Defending Healthcare & ACA Subsidies
The Kitchen Table Activist Focus Issue for December, 2025
Welcome to the Kitchen Table
Hello! And welcome to the very first issue of The Kitchen Table Activist, where I try to break down one issue a month and turn it into simple, doable actions you can take right from your kitchen table.
It’s not intimidating. It won’t overwhelm you. I avoid (or explain) jargon. And I don’t push you to become a full-time activist.
Just small moves, steady reps, and clear values, which is the foundation of Kitchen Table Activism.
Here’s how this works:
Beginning of the Month: You’ll get an Explainer like this one. It’s a clear but detailed walkthrough of the month’s Focus Issue. This is where I’ll explain what’s happening and why it matters.
Weeks 1, 2, 3, 4: Each week, I’ll send you one concrete action you can take in 15 minutes or less, using the tools you already have.
These actions will be accessible, practical, and repeatable… and they won’t require social media fights, marches, or endless emotional labor.
If you’re ready, let’s get to it. This month, we’re starting with a big one:
Defending Healthcare & ACA Subsidies
For millions of Americans, 2025 isn’t just another year. It’s the year that healthcare costs are set to explode. Not because of “inflation” or “market forces,” but because of a deliberate political choice that’s baked into the One Big Beautiful Bill Act (OBBB Act). It’s not an oversight. It’s intentional.
Keep reading and I’ll attempt to break down what’s happening, why it matters, and what we can do about it together, from our kitchen tables.
The Imminent Threat: ACA Subsidies Are About to Vanish
The OBBB Act allowed the enhanced Affordable Care Act (ACA) premium subsidies to expire at the end of 2025. These subsidies have kept millions of people’s insurance affordable.
What does that mean?
The impact is immediate and brutal:
ACA premiums will rise by an average of 75%. That’s not me speculating. That’s from the non-partisan Congressional Budget Office (CBO).
4.2 million more people will become uninsured on January 1, 2026.
By 2034, a projected 14 million people will lose health insurance as the policy’s ripple effects grow.
This subsidy extension was at the center of the government shutdown.
Politically? This is a unicorn issue:
77% of Americans support extending the subsidies, including:91% of Democrats
80% of Independents
63% of Republicans
In a polarized America, that’s about as close to consensus as it gets!
But financial cuts aren’t the only attack.
It’s important to know that procedural changes are quietly shrinking enrollment:
The ACA open enrollment window was shortened (now closes December 15). This makes it more likely that people will miss the enrollment deadline. This is important because…
Automatic re-enrollment was eliminated. That’s right, if you miss the deadline, you don’t just default to what you had before. You lose your health insurance!
Monthly special enrollment for low-income Americans was ended. Hit rock bottom and need to enroll during the year? “Too bad, so sad (not!),” says the GOP.
New income verification hurdles were added, making it even harder to enroll in the first place. These changes threaten 725,000 to 1.8 million people, not because they no longer qualify, but because the process became more burdensome.
This is the quiet bureaucratic strategy that the mainstream media isn’t talking about:
If you can’t kill the ACA outright, you can strangle it with paperwork!
The Big Picture: Systematically Weakening the Safety Net
The subsidy cuts aren’t happening in isolation. They’re part of a larger strategy to make healthcare harder to get, especially for low-income Americans, seniors, and people with disabilities. This is especially heinous in the richest nation in history.
A. Medicaid Cuts & Punitive Work Requirements
The OBBB Act cuts nearly $1 trillion from Medicaid over 10 years.
That’s a 15% reduction in federal Medicaid funding.
The CBO estimates 10 million people will lose coverage by 2034.
These cuts will cause an estimated 51,000 preventable deaths every year.
Then come the work requirements:
Medicaid enrollees must document 80 hours of work monthly.
Research shows these requirements do not increase employment. Instead, they create paperwork traps that push people off coverage even when they’re working.
A Biden-era rule that made Medicaid easier to access for seniors and people with disabilities was reversed. Impact: 1.4 million seniors and disabled Americans are expected to lose dental, vision, long-term care, or premium assistance. WTF?!
B. Medicare Cuts Triggered by PAYGO
Because the OBBB Act is projected to increase the federal deficit by approximately $3.4 trillion over the 2025-2034 period, it will trigger the Statutory Pay-As-You-Go Act, which mandates automatic cuts to Medicare.
These cuts are capped at 4% under the act, but the CBO still estimates a total of at least $490 billion over the next 9 years. Those are very real cuts that will impact seniors, providers, and access to care.
Who Gets Hurt First? The Most Vulnerable
A. Rural Hospitals on the Brink
The OBBB Act also phases down provider taxes and directed payments, which are the most common mechanisms states use to fund Medicaid. That means:
Over 300 rural hospitals across states like Kentucky, Louisiana, California, and Oklahoma are at risk of service cuts or closure.
A $50 billion “rural hospital fund” in the bill is nowhere near enough to offset the damage done by eliminating these other funding mechanisms.
Rural hospitals are the canary in the coal mine. When one closes, entire communities lose access to maternity care, emergency care, mental health care. They lose everything.
B. Emergency Medicaid & Immigrants: A Manufactured Crisis
Republican messaging blames immigrants for Medicaid costs. Here’s the reality:
Emergency Medicaid covers emergency treatment for people barred from regular Medicaid, including:
Undocumented immigrants
DACA recipients
Lawfully present immigrants waiting through eligibility windows
Refugees and asylum seekers
Hospitals must provide emergency care under EMTALA (Emergency Medical Treatment and Active Labor Act). The EMTALA requires hospitals that accept Medicare to provide emergency care to anyone, regardless of ability to pay or immigration status. This only makes sense. Instead of letting people bleed out in the emergency room while staff try to determine if they have adequate health insurance coverage, they simply treat the patients and deal with the paperwork later.
Guess what? The EMTALA remains in place, unchanged by the OBBB Act. Cutting Emergency Medicaid doesn’t hurt immigrants. They’ll still receive emergency care.
So, who do these cuts hurt?
Hospitals. It forces them to eat the costs because they have to provide care but won’t be reimbursed by the government. And the hospitals most adversely impacted by this? Rural hospitals, mainly in deep-red states, which aren’t large enough to absorb such a large financial hit.
The overall amount of funding used to reimburse hospitals through the EMTALA that is attributable to undocumented immigrants is a tiny amount compared the larger health insurance issue, but it will hurt the smallest hospitals in the poorest states the most. And eventually, it raises prices for everyone with insurance because even large hospitals have to charge more to cover the gap in funding.
Oh, and did I mention that the administration is also pushing to bar lawfully present immigrants from Medicaid and CHIP (Children’s Health Insurance Program)? This cruel action alone will affect 1.4 million people. These are families who are legally here and, in most cases, paying taxes like everyone else.
What We Can Actually Do: Real Solutions
This is where Kitchen Table Activism shines: breaking the problem into actions that real people can take.
A. State-Level Leverage: ACA Section 1333 Compacts
Section 1333 of the ACA (42 U.S.C. § 18053) allows states to form Health Care Choice Compacts.
In plain language: States can team up, pool their power, and negotiate as one massive insurance market. These states could enter into an agreement to allow health insurance issuers to sell qualified health plans in each other’s markets.
It may also be possible, under this authority, for the states to create their own public option for health insurance with lower operating expenses and larger purchasing power than many for-profit health insurance providers.
Imagine a bunch of independent grocery stores joining forces as a national buying co-op. One small store has no leverage. Dozens of stores representing a huge percentage of a region’s milk purchases? They can demand better prices from suppliers.
The same is true with healthcare.
A coalition of big Democratic states like California, New York, Illinois, Massachusetts, Michigan, and Washington, represents 97 million people. And all of them are potential customers for a whatever would be offered by such a Health Care Choice Compact.
Together, these states could:
Cap hospital reimbursement rates (like Washington State’s 160% of Medicare benchmark).
Negotiate pharmaceutical prices.
Force insurance efficiencies into the market.
Create the first multi-state public option that drives costs down.
We’ve already seen proof. Colorado’s public option dropped some premiums by $100 a month. And that’s just one state working on its own. How much better could a multi-state compact accomplish?
This is the kind of quiet, structural power that progressives should be building.
B. Demand Political Accountability
This part isn’t glamorous, but it’s necessary. Congress must extend the enhanced ACA subsidies. Period. And we have to remember that progressive pressure matters most before deals are cut. Everyone knows that any GOP “promise” that’s not signed into law is nothing more than empty words. (And even once it’s law, we better be ready to fight for it.)
Actions targeted at Democrats matter here, because it was a group of eight Democratic Senators, including Schumer, Durbin, Kaine, Fetterman, and others, who ended the government shutdown and surrendered their leverage for a likely worthless promise of a future subsidy vote.
As a Kitchen Table Activist, you should:
Tell your members of Congress to extend ACA subsidies immediately.
Oppose further concessions to Republicans on healthcare cuts.
Demand stronger leadership, including challenging or replacing weak leaders when necessary.
Call frequently (not just once), especially during budget negotiations.
(I’ll send you templates for these emails and phone calls in upcoming issues.)
Additional Context & Definitions
A few quick definitions to round out this explainer and help you if you need to talk about these issues with others:
ACA Premium Subsidies
The ACA provides tax-credit subsidies that lower monthly premiums for people buying insurance on Healthcare.gov.
“Enhanced” subsidies (expanded under ARPA and extended once under the IRA) increased the amount of help and eliminated the income cap, making coverage much more affordable for middle-income families. (This won’t just hit the poorest of us.)
What Is the OBBB Act?
It’s a large, multi-part bill that included tax cuts (especially for billionaires and mega-corporations), regulatory rollbacks, and significant healthcare changes… and will contribute over $3.4 trillion to the already ballooning federal deficit. (There’s nothing beautiful about the OBBB Act!)
EMTALA
The Emergency Medical Treatment and Active Labor Act is a federal law requiring emergency departments to stabilize and treat anyone who comes in, regardless of ability to pay or their immigration status. Cutting Emergency Medicaid doesn’t change this obligation, it simply shifts the cost burden.
What Comes Next
Later this week, you’ll receive your first 15-minute Kitchen Table Action. It will be a simple, accessible step you can take to help defend healthcare for millions of Americans.
Remember our approach:
Small moves.
Steady reps.
Clear values.
That’s how we build a movement.
If you found this explainer helpful, please share The Kitchen Table Activist with a friend who cares about healthcare but feels overwhelmed by politics.
And if you’re wondering why Kitchen Table Activism fits into the larger CODA Project, it’s because informed, values-aligned action is one of the clearest expressions of living out our foundational values: integrity, fairness, empathy, cooperation, and curiosity.
See you later this week… at the kitchen table!
~Brandon