Another Reason to Dislike Obamacare: Fraud Rates Costing Taxpayers As Much As $25B a Year

Remember back nearly two decades when the Affordable Care Act, also known as Obamacare, was meant to expand coverage and lower costs? Guess what it ended up doing instead? Far from delivering on its promises, premiums and deductibles remained high, insurer competition was weakened, and Congress continues to spend money. 

As if those shortcomings weren't enough, a new study from the Paragon Health Institute suggests Obamacare may suffer from another serious problem: large-scale enrollment fraud and improper subsidy payments.

The Paragon Institute estimates that approximately 6.2 million people enrolled in Obamacare may be improperly receiving subsidized insurance, which accounts for can account for as much as one-quarter of total exchange enrollment. In fiscal terms, the report argues this could translate into as much as $20–25 billion in annual improper federal subsidy spending, depending on assumptions about eligibility verification and income reporting accuracy.

These issues are not coincidental; they are structural. First, eligibility for subsidies is heavily dependent on self-reported income, which is often based on projections as opposed to verified real-time earnings. This creates natural friction between reported income at the time of enrollment and actual income over the course of the year, especially for workers with variable earnings, gig income, or fluctuating hours.

Second, the system relies on delayed verification and post-enrollment reconciliation instead of strict upfront screening. This means discrepancies may not be corrected until after coverage has already been granted and subsidies disbursed.

Third, the growth of third-party brokers and automated enrollment platforms has increased the number of intermediaries involved in sign-ups. While many operate legitimately, the report argues that commission-based compensation tied to enrollment volume can weaken incentives for careful eligibility verification.

Finally, automatic re-enrollment mechanisms can allow previously enrolled individuals to remain in coverage even if their eligibility status has changed and was never fully rechecked.

This gets into a debate about how estimates of improper ACA enrollment vary widely depending on how “error” is defined and how aggressively small discrepancies are extrapolated across the full exchange population. Federal auditors like the Centers for Medicare & Medicaid Services and the Government Accountability Office generally focus on confirmed, verifiable errors, which tend to produce lower, single-digit to low-teens estimates.

Higher-end estimates, on the other hand, attempt to capture what those same processes are likely to miss when eligibility is based on self-reporting, delayed verification, and automatic renewal. Put simply, the lower estimates only measure what the system catches and acts as a low-bound estimate. The higher estimate is more plausible because it attempts to measure the full scale of eligibility drift.

Enrollment is frequently cited as evidence of the Obamacare’s success, but it is an incomplete metric. It captures participation in the system, not the accuracy or stability of that participation. In a framework built on self-reported eligibility, delayed verification, and automatic renewal, enrollment can rise even as underlying errors persist. The Paragon Institute’s findings highlight how large those gaps may be at scale.

The latest evidence on enrollment and subsidy error does not stand alone. It reinforces a longer pattern of structural problems that have followed the ACA since its inception, much like I pointed out in my 2017 piece listing 15 reasons we should all dislike Obamacare. Whether it is fraud rates, higher premiums, or fewer options, this latest Paragon Health report is a sobering reminder of why Obamacare should never have existed in the first place and how the American people are still paying for this boondoggle.

Autism, Vaccines, and Why the CDC Cannot Be Trusted to Separate Fact from Fear

Having access to accurate and evidence-based healthcare information is an essential ingredient for a well-functioning society in the 21st century. People rely on trusted sources to understand risks and make well-informed decisions for their health and that of their loved ones. As such, even subtle shifts in public-health messaging can have seismic effects. For instance, last week the U.S. Centers for Disease Control and Prevention (CDC) changed its website on "Autism and Vaccines." 

The CDC's update claims that "The claim 'vaccines do not cause autism' is not an evidence-based claim because the studies have not ruled out that infant vaccines cause autism." The CDC did not update the website because there was a shift in the research that found something completely different, such as the case with smoking not being good for your health. No, this was merely a shift in messaging from an HHS Secretary with an axe to grind when it comes to vaccines. Needless to say, the Autism Science Foundation, Infectious Diseases Society of America, and Scientific American did not react positively to the change, and rightfully so. Before delving into what this debacle reveals about the CDC, it helps to start with the scientific reality of vaccines and autism itself.

The Scientific Consensus on Vaccines and Autism

In case it is not clear, it behooves us to iterate that decades of rigorous research has studied the topic and found that vaccines do not cause autism, as the American Academy of Pediatrics has illustrated. The National Academy of Medicine reviewed epidemiological data and found no association or causal mechanism between vaccines and autism (Casadevall, 2016). More recently, a large Danish study covering over 1 million children show that there is no link between aluminum in childhood vaccines and autism (Andersson et al., 2025).

The Burden of Proof and the CDC's Messaging

This piece today is not a treatise on the science of vaccines and autism, but is in part to show that the CDC doing is a classic sleight of hand by shifting burden of proof. While the CDC may claim to act out of precaution, its phrasing shifts the burden of proof unfairly and creates unnecessary fear. If someone claims that vaccines cause autism, they must be the ones to present evidence of that claim. Decades of research have been conducted and consistently found zero association, which means that the burden was met and failed. By saying that the link "has not been ruled out," it has developed a standard so vague that anything is possible. By that "logic," that would mean that Bigfoot, Santa Claus, or the Flying Spaghetti Monster are unresolved scientific questions simply because there is no evidence that disproves their existence with absolute metaphysical certainty. That is not how evidence-based research works, and that is certainly not how the CDC should communicate risk, although the CDC shifted the burden of proof in such a fashion during the pandemic when it came to face masks. 

The CDC's History of Mistrust: The COVID Pandemic

Although the University of Minnesota said that the CDC is no longer trustworthy in light of this website change, I would argue that the CDC has not been trustworthy for a long while when it comes to disseminating evidence-based health information. If there was any time to show that the CDC could not be trusted with such a task, it was during the COVID pandemic. In 2021, I wrote a piece entitled Let's Go Back to Ignoring CDC and Federal Health Guidance Like We Always Have. As my piece shows, there were multiple missteps, but I will cover two today.

The first is with face masks. At the beginning of the pandemic, the CDC said face masks were unnecessary. Then in April 2020, the CDC did an about-face and pushed for face masks, even though the science did not change. I do not want to debate the details, but do want to point out that the CDC's approach increased public confusion while eroding trust when the guidance shifted. 

The second is about school closures. As I illustrated as early as July 2020, schools did not need to close down during the pandemic. The CDC went into fear mode instead of realizing that children have low COVID transmission rates. As a result, the school closures delayed children's educational attainment while eroding their social and mental health for a statistically insignificant benefit, especially relative to the costs.  

Other Historic Examples of CDC Risk Aversion and Bad Advice

The pandemic was not the only time that the CDC took missteps out of risk-aversion or fear. This trend has existed for a number of years and well before the pandemic. Here are a few examples of this phenomenon:

• Raw milk: The CDC has strongly warned against the consumption of raw milk. This zero-risk approach limits personal choice and voluntary risk management, which is something I advocated for in 2016.
• Blood donation of men who have sex with men (MSM): Since the 1980s, the CDC had consistently categorized MSM as a "high-risk" donor group and maintained conservative deferral recommendations even when modeling studies show that shorter deferrals would only minimally increase residual risk. By clinging onto the precautionary principle instead of assessing individual risk, what happened was that the CDC contributed to unnecessarily reducing the donor pool while increasing stigma of gay men.  
• Zika travel bans: In 2016, the CDC recommended a blanket travel ban for pregnant women. It didn't matter that a CDC study showed that risk was minimal above 2,000 meters (Cetron, 2016). As a result of this zero-risk approach, it ended up having an impact on tourism upwards of $63.9 billion.
• West Nile Virus (WNV): In the early days of WNV (1999-2002), the CDC's guidance was highly risk-averse, emphasizing worst-case outcomes while recommending extensive outdoor avoidance and large-scale pesticide spraying. Aside from the insecticide-related illness caused by the spraying, the large-scale pesticide spraying diverted resources from other more targeted and sustainable measures (e.g., larval source reduction, biological control, trap-based adult mosquito control).
• Tuberculosis (TB): In the 1990s, the CDC recommended TB screening for all healthcare workers. This policy led to widespread unnecessary testing, strained resources, and minimal additional benefit in low-risk groups (e.g., Larsen et al., 2002). As a result, it prompted later revision to a risk-based strategy instead of a one-size-fits-all approach. 

The Pattern of CDC Mismanagement

There are other examples of CDC incompetence. What I will say is that the CDC changing its "Autism and Vaccines" website is not an anomaly. It demonstrates how the CDC has mismanaged public health information over the years and how it is slow to update guidelines due to bureaucratic inertia. Recommendations should weigh both risks and benefits, and the CDC's embrace of the precautionary principle above all else shows that it is incapable of doing so. This behavior shows how a top federal agency can mislead millions on scientifically proven topics and how healthcare can become propagandized, whether it was with the COVID pandemic or the latest anti-vaccine crusade. 

When political influence seeps into scientific communication, it undermines public trust in scientific guidance. This certainly was the case when the Biden administration politicized the COVID vaccines, which resulted in the spillover effect of people having less trust in all vaccines. Plus, trust of various health authorities is in decline (KFF). The CDC's recent website change can make parents delay or avoid vaccines, which could increase the risk of preventable disease. More generally, this erosion of trust from the CDC can make matters more difficult in future disease outbreaks.

Recommendation: Reassessing CDC Authority

At a minimum, the CDC should have greater scrutiny and auditing to make sure its information with regards to health recommendations is accurate. However, I do not think that is sufficient given its history because the CDC has proven time and again that federal government health messaging cannot be taken at face value. The CDC should go back to its original role of tracking and containing outbreaks of diseases. The CDC's mission creep is costing lives because precaution without nuance creates harm, needlessly consumes resources, and erodes public trust. Having such a fallible institution in charge of providing evidence-based information is clearly not its forte. 

If the CDC should not be in charge of providing public health directives, who should be? There is the possibility of entrusting it to private organizations. Alternatively, local- or state-level public health agencies can be responsible. At least that way, accountability is higher since the impact is more localized. Why is that the case? 

Ultimately, public health guidance should be accurate, measured, and accountable. Centralizing authority in a single, risk-averse federal agency has shown time and again that even well-intentioned directives can produce harmful unintended consequences. By decentralizing responsibility, we can ensure that the guidance is closer to the populations it affects, is more transparent, and is more responsive to real-world risk (e.g., Rigby et al., 2024; Sessions, 2012). Only by aligning responsibility with accountability can we hope to provide public health recommendations that are both scientifically sound and practically effective, rather than by bureaucratic impulse or political whim. 

Premium in Name Only: The Pricey Truth Behind “Free” Obamacare Under COVID-Era Subsidies

Instead of passing a budget, the United States Congress allowed the government to shut down on October 1, 2025 and has been shut down since. When government shutdowns take place, the federal government limits services and ceases non-essential operations. This is not the first time such a shutdown has occurred. The longest shutdown took place during Trump's first administration in 2018-19 over funding for expanding barriers on the U.S.-Mexico border. The 1995-1996 shutdown under the Clinton administration was over spending cuts, whereas the 2013 shutdown during the Obama administration was about the implementation of the Affordable Care Act (ACA). While commonly referred to as the ACA, I prefer calling it Obamacare over the ACA because the ACA did nothing to make healthcare more affordable (see here and here), but we can call it ACA for shorthand purposes. 

Interestingly enough, the lack of affordability under ACA brings us to today because the current shutdown is primarily about ACA. During the COVID pandemic, Congress passed the American Rescue Plan, which included a temporary expansion of the ACA's premium tax credits (PTCs) to help soften the blow of the COVID pandemic. These tax credits, which account for 7 percent of the Americans who use the Obamacare-run insurance marketplace, had these tax credits extended under the Inflation Reduction Act in 2022. There is nothing permanent like a temporary government measure, right? Because now, the Democrats want to extend the Biden-era tax credits yet again, even though the COVID pandemic ended a few years ago. Democrat's commitment to extending the Biden-era tax credits was strong enough that they refused to pass a budget without them. Let us get into why this insistence to maintain the PTCs is short-sighted and make matters worse. 

It is a common talking point from proponents to say that the premiums will more than double if the PTCs expire. While technically true, the claim is also misleading. The PTCs act as a demand-side subsidy, which both artificially increase price and quantity consumed. Consumers are paying less for out-of-pocket premiums, but it does not mean the total cost of healthcare has decreased.  The subsidies, in fact, shift the cost from the individual enrollee to the taxpayer, a distinction that often involves the same individuals. People think it is cheaper because someone else is footing the bill. It is not about making healthcare cheaper, but it is a matter of budgetary sleight-of-hand. 

This subsidy is a classic economic distortion that functions similarly to the employment sponsored insurance tax credit. Since the subsidies scale with premiums, enrollees are insulated from rising costs, while taxpayers bear the increased burden indirectly. As a result, it encourages overinsurance, thereby reducing market discipline and increasing overall healthcare costs because insurers have less pressure to compete on price, thereby creating an upward price spiral (e.g., Cannon, 2022; Powell, 2012). 

The PTC subsidy fuels premium growth, which in turn raises subsidy payments further. The ACA did not contain premium costs. If anything, individual premiums increased much faster than medical care or overall prices since the ACA was written back in 2009. Individual premiums increased by 143 percent compared to 52 percent of medical care costs and 49 percent for overall consumer prices. Here is data from the Center for Health and Economy showing how ACA premiums have increased over time. As a result, healthcare costs rose in a similar way that federal subsidies to college tuition have caused tuition costs to skyrocket. Even before the pandemic and this PTC expansion, ACA premiums had already doubled, despite Obama's promises of family savings. 

What the PTC subsidies do to make the matter worse is that it lowers price sensitivity. Consumers have less incentive to shop around or demand lower-cost care, which undermines competition and encourages inefficiency. This distorts consumer choice signals, creates a moral hazard, and makes healthcare inflation all the worse. Much like I asked last May with regards to Medicaid, what good does it do to fund an insolvent and unsustainable program?  

In addition to the economic theory and reality of demand-side tax credit, expanding the tax credits will not fix the system. It will merely hide their failures behind market distortion and more debt. Speaking of debt, the Congressional Budget Office (CBO) estimated last month that extending the PTCs will cost $350 billion over the next decade. Combined with the corresponding interest costs of $60 billion, that brings the total cost to $488 billion over the next decade. This is close to the Paragon Health Institute's estimate of $450 billion. 

To put this into context, the PTCs cover 3.8 million enrollees, which would put the per enrollee cost for the premiums at around $13,000. This is crazy because the average spend for all healthcare per person (not only the premiums) is at around $14,000, according to the Centers for Medicare and Medicaid. If those on Obamacare under the PTCs are spending almost the same amount on premiums alone than the average American spends on overall healthcare, this is hardly an efficient or sustainable use of taxpayer dollars. 

To make matters worse, the legislation for the PTCs removed the 400% of poverty line cap, which means that a large share of subsidy dollars are going to higher-income households. The Cato Institute found that a third of those receiving insurance with these PTCs are above the 400% threshold. Similar to student loan forgiveness, these tax credits go to households that are, on average, better equipped to handle their finances, thereby questioning fairness of the PTCs. If you are arguing now that those at this threshold need subsidies, it is another reason showing us how the ACA has failed at making healthcare more affordable. 

This systemic instability is the sort of phenomenon that makes Obamacare even more unsustainable than it was pre-pandemic. As the Tax Foundation argues, the PTCs are a symptom of showing how federal subsidies and tax preferences in healthcare have increased the cost of healthcare, as well as how the healthcare industry is the most subsidized in the United States. The PTCs are another example of how the top-down model of the ACA has failed the everyday American spectacularly. 

The fight is ultimately not about coverage per se, but how far the government is willing to fund a broken system, a question that could also be asked about Social Security. These COVID-era credits were sold as temporary relief during an emergency. The emergency is long over, but the spending remains. This is hardly a new phenomenon. The Cato Institute calculated that at least $12.5 trillion has been spent on emergency spending since 1991. This also shows why the government needs to stop declaring emergencies to continuously expand government largesse into insolvency. As Milton Friedman once quipped, "nothing is so permanent as a temporary government program," and the PTCs are proving the rule.

The enhanced PTCs do not lower costs, but instead masks the cost increases. Instead of helping the vulnerable, they increasingly benefit higher-income households. Instead of fostering competition, they entrench price-insensitive behavior while rewarding the healthcare insurance industry with corporate welfare. And these premiums come at a cost that exceed the average cost of all healthcare spending. These PTCs are fiscal malpractice disguised as compassion. Do not get me started on how the ACA as a whole increases healthcare costs while receiving less care and fewer options. As I wrote last year, Obamacare has unsurprisingly fulfilled its promises, especially the one about more affordable healthcare. 

In the short run, the PTC expansion under the Inflation Reduction Act should expire because pretending that the PTCs make healthcare more affordable is a dangerous illusion. If we are going to have any serious conversation about how to make the quality of healthcare bette while lowering costs, Congress needs to stop doubling down on the very policies that make the problem of skyrocketing healthcare costs a problem in the first place. I am not going to waste my time to highlight real reform if lawmakers cannot take that first step of recognizing that endlessly expanding subsidies masks the systemic failures that they think they are fixing. First, Congress needs to end the PTC expansion and recognize the role that these subsidies play in artificially increasing healthcare costs. Then we can talk real reform.

Mandate the Shot, Not the Choice: Why Florida Should Support Vaccine Requirements with Opt-Outs

The COVID pandemic might be behind us, but the vaccine debate is not. I am not surprised that people did not react kindly to lockdowns so harmful that we still feel their impact in 2025, ineffective face mask mandates, useless travel bans, and deleterious school closures. In aggregate, the COVID pandemic response entailed some of history's worst public policy choice in an era of peace. That being said, there is difference between a proportionate response to such carnage and having the pendulum swing too far to the other extreme. 

Last week, the Florida Surgeon General Joseph Ladapo said at a press conference that he plans to eliminate all vaccine mandates for Florida, including for children in public schools. Setting aside him inflammatory remark of equating a vaccine mandate to "slavery", he made a distinctively libertarian appeal: "Who am I to tell you what you should put in your body?" 

I have advocated for the right to consume marijuana and psychedelic mushrooms, engaging in sex work, not being forced to take a COVID vaccine, selling one's organs for cash, adults having consensual sex with whichever adults they want, eating and drinking what you want (including raw milk and processed foods), and using birth control. This is my way of saying that I understand that few freedoms are more fundamental than what one puts into their body.   

I can understand how the COVID pandemic played a role in this decision. COVID vaccines had newer technology (mRNA) that was politicized from the onset and used executive orders to implement. Furthermore, herd immunity is not possible with COVID, which was evident as early as 2021. The politicization of COVID health measures and COVID vaccines was an overreach by the government. Plus, with the COVID vaccine mandate, it was either get the shot or lose your job. There was no third option. All of these reasons point to why I argued against a COVID vaccine mandate in 2021, both because of the nature of the vaccine and because of how the mandate was imposed.  

Ladapo was hired during the pandemic due to his reputation against harmful COVID interventions. He shaped Florida's COVID response to be focused on medical freedom over public mandate. I pointed out last year the heavy-handed approach with COVID vaccines eroded trust in all vaccines among many Americans. This distrust is now bleeding into policy, as reflected in Florida's move to repeal all vaccine mandates.

For such diseases with legacy vaccines as measles, mumps, and polio, it is unfortunate that Ladopo is conflating them with the COVID vaccines. Ladapo's view is consistent with medical freedom and bodily autonomy. So why is it that I take issue with the COVID vaccine mandate but not for legacy vaccines? There are decades of clinical data showing that legacy vaccines reduce mortality and morbidity with minimal risk. There is generally bipartisan support for the legacy vaccines and were supported by the legislative process, not executive orders. Most importantly, herd immunity is also achievable for many of the legacy vaccines.   

The reality is that completely removing the vaccine mandates increases the risk of outbreaks. A couple of multinational systematic reviews of school vaccine mandates show that immunization mandates generally increase vaccination uptake (Greyson et al., 2019; Lee and Robinson, 2016). This is good because these vaccines are shown to reduce morbidity and mortality, whether that is measles, chicken pox, or rotavirus. The World Health Organization's Expanded Programme on Immunization (EPI) was shown to have averted 154 million deaths from 1970 to 2024 (Shattock et al., 2024). Since vaccines are shown to avert deaths, not having enough children vaccinated undermines herd immunity. 

Much like I expressed with water fluoridation, outcomes are better when there is an opt-out option for such health interventions. Unlike with water fluoridation, there is the ability to have an opt-out option for a vaccine mandate. There are already 28 states that have religious exemptions for a vaccine mandate, as well as 16 states that allow for it on personal or philosophical grounds. An opt-out process should entail something such as a formal written exemption and signing a waiver stating that you acknowledge risks to others. 

As long as an opt-out exists for those who do not want to, society can balance the public health concerns with the matters of personal autonomy. Most will comply with the mandate by default, thereby maintaining herd immunity in most instances (with rare, localized outbreaks taking place) and making sure others are not harmed along the way. The minority that is opposed, which is about 21 percent per recent polling from Harvard, can opt out without state coercion. This "least restrictive means" approach to public health establishes public health standards while still allowing for personal refusal.

Dr. Ladapo's approach appears to be a win for freedom at first glance. In practice, it is a lose-lose for public health and for freedom. Libertarianism is supposed to defend liberty up to the point until it causes harm to others. By discarding minimal requirements for proven life-saving measures, the state of Florida abandons decades of research while exposing its citizens, children in particular, to avoidable risks. A mandate with a clear opt-out option upholds liberty while protecting individual autonomy and public safety. 

Worse still, this could ironically invite more government intervention, whether in the form of emergency powers in the event of an outbreak, a higher burden on state medical services that increase healthcare costs, or federal preemption from the CDC that could undermine Florida's sovereignty. A pragmatic path respects both freedom and evidence. In trying to protect freedom at all costs, Florida may end up sacrificing both liberty and life. A smarter, liberty-respecting state would choose a middle path that trusts people without abandoning its responsibilities. 

Fluoride Is Great for Teeth, But Is It the Government's Job to Fluoridate Water?

President Trump's second term has been shaped by controversial decisions, including making English an official language, imposing tariff rates we have not seen in over a century, deporting undocumented workers, and using price controls on prescription drugs. Out of his confirmations, I would contend that the most controversial of all of them is Trump's Secretary of Health and Human Services, Robert F. Kennedy Jr. Kennedy has spoken out against vaccine safety, opined that vaccines cause autism, and he even said that COVID was "ethnically targeted" to spare Ashkenazi Jews and the Chinese, as if viruses are capable of targeting a specific ethnic group. 

Kennedy's vision for what he would like to do as HHS Secretary is detailed in his Make America Health Again (MAHA) report. One of the major controversies that Kennedy has managed to drudge up is his take on fluoride. Kennedy has long been against the practice of fluoridating water, calling it "industrial waste." He even tried urging Trump to advise U.S. water systems to remove fluoride from their water treatment. The topic caught my eye enough to blog on the topic because I noticed that the Food and Drug Administration is proceeding with its plan to ban prescription fluoride supplements. Opposition to fluoride is nothing new. This opposition dates back to the 1940s, which is when the practice of water fluoridation emerged. It also made an appearance in the 1964 film Dr. Strangelove. 

Analyzing the Health Implications

One of the main reasons for opposition to water fluoridation is for health concerns. The question is whether fluoride actually has unintended health consequences. The meta-analysis that recently made the news shows that, at worst, the decline in pediatric IQ from fluoridation is 1 to 2 points (Taylor et al., 2025). It is worth pointing out that the fluoride levels studied in that controversial meta-analysis were double the recommended amount in U.S. federal guidelines. There is also no link shown between fluoridation and cancer. The National Toxicology Program's 2020 review concluded that high levels of fluoride exposure were problematic, but found scant evidence of harm in the lower levels used in fluoridation.  

While there are some gaps in the research (particularly for larger doses of fluoride), what we know with the best available research is that fluoridation in small doses is shown to have benefits. My support is not mere opinion. It is supported by the American Dental Association, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and Royal Society for Public Health have all advocated for water fluoridation. There is no credible scientific body that currently advises against the practice of water fluoridation.

The strengthened tooth enamel with fluoridation reduces the rate of tooth decay (Nassar and Brizuela, 2023), which could be a reduction of tooth decay as much as 25 percent. This, in turn, reduces the needs for fillings, root canals, crowns, and other dental expenses. The primary reason that fluoridation of water became a practice is because it has been widely accepted as a cost-effective public health measure to mitigate cavities, tooth decay, and dental disparities. All else being equal, fluoridated communities have lower rates of dental decay.

Here is my "on the other hand" argument. There are certain countries that have fluoridated their water, such as the United States, United Kingdom, Ireland, Hong Kong, and Australia. However, the vast majority of countries on the planet have not done so. A study from the 20th century shows that countries that failed to adopt water fluoridation experienced comparable declines in dental decay to those that did fluoridate (Diesendorf, 1986). As you can see from the World Health Organization's report on oral health, there are countries without water fluoridation that enjoy comparable dental health to those that do. 

The maps above give me at least some pause because one could argue that diet, oral hygiene practices, and access to dental care also play a role in dental health. On the other hand, there is an argument to be made that water fluoridation is a helpful public health measure. For argument's sake, let us assume that fluoride unquestionably has positive health benefits. Should the government still be fluoridating water? 

Ethical Issues

My biggest issue with the government fluoridating water has to do with informed consent. As long as you are not hurting somebody else, you should be able to get to decide what substances you consume, regardless of what a healthcare provider might recommend. To give you a sense of how I take it seriously, I have advocated for consumption of marijuana and of psychedelic mushrooms, engaging in sex work, not being forced to take a COVID vaccine, selling one's organs for cash, adults having consensual sex with whichever adults they want, eating and drinking what you want (including raw milk and processed foods), and using birth control. In this respect, mandated water fluoridation violates the concept of bodily autonomy.  

People should be responsible for their own personal dental health, whether that is a healthy diet or proper brushing technique. Even if the decision to fluoridate water made sense in the mid-20th century, it does not make as much sense in 2025. Those who want to use fluoride for dental health have multiple ways to do so, including fluoride toothpaste, fluoride mouthwash, supplements, varnish, and fluoridated salt. The challenge with these alternatives is that they require consistent usage, access to resources, and dedication. Conversely, an advantage of water fluoridation is that it is a passive, population-wide baseline of protection that is more reliable. 

I would be more inclined to support water fluoridation if there were a robust opt-out system. Even as I supported the COVID vaccines in 2021, I still have believed that mandating the vaccines was unnecessary (see here, here, here, and here). Vaccines have a viable way to opt out of getting vaccines. One could argue that it is possible to opt out with fluoridation, whether through bottled water, purified water, or purchasing a water purifier. There are also the possibilities of implementing free access to non-fluoridated water, subsidized filters, or financial assistance for those who cannot afford bottled or purified water, although these options would all but inevitably involve at least some government intervention.Plus, keep in mind theCareQuest Institute for Oral Health released a survey last month showing that only 6 percent believe that water fluoridation should be banned. While it is cumbersome, you would think that those who are the most against water fluoridation would have already implemented these workarounds. Even with the default being fluoridated water, there is still autonomy for the individual to change it if so desired. 

I would also point out that a private company entering the market to provide a non-fluoridated option is impractical, at least in a U.S. context. Building parallel water delivery systems, e.g., pipes, pumps, treatment facilities, is prohibitively expensive. Zoning and utility regulations, along with public utility commissions, de facto block new entrants from entering the market. Plus, there is not much in the way of market demand for a private company to enter the market simply to provide non-fluoridated water. As such, water utilities is one of the notable exceptions in which a government monopoly makes the most sense. Since water utilities end up being a natural monopoly, someone has to decide how the water is treated, which brings us to the next section. 

Individual and Public Healthcare Costs Due to No Water Fluoridation

I think back to when I made a libertarian argument last March in favor of the government supporting the PEPFAR program for HIV/AIDS prevention. I could make a similar argument for water fluoridation. Fluoridating water is a minimal intervention and has a high return on investment. This would explain why the CDC estimates that $1 spent on fluoridation saves about $20 in dental costs, whereas the ADA estimates that it is high as $38 in savings per dollar spent. 

More to the point, this relatively small intervention can save us the headache of more government intervention down the road. If you remove water fluoridation, it could lead to an expansion of Medicare and Medicaid dental coverage, new health care regulations, a federal mandate for dental insurance coverage, dental care subsidies, or price controls similar to the ones that President Trump imposed on prescription drugs earlier this year. Fluoridation falls into a rare category of public policy intervention that paradoxically protects liberty by preventing greater government intrusion.

The reality is that the United States does not have a free-market healthcare system. Healthcare in the U.S. has major elements of socialization with such programs as Medicare, Medicaid, and the Veterans Affairs healthcare system. Since healthcare costs are socialized in this country, the aggregation of poor dental practice can add up quickly. This argument is significant since 35 percent of Americans do not brush twice daily, which is the amount recommended by the American Dental Association. If over a third cannot follow these basic protocols, what are the odds that they would make sure they are taking fluoride alternatives consistently enough to make a difference?

That behavioral failure is a problem in a healthcare system in which healthcare costs are socialized. The fact that about half of Americans cannot manage basic dental hygiene means that non-intervention also has hidden costs. One study estimated that water fluoridation saves the United States $6.5 billion annually [in 2013 dollars] (O'Connell et al., 2016), which would be $8.9 billion in current dollars. Removing water fluoridation would contribute to rising health care costs, much like we have seen take place with obesity raising healthcare costs for all. 

Should the Government Fluoridate Water?

I struggled writing this piece because both sides of the water fluoridation debate make compelling arguments. I genuinely respect individual autonomy and I am an advocate for limited government (emphasis on the word "limited"). Especially with alternatives such as fluoride toothpaste, I take issue with the violation of bodily autonomy. While I understand the ethical implications of mandating water fluoridation, they also become less persuasive given the size of the public benefit of water fluoridation and the existence of workarounds for water fluoridation. Plus, fluoridation has been implemented for over eight decades and it has not resulted in mass medication or erosion of medical autonomy on the whole, thereby negating the slippery slope argument. 

As difficult as it is for me to say, I have to say that water fluoridation is warranted given the circumstances, even from a libertarian lens. I remind myself that there have been other warranted interventions similar to water fluoridation, including water chlorination to prevent cholera and typhoid; iodized salt mandates to address iodine deficiency; traffic signals that lower accidents; and seatbelt laws to reduce fatalities and injuries from automobile accidents. I am not necessarily defending these examples on moral grounds per se, but rather showing that there is a long-established precedent of minor health-protective interventions with a significant return on investment (ROI).

In a country where dental costs are socialized through Medicare and Medicaid, the collective financial burden of preventable dental disease justifies this minimal, narrowly tailored, low-cost intervention tied to a shared resource. The intervention is tightly defined, the evidence base is solid, and the ROI is high. Water fluoridation is a pragmatic approach that recognizes real-world trade-offs while preventing the need for far more exorbitant, intrusive, and coercive government intervention in the future. Since some government action is inevitable, the least intrusive option that yields measurable benefits is preferable to a more coercive alternative. 

Much like I realized when arguing in favor of PEPFAR last March, this conclusion is not a perfect fit with libertarian ideals. In an ideal world, I would like for there to be no government intervention and for the healthcare market to be privatized. However, a world with more limited government is best achieved in practice when balancing principles with real-world application to find the "least worst intervention" in a deeply flawed healthcare system, especially when considering that water utilities are operated as a natural monopoly. Having the government fluoridate water is not a betrayal of liberty in this case because a modest, limited, and well-tailored intervention in an imperfect world beats the alternative. Given the realities of the water market and the science of fluoridation, the pragmatic libertarian in me would rather support a minimal, practical compromise that helps preserve liberty in the long-run than allow for an alternative that allows for government largesse to proliferate even further. 

Congress Needs to Cut Medicaid, Even More Drastically Than in the "Big, Beautiful Bill"

Congress has made its way into the news cycle as the House passed the "Big Beautiful Bill" (HR 1). There has been criticism of how this Bill would exacerbate the deficit, between there being tax cuts and spending increasing. I can understand that argument. When you lower revenue while increasing spending, that increases the deficit run. When a government continuously spends more than it has, it creates debt. That is basic accounting. At the same time, what I brought up last year is that the permanent income tax cuts are not the root issue, but rather exorbitant government spending. This much was made clear when the credit rating agency Moody's downgraded the U.S.' credit rating earlier this month. 

One of the more notable spending cuts in the "Big Beautiful Bill" is with regards to Medicaid. Founded in 1965, Medicaid is the U.S. government's program that helps cover healthcare costs for low-income individuals, typically under 65. Medicare, on the other hand, covers healthcare for individuals over 65. Medicaid currently covers 71 million Americans, which is about a fifth of the overall U.S. population and 40 percent of the U.S. children population. 

The Bill is proposing a number of changes to Medicaid, including: imposing work requirements for able-bodied adults without dependents (I analyzed the requirements before for SNAP); increasing eligibility checks to twice a year; lowering the federal match for states that provide Medicaid to undocumented immigrants; cost-sharing for expansion enrollees; and banning new or increased provider taxes used to draw federal funds. The reason why these reforms are causing such consternation is because the Congressional Budget Office (CBO) estimates that the bill a) will cut Medicaid by $698 billion over the next decade, and b) at least 8.6 million people will lose Medicaid coverage by 2034. 

Medicaid proponents treat Medicaid as a sacred cow and look at critics or opponents as cold-hearted bastards who do not care about the poor. The Left-leaning outlet Vox saw the Republican's move as the "cruelest cut in the Republican budget bill." I saw the numbers and thought that the Republicans are not going nearly far enough, especially given that the Republican's bill is not actual spending cuts but modestly curbing cost growth. Here are some realities around Medicaid that we have to contend with:

1. Medicaid spending is not fiscally sustainable. Medicaid spending was $118 billion in 2000, was $557 billion in 2024, and is projected to be $898 billion in 2034. Outside of interest payments, the major government program with the fastest spending growth is Medicaid. Balancing the federal budget without touching healthcare would require a 40 percent cut in other government spending. 

2. High improper payment rates. According to the Centers for Medicare and Medicaid Services (CMS), there was a 5.09 percent improper payment rate in 2024. That may sound small to some, until you realize that means $31.1 billion of improper payments in 2024. Because CMS ignores eligibility checks (which are the biggest source of error), there effectively has been over a trillion dollars (yes, that is trillion with a "t") spent in improper Medicaid payments over the past decade. If you do not think it is that bad, you can read this 2024 testimony from HHS' Office of Inspector General or this 2024 report from the Government Accountability Office (GAO) showing the extent of the problem. 

3. Medicaid does not help save lives. I wrote on this topic in 2017 because a major component of Obamacare was the Medicaid expansion. 2017 was a time when the Republicans were trying to repeal Obamacare and the Democrats were falsely clamoring about how repealing Obamacare would have killed thousands.

I know that a National Bureau of Economic Research (NBER) was released earlier this month finding that Medicaid expansion saved lives. However, it is methodologically flawed in that it used a "difference in difference" framework. What this means is that the NBER study assumed that difference in outcomes by state was entirely due to Medicaid expansion, which is specious to say the least. RCTs have better causal inference because it eliminates selection bias, has stronger internal validity, and has flexibility in measuring multiple outcomes.That is why I prefer to go to randomized control trials (RCT), which are the gold standard with this sort of research. 

As far as RCTs in this topic go, there is the Oregon Medicaid expansion RCT, which showed that Medicaid expansion did not have statistically significant impact on health outcomes (Baicker et al., 2013). Then there is the RAND Health Insurance Experiment. While it was conducted from 1971 to 1986, this RCT remains to this day to have been the largest U.S. public health study conducted. The RAND study found that cost sharing led to reduced healthcare utilization without affecting outcomes. A working paper from the Mercatus Center similarly shows that Medicaid expansion failed at improving the health outcomes of lower-income adults (Sigaud and Bjoerkheim, 2024). I also wrote last December about how those states that took on ACA Medicaid expansion actually fared worse in terms of life expectancy than those who did not. 

Postscript. As much as I would like government out of healthcare, I do not expect Medicaid to disappear. After all, 71 percent of Trump voters oppose Medicaid cuts. Even so, eliminating the fraud and waste would be a welcomed step in the right direction if there is any chance for Medicaid to have a future. Here are a few ideas that Congress ought to consider:

• Eliminate or lower Medicaid expansion federal match rate. States that implemented Obamacare expansion receive a 90 percent federal match (FMAP) for adults covered under the expansion. The Kaiser Family Foundation (KFF) calculated that removing this FMAP entirely would save Medicaid $1.9 trillion over the next decade, as well as reduce enrollment by 20 million. 
• Penn State's school of health economics argues that a 50 percent federal match floor would be a more measured approach that would still save $530 billion over the next decade without being too burdensome. 
• Eliminate provider taxes. As the Cato Institute points out, provider taxes create the perverse incentive of shifting the costs to the federal government. The "Big, Beautiful Bill" only stops new provider taxes from being created. The CBO found that eliminating the provider taxes would save $612 billion over the next decade. 
• Convert Medicaid into block grant program. This option would provide a capped amount of funding versus open-ended funding based on actual spending. The bipartisan Committee for a Responsible Federal Budget (CRFB) estimates that limiting growth of payments to the level of inflation would save $950 billion over the next decade.
• Reduce supplemental payments. Supplemental payments drive up Medicaid costs by enabling states to inflate total Medicaid expenditures without corresponding increases in care quality or availability, often through financing schemes. You can read the CRFB's primer on supplemental payments here, but essentially, reforming finance law to reduce these supplemental payments would save $500 billion over the next decade (CRFB). 

This piece is not meant to be a treatise on Medicaid reform or to provide a pro/con list of each potential reform, but rather to illustrate how inefficient Medicaid is, how badly it needs spending cuts, and how there is no shortage of policy alternatives. If you are interested in more reforms that would not particularly cut benefits, CRFB created a list, which is below (also see description here). There are clearly fundamental flaws in the Medicaid program that make billions of dollars of waste a prominent feature, not simply a bug. 

If the relatively modest reforms the Republicans are looking to make are unpalatable, the Democrats and Medicaid proponents should wait to see what fiscal chaos waits if the status quo is left to its own devices. It is better that Congress deals with making serious reforms if it wants to avoid even harder choices down the road. However, because politicians tend to operate on myopic thinking motivated by election cycles instead of thinking about long-term sustainability, I suspect that kicking this can down the road is the most likely outcome, one that the American people will pay for dearly. 

Trump's Attempt to Slash Prescription Prices with Price Controls Will Slash Healthcare Quality

In an attempt to slash prescription drug prices, President Trump signed an executive order earlier this week addressing high prescription drug prices. Trump is going to implement a "most favored nation" (MFN) pricing model, which means that the cost of a prescription drug does not exceed the lowest price that other high-income countries pay for the same drug. Trump is exerting pressure on drug manufacturers to accept MFN pricing. While the executive order directs the Secretary of Health and Human Services to take "aggressive measures," it is unclear what those measures are. 

What we see President Trump doing is implementing price controls, which is rich since he called Kamala Harris a communist for her ridiculous idea of price controls for groceries during the presidential campaign. It does not matter which political party endorses price controls: they are a bad policy idea. It is not simply because there are centuries of price controls that have failed, whether that those are rent control, an overdraft fee cap, fixed exchange rates, price-gouging laws during natural disasters, and consumer loan interest rate caps. 

In 2022, I heavily criticized President Biden for the prescription drug price controls in the Inflation Reduction Act (IRA). I will be bringing those same criticisms to Trump's proposal because they still hold. By definition, price ceilings create shortages because the drug companies will be disincentivized to produce more drugs at reduced prices. The truth is that price controls do not eliminate costs, but rather shift costs at the expense of something else. What is that something else? 

One outcome of these price controls is that lower access to drugs would mean greater death. One study from the University of Chicago estimated that the casualties caused by the IRA would be 331.5 million life years across a 20-year timespan (Philipson and Durie, 2021). To give you some context, the COVID pandemic resulted in the loss of 9.7 million life years (Quast et al., 2022), which would be about 34 times the life lost during the worst pandemic in the past century. 

Not only that, but drug price controls in Europe translated into less drug research and development (Golec and Vernon, 2006). Fewer new medicines means worsening healthcare outcomes than would have occurred otherwise. That is not only for the United States, but across the globe. Another study found that the drugs that do get developed can have their entry into the market delayed by a year (Maini and Pammolli, 2023; Danzon et al., 2004). To reiterate an earlier point, a longitudinal study found that these delays reduce life expectancy (Lichtenberg, 2005).

Trump's executive order is going to be even worse than Biden's IRA price controls. Why? At least under the IRA, the laws mainly affected Medicare. With this executive order, Trump is expanding the scope of the price controls to the private sector, which means it will affect all prescription drugs. If Trump actually cares about reducing prices and making prescription drugs great again, he could focus on policy that makes the prescription drug market more competitive, such as allowing for increased reimportation of drugs, expanding access to generic drugs, or ending prescription requirements for a number of drugs. Otherwise, Trump will make prescription drug pricing an even bigger disaster than under the Biden administration.

A Libertarian Case for PEPFAR and Continuing Funding HIV/AIDS Prevention In Other Countries

Since 2003, the President's Emergency Plan for AIDS Relief, or PEPFAR for short, has been USAID's global health initiative to fight HIV/AIDS. PEPFAR has received over $100 billion in funds for the response to HIV/AIDS. It has been the largest global health program dedicated to fighting a single disease.  Why is PEPFAR making it on my blog? Aside from PEPFAR services being disrupted by the Trump administration cancelling various foreign aid contracts (read study on preliminary effects of that disruption here), Congress extended PEPFAR's reauthorization last year. If the reauthorization is not renewed, it is set to expire tomorrow: March 25, 2025.

This begs the question of whether PEPFAR should be reauthorized or not. Some of you might expect a knee-jerk response of "No" from me simply because it is a sizable government program. Last month, I made an argument for shutting down the U.S. Agency for International Development (USAID) in no small part because of the perverse incentives that foreign aid generally creates. That much is true. Additionally, I worry about how much on PEPFAR is spent. In FY2024, the government spent $6.5 billion on PEPFAR. Although it is about 0.1 percent of government spending, I am quite concerned with the ballooning public debt of the U.S. government.  

At the same time, the price tag and the fact that it is a government program are not prima facie adequate reasons for me to automatically say "No." I am first and foremost a consequentialist libertarian. What this means is that my main reason for being libertarian is because I find that freer markets, lower taxes, and fewer regulations generally create more desirable outcomes than government intervention. 

It would not be the first time I argued for at least some government intervention in public health policy. I have done so by arguing for birth control subsidies, partial smoking bans, and paying people to take the COVID-19 vaccine, all of which I did from a libertarian lens. One of the reasons I have such problems with government intervention generally is because it does not solve the problem the policy was intended to address, or even worse, it exacerbates the problem. A government policy that actually helps is a notable exception, not a norm. Looking at the data, it looks like PEPFAR is one of those exceptions from an outcomes-based point of view.

PEPFAR's main success is its considerable positive health outcomes. PEPFAR reports that it has saved 21 million lives. The Kaiser Family Foundation found that PEPFAR reduced the all-cause mortality rate in recipient countries by 20 percent. I came across an independent citizen review of PEPFAR (Piper et al., 2024) that estimated that PEPFAR saved between 7.5 million and 30 million lives between 2004 and 2018. At that point, $70 billion was spent. That would mean PEPFAR costs between $1,500 and $10,000 per life saved. 

Let's create a low-bound estimate for this cost-benefit analysis. Use the average life expectancy payout from life insurance in the U.S. (i.e., $168,000) and the low-bound estimate of 7.5 million lives saved. it would mean $1.26 trillion in benefit for lives saved for the $70 billion spent, or $18 of benefit for each dollar spent. If you use the value of life from FEMA or EPA of around $11 million along with the high-bound estimate of lives saved (i.e., 30 million), the benefit-to-cost ratio increases to over $4,700 in benefit for each dollar spent. 

This back-of-the-envelope cost-benefit analysis is quite frankly astounding. And to think it does not even consider the benefit of greater economic stability. The Kaiser Foundation calculated that PEPFAR was associated with a 2.1 percentage point increase in GDP from 2004 to 2018. Even if the boost to GDP was only 1.4 percentage points (Tompsett, 2020), that would still mean a $14 increase in per capita income for the sub-Saharan region, which is significant for a region with lower purchasing power. An economic analysis in the Public Library of Science found similar boosts to the GDP and education outcomes (Crown et al., 2023). Why would it create better economic outcomes? Because people who are healthier and live longer are able to contribute to the economy. 

One could argue that PEPFAR puts major emphasis on HIV/AIDS while de-emphasizing other health issues in those regions, such as malaria, tuberculosis, maternal health, or malnutrition. One could also argue that the U.S. government should focus on health problems at home, whether that is the opioid crisis or diabetes and heart attacks primarily caused by high obesity rates. Where funds should be spent and how much are subjective policy preferences directed by one's priorities and values. 

I would counter by saying that HIV/AIDS is another example of how a public health problem can be global, much like we saw with the COVID pandemic. Rather than focusing on government-to-government aid, PEPFAR focuses on public-private collaboration with pharmaceutical companies and suppliers of diagnostic tools, treatments, and other health technology to strengthen the private-care healthcare systems of developing countries that have been contending with high HIV/AIDS rates. This means that PEPFAR strengthens local health systems in the long-run instead of creating dependency on foreign governments for treatments and preventative services. 

Focusing on both HIV/AIDS treatment and prevention not only mean a lower mortality rate, but also means that stopping future infections means fewer dollars spent on treatment, especially if those dollars are spent by the government. Tangentially, the Right-leaning Center for Strategic and International Studies (CSIS) makes a case for using PEPFAR to strengthen global security for when the next disease strikes. PEPFAR is an example of what foreign aid should strive for, rather than most foreign aid that perpetuates dependency and malfunctioning economies and political institutions. 

Does that mean that the PEPFAR program is perfect? No. Even someone as critical of PEPFAR as the Right-leaning Heritage does not suggest eliminating PEPFAR, but rather reforming PEPFAR. If USAID is indeed eliminated, PEPFAR could be managed solely by the Centers for Disease Control and Prevention (CDC) or the Department of State instead of having USAID participation. There can also be better programmatic objectives, a focus on more countries due to the global nature of the HIV/AIDS epidemic, or even figure out how PEPFAR could develop sustainable health systems that can address multiple diseases. 

Much like I did with arguing for birth control subsidies, the libertarian in me has to ask what sort of costs would be incurred if the program disappeared versus the cost of the program itself. Some problems that would emerge by eliminating PEPFAR include increased HIV transmission and new infections, rising mortality rates, increased healthcare costs, economic stability and social unrest, and potentially regional instability in parts of the world that already have more than their fair share of issues. The interconnectedness of these problems could create problems not only on a regional level, but a global one. 

Some might balk at the price tag, but I would contend that it would cause more problems in the big picture by removing PEPFAR. I will conclude by saying that even with a need for reform, the number of lives saved and economic benefit derived from PEPFAR, not to mention the problems and headache avoided, make a very strong case for PEPFAR. 

How Lockdowns and Other COVID Measures Have Caused Suffering, Even in 2025 (Part I)

Tomorrow, on March 11, marks the five-year anniversary of when the World Health Organization (WHO) declared the COVID-19 pandemic. China responded to COVID by implementing draconian lockdowns and the world has not been the same ever since. Who cares if there was no evidence for lockdowns and that the pandemic guidance set by such organizations as WHO and Johns Hopkins advised against lockdowns? With Sweden being the notable exception, the world followed suit in terms of locking down the economy. Did the lockdowns help with preventing more death? No, it did not. 

If anything, the lockdowns increased excess death, which is not a surprise when non-COVID healthcare was postponed in 2020 and lockdowns exacerbated mental health. Lockdowns also could not pass a sniff test when it came to a proper cost-benefit analysis, meaning that we ended up paying way more than we should have. While the lockdowns are a thing of the past that almost all of us would prefer to forget, the truth is that the effects of those lockdowns and other non-pharmaceutical interventions (NPI) still live with us today. Since I live in the United States, I take this from a mostly U.S.-based perspective, but will cite other studies when available. In Part I, I want to cover the health-related costs that have reverberated as a result of the lockdowns.

There is still a backlog in healthcare created by the lockdowns. Only allowing hospitals to deal with COVID-related maladies was not a decision taken by the coronavirus, but a policy decision made by humans. Although the NIH does want to acknowledge it was a policy decision, NIH at least acknowledges that there is still a backlog in health services from the pandemic that we are still dealing with today (Pratt, 2024). In November 2022, I analyzed a study that showed that delaying preventative screening resulted in missing one million cancer screenings in Europe. There is no doubt that the delayed procedures and screening have resulted in a backlog that continues across healthcare systems in multiple countries to this day. 

Lockdowns exacerbated obesity rates. There was definitely an issue with obesity prior to the pandemic. However, obesity rates worldwide increased considerably (Nour and Atlinas, 2023), including the United States. With people stuck at home, many people changed their daily habits for the worst, whether that is less physical activity, worse dietary practices, or more sedentary activities (e.g., watching Netflix). That does not count the COVID-induced stress. Another study from the WHO confirmed this trend for children in Europe. The data from the United States indicates that those obesity rates have not declined since the pandemic, which is intuitive since it is not easy to shed those negative habits once started. Given the numerous negative health effects of obesity, this high obesity rate continues to put strain on healthcare systems all over the world.  

High substance abuse rates persist. Back in May 2020, I expressed concern about how the lockdowns were going to cause mental health issues. Sadly, I was right. To deal with the stress of the pandemic (including the lockdowns and the job losses incurred), 13 percent of Americans went to substances to try to ease their woes. A 2024 study from the University of South California found that the pandemic-era increase in alcohol use persists. A similar phenomenon happened with opioid usage, one that is prevalent enough where Trump used it as a pretext to start a trade war. Given that it is difficult to end substance abuse or addiction, it is understandable that high substance use rates would still be with us even after the stress of the pandemic is behind us. 

There unfortunately is less trust in public health institutions. Americans trust their doctors less than they did pre-pandemic. There is also more skepticism about non-COVID vaccines because of all the hullabaloo of trying to force people to take vaccines. With greater skepticism, there are now measles outbreaks. Measles vaccines are effective. Measles outbreaks should be a thing of the past, but that becomes more difficult when the mistrust with the COVID vaccines spills over into all vaccines. With all the half-truths, faux pas, and recommendations not based in science coming from Dr. Anthony Fauci, former CDC Director Rochelle Walensky, and the Biden administration about COVID, it is clear why, at least in a U.S. context, there is less trust when public health officials politicize a pandemic.

Don't you worry! I have more to cover in Part II. 

Obamacare Still Hasn't Delivered On Its Promises: Quelle Surprise!

While President-Elect Trump's stance on tariffs and immigration remain unambiguous, Trump's viewpoint on the Affordable Care Act (ACA), colloquially known as Obamacare, is more tenuous. In November 2023, Trump wrote on his social platform Truth Social that "we should not give up" on repealing Obamacare. In the 2023 presidential debate last September, he said that he has concepts of an idea to replace Obamacare, but "until then, I'd run it as good as it can be run." This is in contrast to his first term where he tried to repeal it but failed. Repealing Obamacare did not even make its way into the official 2024 Republican platform. 

Given that healthcare accounted for 17.3 percent of the U.S. GDP, I think Obamacare is absolutely something worth considering. As this October 2024 report from the Paragon Health Institute illustrates, at least a dozen significant Obamacare-related promises were broken. Here are a few broken promises to make the point more salient:

The ACA would create savings of $2,500 per family. This ended up being such a large faux pas of Obama's that FactCheck.org called this promise one of "Obama's Whoppers." It turns out that average premiums increased from $232 in 2013 to $476 in 2017, according to HHS' Office of the Assistance Secretary for Planning and Evaluation (ASPE). This ASPE finding is similar to that of a March 2021 Heritage Foundation report that found that the average premium increased by 129 percent from 2013 to 2019. 

It should not be a surprise that a demand-side subsidy would drive up healthcare costs: it's Econ 101. Obamacare made healthcare costly when it first started. Even now, about half of Americans have difficulty paying for healthcare (KFF). Not exactly what I would call affordable. 

The ACA would save lives. Obama promised that it would reduce injuries in addition to saving lives. Democrats touting ACA were citing a Harvard study (Wilper et al., 2009) saying that 45,000 excess deaths were caused by lack of insurance. Given that there were 2.6 million annual deaths at the time, a reduction of 45,000 excess deaths would have resulted in an increased average lifespan of 0.4 years. 

The life expectancy decreased by 0.3 years from 2014 to 2017, which is a net difference of 0.7 years of what it would have been had the Harvard study been accurate. Average life expectancy increased slightly in 2019, only to drop again due to the pandemic. Average life expectancy went from 78.3 years to 77.4 years in 2023 (World Bank). This promise became so obviously and patently false I wrote a separate piece on this myth in July 2017. And if that were not enough, life expectancy worsened for the states that adopted the ACA Medicaid expansion versus those that did not (Blase and Balat, 2020). 

 

The ACA would increase economic growth. Obama's chairman of the Council of Economic Advisors, Jason Furman, promised that the ACA would create "healthier, more productive workers," "reduced 'job lock'", and "better macroeconomic performance." A research paper from the Journal of Human Resources found that the ACA "increased low-hours, involuntary part-time employment by 500,000-700,000 workers in retail, accommodations, and food services (Dillinder et al., 2020). The authors contributed this trend to the ACA's penalty to large employers who did not want to provide insurance being incentivized to reduce employment and shift full-time workers to part-time workers. The Congressional Budget Office recognized this disincentive in its 2014 report.

The employer mandate would collect a ton of revenue for the government. The Congressional Budget Office and Internal Revenue Service was predicting all this revenue. The White House's Council of Economic Advisors concluded that 11 years after the ACA passed, only 1 percent of what was projected was actually collected. 

If you like your plan, you can keep it. This was a promise made by Obama in 2009 since he believed that the ACA would not take away anyone's plan. This one ended up being such a bold-faced lie that Politifact called it the Lie of the Year in 2013 since at least 7 million consumers saw their plans disappear.

The ACA would decrease emergency room use. Obama's logic on this promise was that taxpayers were subsidizing the uninsured because a lack of insurance was incentivizing them to seek healthcare only when the situation became dire enough to use an emergency room. 

I will look at this from the angle of Medicaid expansion since the ACA expanded Medicaid enrollment by 16 million more than the Congressional Budget Office initially calculated (Butler, 2016). The Brookings Institution concluded that the ACA's Medicaid expansion increased emergency room visits by 20 percent, primarily due to emergency room visits that could have been treated outside the emergency department (Garthwaite et al., 2020). Scholars from the University of Iowa similarly found that Medicaid expansion in California as a result of ACA increased emergency room use and cost (Ellis and Esson, 2018).

Postscript. Not much good has changed about the ACA since I wrote my scathing piece in 2017 on 15 reasons why we should dislike Obamacare. If anything, repealing the main cost-containing provisions, the Cadillac tax and the health insurance tax, since the creation of the ACA made matters worse. The false promises of Obamacare resulted in higher healthcare costs, increased deficit spending, and significant disruptions to insurance coverage and healthcare access. 

The ACA did little, if anything, to improve healthcare in this country, as is illustrated by this September 2024 report from the Paragon Health Institute on how the ACA reduced healthcare quality. Meanwhile, the ACA guaranteed that health insurance companies are guaranteed profits. We do need something to reform healthcare in the United States. Building an extra room on an already rickety house does not help anyone. It simply means reforming healthcare becomes that much more difficult when policy decision-makers reach that painful fork in the road, much like they eventually will with Social Security. Whether the Trump 47 administration is up for the task remains to be seen. But if the first Trump term is indicative of anything, we are likely to see more of a preservation of the status quo than we are reforms of any significance.