The GOP’s Eight-Year Search for a Healthcare Plan (Still Missing)

What the subsidy collapse reveals about the system they’re building instead.

Congress managed to do the most predictable thing in Washington and still make it shocking: both parties brought their healthcare bills to the Senate floor, and both went down in flames, leaving 21.8 million Americans staring down premium hikes that will make health insurance a luxury good by New Year’s Day. It was the grand finale of the shutdown deal, Democrats got their promised vote, Republicans got to say they’d held one, and the American public got nothing but the bill.

If this all feels familiar, it’s because we’ve been living inside a rerun since at least 2017. The GOP has had eight years to produce an alternative to the Affordable Care Act. Eight years of promises, white papers, task forces, glossy pamphlets, angry Fox monologues, Heritage Foundation op-eds, and whatever that PowerPoint was that Paul Ryan used to carry around like a toddler clutching a security blanket. And yet when the subsidies are about to vanish, when premiums are about to double, when insurers are openly gaming the marketplace because no one knows what system they’ll be operating under in ten days… the Republican Party once again shows up empty-handed.

Or maybe “empty-handed” is the wrong phrase. Maybe they arrived with something else entirely.

I want to be clear: what follows is not an accusation. It’s an exploration of incentives, of how power, policy, money, and ideology tend to align in American healthcare. Sometimes the patterns themselves are the story.

Let’s start with the appointment that should have gotten more attention: Dr. Mehmet Oz becoming the 17th Administrator of the Centers for Medicare & Medicaid Services. CMS is not some ceremonial post. It is the most powerful healthcare regulator in the country, sitting atop more than a trillion dollars in annual spending and directly setting the rules for Medicare Advantage, the fastest-growing, most profitable sector of the insurance industry.

Before his appointment, Oz’s Senate disclosures showed he held up to $600,000 in UnitedHealth Group stock. To be absolutely fair, many wealthy people hold UnitedHealth stock. It has been a wildly successful company. And we do not know what his financial position is today, nor do I claim that he is shaping policy for personal benefit. What we can say is that CMS is now led by someone whose public record consistently praised private-sector models of care, precisely the models fueling the breathtaking expansion and profitability of Medicare Advantage.

And it just so happens that Project 2025’s health blueprint, which the Trump administration is cherry-picking from like it’s a post-apocalyptic Sears catalog, lays out a future where Medicare Advantage becomes the default for seniors, the program’s oversight is weakened, and the private insurers running the MA machine get a great deal more latitude.

None of this proves intent, but it does raise reasonable questions about the direction of travel.

The Senate votes made crystal clear that Republicans do not intend to extend the ACA subsidies, even though the premium tax credits are the only thing preventing the exchange from collapsing into a high-risk, high-cost wasteland. The GOP alternative, Cassidy and Crapo’s HSA coupon program, wasn’t a healthcare plan; it was a polite suggestion that Americans should try budgeting while the house burns down.

Republicans insist they want to “give money to the people, not the insurance companies,” which is an interesting line considering the companies that stand to profit most from the broader Trump-era health agenda aren’t the ACA insurers at all. They’re the giants of Medicare Advantage and the sellers of short-term “junk” plans that blossom in deregulated soil.

Again, no accusations, just an observation about who gets squeezed and who gets rewarded.

If the ACA exchange melts down because subsidies vanish, who exactly picks up the slack? It won’t be Medicaid, which the administration is already tightening, and it won’t be employer plans, which continue to shrink as more companies drop coverage or push workers into bare-bones options. It certainly won’t be some vibrant new market of affordable private choices waiting in the wings to rescue families from premiums that have doubled overnight.

What fills the gap instead is far more familiar: the short-term “junk” plans that flourish in deregulated markets; the high-deductible policies lashed to health savings accounts that shift nearly all upfront costs onto patients; the expanding universe of privatized Medicare products; and, of course, whatever Frankenstein’s monster the House GOP unveils next month and insists will “lower costs for everyone.” These aren’t solutions so much as escape hatches for insurers, mechanisms that shift more and more of the financial burden onto patients while shifting more and more revenue toward private middlemen.

Subsidies stabilize markets. Markets without stabilization implode. When they implode, people beg for relief. When people beg for relief, the party in power gets to define what “relief” looks like.

Republicans cannot produce a true ACA replacement because all functional healthcare systems require things conservatives have spent a generation opposing: subsidies, regulation, risk-sharing, guardrails, negotiation power, and non-profit public oversight. Remove those, and you’re left with the American health-care equivalent of a 1970s muscle car: loud, beautiful to some, financially ruinous, and completely incapable of passing a modern safety inspection.

When the Senate votes failed, what died was not just an extension of subsidies, it was the pretense that this is a debate about affordability. It is a debate about structure, about ownership, about who controls the trillion-dollar river that flows through the U.S. healthcare system.

Maybe that’s why the absence of a GOP plan feels less like incompetence and more like a choice. If you cannot build a replacement, you can dismantle the existing structure and let the private sector backfill the vacuum.

If Medicare Advantage is ascendant, if CMS is led by a man whose career has been intertwined with private-sector medicine, and if deregulation is the only health policy that can pass the Republican House… well, those are simply facts the public should keep in mind as the system reshuffles itself.

To be clear, I am not alleging some grand conspiracy. I’m suggesting that the forces shaping U.S. healthcare often grow from incentives rather than villainy. But the result is the same for the public: instability on the ACA side, privatization on the Medicare side, and an ever-expanding marketplace in which the price of staying alive is recalibrated upward every single year.

Sometimes you don’t need a smoking gun, you just need to look at who keeps getting burned. Then examine who keeps breathing just fine on the other side of the fire.