By Darrell Kirk

Sounder contributor

San Juan County residents face an uncertain future as debate over Affordable Care Act subsidies highlights fundamental flaws in American health care.

As political battles rage over Affordable Care Act subsidies, San Juan County Councilmember Justin Paulsen warns that the real issue isn’t government assistance — it’s a fundamentally broken health care system that makes such subsidies necessary in the first place.

“The subsidy is required because the system is broken,” Paulsen said in a recent interview. “The Affordable Care Act is an imperfect solution to what is a very imperfect healthcare system in our country.”

Paulsen’s assessment comes as residents worry about potential changes to ACA subsidies that could dramatically increase their insurance costs. But he argues the debate misses a critical point: The ACA attempted to solve a health care problem with an insurance solution.

“Insurance is not health care,” Paulsen explained. “We have a healthcare problem in our country, and we have a financial problem related to healthcare because of how we deal with insurance.”

Despite its flaws, the ACA did correct major inequities in the previous system, particularly regarding pre-existing conditions. Before the law’s passage, people with chronic health conditions often couldn’t obtain insurance at any price.

“If we’re looking for positives that came from the ACA, it made sure that people with pre-existing conditions and risk factors weren’t excluded from healthcare,” Paulsen noted.

The current system creates a vicious cycle for uninsured Americans. Without affordable coverage, people avoid doctor visits until medical issues become catastrophic, leading to emergency room visits and eventual bankruptcy. Paulsen estimates he knows about 10 people who have faced medical debt collection in the past decade.

“When you go to the doctor and you have a policy with a high deductible and high maximum out-of-pocket costs, you’re not going to be able to pay that bill when it arrives,” he said. “You either end up on a payment plan or in debt collection.”

The financial burden falls heaviest on working families. When asked about Republican criticism that families earning $106,000 shouldn’t need subsidies, Paulsen was unequivocal: “Yes, they do—when insurance costs $2,500 a month and groceries have tripled in cost.”

He noted that critics often have corporate-provided insurance and have never paid out-of-pocket for health care. “They just don’t understand the reality,” he said.

Meanwhile, insurance companies remain the only guaranteed winners in the current system. Paulsen explained that insurers can adjust their rates annually to maintain prescribed profit margins of around 7.5%. “It’s a no-lose situation for them,” he said. “You and I as users of the healthcare system are not guaranteed success.”

In addition to ACA, Medicare Advantage has come under the scrutiny of Congresswoman Pramila Jayapal. In a May 16, 2025, news brief on the congresswoman’s website, Jayapal noted: “Medicare DisAdvantage, as I like to call it, was initially created as a way to save taxpayer dollars, but in reality, it does the exact opposite. It costs more and consistently has worse patient outcomes. Today, this program is simply a cash cow for big insurance corporations at the cost of seniors and people with disabilities. UnitedHealth must answer to a jury, to the allegations that its network of MA plans intentionally ‘upcoded’ to increase the payments it received from Medicare—taxpayer dollars that did not go to provide healthcare to patients, but rather to pad UnitedHealth’s profits. Americans deserve to know if Medicare funds have been—and could continue to be—abused.”

Paulsen advocates for comprehensive health care reform but acknowledges the political challenges. “You, me, and about ten thousand other smart people need to sit around a table and figure this out,” he said. “It probably isn’t too hard—we probably only need to look at a couple other countries to figure out how to do it right. But our leadership just isn’t there yet.”

He emphasized that health care overhaul “has to be done on a deliberate basis and can’t be done through political posturing during budget season.”

For now, San Juan County residents dependent on ACA coverage face an uncertain future, caught between an imperfect system and the absence of political will to create meaningful reform.