Health care costs are
at crisis level —
and growing fast.
A cost crisis and an access crisis — each making the other worse.
When people talk about America's health care problem, they usually mean the price tag. And the price tag is real: the United States spent $5.3 trillion on health care in 2024 — $15,474 per person, 18 percent of everything the economy produced. Without reform, CMS projects that share climbs to 20.3 percent of GDP by 2033. Because wages have historically grown more slowly than the economy as a whole, that increase will hit families even harder than the raw numbers suggest.
But the problem isn't only cost. The U.S. delivers lower life expectancy and higher rates of preventable death than the average peer nation — despite spending roughly two and a half times as much per person. That gap isn't explained by better outcomes. We are paying more and getting less.
Cost and access feed each other. When costs rise, people drop coverage or delay care. When people delay care, conditions worsen and become more expensive to treat — driving costs higher. When the uninsured show up in emergency rooms, those costs get shifted onto everyone else's premiums. Breaking this spiral requires addressing both sides at once.
We are seeing it happen to us. Idahoans got a rude surprise when 2026 health insurance costs were revealed. Employer-sponsored group insurance rose to roughly $18,500 per employee. When federal subsidies expired at the end of 2025, individual and small-business premiums climbed sharply — an estimated 35,000 Idahoans lost Marketplace coverage as a result. And in rural Idaho, the problem has an additional dimension that no market theory resolves: in many communities, there is simply one hospital, one clinic, one option. Reform has to work for those communities — not just for cities where competition is at least theoretically possible.
The goal of this plan is to bend the cost curve back down — for families, employers, and government together — while protecting and expanding access, with particular attention to the rural communities that are most exposed when the system fails.
Health care doesn't behave like a normal market. Adding competition doesn't automatically bring prices down — and in rural Idaho, there often isn't any competition at all.
The U.S. has a market-based health care system. The problem is that health care doesn't behave like a market.
Unlike virtually every other high-income country, the U.S. relies on private insurance and private providers, with prices influenced by market forces rather than government-set budgets. Markets are almost always the right answer, so why isn't competition solving this?
Several reasons, each reinforcing the others:
Just to open its doors, a hospital needs a 24/7 emergency department, ICUs, operating rooms, specialized equipment, and large administrative infrastructure. Adding a second hospital nearby doesn't reduce costs — it raises the average cost per patient for both. Think of a hospital like an airport. If you plop a new one down by an old one, you don't get competition — you get under-utilization of both.
Kootenai Health, St. Luke's, St. Alphonsus, and most of Idaho's individual insurance providers are non-profit or not-for-profit entities. They don't pay dividends or answer to shareholders. But I spent years working on Air Force budgets, and the Air Force doesn't make a profit either. It answers to Congress, undergoes rigorous audits, and still has well-documented inefficiencies and cost overruns. Removing the profit motive changes the incentive structure; it doesn't eliminate the spending pressure or guarantee disciplined use of resources.
With treatments and drugs, the consumer rarely gets to weigh costs against benefits themselves. Someone else makes those choices — which breaks the feedback loop that normally constrains prices in a competitive market.
In rural areas, residents are fortunate to have a single provider of any service. Market-based pricing theories simply don't apply. Any reform must protect this reality — not paper over it.
Why not Medicare for All?
If the markets are failing us, why not just go to a European system? Why not "Medicare for All" or another single-payer solution? I don't disagree with the goals — universal coverage and lower costs. The problem is that the proposed solution doesn't reliably get us there.
The case for fundamental change rests on a real fact: health care in the U.S. costs more and produces worse outcomes than in other high-income nations. Any replacement system would have to move the needle on costs, outcomes, or both — significantly. Otherwise the disruption isn't justified.
A wholesale shift to single-payer clears neither bar with confidence. On outcomes: for the roughly 160 million Americans with employer-sponsored coverage, the evidence suggests little change in individual experience. The gains are at the population-level. They come from extending coverage to people who currently go without: people in Idaho who are suffering or dying because they can't access care when they need it. That matters. But if we are not going to measurably improve outcomes for the majority of Americans, then it's hard to justify asking them to pay more. And on costs, whether Medicare for All pays for itself depends entirely on the assumptions you make going in. A 2019 RAND analysis estimated total national health expenditures would run 1.8 percent higher than the status quo. The Congressional Budget Office is more optimistic and projects lower overall costs. The honest answer is that nobody knows.
And here's the geographic problem. Rural hospitals don't break even on Medicare and Medicaid patients today — they stay open by charging private insurers more. Extending government reimbursement rates to all payers eliminates that cross-subsidy. Proponents argue that better-designed reimbursement rates could offset this; critics say the political durability of getting those details right, in a single legislative package, on a decade-long implementation timeline, is a significant gamble. For Idaho's First District — where in many communities there is one hospital, one clinic, one option — that gamble isn't abstract.
The plan on this page pursues the same underlying goals — expanded coverage, lower costs, less waste — through the structural reforms described above: restoring competition, reducing drug costs, expanding transparency, and patching the marketplace while those reforms take hold. If those reforms prove insufficient, the case for more fundamental restructuring deserves a serious hearing — with real evidence about what worked and what didn't. But we should know where we're going before we abandon what we have.
Four pillars of reform.
The goal is to take health care costs down several notches and constrain future growth — for both government programs and households — below normal inflation. This will be a long-term, evolving effort. Click any pillar to expand the policy details.
- Site-Neutral Payments Require Medicare and Tricare to pay the same amount for a service regardless of where it is delivered — in a hospital outpatient department, a physician's office, or an ambulatory care center. Limit hospital facility fees charged for services that don't require hospital-level care.
- Anti-Trust & Anti-Monopoly Enforcement Strengthen and enforce laws to oppose and reverse vertical integration — the practice of hospitals buying up physician practices to eliminate competition and charge higher fees. Ban anti-competitive contracting clauses between hospitals and insurers.
- Expand CMS Influence on Payment Rates and Scope of Practice Physician payment rates are largely set through a process dominated by physician professional organizations — with predictable results. Expand CMS authority to set rates using transparent, data-driven methods that account for clinical complexity, resource use, and access needs by locality and specialty, independent of professional association lobbying. Expand use of nurse practitioners and physician assistants where clinical evidence supports equal outcomes — particularly in rural areas where physician shortages leave patients without options.
- Protect Rural & Underserved Communities Phase in reforms gradually, with targeted subsidies where higher costs are genuinely necessary to sustain access. Reform the 340B drug pricing program as part of this effort.
- Fund Comparative Effectiveness Research (CER) Systematically compare different treatments, drugs, and care strategies to determine what works best for which patients under what circumstances. When doctors and patients can compare real-world outcomes — effectiveness, benefits, harms, and costs — the lowest-cost effective option wins more often.
- Clinical Appropriateness Reporting Support Choosing Wisely initiatives to identify and reduce low-value physician services — those that cost money but don't improve outcomes.
- Hospital & Insurer Pricing Transparency Require hospitals to publicly disclose actual negotiated prices — both what they pay for drugs and what they charge insurers and patients. Require insurers to disclose actual negotiated rates and allowed amounts for every payer, for every service.
- Fund Basic Research Invest in methods and technologies that lower the cost of discovering, developing, testing, and manufacturing drugs and medical devices — reducing the cost basis before market pricing even begins.
- Reform Patent Protection Enable earlier entry of generics and biosimilars. Crack down on patent thickets, ever-greening, and misuse of FDA's REMS program to block generic competition. Buy out patents on high-use, high-cost drugs. Support nonprofit or public manufacturing for critical generics prone to shortages.
- Expand CMS Drug Price Negotiations and Reform Pharmacy Benefit Management Increase the list of drugs subject to Medicare price negotiation. On PBM reform: Congress took two important steps in the Consolidated Appropriations Act of 2026, requiring 100% rebate pass-through and banning spread pricing in Medicare Part D, effective 2028–2029. What remains unfinished is the commercial market — those same protections don't yet apply to employer-sponsored and individual plans, where most working-age Idahoans get their coverage. The deeper structural problem — insurers owning PBMs owning pharmacies, with each layer extracting margin — is largely untouched by the 2026 law and remains a primary target.
- Reform U.S. Drug Pricing to Reflect International Reality Pharmaceutical companies charge Americans 2½ to 3 times what they charge patients in other high-income countries for the same drugs. The tools to address this are domestic: expand Medicare price negotiation, use international reference pricing to anchor what Medicare pays to what other wealthy nations pay, and apply that discipline to the commercial market over time.
- Excess Pharmaceutical Profit Surtax (EPPS) Target a surtax on pharmaceutical firms earning double or more the standard return on invested capital. Big-name pharmaceutical firms routinely earn around double typical corporate returns. Revenue from the EPPS would reduce Medicaid and ACA costs and fund the near-term subsidy bridge while structural reforms take hold. As U.S. drug prices approach international benchmarks through negotiation and patent reform, the EPPS phases down accordingly.
- The Subsidy Cliff Problem When enhanced subsidies expired at the end of 2025, Idaho Marketplace premiums spiked sharply. An estimated 35,000 Idahoans lost coverage. Nationally, costs rose 114% out-of-pocket on average. When costs spike, healthier people drop coverage, leaving a sicker and more expensive pool. That drives premiums higher, causing more to drop out. Left unaddressed, it becomes self-reinforcing.
- Use EPPS Revenue to Restore Subsidies Direct pharmaceutical surtax revenue toward restoring as much of the expired ACA subsidies as possible, prioritizing the reduction or elimination of the subsidy cliff — keeping coverage affordable for the broadest possible population while longer-term structural reforms take hold. This is a bridge to buy time for the structural reforms throughout the rest of this plan to reduce what coverage actually costs.
- Monitor and Respond The 2026 coverage losses are now measurable. Track who dropped coverage, at what income levels, and what the downstream effects are on premiums, uncompensated care, and rural hospital finances. Use that data to calibrate the subsidy bridge and make the case to Congress for action. The goal is to arrest the spiral and reverse it.
Where we are, and where we’re going.
Our national conversation about health care costs has been focused too narrowly on shifting costs between the people and the federal government. No matter which way you push it, it’s a losing argument. The CMS projects that overall health care spending – including hospital costs, physician services, insurance, and prescription drug costs – will continue to grow by about 5.8% per year on into the future, outpacing inflation and income growth. It’s too much, no matter who pays the bill. And the kicker is, a series of studies shows that about a quarter of what we pay – a quarter of that $5.3 trillion per year – is waste. It’s valueless tests and procedures, lack of preventive care, and administrative hoops that patients and providers jump through before any care is delivered.
And yet, incredibly, we can make it worse. Congress’s actions in the current term – failing to extend the ACA expanded subsidies and enacting changes to Medicaid in the One Big Beautiful Bill Act – reduce the amount of the federal budget directed toward health care. But in doing so, they added administrative complexity to what remains and increased the burden on our health care institutions. While it will take some time for the impact of their changes to roll through, historically, these changes have meant higher costs and poorer outcomes. This is the wrong direction, and any health care reform agenda has to start with stop making things worse.
But that’s not enough. The CMS made its projections before the current congressional term started. Taming these costs – stopping the growth so that our ability to pay can catch up – will be an effort of many years. In the near term, we start with a bridge while we get the structural reforms in place. That means put back the expanded subsidies (moderated by the excess pharmaceutical profits surtax) and reverse the Medicaid coverage cuts. Enact the structural reforms that run throughout this proposal, and then, when the cost of care is reduced, the government programs that cover the costs of care directly – like Medicare and Medicaid – should also see restrained costs. Over time, we should be able to reduce or eliminate the bridge while we keep attention on improving how health care is delivered.
Health care policy, health care costs — it can all sound abstract. But on the ground it’s deeply personal. It’s someone you love going to the doctor, getting the care they need, and not going into medical debt for the rest of their lives. Our government is supposed to make that easier, not harder.