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The Dictatorship

Trump’s new Obamacare replacement looks awfully familiar

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Trump’s new Obamacare replacement looks awfully familiar

President Donald Trump infamously asserted during the September 2024 presidential debate that he had “concepts of a plan” to replace the Affordable Care Act (ACA). This weekend, almost 10 months into his second term, he offered a glimpse of what that plan might look like.

Posting on his platform Truth Social on Saturday, Trump said that he was recommending to Senate Republicans that they replace the federal subsidies for ACA premiums, which are sent to private health insurers, with money sent directly to the American people. Although Treasury Sec. Scott Bessent said there was no “formal proposal,” Republican lawmakers jumped onboardand Sen. Rick Scott, R-Fla., said he was “writing the bill right now.”

Setting aside the irony that a Democratic politician would surely be pilloried for pursuing the redistribution of payments from private companies to the masses, let’s dig in.

The insufficiency of HSA funds is just the start of the problems with Trump’s proposal.

This is hardly the first time that Trump has proposed repealing the ACA, on which a record-high 24.3 million people now rely for marketplace plans. The most sweeping of these efforts notably fizzled back in 2017, when the late Sen. John McCain voted against it in the middle of the night. Even in the absence of outright repeal efforts, Republicans in Congress reduced the mandate penalty to $0 in the Tax Cuts and Jobs Act of 2017. This summer, the Centers for Medicare & Medicaid Services finalized a rule that will increase out-of-pocket costs and may lead to as many as 1.8 million Americans losing coverage. At the same time, the One Big Beautiful Bill Act advanced several changes that will limit the ACA’s effectiveness.

Amid such vitriol at the ACA, it can be easy to forget that the law brought America’s uninsured rate to a historic lowimproved health outcomes across a range of conditions and reduced health inequities. What’s more — and what’s especially important when evaluating Americans’ health care costs — Medicaid expansion through the ACA is also associated with reductions in medical debt. These gains help explain why 64% of Americans favor the ACAthough it garners considerably less support among Republicans.

Absent the preservation of the ACA’s core provisions, tens of millions of Americans with preexisting medical conditions would be vulnerable to outright denial of coverage by private insurers. In 2017, the health policy research group KFF estimated that 27% of non-elderly American adults had previously declinable preexisting conditions. That share has likely only increased as complications from Covid-19 have become more common and more people have enjoyed the ACA’s protections — whether gaining a primary care doctor or opting for tests that before the ACA might have revealed a preexisting condition.

But perhaps concerns about health care affordability could be offset by the amount of money that would be redirected to the people.

Trump’s first post was characteristically light on details. In a later post, he suggested that consumers bypass health insurers altogether to purchase plans directly, without explaining how or from whom those plans would be purchased. But Sunday morning, he specified that “Republicans should give money DIRECTLY to your personal HEALTH SAVINGS ACCOUNTS.” Through HSAs, people can put money away and withdraw the funds tax-free for qualifying medical expenses if they’re enrolled in a high-deductible health plan.

GOP policymakers have often championed HSAs because, in theory, they reflect Republicans’ preference for individuals’ choices over government intervention. In practice, HSAs tend to benefit people with higher incomes: They’re the ones with the means to contribute to the accounts, and because they’re in higher tax brackets, they benefit more from each dollar saved. Furthermore, researchers at the Center on Budget and Policy Priorities find that HSAs do not significantly benefit those who struggle with health care costs, and relatedly, that they exacerbate the racial disparities the ACA has effectively reduced.

To make matters worse, Trump is proposing these changes amid a shaky economy.

So, how much money are we talking about? The Congressional Budget Office estimated that in 2023, health insurers received approximately $92 billion in ACA subsidies. That would not come close to covering most Americans’ health care expenses — in 2023, Americans shelled out $500 billion just on out-of-pocket costs.

The insufficiency of HSA funds is just the start of the problems with Trump’s proposal. A core concept of health insurance is the spreading of risk across the pool of enrollees, in order to contain the costs of coverage. When the risk pool is diverse, the premiums of younger and healthier patients offset the expenses of covering older and sicker individuals, a principle at the heart of the ACA’s mandate to hold a minimum level of insurance.

With added reliance on HSAs, America would witness what is called “adverse selection” — healthier and wealthier people would more likely switch away from comprehensive health insurance products, leaving the insured population on average sicker and therefore more costly to insure. Thus, insurers would increase the premiums they charge, likely resulting in an increase in the population that only enrolls in insurance when they have more significant health care expenditures.

High health care costs are already a strain on many Americans, leading to delayed or forgone care or — in the case of about 9% of Americans — being uninsured. Trump’s concept of a plan would make this worse: What might appear at first blush to be a welcome move toward more individualized decision-making would ultimately increase costs. The consequences would include higher rates of uninsurance and underinsurance, as well as exacerbated racial and socioeconomic inequities in health care access.

To make matters worse, Trump is proposing these changes amid a shaky economy with considerable strain on Americans’ pocketbooks. In a country whose dominant health insurance model entails tying insurance to employment, when the jobless rate ticks upit is especially important to preserve access to quality, affordable plans through the ACA. That’s especially true given Republicans’ recent historic cuts to Medicaidweakening a key backstop for low-income Americans.

The American people would be forgiven if they looked at Trump’s and Scott’s words with skepticism in light of congressional Republicans’ opposition to extending marketplace subsidies for even one more year. That refusal has led to sticker shock for marketplace consumers during open enrollment and helped spark a weekslong government shutdown.

Politicians are right to want to confront the problem of high health care costs. But the president’s new proposal is the latest example of his administration’s policy preferences working against that important stated objective, sabotaging effective programs (the ACA) in favor of programs that research consistently shows are comparatively ineffective (HSAs).

Trump’s pledge to replace comprehensive health coverage with direct payments toward health care offers only a hollow hope, promising individual freedom while actually leaving Americans to fend for themselves.

Miranda Yaver

Miranda Yaver is an assistant professor of health policy and management at the University of Pittsburgh and a health care fellow at the Roosevelt Institute.

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The Dictatorship

Trump optimistic about Iran war as Lebanon truce takes effect

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Trump optimistic about Iran war as Lebanon truce takes effect

BEIRUT (AP) — Iran said it fully reopened the Strait of Hormuz to commercial vessels, but questions lingered Saturday about how much freedom ships actually had to transit the waterway as Tehran maintained its grip on the who got through and threatened to close it again if the U.S. kept in place its blockade of Iranian ships and ports.

Iran’s Friday announcement about the opening of the crucial body of water, through which 20% of the world’s oil is shipped, came as a 10-day truce between Israel and the Iranian-backed Hezbollah militant group in Lebanon appeared to hold.

U.S. President Donald Trump, meanwhile, said the American blockade “will remain in full force” until Tehran reaches a deal with the U.S., including on its nuclear program.

Asked by a reporter Friday night what he will do if there’s no deal when the ceasefire expires next week, Trump said, “I don’t know. … But maybe I won’t extend it, so you’ll have a blockade and unfortunately we’ll have to start dropping bombs again.” But he also told reporters accompanying him aboard Air Force One to Washington that a deal is “going to happen,” and flatly rejected the idea of restrictions or tolls by Iran on the Strait of Hormuz.

Trump had earlier celebrated the Iranian announcement, posting on social media that the strait was “fully open and ready for full passage.” But minutes later, he issued another post saying the U.S. Navy’s blockade would continue “UNTIL SUCH TIME AS OUR TRANSACTION WITH IRAN IS 100% COMPLETE.”

Iranian Foreign Minister Abbas Araghchi posted on X that ships would use routes designated by the Islamic Republic in coordination with Iranian authorities, suggesting Iran planned to retain some level of control over the channel. It was not clear if vessels would have to pay tolls.

Iranian officials said the blockade was a violation of last week’s ceasefire agreement between Iran and the U.S. The strait “will not remain open” if the blockade continues, Iran’s parliamentary speaker, Mohammad Bagher Qalibaf, posted on X early Saturday.

A data firm, Kpler, said movement through the strait remained confined to corridors requiring Iran’s approval.

U.S. forces have sent 21 ships back to Iran since the blockade began on Monday, U.S. Central Command said on X.

Trump says new talks could happen soon

Trump imposed the blockade as part of his effort to force Iran to open the strait and accept a Pakistan-brokered ceasefire to end almost seven weeks of war that has raged between Israel, the U.S. and Iran.

The president’s decision to continue the blockade despite Iran’s announcement appeared aimed at sustaining pressure on Tehran as the fate of the two-week ceasefire reached last week remained uncertain.

Direct talks between the U.S. and Iran last weekend were inconclusive, as the two nations could not agree about Iran’s nuclear program and other points.

Trump suggested a second round of talks could happen this weekend.

“The Iranians want to meet,” he said in a brief telephone interview with the news outlet Axios. “They want to make a deal. I think a meeting will probably take place over the weekend.”

Oil prices fell Friday on hopes the U.S. and Iran were drawing closer to an agreement . The head of the International Energy Agency had warned that the energy crisis could get worse if the strait did not reopen.

Two Iranian semiofficial news agencies seemed to challenge Araghchi’s announcement about the strait.

Considered close with Iran’s powerful Revolutionary Guard, the Fars news agency issued a series of posts on X criticizing what it said was a lack of clarity over the decision to reopen the waterway and a “strange silence from the Supreme National Security Council and the negotiating team.”

Iran’s Supreme National Security Council has recently acted as the country’s de facto top decision-making body, amid doubts over the status of the new supreme leader, Mojtaba Khamenei, who was reportedly wounded early in the war.

The Mehr news agency also said the decision to reopen the strait needed “clarification” and required the supreme leader’s approval.

Truce in Lebanon could help US-Iran peace efforts

The ceasefire in Lebanon could clear one major obstacle to an agreement between Iran, the United States and Israel to end the war. But it was unclear to what extent Hezbollah would abide by a deal it did not play a role in negotiating and which will leave Israeli troops occupying a stretch of southern Lebanon.

Trump said in another post that Israel is “prohibited” by the U.S. from further strikes on Lebanon and that “enough is enough” in the Israel-Hezbollah war.

The State Department said the prohibition applies only to offensive attacks and not to actions taken in self-defense.

Shortly before Trump’s post, Israeli Prime Minister Benjamin Netanyahu said Israel agreed to the ceasefire in Lebanon “at the request of my friend President Trump,” but that the campaign against Hezbollah is not complete.

He claimed Israel had destroyed about 90% of Hezbollah’s missile and rocket stockpiles and added that Israeli forces “have not finished yet” with the dismantling of the group.

Celebrations in Beirut

In Beirut, celebratory gunshots rang out at the start of the truce. Displaced families began moving toward southern Lebanon and Beirut’s southern suburbs despite warnings by officials not to return to their homes until it became clear whether the ceasefire would hold.

The Lebanese army and U.N. peacekeepers in southern Lebanon had reported sporadic artillery shelling in some parts of southern Lebanon in the hours after the ceasefire took effect.

An Israeli strike in the area of Kounine hit a car and a motorcycle, killing one person and wounding three, including a Syrian citizen, the Lebanese Health Ministry said Friday. It was the first airstrike and first fatality reported since the truce took effect.

There was no immediate response from the Israeli army or Hezbollah.

An end to Israel’s war with Hezbollah was a key demand of Iranian negotiators, who previously accused Israel of breaking last week’s ceasefire with strikes on Lebanon. Israel had said that deal did not cover Lebanon.

The fighting has killed at least 3,000 people in Iran, more than 2,290 in Lebanon, 23 in Israel and more than a dozen in Gulf Arab states. Thirteen U.S. service members have also been killed.

Israel says it will keep troops in Lebanon

Israel’s hard-line Defense Minister Israel Katz said Israel would continue to hold all the places where it is currently stationed, including a buffer zone extending 10 kilometers (6 miles) into southern Lebanon. He said many homes in the area would be destroyed and Lebanese residents will not return.

Hezbollah has said Lebanese people have “the right to resist” Israeli occupation and that their actions “will be determined based on how developments unfold.”

Israel and Hezbollah have fought several wars and have been fighting on and off since the day after the start of the Israel-Hamas war in Gaza. Israel and Lebanon reached a deal to end the earlier fighting in November 2024, but Israel has kept up near-daily strikes in what it says is an effort to prevent the Iran-backed militant group from regrouping. That escalated into another invasion after Hezbollah again began firing missiles at Israel in response to its war on Iran.

Mediators seek compromise on three points

In the Iran war, mediators are pushing for compromise on three main points: Iran’s nuclear program, the Strait of Hormuz and compensation for wartime damages, according to a regional official involved in the mediation efforts.

Trump on Friday suggested Iran has agreed to hand over its enriched uranium.

“The USA will get all the nuclear dust,” Trump said in a speech in Arizona. “We’re going to get it by going in with Iran with lots of excavators.”

Nuclear dust is the shorthand Trump frequently uses to refer to the highly enriched uranium that is believed buried under nuclear sites the U.S. bombed during last year’s 12-day war between Israel and Iran.

If true, it would be a major concession from Iran and would lock in a key demand of the U.S. to end the conflict. Neither Iran nor countries acting as intermediaries in the conflict have said Tehran has made such an agreement.

Trump said no money would exchange hands to end the war.

___

Madhani reported from Washington. Associated Press writers Matthew Lee and Ben Finley in Washington, Samy Magdy and Amir Rajdy in Cairo, Munir Ahmed in Islamabad, Abby Sewell in Beirut and Melanie Lidman in Tel Aviv, Israel, contributed to this report.

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The Dictatorship

Iran reimposes restrictions on Strait of Hormuz, accusing U.S. of violating deal to reopen it

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Iran reimposes restrictions on Strait of Hormuz, accusing U.S. of violating deal to reopen it

CAIRO (AP) — The dueling blockades in the Strait of Hormuz lurched into uncharted waters on Saturday. The United States pressed ahead with its campaign to choke off Iranian ports and Iran reversed an initial move to reopen the waterway, firing on a ship attempting to pass.

Confusion over the critical chokepoint threatened to deepen the energy crisis roiling the global economy and push the two countries toward renewed conflict, even as mediators expressed confidence a new deal was within reach.

Iran’s joint military command said on Saturday that “control of the Strait of Hormuz has returned to its previous state … under strict management and control of the armed forces.” It warned that it would continue to block transit through the strait as long as the U.S. blockade of Iranian ports remained in effect.

Two gunboats from Iran’s Revolutionary Guard opened fire on a tanker transiting the Strait of Hormuz, the British military’s United Kingdom Maritime Trade Operations center said on Saturday. It reported the tanker and crew as safe, without identifying the vessel or its destination. TankerTrackers.com reported vessels were forced to turn around in the strait, including an Indian-flagged super tanker, after they were fired on by Iran.

Iran announced earlier Saturday it was reimposing restrictions on the strait in response to a U.S. blockade on Iranian shipping and ports. Iran has prevented vessels from crossing throughout the seven-week-long war, except for ones it authorizes.

Ebrahim Azizi, head of the Iranian parliament’s National Security Commission, said that the strait was “returning to the status quo,” which he had earlier described as ships requiring Iranian naval authorization and toll payment before transiting.

The shift came a day after Iran’s Foreign Minister Abbas Araghchi declared the strait open while a 10-day trucewas announced between Israel and the Iranian-backed Hezbollah militant groupin Lebanon. An end to Israel’s war with Hezbollah was a key demand of Iranian negotiators, who previously accused Israel of breaking last week’s ceasefire with strikes on Lebanon. Israel had said that deal did not cover Lebanon.

U.S. President Donald Trump first appeared to take a similar position on reopening the strait before later saying the American blockade“will remain in full force” regardless of what Iran does until a deal is reached, including about Iran’s nuclear program.

Even as the U.S.-Iran ceasefire appeared to hold, the back-and-forth over the strait — through which roughly one-fifth of the world’s oil typically passes — highlighted how easily it could unravel

Control over the strait has proven to be one Iran’s main points of leverage and prompted the United States to deploy forces and initiate a blockade on Iranian ports as part of an effort to force Iran to accept a Pakistan-brokered ceasefireto end almost seven weeks of warthat has raged between Israel, the U.S. and Iran.

A data firm, Kpler, said movement through the strait remained confined to corridors requiring Iran’s approval.

U.S. forces have sent 21 ships back to Iran since the blockade began on Monday, U.S. Central Command said on X.

Pakistan announces progress toward new deal

Despite the escalation in the Strait of Hormuz, Pakistani officials say the United States and Iran are still moving closer to a deal ahead of the April 22 ceasefire deadline.

The ceasefire in Lebanon could clear one major obstacleto an agreement. Speaking at a diplomatic forum in Antalya, Turkey, Pakistan’s Foreign Minister Ishaq Dar said the ceasefire in Lebanon was a positive sign, noting that fighting between Israel and Hezbollah had been a key sticking point before talks in Islamabad ended “very close” to an agreement last weekend.

Pakistan’s army chief Field Marshal Asim Munir visited Tehran, while Prime Minister Shehbaz Sharif met with Turkish President Recep Tayyip Erdogan and Qatar’s Emir Tamim bin Hamad Al Thani in Antalya, the military and Sharif’s office said. Pakistan is expected to host a second round of talks between Iran and the U.S. early next week.

Questions linger about Lebanon truce

Even though mediators were optimistic, it was unclear to what extent Hezbollah would abide by a truce it did not play a role in negotiating and which will leave Israeli troops occupying a stretch of southern Lebanon.

Trump said in another post that Israel is “prohibited” by the U.S. from further strikes on Lebanon and that “enough is enough” in the Israel-Hezbollah war.

The State Department said the prohibition applies only to offensive attacks and not to actions taken in self-defense.

Shortly before Trump’s post, Israeli Prime Minister Benjamin Netanyahu said Israel agreed to the ceasefire in Lebanon “at the request of my friend President Trump,” but that the campaign against Hezbollah is not complete.

He claimed Israel had destroyed about 90% of Hezbollah’s missile and rocket stockpiles and added that Israeli forces “have not finished yet” with the dismantling of the group.

In Beirut, displaced families began moving toward southern Lebanonand Beirut’s southern suburbs despite warnings by officials not to return to their homes until it became clear whether the ceasefire would hold.

The Lebanese army and U.N. peacekeepers in southern Lebanon reported sporadic artillery shelling in some parts of southern Lebanon in the hours after the ceasefire took effect.

The war, which began with U.S. and Israeli strikes on Feb. 28, has killed at least 3,000 people in Iran, more than 2,290 in Lebanon, 23 in Israel and more than a dozen in Gulf Arab states. Thirteen U.S. service members have also been killed.

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The Dictatorship

Regime change in Iran remains as necessary as ever

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As a former deputy commander of U.S. Central Command, a Navy SEAL and a member of the National Security Council under former President George W. Bush, I spent decades helping oversee U.S. military operations across the Middle East under leaders including Jim Mattis and Lloyd Austinboth of whom later served this nation as Defense secretary. If I were advising President Donald Trump now, my message would be simple: Do not confuse a pause in hostilities with Iran — or even a limited, chaotic “opening” of the Strait of Hormuz — with a durable solution to the hostility between our nations.

The president’s position on Iran has, at times, appeared inconsistent.

The president’s position on Iran has, at times, appeared inconsistent. At times, he has suggested regime change in Iran as an objective. At others, his focus has shifted toward more limited goals, such as preventing a nuclear weaponreopening the Strait of Hormuz or securing concessions through negotiation. Those are important objectives but they are not, by themselves, a strategy for ending the threat posed by the regime in Tehran. A lasting resolution requires a clearly defined end state.

That kind of clarity has been missing in how the United States has communicated its objectives. Statements suggesting overwhelming or immediate destruction may project strength, but they can also create ambiguity about U.S. intent. Deterrence works best when it’s consistent and tied to clear strategic objectives.

That starts with being clear about the threat. Iran’s leadership has consistently pursued nuclear capability, advanced its missile program, expanded proxy networks across the region and actively supported U.S. adversaries. Those are still their goals, and those goals are not going away. Iran will continue pursuing them regardless of temporary pauses or agreements.

For nearly five decades, U.S. policy has focused on slowing Iran’s progress rather than stopping it outright. Sanctions, limited strikes and negotiated agreements have each had moments of success. But nothing yet has altered the regime’s direction. Instead, our actions have bought more time for Iran to rebuild and continue advancing under less immediate pressure. The current ceasefire fits that pattern. It will lower tensions in the short term, but it will not resolve the underlying conflict.

That raises a more fundamental question: What is the objective? If the goal is simply to manage the threat, then another ceasefire and another round of negotiations may suffice. But if the goal is a lasting resolution, then the U.S. must be clear about what that requires. As long as the current regime remains in power, Iran will continue pursuing the same policies it has for decades. That’s why regime change is not a secondary objective; it is the only path to a durable resolution.

But that does not mean a U.S. invasion of Iran. It means pursuing a different strategy: one that applies sustained economic and operational pressure to the regime’s core institutions, including measures such as targeted economic and maritime restrictions, one that sets clear and enforceable conditions in any negotiation and creates the conditions for internal change over time.

Iran’s nuclear infrastructure must be fully dismantled. Its stockpile of highly enriched uranium must be removed.

First, any negotiation must be anchored in non-negotiable outcomes. Iran’s nuclear infrastructure must be fully dismantled. Its stockpile of highly enriched uranium must be removed. Support for proxy militias and terrorist networks must end. The free flow of commerce through critical waterways such as the Strait of Hormuz must be guaranteed.

Second, pressure must extend beyond military targets to the core structures that sustain the regime’s power. That includes the Islamic Revolutionary Guard Corps, its financial networks and the internal security apparatus that enforces control at home.

Third, the U.S. should more clearly support Iranians. If regime change is to occur, then it will ultimately be driven from within. American policy can influence the conditions under which that change becomes possible: through information access, economic pressure and coordinated international isolation of the regime’s leadership.

The events of the past several weeks have already shifted the landscape. Iran’s leadership is under greater strain, its capabilities have been tested and its vulnerabilities are more visible than they have been in years. This is not a moment to reset the status quo on a regime that’s now operating from a weaker and more exposed position.

Trump was right to act on the threat Iran poses. But a ceasefire without a clearly defined political objective risks turning military gains into another temporary pause in a decades-long cycle. If the U.S. wants something more than a moment of calm, then it must be willing to define and pursue a different outcome.

There can be no lasting peace with the current regime in Tehran, which is why the current blockade is a step in the right direction. By applying sustained economic pressure without causing further destruction, or making sweeping financial concessions to Iran, it weakens the regime from within and moves us closer to the only outcome that can deliver lasting stability and peace.

Robert “Bob” Harward is a retired vice admiral, and former Deputy Commander of U.S. Central Command who served under General James Mattis helping oversee U.S. military operations across the Middle East. Harward lived in Tehran as a teenager and graduated from the Tehran American School

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