The shutdown dispute offered a clear view into a problem that has shaped federal health policy for more than a decade. The Affordable Care Act (ACA) directs subsidies to insurance companies rather than to individual Americans. Democrats portrayed their position as a defense of middle-class families, but the system of subsidies they have created primarily protects and enhances insurance company profits.
The current ACA framework needs amendment to make structural reform possible. Republicans should state clearly what they are for: real choices for quality medical care that is affordable, secure, transparent, and accessible. There are three systemic reforms that can get us there.
The first reform is this: Americans should have a medical wallet on their phones. Instead of subsidies going to insurance companies, money would go into a medical wallet the patient owns and can directly control. It would resemble a Health Savings Account, but unlike current law, it wouldn’t be restricted to just those with high-deductible insurance plans. Families could use a medical wallet for routine needs or save for later expenses. Ownership changes behavior. People compare prices, judge value, and choose services based on their own priorities. None of this is possible when the subsidies bypass individuals and go directly to insurance companies.
