迈阿密中城的 Care Resource 在 2024 年有超过一半患者没有医保，而附近居民去年约有三分之一通过 ACA 市场购险；随着疫情时期补贴结束，诊所预计无保险比例还会进一步上升。全国层面上，医疗改革的核心冲击来自医疗补助（Medicaid）：该项目覆盖近 7700 万美国人，国会预算办公室估计未来十年将削减超过 9000 亿美元，尽管这只是到 2035 年约 8 万亿美元联邦支出中的一小部分。

政策设计与现实人群结构之间存在明显错配：政府强调 Medicaid 工作要求，但参保者中仅 8% 既不工作也不符合豁免，说明更多退保可能来自行政与文书摩擦而非“拒绝工作”。同时，KFF 估算市场平均保费已上涨 114%，目前参保人数仅下降 5%，但随着自动续保者看到账单和健康人群退出，短期与长期退保压力都可能加大。

财政节省与健康代价形成鲜明对比：国会预算办公室预计到 2034 年最多将新增 1400 万无保险人口，而宾夕法尼亚大学与耶鲁大学研究估算这类覆盖流失叠加其他改革每年可能对应额外 5.1 万死亡。即使特朗普政府推动低价处方平台并宣称控费为“北极星”，两项关键趋势仍在并行：2026 年 1 月 KFF 民调显示三分之二美国人担忧医疗支付压力，且 Medicaid 削减被后置到中期选举之后，反映政策时点与公众痛感之间的政治张力。

In Midtown Miami, Care Resource had over half of patients uninsured in 2024, while about one-third of nearby residents bought coverage on the ACA marketplace last year; with pandemic-era subsidies ending, the clinic expects the uninsured share to rise further. Nationally, the central shock in health policy is Medicaid: it covers nearly 77 million Americans, and the CBO estimates more than $900 billion in cuts over the next decade, even if that is a small slice of roughly $8 trillion in federal spending through 2035.

There is a clear mismatch between policy design and enrollee realities: the administration stresses Medicaid work requirements, yet only 8% of enrollees neither work nor qualify for an exemption, implying coverage losses are more likely to come from administrative friction than from widespread non-work. At the same time, KFF estimates a 114% jump in average marketplace premiums, enrollment is down only 5% so far, but near-term and long-term attrition pressures likely grow as auto-renewed consumers face higher bills and healthier people exit the risk pool.

Fiscal savings and health costs diverge sharply: the CBO projects up to 14 million more uninsured people by 2034, and University of Pennsylvania and Yale researchers estimate that coverage losses plus other reforms could correspond to about 51,000 additional deaths per year. Even as the Trump administration promotes a low-price prescription platform and frames affordability as the “North Star,” two trends persist: a January 2026 KFF poll shows two-thirds of Americans worry about paying for health care, and major Medicaid cuts were backloaded until after the midterms, highlighting political timing against voter pain.

Source: Donald Trump’s policies are reshaping American health care

Subtitle: And the consequences will ripple through both health and politics

Dateline: 2月 19, 2026 04:53 上午 | Miami