The real cost of the ACA subsidy fight: Who’s paying?

In 2022, Democrats extended billions in Affordable Care Act subsidies through the Inflation Reduction Act — money meant to keep coverage affordable post-COVID. The catch? A hard sunset at the end of 2025. Now, that expiration was the core of the government shutdown. Democratic lawmakers held the entire federal government hostage — not over border security, not over spending caps, but over whether to keep sending your tax dollars straight to insurance companies.

With weak oversight, ACA enrollment exploded. It is ripe with fraud — and full of enrollees who didn’t need the plans in the first place. Other patients found themselves enrolled in plans they never signed up for. Insurers collected billions anyway. And taxpayers paid the bill.

That isn’t a mistake. It’s the system working exactly as designed: middlemen first, patients last. There’s a better way: Stop funding corporations and conglomerates. Start funding the patient.

It sounds simple. But inside the Beltway, smart policies often go to die. For the sake of patients across America, I hope this time they don’t.

There has never been a better time than right now to propose common-sense reforms that put patients first, not the bloated health systems that profit from our pain. If Congress is listening: Drop the subsidy standoff. Focus on health care reforms for the people you represent — the families battling chronic illnesses, the workers skipping check-ups to save a buck — not on padding the balance sheets of Fortune 10 companies.

I’ve spent years at Patients Rising hearing from patients who feel trapped in a system that treats them like data points rather than people. America’s health care challenges trace back to third-party middlemen who’ve inserted themselves between patients and doctors.

Sprawling hospital conglomerates, profit-driven insurance companies and cumbersome government programs — they control the money, the rules and the choices. Day in and day out, patients face soaring costs, barriers to access and zero real say in their care.

Look at access: About 1 in 7 Americans can’t find a doctor who fits their life. Network restrictions turn routine care into a logistical nightmare, forcing people to delay or skip it altogether.

And on costs? The promises of affordability ring hollow. Even those on ACA plans think their cost problems are falling on deaf ears. Bureaucratic hurdles block price transparency, while large hospital systems drive up bills by snapping up smaller practices and consolidating power nationwide.

If the system seems stacked against patients, that’s because it is.

But this moment of gridlock is an opportunity to change course — by urging lawmakers to restore decision-making power to individuals. It begins with policies that empower patients to choose wisely, backed by value rather than slogans.

Lawmakers should champion solutions that let patients seek real value, such as broadening access to Health Savings Accounts for millions more Americans. These accounts offer a triple-tax advantage — tax-free contributions, growth and withdrawals for qualified medical needs — allowing people to save, invest and spend on care that fits their lives. Pair that with expanded options such as direct primary care practices, where patients pay a straightforward monthly fee for routine services, bypassing insurance red tape for more affordable, personalized attention.

I’ve seen it work firsthand. I recently used an online platform for a routine visit — cheaper, faster and I got a real doctor who delivered exactly what I needed in under 24 hours. That’s the kind of care patients deserve: convenient, transparent and under their control.

In a better system, every dollar from subsidies or premiums would flow directly to patients, making them the true owners of their health-care resources. We’re not there yet, but advancing HSAs and direct care models moves us closer — fostering transparency, accountability and real choice where it’s needed most.

These changes hinge on third parties staying in their lane. Insurance plays a vital role in shielding against major injuries or illnesses, just as government safety nets protect society’s most vulnerable. But when they overstep — micromanaging treatments, denying claims or prioritizing profits over people — care becomes the casualty.

Reforming American health care transcends party lines. It’s about curbing overreach to build a nation that’s healthier and more resilient. We lead the world in health-care spending, yet we trail other developed nations in outcomes. That gap won’t close until we tackle the root issue: why costs soar while results lag.

The path forward is clear: Stop propping up systems and start lifting up patients. Lawmakers, the shutdown controversy should be your moment. Don’t waste it on another corporate bailout. Use it to deliver real reform. Put patients in the driver’s seat — where they’ve always belonged.

Terry Wilcox is the co-founder and executive director of Patients Rising, a patient advocacy organization. She wrote this for InsideSources.com.