The Business of Health Insurance in America

By Erica Bersin, BCPA

The business of healthcare is not broken; it is working exactly how it was intended. It was designed for people to pay in just in case something happens and then not to pay out when it does. It was intended to “maximize shareholder value.” 

As recently as yesterday, the Senate voted 58 to 41 not to extend the critical Affordable Care Act (ACA) subsidies. Though they were previously set to expire on December 31, 2025, they had the ability to help the American people. Instead, they chose to intentionally harm. 

Some have said their premiums and deductibles are doubling or even tripling with tens of thousands in deductibles before coverage kicks in. While absolutely imperfect, we must keep the ACA intact for everyone, otherwise the cost of Medicare, Medicaid and private and employer-based insurance will skyrocket, resulting in millions of people losing coverage due to lack of affordability. 

Accessible insurance is a huge part of living a healthy life. Because of this, we need to expand coverage and make it fair for everyone. The goal should be for every single person in the U.S. to have head-to-toe healthcare. as DPH argued recently in our report, Improving the Health of Americans Together.

My Story

As a single-person LLC consultant, I have navigated the New York State Exchange (ACA) for years. It is the most expensive Exchange in the country for those who do not qualify for subsidies. If subsidies are received, an increase in income requires repayment via federal tax returns the following year. 

For 2025, I resigned myself to a catastrophic plan at $330 per month with a $10,000 deductible, as other options approached $1,000 monthly. While applying in November 2024, my temporarily being in-between projects / contracts was interpreted by the NYS Exchange as being unemployed, which led me to unexpectedly qualifying for Medicaid. The state market assured me that this was correct for consultants in my situation, and they “saw it all the time.” 

However, during open enrollment this year (October 2025), I was informed that despite meeting the income threshold, I no longer qualified for either Medicaid or financial assistance / subsidies. The catastrophic plan doesn’t seem to exist now, and the “least expensive” option is $675 with poor / limited coverage. 

Living with two chronic diseases, I’m unsure if I will have health insurance after February 2026. And this “free” health insurance has already cost me $14,325 from savings. My experience with a single-payer system this year has led me to believe that, for the most part, it works and should be available to everyone. Healthcare should be a right of birth, not a privilege for the rich.  

This is just one person’s story. The rise in healthcare costs impacts everyone, but especially lower income Americans. See some of their fears here.