The Cost of Cruelty: How Trump Engineered America's Insurance Crisis

May 19, 2026

The Cost of Cruelty: How Trump Engineered America’s Insurance Crisis

ACA benchmark premiums have surged by more than 21 percent for 2026 — the sharpest spike in nearly a decade — as millions lose coverage and struggle to afford basic medical care. This is not a market anomaly. It is the deliberate consequence of policy choices made by a president whose behavior raises urgent constitutional questions about his fitness to govern.

In the annals of American health policy, few crises have been so nakedly engineered by a sitting president. As of January 2026, marketplace benchmark premiums — the second-lowest-cost silver plans that anchor the entire ACA subsidy structure — have increased by an average of 21.7 percent, according to the Urban Institute. That number, staggering on its own, conceals an even more disturbing reality: for the millions of Americans who depended on enhanced premium tax credits that expired on January 1st, the out-of-pocket cost of their health coverage has more than doubled. And the president who promised to fix American healthcare has spent every month of his second term systematically dismantling the mechanisms that once made it affordable.

What we are witnessing is not the predictable ebb and flow of market forces. The Commonwealth Fund has been explicit: prior to this year, average ACA benchmark premium growth from 2020 through 2025 was just 2.0 percent annually. The 2026 surge — four to ten times higher depending on state and circumstance — is an aberration with a traceable cause. That cause has a name: the Trump administration and its congressional allies in the Republican Party, whose “One Big Beautiful Bill” Act cut nearly one trillion dollars from Medicaid and the Affordable Care Act while letting enhanced premium subsidies expire, and whose regulatory assault on marketplace enrollment has made coverage harder and more expensive to obtain for tens of millions of working Americans.

1. The Numbers Behind the Crisis

The scale of what has unfolded demands careful accounting. The Urban Institute’s December 2025 analysis found that the 21.7 percent benchmark premium increase is not uniformly distributed — it is catastrophically concentrated in states with fewer insurers, less competition, and more rural geography. Arkansas leads the nation with a 67 percent premium increase, adding nearly $330 per month in costs for unsubsidized enrollees. Florida and Texas, two of the nation’s most populous states, both exceed 30 percent increases. Meanwhile, the Kaiser Family Foundation has documented that for the 92 percent of marketplace enrollees who received enhanced premium tax credits in 2025, keeping the same plan in 2026 means net premiums rising by an average of 114 percent.

Benchmark Premium Increase

21.7%

Average rise in ACA second-lowest silver plans for 2026 — the largest increase since 2018, per Urban Institute.

Net Premium Shock

114%

Average increase in what enrollees actually pay out-of-pocket when keeping their 2025 plan, after subsidy expiration, per Peterson-KFF.

New Uninsured — 2026

3.4M

Additional Americans expected to lose coverage in 2026 alone, rising to 7.5 million by 2027, per the Congressional Budget Office.

Medicaid & ACA Cuts (H.R. 1)

$1T

Approximate amount stripped from Medicaid and ACA programs by the “Big Beautiful Bill,” reducing coverage for an estimated 15 million Americans.

Coverage Dropped (ACA 2026)

1 in 10

Share of the 24.3 million Americans enrolled in ACA plans who dropped coverage in 2026, with cost cited as the deciding factor by the vast majority, per KFF survey.

Long-Term Uninsured Projection

35M+

Americans projected to be uninsured by 2028 — 33 percent higher than in 2025 — nearing pre-ACA levels, per CBO baseline.

The human reality behind these statistics is not abstract. A 54-year-old man in Texas told KFF researchers simply: “Without the subsidy, I cannot afford the premium payments.” A Florida resident named Kelly Rose described being quoted a $1,700 monthly premium — more than her mortgage — and is now uninsured, obtaining her asthma medication from a Canadian pharmacy because it would cost $800 per month without coverage in the United States. A KFF survey found that 55 percent of ACA enrollees who maintained coverage are cutting spending on food, household goods, and clothing to afford their premiums. Forty-three percent are looking for additional work. These are not statistics of a thriving republic. They are dispatches from a managed catastrophe.

“Republicans shut down the government because they’d rather make health care more expensive than keep the government running. Donald Trump and Republicans own this shutdown.”

— Sen. Elizabeth Warren (D-MA) · Senate Floor Statement, October 2025

2. A Policy Crisis in Chronological Order

This crisis did not materialize overnight. It was constructed, step by deliberate step, through a sequence of administrative and legislative decisions that can only be understood as a coordinated assault on the infrastructure of affordable coverage.

January 2025

President Trump takes office and immediately begins reversing ACA marketplace rules, narrowing enrollment windows and adding verification barriers projected to push 750,000 to 2 million people off coverage.

Spring 2025

Congressional Republicans on the House Ways and Means Committee reject an amendment to extend enhanced premium tax credits, choosing instead to preserve tax cuts for high-income earners and corporations.

July 2025

Trump signs H.R. 1, the “One Big Beautiful Bill,” cutting nearly $1 trillion from Medicaid and the ACA. The CBO projects the legislation will directly terminate health insurance for 15 million Americans, while imposing work requirements and six-month Medicaid eligibility redeterminations.

August 2025

Insurers begin filing proposed 2026 rates reflecting the expected expiration of subsidies — a median increase of 18 percent in initial filings, with 125 insurers requesting increases of 20 percent or more. Insurer participation drops in 21 states.

October 2025

A 43-day government shutdown begins after Senate Democrats demand an extension of expiring ACA subsidies and Republicans refuse. At least 36 hospitals nationwide announce closures, many in rural communities.

January 1, 2026

Enhanced premium tax credits officially expire. ACA marketplace open enrollment for 2026 closes with an estimated 7.3 million people having lost ACA coverage. The benchmark monthly premium rises from $497 to $625 on average nationally — with Arkansas seeing $329 per month in additional costs for unsubsidized enrollees.

March 2026

CBO reaffirms its projections: the combined effect of H.R. 1 and subsidy expiration will increase the uninsured population by 8.7 million by 2028, pushing the total above 35 million — approaching pre-ACA levels.

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3. Who Is Paying — And Who Is Exempt

The structure of this suffering follows a clear political logic. Families USA has documented that the majority of Americans who purchase health insurance independently — the self-employed, early retirees, small business owners, gig workers — live in Republican-represented congressional districts. These are precisely the voters whose representatives voted to strip them of the subsidies that made their coverage affordable. A family of four with two parents aged 40 and 38 earning $129,000 per year — solidly middle class — saw their monthly silver plan premiums jump from $914 to $1,575, an annual increase of nearly $8,000. A 60-year-old couple earning $85,000 faces, according to testimony before Sen. Elizabeth Warren’s Senate committee hearing, a premium increase of approximately $24,000 per year — an amount equal to roughly a quarter of their annual income.

Meanwhile, the same legislation that gutted Medicaid and let premium credits expire extended and expanded tax cuts for the wealthiest Americans and largest corporations. The Center for American Progress has documented the trade-off with precision: the “Big Beautiful Bill” rejected extended healthcare tax credits for working families while delivering hundreds of billions in additional benefits to individuals and corporations at the top of the income ladder. This is not fiscal discipline. It is redistribution — upward, by design, at the cost of the sick and the working poor.

Senate Finance Committee Ranking Member Ron Wyden of Oregon has been among the most vocal chroniclers of the wreckage. “The reality is Trump and his Republican allies in Congress are taking a sledgehammer to the American health care system,” Wyden told reporters in November 2025. “Every month, essential health care providers are shutting down critical services and watching their balance sheets with dread.” The senator’s office has documented a cascade of institutional failures: freestanding emergency rooms in rural Texas closing their doors; a children’s hospital in California laying off 87 workers; community health centers shuttered across Maine; essential medical workers losing their jobs as uninsured patient loads overwhelm safety-net institutions no longer able to absorb uncompensated care.

“15 million people lost their health care coverage. This is an issue that the Republicans cannot mention, because people are suffering in every state.”

— Sen. Elizabeth Warren (D-MA) · NOTUS Interview, April 2026

4. The Deliberate Architecture of Abandonment

One of the most revealing aspects of this crisis is the degree to which it was predicted, documented, and ignored by those with the power to prevent it. The nonpartisan Congressional Budget Office warned lawmakers explicitly before their vote on H.R. 1 that its health provisions would terminate insurance for 15 million Americans. The Urban Institute, the Commonwealth Fund, the Kaiser Family Foundation, and the Center for American Progress all published detailed analyses projecting the premium surge months before it materialized. Insurer filings made the mechanism transparent: companies were raising rates precisely because they expected healthier people to drop coverage once subsidy support disappeared, leaving a sicker, more expensive risk pool behind.

Sen. Bernie Sanders summarized the stakes during the October 2025 government shutdown standoff: “This government shutdown is all about whether Republicans will get away with raising health care premiums by 75 percent for 20 million Americans and throwing 15 million people off their health care.” In the updated KFF analysis — accounting for both premium growth and the mechanics of how subsidy calculations changed under Trump administration rules — the projected net increase rose from 75 percent to 114 percent. Sanders’ number, already alarming, was in fact an understatement.

The Commonwealth Fund’s Sara Collins has written that the combined effects of H.R. 1, the subsidy expiration, and the Trump administration’s marketplace rule changes will increase the uninsured population by approximately 15 million by 2034 — potentially pushing the total above 40 million, close to the pre-ACA levels that existed before the law’s coverage expansions began. The progress of over a decade — 24 million people enrolled in marketplace plans; an uninsured rate that had fallen from 15.4 percent in 2010 to 8.2 percent in 2025; record coverage gains among Black and Hispanic Americans — is being systematically erased.

5. A President Who Has Chosen Billionaires Over Patients

What distinguishes this crisis from prior periods of health policy turbulence is the clarity with which it reflects the president’s priorities. Donald Trump has made no secret of his contempt for the Affordable Care Act — he failed to repeal it in 2017 during his first term, then returned to the project in his second. But the 2025–2026 assault has been more systematic and more damaging than the failed legislative gambits of eight years ago. The administration has used regulatory power to constrain enrollment, legislative power to cut funding, and political influence to prevent extensions of the programs that kept premiums affordable for working families.

At the same time, the president has pursued an Iran war of his own initiation, threatened to bomb civilian infrastructure on social media, waged rhetorical warfare against American allies, and has — by the accounts of his own former allies and supporters — exhibited behavior so erratic as to prompt bipartisan alarm about his capacity to discharge the basic duties of his office. The question before the country is not merely whether Trump’s healthcare policies are cruel — they are — but whether a president so consumed with grievance, so oriented toward the interests of wealth and power, so disconnected from the lived experience of ordinary Americans struggling to pay their premiums, is genuinely capable of governing in the public interest at all.

Sen. Andy Kim of New Jersey, a member of the Senate HELP Committee, put the contradiction plainly in a recent statement to NOTUS: “We’re showing the trade-offs here, which is that for the amount of money that this president is pushing with this war, we could have so much of this effort to be able to lower health care costs.” The arithmetic of those trade-offs speaks for itself: the administration has found resources for a conflict it launched unilaterally and without Congressional authorization, while telling millions of Americans that the $705 per year in average premium savings they depended on was simply too expensive to maintain.

When Failure of Governance Becomes a Question of Fitness

The 25th Amendment to the United States Constitution, ratified in 1967 in the aftermath of President Kennedy’s assassination, establishes a formal mechanism for addressing presidential incapacity. Section 4 — the provision that has never been invoked — allows the vice president, together with a majority of the Cabinet, to declare the president “unable to discharge the powers and duties of his office,” triggering a transfer of authority. If the president disputes that declaration, Congress must then vote within 21 days, with a two-thirds majority required in both chambers to sustain the transfer.

What lawmakers are saying: On April 10, 2026, Rep. Jamie Raskin, Ranking Member of the House Judiciary Committee, wrote formally to the White House physician demanding “an immediate and comprehensive cognitive and neurological evaluation” of the president, along with full public disclosure of the findings. Raskin’s letter followed what he described as “a series of increasingly volatile, incoherent, and alarming public statements” about the Iran conflict. He wrote: “This is plainly out of the realm of normal politics. When the President of the United States threatens to extinguish a civilization on social media, rants about combat missions with children at the Easter Egg Roll, and drops profane tirades on Easter morning, we have indisputably entered the realm of profound medical difficulty and concern.” Raskin has also introduced legislation that would create a 17-member independent commission of physicians and former executive officials empowered to evaluate presidential fitness and work alongside the vice president in invoking Section 4.

The healthcare dimension: The 25th Amendment debate is typically framed around acute behavioral episodes — threats, incoherence, incapacity under stress. But constitutional scholars have long recognized that the provision’s language — “unable to discharge the powers and duties of his office” — encompasses a broader incapacity, including the failure to govern in good faith on behalf of the public. A president who cuts health care for 15 million Americans while claiming to champion working people; who ignores bipartisan expert consensus predicting exactly the suffering that has now materialized; who prioritizes the financial interests of corporations and billionaires over the basic medical security of citizens — such a president raises, at minimum, the question of whether his judgment is structurally impaired in ways that bear on his fitness to hold office.

The constitutional argument: The Framers did not draft Section 4 as a mechanism solely for physical incapacitation. They drafted it to protect the republic from a president whose actions, however deliberate, reflect a fundamental incapacity to serve the interests of the governed. A governance pattern that predictably produces mass loss of health coverage, ignores its own experts’ warnings, redistributes resources from the sick to the wealthy, and then initiates an unauthorized war — while exhibiting the behavioral volatility documented by Rep. Raskin — may constitute precisely the condition the Amendment was designed to address.

The practical barriers: Invoking Section 4 requires a vice president willing to act and a majority of the Cabinet — most of whom serve at the president’s pleasure and owe their positions to his approval. With a Senate supermajority of 67 votes required to sustain any transfer of power, the political arithmetic is forbidding. These barriers are real. But as Rep. Raskin has argued, their existence does not diminish the moral and constitutional imperative to name the crisis clearly, to place it on the record, and to insist that presidential fitness — including the fitness to make rational, humane, evidence-based policy decisions that protect the lives of American citizens — is a matter of national concern, not partisan politics.

6. What Must Be Done

The Medical Care Blog stated the case plainly: “The 2026 premium spike is not an inevitability of healthcare economics. It is the result of policy choices, or more precisely, a failure to sustain policy mechanisms that kept care affordable.” The path back requires immediate congressional action to restore enhanced premium tax credits, reverse the Medicaid work requirements and eligibility restrictions imposed by H.R. 1, and repeal the enrollment barriers inserted by the Trump administration’s marketplace rule. The resurgence of interest in Medicare for All among Democratic candidates — a response to the demonstrable insufficiency of incremental reform in the face of determined sabotage — reflects a growing recognition that a system reliant on annual political negotiations to survive cannot guarantee the stable, universal coverage that Americans deserve.

Sen. Martin Heinrich of New Mexico told NOTUS that the question Democrats keep returning to is direct: “A lot of people are talking about how we can afford a billion dollars a day on the war in Iran and we can’t afford to help people with their health care costs.” That contrast — between the costs of an unauthorized war and the costs of keeping a 54-year-old Texan insured — defines the moral ledger of this administration. A country that cannot hold both simultaneously, in the wealthiest nation in human history, is a country governed by choices, not constraints. And the people responsible for those choices must be held to account: at the ballot box, in the courts, before congressional committees, and — if the constitutional moment demands it — under the mechanisms the Framers provided for exactly such a failure of presidential governance.

Editorial Conclusion

A president who signs legislation cutting health care for 15 million Americans, lets the premium credits that kept coverage affordable for 24 million more expire without replacement, and then launches an unauthorized war while threatening to bomb civilian infrastructure, has not merely failed at governance — he has demonstrated a structural incapacity to act in the interest of the people he was elected to serve. The 2026 health insurance crisis is not a market failure. It is a governance failure, engineered in plain sight, with predictable victims and identifiable authors. The Constitution provides tools for this moment. The American people, suffering through rationed insulin and foregone cancer screenings, deserve a Congress willing to use them — and a political movement courageous enough to demand it.