The Affordable Care Act Will Survive Despite The Best Efforts of President Trump

The Existentialist Republic The ACA Has an Absolute Bombshell Hidden in It, and Dems Can Take Advantage of It We can build a system that is resilient to Trump's sabotage efforts. Christopher Armitage Nov 01, 2025 Ngan/AFP/Getty mages ohomen171@gmail.com password ohomen171@gmail.com Subscribe California, New York, Illinois, Massachusetts, and Washington combined represent 87 million people. If those five states formed a unified health insurance market, they would have enough negotiating power to force down hospital reimbursement rates, slash pharmaceutical prices, and cut premiums by hundreds of dollars per month. The legal authority to do this already exists. Section 1333 of the Affordable Care Act explicitly authorizes states to form Health Care Choice Compacts where qualified health plans operate across state lines. The provision became law in 2010. It took effect January 1, 2016. Zero states have used it. Not one. Democratic governors are forming regional alliances to coordinate vaccine recommendations, which is progress, but Section 1333 (42 U.S.C. § 18053) offers something transformative: actual market power to deliver billions in savings to tens of millions of people. The law has been sitting there for 15 years, waiting to be deployed. Specifically, section 1333 permits two or more states to enter into compacts allowing health insurance issuers to sell qualified health plans across state lines. States must pass enabling legislation, then apply to the Department ot Health and Human Services (HHS) for approval. HHS must approve any compact if it provides coverage at least as comprehensive as essential health benefits, maintains affordability protections at least as strong as the ACA, covers at least as many residents, does not increase the federal deficit, and does not weaken enforcement of applicable laws. These guardrails ensure compacts create genuine public benefit rather than allowing junk insurance to cross borders. Although the provision became effective January 1, 2016, HHS has never issued implementing regulations, though federal law does not require them. According to the 2019 Federal Register, HHS received zero applications and zero states had passed enabling legislation. Georgetown University's Center on Health Insurance Reforms confirmed in 2025 that this status remains unchanged after 15 years. The authority sits dormant. If you found this article helpful then you may find more useful information in my latest book “Conservatism: America’s Personality Disorder” https://a.co/d/aAWmZKO Colorado launched its public option in 2023. The program enrolled 132,791 people in 2025, nearly half of marketplace enrollment. Lowest cost Silver plan premiums dropped by $100 per month. Now imagine that market power scaled up. An interstate public option covering 87 million people gives state governments leverage to negotiate hospital reimbursement rates, pharmaceutical prices, and administrative fees that individual state programs cannot achieve. If an interstate public option achieved Colorado's $100 monthly savings across just 10 percent of that market, families save $10 billion annually. The Northwest Prescription Drug Consortium documented over $99 million in savings from 2016 to 2019 through coordinated purchasing. Healthcare insurance purchasing operates on the same economic principles. Bigger markets drive better prices. Political barriers, not legal or economic ones, explain why Section 1333 remains unused. HHS under both parties never issued regulations. States never pressured for action. Health insurance lobbying groups oppose anything increasing government negotiating power. State insurance regulators protect turf. Provider networks represent the operational challenge, but combined market power solves this. An interstate public option representing 87 million people has leverage to bring providers to the table. States could require provider participation as a condition of Medicaid contracts or facility licensing. Some analysts argue Section 1333 was designed to enable conservative deregulation rather than progressive public options. Republicans included the provision hoping states would use it to allow cheaper, less comprehensive plans to compete across borders. That political origin does not change what the statute actually authorizes. The text requires comprehensive benefits and affordability protections. States can use Section 1333 to build exactly what the provision's original sponsors feared: genuine public alternatives with real market power. Blue state governors formed regional health alliances to coordinate vaccine guidance after Trump administration officials gutted federal public health agencies. Those alliances demonstrate appetite for interstate cooperation and frustration with federal dysfunction. But vaccine recommendations do not materially change people's economic circumstances. An interstate public option covering tens of millions of people with billions in savings does. Section 1333 represents unused legal authority sitting dormant while the public pay inflated premiums. This is actual resistance with material consequences. Not symbolic gestures. Real policy delivering real savings to the public. Ten Democratic governors need to hear that this matters. Contact them and tell them you want them to use Section 1333 authority to create an interstate public option. Explain that an interstate public option covering tens of millions of people would have negotiating power to drive down premiums, reduce pharmaceutical costs, and force hospitals to accept reasonable reimbursement rates. Also, mention that Colorado's public option achieved an average of $1,200 per year premium savings, and scaled across multiple states this could save families billions annually. Then personalize your message with your own story about why healthcare costs matter to you. Ask them to work together to draft Section 1333 compact legislation. Tell them this is how blue states actually fight back, not with strongly worded letters but with policies that materially improve people's lives. You can support the work being done at TheExistentialistRepublic.com by checking out or even just sharing your favorite merch. Contact these governors: California Governor Gavin Newsom: https://www.gov.ca.gov/contact/ | Phone: (916) 445-2841 New York Governor Kathy Hochul: https://www.governor.ny.gov/content/governor-contact-form Illinois Governor JB Pritzker: https://gov.illinois.gov/contact-us/contact-the-governor.html | Phone: (217) 782-0244 Massachusetts Governor Maura Healey: https://www.mass.gov/info-details/email-the-governors-office | Phone: (617) 725-4005 Washington Governor Bob Ferguson: https://governor.wa.gov/contacting-governor/contacting-governors-office | Phone: (360) 902-4111 Pennsylvania Governor Josh Shapiro: https://www.pa.gov/governor | Phone: (717) 788-8990 Michigan Governor Gretchen Whitmer: https://www.michigan.gov/whitmer/contact | Phone: (517) 335-7858 Colorado Governor Jared Polis: https://governorsoffice.colorado.gov/governor/contact-us | Phone: (303) 866-2471 New Jersey Governor Phil Murphy: https://www.nj.gov/governor/contact/all/ | Phone: (609) 292-6000 Minnesota Governor Tim Walz: https://mn.gov/governor/contact/ | Phone: (651) 201-3400 Send your message today. Healthcare costs are crushing people. Democratic governors have the legal authority to do something about it right now. They just need to use it. Author's note: I wanted to congratulate Glass Empires and W. A. Lawrence on breaking the top 100 for US Politics on Substack. Her content is top notch and I encourage you all to check out some of her explorations and insights on the role of psychology and narrative in the modern political climate. References Centers for Medicare & Medicaid Services. (2019, March 11). Patient Protection and Affordable Care Act; Increasing consumer choice through the sale of individual health insurance coverage across state lines through health care choice compacts. Federal Register, 84(47), 8657–8660. https://www.federalregister.gov/documents/2019/03/11/2019-04270 Colorado Division of Insurance. (2025, January 15). Colorado Option lowers premiums and saves Coloradans money – Findings from Brown University research [Press release]. https://doi.colorado.gov/news-releases-consumer-advisories/colorado-option-lowers-premiums-and-saves-coloradans-money Governor of California. (2025, September 3). California, Oregon, and Washington to launch new West Coast Health Alliance to uphold scientific integrity in public health as Trump destroys CDC's credibility [Press release]. https://www.gov.ca.gov/2025/09/03/california-oregon-and-washington-to-launch-new-west-coast-health-alliance-to-uphold-scientific-integrity-in-public-health-as-trump-destroys-cdcs-credibility/ Governor of California. (2025, September 4). Hawaii to join West Coast Health Alliance with California, Oregon, and Washington [Press release]. https://www.gov.ca.gov/2025/09/04/hawaii-to-join-west-coast-health-alliance-with-california-oregon-and-washington/ Massachusetts Department of Public Health. (2025, September 18). Several Northeastern states and America's largest city announce the Northeast Public Health Collaborative [Press release]. https://www.mass.gov/news/several-northeastern-states-and-americas-largest-city-announce-the-northeast-public-health-collaborative Murray, R. C., & Whaley, C. M. (2025, January 15). Can public option plans improve affordability? Insights from Colorado. Health Affairs Forefront. https://doi.org/10.1377/forefront.20250113.844529 Northwest Prescription Drug Consortium. (2020). NW Consortium overview [Presentation to Nevada Legislature]. Nevada Legislature. https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/15817 Patient Protection and Affordable Care Act § 1333, 42 U.S.C. § 18053 (2010). Pogue, S. (2025, March 27). A blast from the past: Dusting off ACA Section 1333 compacts. Center on Health Insurance Reforms. https://chirblog.org/a-blast-from-the-past-dusting-off-aca-section-1333-compacts/ Polis, J. (2025, January 23). Governor Polis, Lt. Governor Primavera, and Colorado Division of Insurance announce record 2025 Colorado Option enrollment numbers [Press release]. State of Colorado, Office of the Governor. https://www.colorado.gov/governor/news/governor-polis-lt-governor-primavera-and-colorado-division-insurance-announce-record-2025