Let Americans Control Their Health Care

 President Trump is right about one crucial point in the health care debate. Sending money through insurance companies has failed. Patients should control health care dollars, not Washington. Where his latest proposal goes wrong is in how to do it.

Trump’s call to redirect funds from insurers to individuals comes as families face higher costs following the expiration of pandemic-era Obamacare subsidies. That instinct recognizes a real problem.

Subsidies that flow through insurers insulate prices, weaken competition, and leave patients disconnected from costs. But using those same temporary subsidies as the vehicle to send money to individuals would move in the wrong direction by expanding government involvement and adding to deficit spending, rather than fixing the system’s underlying financing failure.

The problem in American health care is not a lack of spending. The United States already spends about $5 trillion a year, close to 20 percent of GDP, yet families still face rising premiums, growing deductibles, and shrinking access. The issue is not how much money is in the system. It is where that money goes and who controls it.

Under the Affordable Care Act, premium assistance takes the form of advanceable, refundable tax credits tied to a government-defined benchmark plan. Consumers never receive these dollars. Instead, the federal government directs taxpayer dollars as payments to insurance companies each month, automatically adjusting subsidies as premiums rise.

That structure, highlighted again as subsidies expired at the end of 2025, is precisely what disconnects patients from price signals and allows costs to climb unchecked.

Using expired pandemic-era Obamacare subsidies as the basis for a new individual payment system would lock in the same mistake. It would extend a temporary COVID policy, expand federal spending, and embed Washington even deeper into health care financing. That is not empowerment. It is rebranding the same approach with a different messenger.

The real opportunity lies elsewhere.

The largest pool of health care-related dollars is not on the ACA exchanges. It is in employer-sponsored health insurance, a system built on a tax exclusion created during World War II wage controls that has never been repealed.

Because compensation is routed through health insurers rather than paychecks, workers never see the money or control how it is spent. In 2025, the average annual premium for employer-sponsored family coverage reached nearly $27,000. Those are wages workers never receive.

If policymakers want to give money to people instead of insurance companies, that is where the reform must start.

Redirecting a few thousand dollars from exchange subsidies helps at the margins. Redirecting nearly $27,000 in hidden compensation would fundamentally change incentives throughout the system without increasing federal spending or deficits.

This distinction matters. Expanding subsidies requires more government, more bureaucracy, and more borrowing. Unlocking existing compensation does not. It simply allows workers to keep and control the money they earned.

An effective way to do that is through No-Limit Health Savings Accounts, where families can save and spend health care dollars tax-free, without arbitrary caps or micromanagement. Combined with voluntarily-chosen catastrophic insurance, this approach would help restore price competition and patient choice while reducing reliance on third-party payments (i.e., government subsidies or private insurance providers).

We know this works. Transparent cash-pay providers such as the Surgery Center of Oklahoma publish bundled prices and routinely deliver care at often half the cost (or lower!) than hospital systems that bill through insurance. Direct Primary Care practices offer same-day access and predictable pricing because they operate outside the subsidy-driven insurance model.

By contrast, expanding subsidies or imposing price controls reduces access and innovation.

Physician appointment wait times continue to grow nationwide, according to workforce data, while patients in heavily regulated systems face care delays and, in extreme cases, death by queue.

These outcomes are not accidents. They are the predictable result of third-party dominance and centralized payment rules.

Trump deserves credit for identifying the problem. Health care-related dollars should follow patients, not insurers. But the solution is not to revive pandemic-era subsidies or create new federal payment streams. That approach would deepen government control and worsen the fiscal outlook.

The money is already in the system. It just isn’t in patients’ hands.

Real reform means ending the employer-based tax distortion, letting workers control their compensation, and allowing families to choose how to spend their health care dollars. That is the foundation of the Empower Patients Initiative.

Empowerment comes from ownership, not subsidies. Health care does not need more Washington spending or regulations. It needs to trust patients with the money that already belongs to them.

Vance Ginn, Ph.D., is president of Ginn Economic Consulting, host of the Let People Prosper Show, fellow at more than 20 free-market organizations, and previously served as Chief Economist at the first Trump White House’s Office of Management and Budget (2019–2020). 

https://vanceginn.substack.com/p/let-americans-control-their-health