As a physician with decades of experience, I have watched health care in this country change from a patient-centered calling into a profit-driven corporate enterprise. Much of the current political rhetoric surrounding the Affordable Care Act (ACA) conveniently ignores the real structural issues that drive up premiums and reduce access for ordinary Americans.
The recent claim that, if Republicans “get their way” and ACA tax credits expire, insurance costs will skyrocket by thousands of dollars is a gross oversimplification. The Affordable Care Act originally provided premium tax credits for individuals earning up to 400 percent of the federal poverty level (FPL). The 2021 American Rescue Plan temporarily expanded those subsidies to cover incomes up to 700 percent of the FPL, effectively extending taxpayer-funded aid to many upper-middle-income households. It is this temporary expansion, not the original ACA assistance, that is scheduled to expire.
Yes, the cost of ACA coverage continues to climb, but not for the reasons being advertised. The true drivers of increasing costs lie in the system’s structural design and its exploitation by corporate stakeholders who have learned to game it.
The ACA’s medical loss ratio rule and other payment regulations reward higher spending rather than better outcomes, incentivizing the inflation of health care costs rather than controlling them.
Consolidation among hospitals and insurers has decimated competition. Large health systems now own most physician practices, gaining monopoly power that allows them to set virtually any price. They close community hospitals, force patients into their networks, and apply new “facility fees” to ordinary office visits, doubling or tripling the cost of care that used to be affordable.
Independent physicians, who once provided continuity and personal accountability, have been driven out of practice by government reimbursement policies intentionally tilted toward large institutions. Every merger and practice acquisition further reduces patient choice.
Many so-called nonprofit hospital systems exploit tax exemptions while behaving like aggressive for-profit corporations. They post huge surpluses, purchase luxury real estate, and send low-income patients to collections, all while claiming to serve the public good.
The 340B drug discount program, once a lifeline for underserved patients, has turned into a profit engine. Hospitals buy drugs at steep discounts meant for the poor, resell them at full price, and keep the difference as pure profit.
Drug costs, particularly for specialty biologics, continue climbing unchecked. Pharmacy Benefit Managers (PBMs) add another layer of distortion by manipulating rebates and formularies in ways that pad corporate profits rather than reduce patient costs.
If we are serious about restoring affordability and integrity in American health care, we must move beyond partisan talking points and confront the entrenched incentives that prioritize corporate revenue over patient well-being. Until that happens, no amount of subsidy tinkering will fix the deeper disease in our system.
Andrew Murphy is an allergy-immunology physician.
