healthcare system

Californians renewing their public health plans or who plan to sign up for the first time will be in for sticker shock when open enrollment begins on Saturday. Monthly premiums for federally subsidized plans available on the Covered California exchange — often referred to as Obamacare — will soar by 97% on average for 2026.

The skyrocketing premiums come as a result of a conflict at the center of the current federal government shutdown, which began on Oct. 1: a budgetary impasse between the Republican majority and Democrats over whether to preserve enhanced, Biden-era tax credits that expanded healthcare eligibility to millions more Americans and kept monthly insurance costs affordable for existing policyholders. About 1.7 million of the 1.9 million Californians currently on a Covered California plan benefit from the tax credits.

Open enrollment for the coming year runs from Nov. 1 until Jan. 31. It’s traditionally the period when members compare options and make changes to existing plans and when new members opt in.

Only this time, the government shutdown has stirred uncertainty about the fate of the subsidies, first introduced during the COVID-19 pandemic and which have been keeping policy costs low, but will expire at the end of the year if lawmakers in Washington don’t act to extend them.

Californians window shopping on the exchange’s consumer homepage will have to make some tough decisions, said Covered California Executive Director Jessica Altman. The loss of the tax credits to subsidize premiums only adds to what can already be a complicated, time-consuming and frustrating process.

Even if the subsidies remained intact, premiums for plans offered by Covered California were set to rise by roughly 10% for 2026, due to spikes in drug prices and other medical services, Altman said.

Without the subsidies, Covered California said its members who receive financial assistance will see their monthly premiums jump by an additional $125 a month, on average, for 2026.

The organization projects that the cost increases will lead many Californians to simply go without coverage.

“Californians are going to be facing a double whammy: premiums going up and tax credits going away,” Altman said. “We estimate that as many as 400,000 of our current enrollees will disenroll and effectively be priced out of the health insurance that they have today. That is a devastating outcome.”

Indeed, the premium spike threatens to lock out the very Americans that the 2010 Affordable Care Act — President Obama’s signature domestic policy win — was intended to help, said Altman. That includes people who earn too much to qualify for Medicaid but who either make too little to afford a private plan or don’t work for an employer that pays a portion of the premiums.

That’s a broad swath of Californians — including many bartenders and hairdressers, small business owners and their employees, farmers and farm workers, freelancers, ride-share drivers, and those working multiple part-time gigs to make ends meet. The policy change will also affect Californians who use the healthcare system more frequently because they have ongoing conditions that are costly to treat.

By raising the tax-credit eligibility threshold to include Americans earning more than 400% of the federal poverty level, the Biden-era subsidies at the heart of the budget stalemate have brought an estimated 160,000 additional middle-income Californians into the system, Covered California said. The enhanced subsidies save members about $2.5 billion a year overall in out-of-pocket premium expenses, according to the exchange.

California lawmakers have tried to provide some relief from rising Covered California premiums by recently allocating an additional $190 million in state-level tax credits in next year’s budget for individuals who earn up to 150% of the federal poverty level. That would keep monthly premiums consistent with 2025 levels for a person making up to $23,475 a year, or a family of four bringing in $48,225 a year, and provide partial relief for individuals and households making slightly more.

Altman said the state tax credits will help. But it may not be enough. Forecasts from the Urban Institute, a nonprofit research group and think tank, also show a significant drop-off of roughly 400,000 enrolled members in Covered California.

The national outlook is even worse. The Congressional Budget Office warned Congress nearly a year ago that if the enhanced premium subsidies were allowed to expire, the ranks of the uninsured would swell by 2.2 million nationwide in 2026 alone — and by an average of 3.8 million Americans each year from 2026 to 2034.

Organizations that provide affordable Obamacare plans are preparing for Californians to get squeezed out of the system if the expanded subsidies disappear.

L.A. Care, the county’s largest publicly operated health plan, offers Covered California policies for 230,000 mostly lower-income people. About 90% of the Covered California consumers they work with receive subsidies to offset their out-of-pocket healthcare insurance costs, said Martha Santana-Chin, L.A. Care’s CEO. “Unless something drastic happens … a lot of those people are going to fall off of their coverage,” Santana-Chin said.

That outcome would ripple far and wide, she said — thanks to two factors: human behavior and basic economics.

If more and more people choose to go uninsured, more and more people will resort to visiting hospital emergency rooms for non-emergency care, disrupting and overwhelming the healthcare system.

Healthcare providers will be forced to address the cost of treating rising numbers of uninsured people by raising the prices they bill to insurers for patients who have private plans. That means Californians who are not Covered California members and don’t receive other federal healthcare aid will eventually see their premiums spike too, as private insurers pass any added costs down to their customers.

But right now, with the subsidies set to end soon and recent changes to Medicaid eligibility requirements threatening to knock some of the lowest-income Californians off of that system, both Altman and Santana-Chin said their main concern is for those who don’t have alternatives.

In particular, they are concerned about people of color, who are disproportionately represented among low-income Californians, according to the Public Policy Institute of California. Any hike in out-of-pocket insurance costs next year could blow the budget of a family barely getting by.

“$100, $150, $200 — that’s meaningful to people living on fixed incomes,” Altman said. “Where is that money coming from when you’re living paycheck to paycheck?”

President Trump’s choice of Dr. Casey Means, a Los Angeles holistic medicine doctor and wellness influencer, as his nominee for surgeon general appears to mark another attempt to defy establishment medicine and longstanding federal policy.

Trump portrayed Means — a 37-year-old Stanford medical school graduate and author who describes herself on LinkedIn as a “former surgeon turned metabolic health evangelist” — in his announcement as fully in sync with Robert F. Kennedy Jr.’s mission to “Make America Healthy Again.”

“Casey has impeccable ‘MAHA’ credentials, and will work closely with our wonderful Secretary of Health and Human Services, Robert F. Kennedy, Jr., to ensure a successful implementation of our Agenda in order to reverse the Chronic Disease Epidemic, and ensure Great Health, in the future, for ALL Americans,” Trump said in a statement on Truth Social.

But some who know Means question whether she is completely aligned with Kennedy.

Robert Lustig, professor emeritus of pediatrics in the division of endocrinology at UC San Francisco, who is a friend of Means, told The Times he was shocked and surprised.

“What’s surprising to me is that she wanted the job, because she had difficulties adopting RFK’s full portfolio,” Lustig said, citing Kennedy’s controversial pronouncements on vaccines and fluoride in public water supplies. “She didn’t want to be part of the administration, in part because she couldn’t accede to those views. So what has changed is not clear.”

Means did not respond to requests for comment. Still, she celebrated in February when Kennedy was sworn in, saying on an X post that “his vision of the future aligns with what I want for my family, future children, and the world.”

Over the last year, she has raised public concerns about some vaccines. In August, she spoke out on X against CDC guidelines that all infants should receive a dose of hepatitis B vaccine at birth.

“The idea of giving a newborn the hepatitis B vaccine (followed by 2 additional doses) if the baby is born to parents *without hepatitis B* is absolute insanity and should make every American pause and question the healthcare system’s mandates,” she said.

“I have said innumerable times publicly I think vaccine mandates are criminal,” she said on X in November.

But when Lustig spoke to Means four weeks ago, he told The Times, Means had left her home in Pacific Palisades, worried about toxic air and water after the L.A.-area wildfires, and had moved to Hawaii. He said she wanted to start a family and did not express interest in working with Kennedy at the time.

“I know that her views are not his — that’s why she didn’t accept it earlier,” Lustig said. “If you’re an employee, you have to take the whole portfolio. You don’t get to choose parts of it, and she was uncomfortable.”

The president announced Means as his pick a day before his initial choice for the position, New York family physician and Fox News contributor Janette Nesheiwat, was scheduled to have a hearing with senators Thursday.

Trump has yet to explain why Nesheiwat was replaced as his nominee, but he said she would work at the Department of Health and Human Services in “another capacity.”

The U.S. surgeon general is known as “the nation’s doctor.” According to the Department of Health and Human Services, the role is to provide Americans with “the best advice on how to improve their health, by issuing advisories, reports and calls to action to offer the best available scientific information on crucial issues.”

Lustig said he had no doubt Means — whom he got to know by advising Levels Health, a digital metabolic health company she co-founded — would bring a different perspective to the U.S. government.

“Here’s the problem: We have an epidemic of chronic disease and there are no medicines that fix any of these diseases,” Lustig said. “They’re not fixable by drugs. They’re fixable by food. And the reason is because all of these diseases are mitochondrial diseases, and we don’t have drugs that get to the mitochondria.

“We have to change the food supply,” he added. “There is no option. Casey knows that. So as surgeon general, she would be able to make that case.”

In that sense, Lustig agreed with Trump, who said, “Dr. Casey Means has the potential to be one of the finest Surgeon Generals in United States History.”

“I think she’s a terrific person,” Lustig said. “She will bring a very different mindset to the office.”

But Lustig said he believed Kennedy was flat out wrong on vaccines.

“I know why he’s wrong on vaccines,” he said. “I understand where his brain is, because I got a half hour with him on the phone, one on one. But I cannot alter my integrity to match that — and I thought that Casey couldn’t either.”

Means is an unorthodox pick for a president famed for his diet of Big Macs and Diet Cokes.

Her website features pictures of broccoli and almonds. Her Instagram page shows bright bowls of tofu scrambles with heirloom tomatoes, avocado and beet sauerkraut.

Her newsletter recounts how, at the age of 35, after she moved to L.A., she embraced the “woo woo (aka, the mystery),” set up a meditation shrine in her home and sought relationship advice from trees.

Means was raised in Washington, D.C., the daughter of mildly religious, Republican parents. Her Californian-born father, Grady Means, a retired American business executive and government official, served in the White House as assistant to Vice President Nelson Rockefeller, led the Food and Nutrition Task Force to reform the food stamp program and provided oversight to the National Health Insurance Experiment.

After graduating from Stanford Medical School, Means was 4½ years into a five-year residency to be a head and neck surgeon at Oregon Health & Science University when she dropped out, disillusioned with the healthcare system.

“During my training as a surgeon, I saw how broken and exploitative the healthcare system is and left to focus on how to keep people out of the operating room,” she says on her website.

“The reason she quit was because she saw that the same patients were coming back with the same problems, and her mentors, the faculty at Stanford, when she would ask, ‘Why is this happening?’ would say, ‘Shut up and operate,’” Lustig said.

“She had a crisis of confidence that she was actually not helping the problem, or was actually part of the system that was actually making the problems.”

In 2019, Means co-founded Levels Health, which works to “empower individuals to radically optimize their health and wellbeing by providing real-time continuous glucose biofeedback.”

Two years later, her break with establishment medicine became more intense — and more personal — when her mother was diagnosed with Stage 4 pancreatic cancer.

“What put her over the edge was when her mother passed away of pancreatic cancer, and it was missed,” Lustig said. “She had all the symptoms and signs of metabolic syndrome in her and none of her doctors addressed any of them.”

Means served as Levels Health’s chief medical officer until last year, when she and her brother, Calley, published a 400-page diet and self-help book titled “Good Energy: The Surprising Connection Between Metabolism and Limitless Health.”

In August, she catapulted to mainstream fame — particularly on the right — when Tucker Carlson featured her and her brother on his podcast for a show titled “How Big Pharma Keeps You Sick, and the Dark Truth About Ozempic and the Pill.”

“The system is rigged against the American patient to create diseases and then profit off of them,” Means told Carlson.

Over the last few months, Means and her brother, who now serves as a White House health advisor, made public appearances at “Make America Healthy Again” events.

In September, she addressed a U.S. Senate roundtable on chronic disease listing all the things she didn’t learn in medical school: “For each additional serving of ultra-processed food we eat,” she said, “early mortality increases by 18%.”

Critics were quick to take to X to mock her statistics.

“I’ve easily had 1000 bags of chips in my life,” said Brad Stulberg, adjunct clinical assistant professor of health management and policy at the University of Michigan’s School of Health. “If this is true, it means my mortality risk has increased by 18,000 percent. That seems unlikely.”