Health care costs are
for a crisis —
and growing fast.
Taming them requires determined, focused, long-term Congressional action. Here's where we start.
Two forces — compounding one another.
Idahoans got a rude surprise when health insurance costs for 2026 were revealed. Employer-sponsored group insurance rose from roughly $17,500 to $18,500 per employee. For individuals and small businesses with fewer than 50 employees, premiums climbed 10–11% — more moderate than much of the country thanks to Idaho's reinsurance program. That moderation is itself evidence that government action can impact affordability. But when federal subsidies expired at the end of 2025, Idahoans faced higher, sometimes unmanageable, costs.
Health insurers report the reasons behind their premium increases to the Idaho Department of Insurance. They come down to two things: the cost per service is rising (hospital, physician, and drug costs), and the number of services people use is rising, driven by increased rates of chronic illness. Both trends compound each other.
The Centers for Medicare & Medicaid Services (CMS) reports that U.S. health expenditures were almost $5 trillion in 2023 — 17.6 percent of GDP. Without reform, CMS projects that share grows to 20.3 percent 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. We need to bend that cost curve back down.
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. The U.S. spends roughly 2½ times the Organization for Economic Cooperation and Development (OECD) average per person on health care — yet delivers lower life expectancy and higher preventable mortality than the OECD average. That gap is not explained by better outcomes.
Why don't standard market corrections work? 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 6 of Idaho's 8 individual insurance providers are non-profit or not-for-profit entities. They charge for services, they collect revenue, and they pay salaries, but they don't respond to the same incentive structure as for-profit firms. Standard competitive pressures don't apply.
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.
Many people press for a European-style system — nationalized or tightly regulated, with government-set prices. It's a reasonable argument: other high income nations spend far less and achieve better outcomes. But there are real reasons we got where we are — entrenched employer-based coverage, deep distrust of government administration, powerful influence groups, the intangible value of innovation incentives, as well as serious concerns about disruption at scale for 340 million people. The goal here is to improve this system through targeted, proven reforms — and then keep working new ones.
Every year, the U.S. pays an estimated $250–300 billion more for prescription drugs than we would at average OECD prices for the same medications. The U.S. pays roughly 2½ to 3 times as much as other high income nations for brand-name drugs. This is not an innovation subsidy — it is an unsustainable structural imbalance that American patients bear alone.
The U.S. spends about two and a half times the OECD average per person on health care — yet achieves lower life expectancy and higher preventable mortality than the average member nation. The OECD has 38 member countries and a combined population of 1.39 billion. There should be room to spread costs far more fairly.
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 Physician Payment Authority Expand CMS authority to impact physician payment rates using transparent, data-driven methods that account for clinical complexity, resource use, and access needs by locality and specialty.
- 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. This is not rationing; it is evidence-based medicine.
- 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 Increase the list of drugs subject to Medicare price negotiation. Reform pharmacy benefit management to require rebate pass-through, ban spread-pricing, regulate self-dealing, and increase drug cost transparency to patients and insurers.
- Spread Costs Across OECD Nations The OECD has 38 member countries and a combined population of 1.39 billion people. Explore frameworks to better distribute pharmaceutical development costs across that broader base — rather than having American patients shoulder the majority of costs alone.
- 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.
- The Subsidy Cliff Problem When the enhanced subsidies expired at the end of 2025, Idaho marketplace plan costs rose 75% out-of-pocket — 114% on average nationwide. When costs spike, healthier people drop coverage, leaving a sicker pool. That drives premiums higher, causing more to drop out. It is a spiral that must be stopped.
- 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.
- Monitor and Respond Track how many people dropped coverage and from what income levels as the 2026 marketplace played out. Use that data to adjust the subsidy bridge. The goal is to stop the predicted spiral before it becomes self-reinforcing.
What will these reforms add up to?
Some of the proposals above are already under consideration in some form by Congress, and the Congressional Budget Office has scored anticipated financial impacts for several of them. In combination, these reforms could slow the growth of health care costs for the government and for families by 5–10%.
That means by 2033, instead of reaching the CMS-projected 20.3% of GDP, national health care expenditures could stabilize near 18–19% of GDP — still too high, but a meaningful reversal of the trend and a real foundation for continued reform. We need to keep finding opportunities and support the states as they implement reforms as well.
When Congress doesn't work, families pay the price — in higher costs, fewer opportunities, and growing insecurity. This is a reform agenda. Not bigger government, not smaller government — government that works.