{"id":294068,"date":"2025-11-19T21:19:19","date_gmt":"2025-11-19T21:19:19","guid":{"rendered":"https:\/\/www.newsbeep.com\/ca\/294068\/"},"modified":"2025-11-19T21:19:19","modified_gmt":"2025-11-19T21:19:19","slug":"the-not-so-impressive-new-health-care-ideas-republicans-want-to-rush-out","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/ca\/294068\/","title":{"rendered":"The Not-So-Impressive \u201cNew\u201d Health Care Ideas Republicans Want to Rush Out"},"content":{"rendered":"

\"\"<\/a>Dr. Mehmet Oz, the administrator for the Centers for Medicare & Medicaid Services, at a press conference with Senate Republicans in September 2025. (Photo by Nathan Posner\/Anadolu via Getty Images)<\/p>\n

REPUBLICANS APPEAR TO HAVE finally figured out that the coming insurance premium spike for more than 20 million Americans will hurt many of their own constituents\u2014and, not coincidentally, damage their party\u2019s prospects for next year\u2019s midterm elections.<\/p>\n

They just haven\u2019t figured out what to do about it.<\/p>\n

Florida Senator Rick Scott keeps talking<\/a> like the looming expiration<\/a> of those enhanced Affordable Care Act subsidies is an opportunity to get rid of the law\u2019s private insurance reforms once and for all, and simply give people money they can use to pick their own coverage or pay their own medical bills directly. Louisiana Senator Bill Cassidy<\/a> is promoting a far more limited plan, one that would simply take the money now being used to fund those enhanced subsidies and use it instead to fill individual private accounts, which people could use to cover copays, deductibles and other out-of-pocket costs.<\/p>\n

House Speaker Mike Johnson hasn\u2019t committed to anything so specific, promising<\/a> instead that his caucus has \u201clots of ideas\u201d to be \u201crolled out in the next couple of weeks.\u201d Mehmet Oz, administrator for Medicare and Medicaid, says actually everything is on the table. \u201cThere are many ideas out there,\u201d he told<\/a> CNN\u2019s Dana Bash on Sunday. \u201cSome of them could replace Obamacare. Many of them will not.\u201d<\/p>\n

And then there is Donald Trump, who on Tuesday morning posted<\/a> (sorry for the all-caps) that \u201cTHE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES. . . . THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! \u201c<\/p>\n

The post seems to reflect about as much deep thinking as Trump usually puts into policy\u2014which is to say, not much. It also raises a bunch of questions.<\/p>\n

Where is this new, much better insurance going to come from, if not from the \u201cbig, fat insurers\u201d? Exactly how are people going to negotiate with insurers, and over what? Prices? Benefits? Is this a scheme for wrecking\u2014i.e., repealing\u2014the Affordable Care Act\u2019s rules and regulations that protect people with pre-existing conditions, like Scott wants? Or is this a substitute only for the enhanced subsidies, as Cassidy is proposing?<\/p>\n

Trying to extract and analyze a concrete, coherent policy proposal out of these kinds of statements is pretty much impossible\u2014or, as Harvard health policy professor Adrianna McIntyre<\/a> put it to me, like \u201ctrying to read tea leaves, only the cup is full of mud.\u201d But Trump and the other Republican leaders do seem to have coalesced around at least one idea: that taking some or all of the money now going to insurers, and giving it directly to people, will make for a cheaper, more efficient health care system.<\/p>\n

The concept is not new. It\u2019s been kicking around in health policy for decades, as a way for both the public and the private sector to get health care costs under control. It\u2019s also been implemented in a variety of places, in a variety of forms. Which means there\u2019s a lot of evidence of how it works in practice. And that evidence is pretty discouraging.<\/p>\n

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A FUNDAMENTAL CHALLENGE of any insurance scheme is how to avoid what economists call \u201cmoral hazard<\/a>,\u201d which, in this context, refers to the potential of insurance to discourage responsible or cost-conscious behavior because insurance has insulated those who buy it from financial danger. Overly protective property insurance, for example, might discourage an owner from investing in updated smoke detectors since they know that fire damage will be covered by the insurer. Overly generous auto insurance might lead a driver to be less careful on the roads.<\/p>\n

One way of combatting moral hazard is to make sure whoever has insurance remains responsible for some of the costs of misfortune. In health insurance, that can take the form of copayments, coinsurance, and deductibles. In the 1970s and 1980s, when rising health costs first became a major topic of national political conversation, both political and corporate leaders began looking for ways to increase these out-of-pocket costs, in the hopes that giving people more \u201cskin in the game\u201d would get medical spending under control.<\/p>\n

Among the big champions of this approach was Republican Newt Gingrich, who as House speaker in the 1990s embraced the idea of pairing high-deductible private insurance with tax-favored, private saving accounts people could use to pay the out-of-pocket costs. He even eyed it as an option for people in Medicare<\/a>, as an alternative to the traditional program.<\/p>\n

That particular version did not prove especially popular, in part because seniors\u2014who expect to have high medical costs\u2014perceived it as a way to give them less help with their medical bills. Among other things, they knew Gingrich was looking to cut Medicare spending overall, and figured whatever money got deposited in those accounts wouldn\u2019t be enough to cover their bills. That was enough to kill the idea, at least as far as Medicare goes.<\/p>\n

But private employers were able to plow ahead, leaning increasingly<\/a> on higher out-of-pocket costs as a way to hold down the expense of insurance they provided to employees. This has become the standard for private insurance in America today. And while employees have not exactly been thrilled about this development, advocates for this approach have talked it up as a way to empower individuals\u2014and to unleash what they call \u201cconsumer-driven health care<\/a>.\u201d<\/p>\n

The theory is that with a combination of incentives and information, people can go around and shop for the best deals on health care\u2014by, for example, seeking out cheaper sources of prescription drugs or MRI centers that will offer the lowest prices per scan. This, in turn, is supposed to force anybody providing medical care to compete on price and quality, unleashing market forces that would drive the entire system towards greater efficiency.<\/p>\n

Pretty much every Republican talking about health care in the last few weeks has offered a version of this. \u201cWe empower patients to shop, to find the best deal for their dollar,\u201d Cassidy said in a recent floor speech<\/a>. \u201cThat drives competition and that lowers cost.\u201d<\/p>\n

IT SOUNDS LOVELY. But scholars have now had many years to see how this approach<\/a> works<\/a> out<\/a> in<\/a> practice<\/a>. \u201cThere\u2019s loads of evidence on this, zillions of studies,\u201d Sherry Glied<\/a>, a professor and health economist at New York University, told me. \u201cEssentially they show that no one shops.\u201d<\/p>\n

One reason, Glied explained, is the reality of what it\u2019s like to get medical care. \u201cOnce you\u2019re in the system and you\u2019ve decided to go to the doctor, you pretty much do whatever the doctor says, and certainly once you\u2019re in the hospital, you do whatever is recommended,\u201d said Glied, who is the author of widely cited research<\/a> on the subject. \u201cWhen you\u2019re in the emergency room, nobody says to you, \u2018Would you like to have this CT scan or not?\u2019\u201d<\/p>\n

Glied added that the best evidence in favor of the \u201cconsumer-directed\u201d approach comes from a pilot program in the health system for California retirees, in which the administrators made sure beneficiaries knew where to get cheaper, but still high-quality knee replacements. A widely cited study<\/a> found people did indeed gravitate toward those cheaper providers.<\/p>\n

But, she noted, knee replacements represent the best-case scenario for shopping\u2014a discrete procedure that can be planned well in advance, and for which people can carefully compare prices. That\u2019s simply not possible in many health care contexts, especially when charges for most medical services typically consist of multiple fees, with all kinds of confusing codes and jargon.<\/p>\n

Employers and insurers have even invested in online apps, in the hopes of helping consumers navigate this mess and find the best deals. But the tools just don\u2019t work that well\u2014not even for a relatively routine doctor\u2019s visit, let alone for a hospital stay.<\/p>\n

\u201cYou both need to have magical insight into what your doctor is going to do during your visit, and what they\u2019re going to bill you for,\u201d McIntyre said. \u201cAnd then also, you have to trust that the information your price shopping tool has is the most up-to-date information and is accurate for the specific provider you are seeing. We\u2019ve seen with other such tools\u2014like provider listings in networks\u2014that frequently doesn\u2019t happen.\u201d<\/p>\n

But the bigger worry for many experts is the possibility that shifting more costs onto individuals will lead them to cut back on care they need<\/a>. When they don\u2019t get the care they need now, they may end up spending even more for care they need later; even if they spend less, they\u2019re likely to end up in worse<\/a> shape medically<\/a>.<\/p>\n

\u201cWhen people do have a high deductible, they cut back on the good stuff as much as they cut back on the low value stuff,\u201d Tom Buchmueller<\/a>, a health economist at the University of Michigan, told me. \u201cEven when people are incentivized to be consumers, they are not very good consumers.\u201d<\/p>\n

The effects can be particularly tough on lower-income people, who are at once more likely to have serious, chronic conditions that need attention, more likely to be price sensitive about consuming health care, and more likely to have difficulty researching options for care and providers. So they\u2019re the ones most likely to skip a doctor\u2019s visit or recommended test\u2014or split or skip prescriptions\u2014to save money.<\/p>\n

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THE ARCHITECTS OF THE AFFORDABLE CARE ACT actually tried to find a policy sweet spot\u2014a way to put enough expenses onto individuals to promote some cost-consciousness but without making the out-of-pocket costs so high it discouraged people from getting care they needed or exposed them to overly punishing expenses.<\/p>\n

That is why all but the most generous plans<\/a> available to people through the Affordable Care Act marketplaces have substantial deductibles, well into the thousands of dollars, but preventive care is free and people at lower incomes can get policies with much lower out-of-pocket costs.<\/p>\n

Even with those provisions, the high deductibles were a source of frustration and criticism<\/a> when the Affordable Care Act first took full effect in 2014. It\u2019s one reason Democrats were so eager to add extra financial assistance<\/a>\u2014which they did during the pandemic\u2014and then renew it. With the enhanced subsidies, millions were able to \u201cbuy up\u201d and get policies with lower deductibles and copays.<\/p>\n

But those enhanced subsidies were extended only through the end of this year. And now a replacement is being left to whatever the Trump White House and Republican leaders are willing to cook up or sign off on.<\/p>\n

It\u2019s impossible to get specific about the likely effects of their replacement proposals without having actual, fleshed-out legislation, because so much depends on the details\u2014like whether the accounts meant to replace the enhanced subsidies would be health saving accounts (which accrue over time) or flexible savings accounts (which must be spent within the year), how the amounts would be calculated and when they would be paid out, what kind of restrictions would come on the uses of the accounts, and so on.<\/p>\n

Figuring that out would take time. So would debating and passing a law to put one of these schemes in place, as would setting up whatever legal and practical mechanisms the new scheme might require. Meanwhile, open enrollment is currently in its third week and the new plan year starts in less than two months. People are already shopping and making decisions, and within a few weeks they\u2019ll be paying premiums unless they decide the price spike makes coverage unaffordable<\/a>\u2014as nearly 4 million<\/a> people are expected to do.<\/p>\n

\u201cIf this is an idea that you really want to develop, then fine, do it for next year\u2019s open enrollment, do it down the line,\u201d Buchmueller, who served in HHS under the Biden administration, told me. \u201cThere are so many operational details that you\u2019d have to work out\u2014how are you not going to get it completely wrong?\u201d<\/p>\n

AN ALTERNATIVE APPROACH does exist. Earlier this month, two House Republicans and two House Democrats put forward a bill<\/a> that would extend the existing subsidies for two years, with a few modest changes (like phasing out eligibility at higher incomes) to accommodate some of the concerns Republicans have made about the cost of the enhanced subsidies.<\/p>\n

It\u2019s not hard to imagine something like that passing if the White House and GOP leaders would allow the bill to get a vote. That would leave Republicans plenty of time to work out\u2014and then implement\u2014whatever bigger changes they have in mind, while sparing more than 20 million Americans a jump in health care costs next year. Republicans could even take the opportunity to consider new ideas<\/a>, or to work on bipartisan<\/a> methods of holding down costs.<\/p>\n

Of course, a longer debate would also mean confronting the downsides and tradeoffs of what Republicans seem to have in mind right now. It would mean addressing\u2014and answering\u2014all the evidence showing that \u201cshopping\u201d for health care doesn\u2019t lead to more efficient care. And it would force Republicans to prove that whatever they propose wouldn\u2019t simply amount to less financial assistance on health care, which would almost surely mean more hardship for people with lower incomes and serious medical needs.<\/p>\n

That might be pretty tough for them to do. \u201cCash accounts to pay for health services will never provide the kind of access to health care that people who become ill, get into an accident, or have pre-existing conditions need or the kind of financial protection that health insurance provides,\u201d Gideon Lukens<\/a>, senior fellow at the left-leaning Center on Budget and Policy Priorities, wrote in an analysis<\/a> of the concepts Republicans have been floating.<\/p>\n

That conclusion was based in part on the history of GOP policy\u2014a history littered with promises of better, cheaper health care that somehow never match up<\/a> with their actual proposals, if those proposals are ever introduced at all. There\u2019s no reason to think this month\u2019s confused, frenzied rush to devise policy in time for 2026 will turn out any different.<\/p>\n

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