The latest House GOP healthcare reform proposal emphasizes choice but fails to address the complexities ordinary Americans face in selecting and affording healthcare.
House Republicans have introduced a new healthcare package aimed at replacing the Affordable Care Act (ACA) subsidies, framing it as a market-based solution to the impending expiration of enhanced ACA support. The proposal highlights expanded choice, increased employer flexibility, and a renewed focus on defined-contribution models, such as the newly branded CHOICE Arrangements.
On the surface, the plan appears to return to foundational principles: empowering individuals, minimizing government interference, and allowing markets to function effectively. However, similar to previous health policy initiatives, the bill articulates what policymakers hope will occur while neglecting to address how ordinary Americans will navigate the realities it creates.
Central to the House GOP proposal is the belief that providing employees with financial contributions instead of insurance will foster efficiency and competition. Under the CHOICE Arrangements, employers would offer a fixed amount of money, which employees can use to purchase individual health plans independently.
This concept is not novel; it resembles Individual Coverage Health Reimbursement Arrangements (ICHRAs) under a different name. It is based on the long-standing assumption that consumers will make rational decisions when given choices, thereby controlling costs. However, health insurance is not a typical consumer product. Selecting a health plan involves forecasting potential health issues, understanding complex actuarial trade-offs, deciphering provider networks, anticipating medication needs, and estimating out-of-pocket expenses—all under conditions of stress and uncertainty. Even well-educated individuals often struggle with these decisions.
Expecting the average employee to choose the best plan for themselves and their families, even with financial contributions, is less a practical solution than a theoretical exercise. This approach can be likened to asking someone to pick an item from a vending machine while blindfolded. While they may have money and a variety of options, they lack the necessary information to understand what they are selecting, its future costs, or whether it will meet their needs when it matters most. Choice devoid of context does not empower; it relinquishes responsibility.
This flaw becomes particularly evident when considering those who require healthcare the most. Patients with chronic illnesses, limited health literacy, or socioeconomic challenges are often the least equipped to navigate fragmented insurance markets. These individuals are not outliers; they represent the core users of the healthcare system. Any reform that assumes a uniformly informed, proactive consumer is based on a model that fails to reflect reality.
Since the ACA’s passage in 2009, I have consistently argued that its foundational assumptions were flawed—not because it expanded coverage, but because it did not significantly shift the balance of power in the healthcare marketplace. Insurers adapted, consolidated, and ultimately strengthened their positions, leading to continued premium increases. Pharmacy benefit managers (PBMs) became even more opaque and influential. While the flow of money changed, the destination remained unchanged.
The House GOP bill risks repeating this pattern. Although it suggests accountability and transparency for PBMs, it does not fundamentally alter the negotiating dynamics that dictate pricing and access. Insurers and PBMs continue to control critical data, networks, and formularies, dictating terms to employers. Self-insured employers, in particular, remain at a disadvantage, lacking the comprehensive, interoperable data and technological tools necessary for meaningful negotiation, regardless of how many defined contributions they provide.
Accountability in healthcare does not begin with regulation alone; it starts with leverage. Insurers and PBMs cannot be held accountable when they maintain asymmetrical control over information and pricing. True reform would require equipping employers and purchasers with real-time data, transparency regarding outcomes, and AI-enabled decision-making tools that allow them to assess value rather than merely price. Without this infrastructure, market-based reforms are more performative than transformative.
The irony lies in the fact that this is not merely a partisan issue but a recurring oversight in policy-making. Time and again, Washington produces solutions that prioritize financing mechanisms while overlooking the cognitive and informational realities of healthcare decision-making. While defined contributions, expanded choice, and market competition may sound appealing in theory, they often falter under the complexities of real-world scenarios.
Former President Trump often spoke about the art of the deal, emphasizing that outcomes depend on who holds the cards. In healthcare, despite decades of reform efforts, the winning hands remain firmly in the possession of insurers and PBMs. Until this dynamic changes, no amount of rebranding, restructuring, or rhetorical emphasis on choice will provide meaningful relief to patients or employers.
While the House GOP bill may be well-intentioned and offer a valid critique of subsidy dependency, it fails to address how individuals actually select insurance, how power operates within the system, and how data and technology must underpin any functional market. As a result, it presents an answer to a question that Americans are no longer asking.
Healthcare reform cannot succeed by ignoring human limitations. Choice is not a cure-all; structure is essential. Until policymakers are willing to design reforms that reflect how people think, decide, and negotiate in the real world, we will continue to cycle through ambitious plans that promise empowerment while leaving the blindfold firmly in place.
According to Sreedhar Potarazu, MD.