patient Costs: Millions of Lives”
- Chung et al., J Am Geriatr Soc — “Cost-Related Medication Nonadherence Among Older Adults”
- Int’l Journal for Quality in Health Care — “Cost-related medication nonadherence in adults with hypertension”
- CDC / Preventing Chronic Disease — “Attitudes, Beliefs, and Cost-Related Medication Nonadherence”
- Sen. Ruben Gallego — Press release on Medicare premium hikes
- Rep. Jamie Raskin — Letter demanding cognitive evaluation of President Trump
- The Hill — “Concerns Grow Over Trump’s Mental Fitness for Presidency”
- Medicare.gov — Inpatient Hospital Care Coverage (2026 rates)
Related News
