Health Care Affordability Is Not Enough

Affordability is the new watchword for both parties, particularly with regard to healthcare. NPR warns, "Healthcare costs could soon skyrocket for millions." Politico predicts, "The White House...[must] act on health care affordability." An answer was suggested on November 7, 2025, but no one seems to take it seriously.

Writing on Truth Social about ACA subsidies, President Trump suggested giving money "directly to the people" rather than sending billions to "BIG, BAD insurance companies" (capitalization per Trump.) That could improve affordability, he said.

For healthcare, affordability is necessary — it is not sufficient.

Affordable for whom?

Healthcare as one word is the system. As two words, health...care is really medical care, referring to a fiduciary, confidential service contract between one patient and one care provider.

Health care, the service, can be free to patient at point of service. That was true for Russians in the U.S.S.R. While there was no charge (and therefore affordable) to the patient, the government had to pay for goods, services, construction, upkeep, and administration.

While health care could be free to patients, it cannot be free to those who provide it. In fact, free health care makes healthcare impossibly expensive and unsustainable. Senator Bernie Sanders' Medicare-for-All, single payer plan promises to provide universal care for no charge to patients. Sanders admitted his plan could cost up to $40 trillion, which is one third of the combined GDP of all nations on earth.

Making healthcare affordable

Giving ACA subsidies directly to the people would make health care (both care and insurance) more affordable for patients but at a cost of $350 billion over ten years to taxpayers. Affordable for individuals but unaffordable for the nation.

There is a way to give money to the people without bankrupting the country — give them wages they are currently being denied.

Shortly after the U.S. entered World War II, Congress passed price and wage freezes in order to control our wartime economy. To allow employers to recruit, retain, and reward good workers when wages could not be raised, Congress passed a law allowing employers to pay tax-free for employees' health insurance. This became the "employer-sponsored health benefit," financed by wages foregone.

After the war, all the price and wage freeze laws were repealed, but one. The tax-advantaged employer-sponsored health benefit remained on the books. Over time, the background facts seemed to fade away, that the dollars going to insurance companies from employers were really employees' wages they never received.

U.S. healthcare has evolved into a centrally controlled, third-party decision-maker, un-free market. He who has the gold makes the rules. As consumers (patients) don't have (control) the "gold", consumers don't make the rules (of how to spend their money.) "BIG, BAD insurance companies" do, following rules promulgated by Washington. Just like every other centrally-controlled economy, viz., U.S.S.R. or Venezuela, there is overspending, shortages, low quality, and slow service — just what Americans experience in their healthcare system.

According to Kaiser Family Foundation, "The average annual premiums for employer-sponsored health insurance [paid to insurance companies] in 2024 were...$25,572 for family coverage." Instead of giving ACA subsidy monies (taxpayer dollars) to people, pay employees their full wages. Let employees pay their own healthcare expenses, using their own dollars tax-free.

Last year's out-of-pocket spending on healthcare averaged $1,142. That would leave more than $24,000 for a family to shop for and pay directly for care. Even the most pessimistic scenario, with a patient having the highest deductible recorded last year — $10,310 — and the associated premium of $5,000, the person would still have more than $10,000 to shop for care and medications or to roll over for next year's expenses.

This approach would require minimal BURRDEN: bureaucracy, unnecessary rules and regulations, directives, enforcement, noncompliance activities. Federal BURRDEN consumes half of all healthcare spending. Last year, 2.45 trillion healthcare dollars produced no care in any form for patients. Much of this spending on regulations would be avoided if employer-sponsored health insurance funds were given directly to the employees instead of to insurance companies.

Affordable health care is not enough

Great Britain's single payer system (NHS, National Health Service) shows why affordability is not enough. The NHS is affordable to both individuals (no charge at point of service) and to their nation. In 2024, average per capita spending on healthcare in the United Kingdom (U.K.) was less than half what the U.S. expended: $5,493 v. $12,555.

The U.K. achieves affordability by rationing: restricting the dollars allotted to hospitals and providers, building new facilities, research and development, and pharmaceuticals.

British belt-tightening dramatically reduces access to care. Nearly ten percent of the entire British populace, 6.2 million, is on a waiting list for care. There aren't enough operating rooms, MRI machines, burn units, pharmaceuticals, and doctors.

Even a one-month delay in cancer diagnosis increases mortality. More than one third of patients in the U.K have been waiting longer than 4 1/2 months. The phrase death-by-queue (British for a line of people) was coined in the NHS. It describes people waiting in line so long for care that they die while waiting. Death-by-queue is an unavoidable feature of governmental rationing of care.

Affordability by free market

The only system that can drive prices down while simultaneously raising up quality and quantity is the free market. A command economy, i.e., socialist fiscal control, never has done so and never will. The NHS example proves this.

The U.S. centrally controlled healthcare system has produced both unaffordability — for individuals and the nation — as well as inaccessibility. We waste as many healthcare dollars on BURRDEN as the entire GDP of Russia. Average maximum wait times are more than 132 days, similar to U.K. wait times. Death-by-queue has been reported in both Medicaid and the VA system.

Implement Trump's off-hand suggestion to give money "directly to the people." Instead of handing out subsidies, give U.S. workers their full wages; let workers put the additional $25,000 into new no-limit HSA; and use the money to shop for care as well as health insurance. These two actions — full wages and no-limit HSA — would instantly create a free market in healthcare for half of the nation. The resulting free market forces would both drive down prices and speed up delivery of care. As an added bonus, wasteful spending on healthcare BURRDEN would be significantly curtailed.

Deane Waldman, MD, MBA, is professor emeritus of pediatrics, pathology, and decision science; former director of the Center for Healthcare Policy at the Texas Public Policy Foundation; and former director of the New Mexico Health Insurance Exchange. His latest book, Empower PATIENTS – Two Doctors' Cure for Healthcare will be available Thanksgiving 2025. Follow him on X @DrDeaneW or visit deanewaldman.com.

Image: Free image, Pixabay license.