WILLIAM BRANGHAM: So extending these# subsidies would cost an estimated## $350 billion over the next decade.

The president# and a number of Republicans have suggested## they would rather give that money to people# directly, rather than to insurance companies.

So, for a deeper dive on what we do now,# we get two different views.

Jonathan Cohn## is senior writer at The Bulwark# and author of "The Ten Year War:## Obamacare and the Unfinished Crusade for# Universal Coverage."

And Brian Blase is## president of Paragon Health Institute.

He served# on the National Economic Council during the first## Trump administration.

He testified in front of# Congress yesterday on rising health care costs.

Gentlemen, welcome to you both.

Jonathan Cohn, to you first.

We# just heard from several of people## who are alarmed at the prospect of what# might happen to their insurance if these## subsidies are not extended.

Given# the deadline that we are up against,## what do you think is the best course# of action?

What should we be doing now?

JONATHAN COHN, The Bulwark: Well, if you're# just talking short term, I think there's## a pretty easy answer to that.

Extend the# subsidies for one year or for two years.

There's a broader conversation to be had# about how to fix the health care system,## how to either improve or change the# Affordable Care Act.

This is a debate## we have been having for 10 years.

Democrats# put forward legislation at the beginning of## this year to talk about that.

People like# us have been talking about this for months.

The time to sort of do a bigger# conversation was six months ago,## because it takes time to work these things out.

WILLIAM BRANGHAM: Brian Blase, you testified# before Congress yesterday, arguing that the## ACA and somehow the way these subsidies are# structured is a principal driver of rising costs.

The president, as I mentioned, has suggested# funneling that money directly to individuals## instead.

What do you make of that idea?# What do you think we ought to be doing now?

BRIAN BLASE, President, Paragon Health# Institute: Yes, and thanks for having me on.

So there was bipartisan agreement at the# hearing yesterday that t.. Act has failed to make health insurance# affordable.

It's led to coverage with## significantly higher premiums,# deductibles, and narrow networks.

And one of the areas of confusion here# is that the subsidies remain in place.## For 94 percent of the enrollees, they will# maintain significant taxpayer assistance,## assistance for coverage.

That is not# going away.

What is at issue is a COVID## era policy that increased these subsidies that# go directly to health insurance companies.

And there are key structural problems# with the ACA.

And these subsidies that## go directly to health insurance companies go# to many enrollees that don't use health care## services at all.

So 35 percent of all enrollees# in 2024 didn't use their plan a single time.

Part of the problem is a surge of fraud that has# entered the program with these enhanced subsidies.## And so what is happening is, taxpayers are sending# a lot of money to insurers on behalf of people## that don't get any medical care.

And I think# we need to address the core structural problems## at the roots of the ACA that have led to a# deterioration in the quality of health insurance.

And continuing these inefficient# subsidies will mean that we don't## improve the quality of coverage in that program.

WILLIAM BRANGHAM: Jonathan Cohn,# how do you respond to that,## that something -- that the way these subsidies# are structured, they're going to people who## may not necessarily seem to need them# immediately, they're incredibly costly,## and that perpetuating them only# kicks the can down the road.

JONATHAN COHN: OK.So, well, there's a lot to# unpack there.

Let's focus on this one question of## the people who are getting subsidies and not using# them for claims, because this has come up a lot.

It is true, there's data from the government that# 30 percent or what -- I think it's actually even## a little higher now of enrollees at the ACA don't# file a claim during the year.

And this is supposed## to be evidence that you have people who are# sort of misenrolled, fraudulently enrolled.

Something to remember, I mean, the fact that you# don't use insurance in a year doesn't mean it's## wasted.

Especially younger, healthier people# are going to go and have periods when they're## not -- when I was 27, I don't think I went to# the doctor for like three years at one point.

Then the fraud issue is real.

There has been# an uptick in fraud.

But if you look at where## the fraud is -- and, actually, there's# some really good research on this from## Brian's research organization, Paragon.# What they note, it's really concentrated## in the states where they use the# federal Web site healthcare.gov.

And there were a number of changes made# to healthcare.gov that made it easier## for brokers to enroll people directly.

And# everything we -- you look at what's going on,## a lot of this is brokers behaving badly.

That's# terrible.

We should do something about that.

But you can do something about that without taking## away financial assistance from people.# And the proof is that the states that## didn't make those broker changes didn't# see nearly the kind of broker fraud.

WILLIAM BRANGHAM: Brian, back to this issue# of the deadline that we have approaching here,## there is, both from a political# perspective -- with midterms looming,## Republicans don't want to be blamed# for this sudden spike in premiums.

Do you think that what the president and# some Republicans have floated as far as,## rather than extending the subsidies,# but funneling the money to individuals,## do you think that is workable?

And do you think# it is workable in the time frame allotted?

BRIAN BLASE: So let me clarify again# that the subsidies remain in place,## and 94 percent of the enrollees# will receive subsidies still.## It means the government is paying a# substantial share of their premium.

So, for the typical enrollee next year,# the federal government is going to pay## more than 80 percent of the subsidy.# I think that there are proposals out## there that can redirect the portion of the# subsidies from the insurer to the patient.

There's actually a policy that was put in the# House-passed version of the reconciliation## bill.

It would have lowered premiums by 12# percent.

And you could -- what you could do is,## you could allow individuals to take a portion# of that subsidy that currently goes to insurers## to reduce planned deductibles and# out-of-pocket limits, and you can## give it to enrollees as an HSA contribution,# so that the enrollee controls the spending.

And, fundamentally, the way that# we reform our health care system## and make it more affordable is# to give more power to the patient## and stop sending so much federal government# directly to health insurance companies.

That## is not the way to make a system more efficient.# It's the way to keep premiums and prices rising,## because it gives insurers very bad incentives,# where their incentives are just to continue to## inflate premiums and the prices that# they pay for health care services.

WILLIAM BRANGHAM: Jonathan, last question to you.

What about that idea?

And will it# get done in time, do you think,## by the end of this year?

And what might# this do to the marketplace itself?

JONATHAN COHN: Yes, so I mean,# I think trying to put in place## something like this the next six weeks -- I# mean, we're three weeks into open enrollment,## the next plan year begins in less# than two months -- is ridiculous.

Trying to set something up like this on short# notice is not going to work.

There are lots## of reasons to be skeptical.

I mean, there# are versions of accounts that would work## perfectly fine.

And I think we're just getting# the legislative details now.

And something would## work out quite well for some people, but there's# lots of reason to think it's not a magic bullet.

People -- we have got data on this.

People# are terrible at shopping for health care,## and lots of reasons to fear that this will# shift the burden of health care spending## on to people with big medical expenses.

And# I think that gets to the basic divide here.

Is your top priority to spend less money,# believing maybe that will make the health## care system more efficient and less government# is better?

That's a respectful point of view.## Or is your top priority to make sure people get# as much help as possible because health care is## so expensive, even if that means spending more# money, even if that means bigger government?

And I think that's the choice we face here.

BRIAN BLASE: Honestly, my top# priority is a more affordable,## accountable health system that# improves Americans' health over time.

And I think Obamacare has fundamental# problems in it.

And we can't just keep## doing more of the same and sending more# money to health insurance companies.## That's just going to lead to worse# health care and worse health outcomes.

WILLIAM BRANGHAM: All right,# Brian Blase, Jonathan Cohn,## very important debate we are having here.# Thank you so much, both of you, for being here.

JONATHAN COHN: Thank you.