March 23, 2010. 16 years ago, President Barack Obama signed the Affordable Care Act (ACA) into law, thus locking into statutory concrete the dysfunctional status quo that burdens us today. Recall this was Obama’s “signature” legislative achievement.
Of course, Obama’s congressional allies knew exactly what they were doing. They conscientiously read and fully grasped the 2700-page product they were enacting. Right?
Well, not to worry, said then Democratic House Speaker Nancy Pelosi: “ We have to pass the bill so you can find out what is in it—away from the fog of the controversy.”
Also, do not forget Obama’s absurd promises, just to name a few: If you liked your health plan, you could keep it, and nothing would change; the bill would create robust and competitive health insurance markets; the bill would expand access to high quality health care; the bill would save the typical family $2500 in yearly health care costs; and the bill would bend the soaring health care cost curve downward.
So, what have Obama and Congressional Democrats wrought? After 16 years, they have imposed a complex health care law that is unaffordable and dysfunctional. Consider the evidence:
Accelerating health insurance premiums. In the individual and small group markets, beneficiaries and taxpayers have been financing skyrocketing premiums. In 2014, when ACA insurance provisions went into effect, America’s health insurance markets were jolted by “sticker shock,” and premium increases subsequently accelerated. In 2013, according to a Heritage Foundation analysis, an individual’s monthly premiums in the nation’s individual markets averaged $244, but by 2022, they had risen to $568—a 133% increase. And for beneficiaries and taxpayers, the situation is worsening. For 2026 Kaiser Family Foundation analysts projected a breathtaking 18% average increase. Some affordability.
Crazy Deductibles. When one buys a low-premium “bronze” ACA health plan, one can expect to pay more out of pocket in the form of higher deductibles. But ACA deductibles are the very definition of “unaffordable.” Between 2014 and 2024, ACA deductibles have jumped 40%. Over that same period, Heritage reports, the average ACA deductible for family coverage increased from $10, 278 to $14,310.
Reduced Access to Medical Professionals. ACA plans have routinely adopted “narrow” provider networks, even among the most popular plans, resulting in a steady decline in patient access to doctors, specialists, and other medical professionals. In 2014, according to the Heritage analysis, among the ACA’s standard “silver plans,” 53% of them had “more restrictive” provider networks, but such networks characterized 80% of such plans by 2024.
Reduced Choice and Competition. In 2013, before the ACA’s insurance provisions went into effect, there were 395 insurers in the nation’s individual markets. But here, too, the ACA delivered an anti-competitive shock to the market and contributed to a rapid consolidation of the nation’s health care markets. By 2018, there were only 181 plans in the ACA exchanges, and 52% of US counties had just one insurer and 30.5% had just two insurers. In fact, the first Trump administration, then falsely accused of “sabotaging” the program, improved and stabilized the ACA markets. By 2024, these markets had 304 insurers offering coverage, but the vast majority of states still had fewer participants in their markets than before ACA’s implementation.
Massive Fraud. About 76 million people are enrolled in Medicaid and CHIP up from 61 million in 2013. The Center for Medicare and Medicaid Services reports, that of the estimated 24.3 enrollees in the ACA exchanges in 2025, taxpayers subsidized the premium costs of 93% of enrollees, while 53% also got taxpayer subsidies to offset “cost sharing” or out-of-pocket costs. So, in effect, taxpayers overwhelmingly fund ACA’s rigidly standardized plans and absorb, year by year, their relentlessly rising premium and out of pocket costs.
But, as we previously noted, there is a much darker multibillion dollar problem. Analysts with the Paragon Health Institute, undertaking a detailed analysis of the ACA’s 2025 data, estimated that 6.4 million enrollees were ineligible for taxpayers’ subsidies; persons enrolled by unscrupulous brokers or insurers without their knowledge and who did not submit a claim. Likewise, as part of a preliminary investigation to determine the program’s vulnerability to fraud, the Government Accountability Office submitted 20 applications of purely fictitious people for ACA exchange for taxpayer subsidized enrollment, and the ACA enrolled 19 of them. Sen. Mike Crapo. Chairman of the Senate Finance Committee, said it best: “Premiums and out-of-pocket costs are rising for all Americans, but as we look for ways to improve the health care system, this investigation serves as a stark reminder that we cannot simply throw good money after bad policy.”
Sen. Crapo is exactly right. The Congressional Democrats’ agenda of maintaining the bureaucratic status quo and papering over rising ACA costs with hundreds of billions of additional taxpayer subsidies—hiking the federal deficit by $350 billion over ten years—is an unaffordable response to the ACA’s affordability problem.
A New Direction. President Trump has proposed a revolutionary concept that would usher in a new era of real consumer and genuine market competition: Bypass the big insurance companies and redirect the generous ACA subsidies to eligible individuals and families through an updated system of health savings accounts. Make health plans and providers compete directly for patients’ dollars and unleash an unprecedented level of cost-cutting competition. Incidentally, McLaughlin and Associates conducted a national survey in January 2026 that found that 73% of respondents supported a proposal to “directly pay individuals by depositing health care dollars every year into a personal account.”
Congress should codify Trump’s proposal and complement it with a program of radical health care price transparency, targeting the oft hidden insurers’ negotiated prices with providers. Such a policy is embodied in The Patients Deserve Price Tags Act (S. 2355).
Knowing the price of a health care procedure is of limited value, of course, unless the patient can act and choose the most cost-effective provider and pocket the savings of making that choice. That is why the Heritage Foundation has championed a patient’s savings proposal, allowing patients to share directly the savings with an insurer when choosing a cost-efficient medical provider, and pocketing those dollars tax free.
Working with the White House, Congress can do a much better job in fixing America’s health care. And perhaps next year, there will be a real reason to celebrate.
