Fresh Out of the Shutdown, Let’s Talk Honestly About Health Care—and Why the ACA Still Isn’t Working

We just walked out of another exhausting standoff in Washington. Families held their breath, small businesses paused hiring, and local officials wondered which federal streams might slow to a trickle. Now that the immediate drama is past, the national conversation is snapping back to a familiar sore spot: health care—especially the Affordable Care Act (ACA) and those ever-shifting tax credits. If there were ever a perfect time to reset the discussion with clarity, it’s right now.

At Guardians of Liberty, we hear the same stories town to town: premiums that climb like clockwork, deductibles so high families avoid using the insurance they pay for, networks so narrow that “coverage” feels like a mirage, and a tax-credit scheme that papers over deeper structural problems while quietly distorting incentives. This isn’t abstract policy talk; it’s kitchen-table math. So let’s take a clear, good-faith look at where the ACA promised one thing and delivered another—and then outline better, practical solutions that put patients and communities back in charge.

The ACA’s Core Promises—and What Really Happened

“If you like your plan, you can keep it.” That was the selling point. In reality, millions saw plans canceled when one-size-fits-all federal rules made previously affordable options illegal. The new plans often came with higher premiums and deductibles, narrow hospital networks, and fewer specialist options. Coverage expanded on paper, but usable care receded for many middle-class families who don’t qualify for substantial subsidies.

“Lower costs for everyone.” The law promised to bend the cost curve. Yet individual-market premiums rose sharply in many states after the ACA’s core rules took effect. Deductibles soared, cost-sharing climbed, and insurers pulled back from rural counties, reducing competition. Even where headline premiums appear lower, it’s often because of taxpayer-funded credits—not because underlying costs fell.

“More competition.” In practice, the opposite often happened. Regulatory and compliance overhead pushed smaller insurers to the sidelines, while hospital mergers accelerated. Fewer hospital systems and fewer insurers mean less pressure to keep prices in check. When the only hospital in a region acquires independent clinics and practices, negotiated prices tend to rise and patients lose leverage.

“Protection for preexisting conditions.” Americans want protections for the sick—we agree. But the way the ACA structured these protections transferred costs into higher premiums for everyone in the individual market by replacing targeted, well-funded risk solutions with broad, blunt mandates. We can and should protect vulnerable patients without punishing younger families and small business owners with inflated premiums.

The ACA Tax Credits: A Bandage on a Bigger Wound

After the ACA’s rules drove up underlying premiums, Washington leaned harder on tax credits to keep monthly sticker prices tolerable for some households. That may feel helpful in the short term, but it masks the real problem—high, rising costs. Worse, the credit design creates two serious side effects:

1. The “income cliff” trap. Families who work overtime, launch a side hustle, or accept a raise can lose thousands in subsidies almost overnight. That turns upward mobility into a math problem with a penalty for success. Ambitious people shouldn’t have to decide between earning more and keeping their health plan affordable.
2. Distorted market signals. When taxpayers buffer price hikes, insurers face less pressure to deliver value. Providers have fewer incentives to post transparent prices or adopt efficiency tools. Subsidies grow, costs keep climbing, and the cycle repeats. It’s like pouring water into a leaky bucket instead of fixing the hole.

Put simply, the tax-credit scheme is a poor attempt to hide the inflationary consequences of the ACA’s own architecture. It may reduce pain for some families today, but it entrenches the very dynamics that make care unaffordable tomorrow. 

The Human Reality: Coverage Isn’t Care

Walk through the numbers with any family you know. A premium that eats a car payment. A $7,000–$10,000 deductible before insurance meaningfully helps. Surprise bills because the “in-network” list is a moving target. Parents ration primary care visits to save for the deductible in case a child sprains an ankle this spring sports season.

That’s not health security. That’s paying for a plastic card that too often buys stress instead of care.

The ACA blurred a crucial distinction: coverage vs. care. Real reform has to make everyday care—checkups, prescriptions, urgent care visits, mental health counseling—predictable and affordable at the point of service. If people fear using their insurance, the system is failing—even if spreadsheets in D.C. say “coverage” is up. 

What Better Actually Looks Like

We don’t need another thousand-page law that tries to micromanage the entire health-care ecosystem. We need focused, practical steps that empower patients, expand choices, and reward value instead of bureaucracy. Here’s a blueprint:

1) Put Patients, Not Middlemen, in the Driver’s Seat

• Supercharge Health Savings Accounts (HSAs). Let more families contribute more, use HSA dollars for a wider range of services, and allow HSA contributions even when someone opts for a direct primary care membership. When people control dollars, providers compete on price and quality.
• Make insurance portable. End the penalty for buying your own plan by giving individuals the same tax treatment employers enjoy. When coverage follows the person—not the job—insurers compete for your business every year, not your employer’s HR department. 
  
  

2) Restore Real Competition

• End state-line silos for insurance. Allow interstate competition so families in states with fewer choices can buy proven plans from states with robust markets.
• Kill Certificate-of-Need (CON) barriers. These 1970s relics let incumbents veto new facilities or services. Competition lowers costs and improves access—especially in rural areas.
• Expand scope of practice responsibly. Allow nurse practitioners, physician assistants, and pharmacists to do more within safe boundaries. More entry points mean shorter waits and lower costs. 
  
  

3) Pay for Care, Not Red Tape

• Price transparency with teeth. Post real, binding prices for shoppable services and back them with meaningful penalties for non-compliance. Empower families to compare cash prices and insurance prices side by side.
• Site-neutral payment. Pay the same for the same service whether it’s performed in a hospital-owned building or an independent clinic. This ends the “location markup” game that drives consolidation and inflates bills.
• Reference-based pricing. Tie reimbursement to a transparent benchmark (for example, a multiple of a well-known baseline). When prices float untethered, families lose. Anchors matter.

4) Rebuild the Individual Market the Right Way

• Guaranteed renewability + true catastrophic options. Let people buy lean, low-premium protection against major events while pairing it with HSAs and direct primary care for everyday needs. Protect those who get sick from losing or being priced out of their existing plan.
• Targeted, transparent help for high-risk patients. Use well-funded, state-run invisible high-risk pools or reinsurance programs that subsidize expensive claims directly—not across-the-board premium hikes. Help the few without punishing the many.
• End benefit-mandate bloat. Let people choose plans that fit their life stage and budget. Young families shouldn’t be forced to buy gold-plated benefits they’ll never use. 
  
  

5) Make Everyday Care Simple Again

• Direct Primary Care (DPC). Encourage monthly-membership primary care that covers routine visits, same-day texting, and wholesale labs for a transparent fee. DPC reduces ER overuse, catches problems early, and keeps families out of deductible purgatory.
• Pharmacy freedom. Require real-time, patient-visible prescription prices and open the door to cash-pay options that often beat insurance copays. When patients see price differences, pressures align.
• Telehealth without borders. If you can legally practice in one state, let patients see you across state lines—with appropriate safeguards. Rural and busy families benefit most from flexible access.

6) Fix Medicaid Without Empty Promises

• Focus on outcomes, not enrollment stats. Expand primary care capacity, reward states that reduce wait times and improve continuity of care, and open the door to DPC models for Medicaid populations where appropriate.
• Prioritize the truly vulnerable. Stop stretching programs beyond their original mission. When everything is a priority, nothing is.

7) Real Legal Reform That Protects Patients

• Malpractice reform that protects the harmed without feeding jackpot litigation. Encourage safe-harbor guidelines and specialized health courts. Defensive medicine is a silent tax on every visit and scan.
• Crack down on anti-competitive contracting. Ban “all-or-nothing” and anti-steering clauses that keep employers and patients from accessing better-priced facilities.

What This Means for Families, Employers, and Communities

For families: You should be able to blend a low-premium catastrophic plan with a funded HSA and a direct primary care membership so everyday care is easy and predictable. Transparent prices let you shop for labs, imaging, and procedures without fear.

For small businesses: Portable, individually owned coverage breaks the annual renewal hostage situation. Employers can contribute a defined amount through HRAs and let employees choose what fits their family best—ending one-size-fits-none.

For rural communities: Ending CON laws, enabling telehealth, and allowing interstate insurance mean more clinics, more specialists, and better access without driving two hours for a basic scan.

For doctors and nurses: Less paperwork, more time with patients, and freedom to innovate with membership models, cash pricing, and telemedicine. Burnout falls when clinicians are allowed to practice medicine, not bureaucracy.

Why This Approach Works (and the ACA Doesn’t)

The ACA standardized benefits, centralized rulemaking, and attempted to fix price inflation with subsidies and penalties. That model treats symptoms instead of causes and consolidates power away from patients. It makes sense politically because it’s visible and easy to message: “We’re giving you help.” But it ignores the structural incentives that keep costs rising—third-party payment, opacity, regulatory barriers to competition, and legal frameworks that reward consolidation.

A better approach reverses those incentives: money and decisions flow back to patients; providers compete; prices are posted; insurance covers the unpredictable, not the routine; and targeted mechanisms support high-risk patients without distorting the entire market. That combination bends the cost curve by design, not decree.

What About Preexisting Conditions?

We should never let people be priced out of care because they got sick. The good news: protecting preexisting conditions and restoring market discipline are not mutually exclusive. Guaranteed renewability ensures people who maintain continuous coverage cannot be singled out. Invisible high-risk pools or reinsurance spread the cost of very expensive cases across a broad base without forcing premiums up for everyone else. And robust DPC plus transparent pricing dramatically lowers routine costs, making gaps less catastrophic in the first place.

A Word on Personal Responsibility—And Community

Health care is personal. No federal scheme can substitute for the choices families make every day—or for the compassion neighbors show when life blindsides someone. A system that respects personal responsibility doesn’t abandon people; it empowers them. It makes prevention affordable, rewards prudent decisions, and ensures that when someone needs help, aid flows efficiently to the point of need—not into a maze of intermediaries.

The Road Ahead

Fresh out of the shutdown, we have a choice. We can keep arguing about how big the subsidy should be, how wide the mandate should run, and which knobs to twist in a system that still charges too much for too little. Or we can re-center the entire conversation on the people who actually use and pay for care.

Here’s our commitment at Guardians of Liberty:

• We’ll champion reforms that lower costs by design—competition, transparency, portability, and patient control.
• We’ll fight to protect the sick with targeted, effective tools instead of across-the-board price hikes.
• We’ll elevate local solutions—direct primary care, independent clinics, community pharmacies, employer HRAs—that are already working in real towns with real families.
• And we’ll stand against policies that trap families on subsidy cliffs, punish advancement, and hide inflated prices behind layers of paperwork.

The ACA took a massive swing at the health-care problem. It hit some important notes—like insisting that people with preexisting conditions shouldn’t be left out—but it wrapped those goals in a structure that made coverage more expensive, care less accessible, and markets less competitive. The tax credits that followed were a concession to that reality, not a cure. A bandage on a gunshot wound.

We can do better. In fact, Americans are already doing it—quietly building practices, payment models, and employer solutions that give control back to patients. Washington doesn’t need to reinvent those successes; it needs to get out of their way and protect patients from the few places where markets genuinely can’t carry the load alone.

If you’re a parent trying to make the budget work, a small business owner wrestling with renewals, a clinician frustrated by paperwork, or a neighbor who sees families avoid care because they fear the bill—know this: there is a better path. It’s practical, it’s humane, and it starts by trusting people over bureaucracy.

Let’s stop arguing about how to make an expensive system slightly less painful—and start building a system that is straightforward, affordable, and worthy of the people it serves. That’s the conversation we’re determined to lead. And coming out of this latest shutdown, there’s no better time to start.