Is it too late for healthcare freedom?

Rising premiums and expiring subsidies have pushed the right to the brink of a healthcare reckoning.

Photo by Ian Hutchinson on Unsplash

The government shutdown is over, yet the critical healthcare issues that prompted it remain unresolved.

Federal government operations were stalled for 43 days in October and November over the question of whether to extend Obamacare subsidies from the COVID pandemic in 2020. In order to win the Democratic votes needed to reopen the government, Congressional Republicans agreed to hold a December vote on the extension of subsidies and other healthcare policy provisions. The legislation comes on the heels of rising premiums for the program, with further hikes expected if the subsidies expire.

This leaves many on the right asking themselves what answers they can offer to healthcare affordability and accessibility.

Since the 1960s, Democrats have endlessly expanded government control over the healthcare market through the creation of various welfare programs. Beginning with President Lyndon B. Johnson’s creation of Medicaid and Medicaid under the Great Society, the most recent iteration of this endless march toward fully “universal” government-provided healthcare is Obamacare.

Created by the Affordable Care Act in 2010, the Obamacare program subsidizes health insurance programs to expand coverage to those otherwise uninsured. Since its inception, conservatives and libertarians have generally opposed the program’s subsidies on the basis of distorting free markets and price signals.

That sentiment coalesced in the fervor of “Full and Repeal” throughout the 2016 election, coming to a crashing end during the first Trump administration when the late Sen. John McCain cast the decisive historic vote against the proposal.

As the late David Boaz, Cato scholar and prominent libertarian thinker, shared in one of his last interviews, “Once you create a program that people think they’re getting benefits from, it’s very hard to take those benefits away.” Fully ending a government program — a “benefit” or “entitlement”, depending on who you ask — is a near impossible task and guaranteed to result in serious political repercussions.

And such may very well be true. While progressive efforts to push Medicare for All become a dominant priority of the Democratic Party, Republicans have largely abandoned calls for a full Obamacare repeal. Instead, they’ve turned their attention to taking a scalpel to the healthcare system and enacted reforms such as Medicaid work requirements.

Policy analysts committed to allowing people to choose their insurance coverage or other payment models are now gearing up for a pre-Christmas fight over the healthcare bill. Defeats in the 2025 gubernatorial and downballot election have shaken up the conversation, centering affordability as the name of the game.

The Oval Office is particularly concerned with the cost of healthcare, from efforts to bring down drug prices to proposals to lower premiums. President Trump previously suggested redirecting Obamacare subsidies away from insurance companies and instead toward individuals — likely in the form of some sort of health savings account (HSA).

“One of the reasons why those premiums are so high is because Obamacare is very heavily regulated,” says senior fellow and economist Jeremy Nighohossian at the Competitive Enterprise Institute. “The more that you load these requirements on plans, the more they are going to cost for everyone and then they drive up premiums for everyone.”

Efforts to deregulate the program, rather than end it, have popped up in recent conversations. In a recent piece for National Review, The Foundation for Research on Equal Opportunity’s co-founder and chairman Avik Roy recommended widening the “age-bands” on rates for younger people from 3:1 to 5:1 – allowing them to pay one-fifth the premium of older enrollees, compared to the current one-third.

Nighohossian believes reforms like this could offset, to some extent, the impact on premiums that ending the COVID era subsidies may have. But nothing is certain, and any by-products of the policy would only become clear after the fact.

As Paragon Institute policy analyst Niklas Kleinworth shared with me, lawmakers are in the brainstorming phase. “There are a lot of conversations about alternatives to insurance altogether,” Kleinworth explained. These include proposals like the president’s to expand HSAs, empowering patients to choose direct primary care or other healthcare models — likely tangential with catastrophic insurance for major accidents and terminal illnesses.

There’s no single bill or policy that can fix America’s healthcare system, argues Thomas Savidge of the American Institute for Economic Research. “On this side of the aisle, there is no majority, or even plurality, rallying behind one solution.”

Policy proposals aimed at overhauling spending and tax codes may sketch out possible paths forward, but Savidge says “the reality on the ground is totally different.” As he puts it, “It’s an interesting kind of mess we have.”

Savidge also anticipates some “voter backlash” once the COVID subsidies expire. A future administration could move not only to reinstate them but to expand them even further. For now, the nation’s healthcare framework remains what Savidge describes as an overly complex—and often contradictory—regulatory system.

Any meaningful progress will likely “start by undoing a lot of the damage that was done by the Affordable Care Act (Obamacare),” as Kleinworth suggests. In his view, the ACA is a broken system that offers little by way of options. “The lionshare of the benefit of the subsidies go to the insurance companies,” he says, not patients.

This is not the moment for despair. As Kleinworth says, speaking of Obamacare’s legacy, “I was a lot more pessimistic before the Trump administration.” Even as healthcare freedom remains an uphill climb, both Kleinworth and Savidge remain optimistic. The system can be improved with the right mix of policy discipline and political will.

Real progress, however, will require more than simply criticizing Obamacare and other programs. It demands creative policymaking capable of confronting long-standing regulatory barriers while responding to the needs of the American people. Crafting solutions to lower costs and widen access will hinge on understanding these dynamics, not wishing them away.

The road ahead is undeniably complex. But the pressing issue of healthcare coverage is not going away anytime soon. With another election looming, conservatives and libertarians ignore the issue at their own political peril.

Sam Raus is the David Boaz Resident Writing Fellow at Young Voices, a political analyst and public relations professional. Follow him on X: @SamRaus1.