EDITOR’S NOTE: Here’s an installment from Tillamook County’s State Representative Cyrus Javadi’s Substack blog, “A Point of Personal Privilege.” Oregon legislator and local dentist. Representing District 32, a focus on practical policies and community well-being. This space offers insights on state issues, reflections on leadership, and stories from the Oregon coast, fostering thoughtful dialogue. Posted on Substack, 12/14/25
What the Affordable Care Act Solved, and What It Never Could
By State Representative Cyrus Javadi
There are few phrases in American life more comforting (and more misleading) than “at least you’re covered.”
It belongs in the same category as “this won’t hurt,” “we’ll circle back,” and “kids are cheaper than you think.” All technically possible. None reliably true.
About fifteen years ago, I was a young dentist with enough kids to justify a minivan and just enough confidence to think I knew what I was doing. With dental school officially over, I packed up a U-Haul and headed to Oregon to start my career.
My first employer in Astoria offered a high-deductible health plan. One of those plans where insurance mostly exists as a theory until you’ve paid the first $5,000 per person out of pocket.
The premium? About $250 a month for the whole family.
On paper, this was supposed to be reassuring. If something truly catastrophic happened, we were “covered.” In real life, it meant living with a constant, low-grade anxiety, and the hope that we had tens of thousands of dollars lying around in case a kid broke an arm, needed stitches, or did whatever it is kids do when you stop watching them for nine seconds.
Then Congress passed the Affordable Care Act (aka Obamacare) with slogans like “Healthcare for everyone” and, “You can keep your doctor” and, “Affordable.”
And almost overnight, my insurance premium for a family jumped from $250 a month to about $1,800. (Dentists, it turns out, do not qualify for subsidies.)
Affordable for Whom
Sure, the coverage was better. That mattered. Fewer asterisks. Fewer exclusions. Less fine print pretending cancer was optional.
But the tradeoff was impossible to miss.
Instead of worrying about whether we might face tens of thousands of dollars in medical bills, we now knew we would…just paid out steadily, month after month, in premiums instead of unpredictably in deductibles.
From where I was sitting at the time, far away from hospital boardrooms, actuarial tables, and the fluorescent back offices where healthcare math actually lives, the new “Affordable Care Act” raised a very reasonable question:
Affordable for whom?
People were angry. I was angry. And that anger didn’t come out of nowhere. It powered the Tea Party wave, fueled accusations that Obama had misled the public, and kept replaying that now-famous Pelosi line about having to pass the bill to see what was in it.
The frustration was real. The experience was real.
But the explanation people were offered was incomplete.
Fifteen years later, we’re still arguing about Obamacare using the same talking points, the same accusations, and the same promise that if we just repeal it (if we just unleash competition and let insurers “compete on price”) everything will magically get cheaper again.
Spoiler: that’s wrong.
So let’s slow down and talk about what actually happened, what Obamacare did, why it did it, and why pretending we can simply wish it away would leave us worse off, not better.
We Didn’t Break Healthcare With Obamacare. We Just Stopped Lying About It.
If you want to understand how Americans think about Obamacare, imagine a bridge that’s been quietly rusting for thirty years.
Cars are still driving across it. Some of them make unsettling noises. A few bolts fall into the river. Engineers put up cones. Everyone pretends not to notice because, hey, the bridge hasn’t collapsed yet.
Then one day, someone shows up and says, “We should probably reinforce this thing before it kills someone.”
The repairs are expensive. Traffic slows. Tolls go up.
And suddenly half the town is screaming, “See? The bridge was fine until you touched it.”
That, in a nutshell, is how most conversations about the Affordable Care Act go.
The popular story is tidy and emotionally satisfying: before Obamacare, healthcare was basically working. Then Washington passed a giant bill no one read, insurance companies got rich, premiums exploded, and now everyone’s miserable. If only we’d left well enough alone, insurers would have competed on price, premiums would have fallen, and unicorns would roam the land.
It’s a great story. It’s also almost entirely wrong.
The Market Before the Market “Collapsed”
By the time Barack Obama took office, the American health insurance market was not stable. It was not healthy. It was not “working, but imperfect.”
It was collapsing, just quietly enough that most people didn’t notice.
Premiums were rising rapidly long before the ACA. In the decade before it passed, individual-market premiums more than doubled. Employer plans rose too, but those increases were conveniently hidden behind tax exclusions and HR departments. You didn’t see the bill. Your employer did.
But remember, even after doubling, premiums still weren’t high enough to cover the actual cost of care.
Hospitals were becoming far more expensive to run. Chronic disease was rising. Imaging and specialty drugs went from rare to routine. Labor, technology, and liability costs all climbed at once.
Insurers saw the math. They just couldn’t charge what care really cost without losing customers.
So they pulled the only levers available.
They narrowed networks.
They denied coverage to people who were already sick.
They excluded cancer and mental health.
They imposed lifetime caps.
They rescinded people’s insurance policies.
Not because they were uniquely villainous, but because, like I’ve said before, insurance is a math problem before it is a moral one.
The system looked cheaper because it was selective. It worked beautifully — until you needed it.
Hospitals absorbed the difference. Tens of billions of dollars a year in uncompensated care. Emergency rooms became default primary care clinics. Rural hospitals ran on margins so thin they bordered on fiction.
And, the uninsured? They weren’t freeloading. They were going bankrupt.
Sound familiar? History is repeating itself in 2025.
Enter the Man With the Clipboard
When Obama ran for president, he didn’t invent the problem. He inherited it.
And when his administration asked, “What do we do?” the answer they landed on wasn’t elegant. It wasn’t libertarian. It wasn’t socialist. It was blunt.
Everyone has to pay in.
If everyone is insured (young, old, healthy, sick) you spread the cost. Not enough to make healthcare cheap. But enough to keep the system from cannibalizing itself.
That meant premiums would go up. They had to. You can’t ban exclusions, require coverage of expensive conditions, expand benefits, cap out-of-pocket costs, and somehow make insurance cheaper at the same time.
But more people would be covered. Coverage would actually mean something. Hospitals could bill insurers for care that had previously been written off. Insurers could stop pretending risk could be engineered away with fine print.
Of course, this created an immediate problem. Premiums were too expensive for millions of low-to-middle income families.
That’s right. Many people still couldn’t afford the premiums. And many who could afford premiums couldn’t afford the deductibles and copays.
So the government stepped in with subsidies for premiums. Cost-sharing reductions for out-of-pocket costs. Paid for by taxpayers, because there was no other place for the money to come from.
The Year the Mask Slipped
In 2017, during President Trump’s first term, the federal government stopped reimbursing insurers for cost-sharing reductions, as in, the subsidies that lower deductibles and copays for lower-income enrollees.
Important detail: insurers were still legally required to provide those benefits.
Also important, the care didn’t get cheaper just because subsidies stopped. And, the obligation to treat all people didn’t disappear. Only the reimbursement vanished.
So insurers did what their accountants demanded. They raised premiums.
Nationally, premiums jumped about 34 percent in a single year.
Not because Obamacare suddenly got worse. Not because insurers got greedy overnight. But because the government stopped paying for benefits it still required insurers to provide.
And it accidentally proved something devastating to a decade of talking points.
Removing subsidies does not lower premiums. It raises them.
Read that last sentence again. Slowly.
The Fantasy of “Competition Will Fix It”
The idea that ending Obamacare would force insurers to compete on price and drive premiums down is deeply appealing.
It’s also fantasy.
Before the ACA, insurers didn’t compete by making care cheaper. They competed by avoiding risk. By excluding sick people. By making coverage cheaper because it covered less.
Ending the ACA doesn’t make hospitals cheaper to run. It doesn’t lower labor costs. It doesn’t make cancer drugs affordable. It doesn’t shrink administrative overhead. It doesn’t cure chronic disease.
What it does is make insurance nastier.
Healthy people pay less. Sick people pay more (or can’t get coverage at all). Hospitals absorb more uncompensated care. Those losses get shifted back into the system. Premiums rise elsewhere.
We’ve seen this movie. It didn’t end with falling prices.
Sorry Trump. Sorry MAGA. The answer isn’t repealing Obamacare. That would be devastating.
The only option is to keep the ACA intact until we are ready to overhaul America’s healthcare system.
So… What Do We Do Now?
Once you accept all of this, the question changes.
It’s no longer “Should we repeal Obamacare?”
That question has been answered. Repeal would make things worse, not better.
The real question is harder, and much less satisfying:
How do you make healthcare cheaper without pretending it already is?
Because every honest path forward runs straight into tradeoffs Americans hate talking about.
- You can lower costs by paying doctors and nurses less, but good luck explaining that to a workforce that’s already burning out.
- You can lower costs by limiting access, but we already recoil at waitlists and rationing.
- You can lower costs by regulating prices, but that means admitting healthcare isn’t a normal market.
- You can lower costs by improving population health, but that requires patience, prevention, and behavior change, none of which fit neatly into an election cycle.
Insurance doesn’t create the cost of care. It only decides how the bill gets split.
That’s the mistake we keep making.
We argue endlessly about premiums and deductibles and subsidies, while the actual drivers of cost, labor shortages, chronic disease, specialty drugs, administrative complexity, consolidation, and an aging population churn along mostly untouched.
The Affordable Care Act was a tourniquet. It stopped the bleeding. But it was never the cure.
Which brings us to the question we should have been asking all along:
If we’re finally done lying to ourselves about what healthcare costs, how do we actually bring the cost down?
That’s the conversation worth having next.