Ge Bai is a professor of accounting and health policy at Johns Hopkins University.
Paula Muto is an independent practicing surgeon and founder of UBERDOC.

The battle over the Affordable Care Act premium subsidies, which triggered the longest government shutdown in U.S. history at 43 days, continues to rage on Capitol Hill. To end the shutdown on Nov. 12, Senate Republicans promised Democrats a vote on the subsidies before they expire Dec. 31.

President Donald Trump and Republican members of Congress have proposed allowing Americans to directly control their subsidized health care dollars. Is this the right approach?

ACA plans are expensive. In 2025, taxpayers poured more than $130 billion into subsidizing insurance premiums. Yet average deductibles will top $5,000 in 2026, out-of-pocket maximums will reach $21,000 for a family, and HealthCare.gov insurers deny nearly 1 in 5 medical claims. Networks are narrow, wait times are long and finding a specialist for timely follow-up is nearly impossible.

Patients already pay into the system multiple times ‒ through taxes, premiums, deductibles and co-pays ‒ yet many still cannot access care. ACA plans have proved so unhelpful that many are avoiding care altogether. Every physician can tell a story of a patient who suffered as a result.

High premiums aren’t just an ACA problem. The average family premium for employer-sponsored plans hit $26,993 in 2025. Every dollar spent on health benefits drags down take-home pay, traps Americans in mismatched jobs and stifles entrepreneurship.

Meanwhile, technology has made it possible to deliver care faster and cheaper. A knee replacement that once required a five-day hospital stay and weeks of rehab can now send patients home the same day from a surgery center. Yet most patients see only rising health care spending. Why?

Health care prices remain hidden from patients

The root cause lies in the third-party payment system, which has stripped power from patients, distorted incentives and disrupted markets. It doesn’t trust patients to choose, doctors to care or entrepreneurs to innovate. Prices remain hidden from patients because someone else is paying.

Patients, unable to benefit from lower prices or better health, exert little downward pressure on price or upward pressure on quality ‒ unlike consumers in other markets. The result: high prices, low quality and stagnant innovation prevail, all at the expense of patients.

As insurers and government programs seize control of health care dollars, medicine has become a compliance industry rather than a healing profession. Heavy compliance burdens fuel consolidation. Instead of private practice, more than three-quarters of physicians are now employed by hospitals/health systems and other corporate entities, with incentives tied to following corporate orders rather than improving patient outcomes.

Worse, policymakers often misdiagnose these predictable consequences of policy failures as a need for more central planning ‒ further distorting incentives, compounding money-grabbing opportunities, and leaving patients worse off clinically and financially.

Whoever pays holds the power in health care

Health care begins with the patient. In control of their dollars, patients make the best choices. When they pay directly, care happens faster. Providers must satisfy patients to earn their business ‒ aligning incentives, fostering competition and innovation, and creating a dynamic, vibrant marketplace for care.

Imagine Americans receiving deposits into health savings accounts (HSAs) to pay for cash transactions and premiums for patient-driven insurance plans, backed by taxpayer-funded reinsurance as a safety net. If an Electronic Benefits Transfer (EBT) card can buy groceries, why shouldn’t it cover a dental exam or a visit to an endocrinologist?

Disadvantaged Americans should also receive subsidies through their HSAs, where funds are transferrable, inheritable and eligible for tax-deductible charitable contributions ‒ thereby incentivizing comparison shopping, promoting healthy living and transforming health care philanthropy.

Whoever pays holds the power. Funding patients directly would align incentives across the health care system, forcing all players to demonstrate and deliver value to individual patients in order to earn their business.

Competition, innovation, price and quality transparency, and patient education would naturally follow, fostering vibrant markets that best serve patients’ diverse needs.

Health care unaffordability is undermining both Americans’ well-being and America’s global leadership. The solution is simple: Patients must gain control of their earned or subsidized health care dollars. The power of free people and free markets can unleash American dynamism, uplift patients and ignite market transformations capable of defeating any entrenched special interest.

Fund the patient.

Ge Bai is a professor of accounting and health policy at Johns Hopkins University. Paula Muto is an independent practicing surgeon and founder of UBERDOC.

This article originally appeared on USA TODAY: End the ACA subsidies and give patients their power back | Opinion

Reporting by Ge Bai and Paula Muto, Opinion contributors / USA TODAY

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