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REPUBLICANS WILL NEVER FIND A HEALTH CARE REPLACEMENT  
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Ryan Cooper
November 18, 2025
The American Prospect
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_ The GOP is too wedded to free markets and scornful of the welfare
state to ever make anything in health care work. _

, J. Scott Applewhite/AP Photo

 

Republicans, for once, are sounding downright squeamish about
onrushing massive cuts to Obamacare subsidies, with premiums on the
exchanges expected to more than double on average starting next year.
GOP House committee chairs are reportedly having some “brainstorming
sessions
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about what to do, and House Speaker Mike Johnson claims
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that they will “be rolling out some of those ideas” at some point.

So far, the genius idea in the lead is Trump’s pitch to reroute
subsidies from health insurance companies to the American people, so
they can buy health care. (House Republicans have already filed a bill
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that looks like this.) When asked whether people wouldn’t then just
use that money to buy health insurance, Trump replied
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“Ahh … some may. I mean, they’ll be negotiating prices.”
Congratulations, folks, you now get to be your own private dealmaker
with the health care system, and with your purchasing power and risk
pool of one household, I’m sure you’ll get the best price!

The stupidity is the point. For decades now, the Republican Party has
been dedicated to the proposition that rich people are too highly
taxed and the working and middle classes get too many benefits from
the government. With the passage of the One Big Beautiful Bill, they
have finally caught the car. Medicaid and Obamacare have been slashed
to free up budget headroom for tax cuts heavily slanted to the
wealthy. Republicans don’t have a “health care plan” per se
because this is their plan: to take your health care funding and give
it to Elon Musk, Donald Trump, and the rest of the fascist billionaire
class.

American conservatism is a strange political beast. Like all
conservatisms across the world, it stands in defense of hierarchy and
privilege, but it is welded clumsily to 19th-century orthodox
capitalism. By this view, all income should come from working or
owning property, and all goods and services should be obtained through
the market. It would be unjust for anyone to receive a welfare benefit
from the government, because they did not work to earn it. This is a
philosophical problem for conservatism, as George Scialabba writes
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because capitalism regularly and wildly disrupts the established
social order as technologies and businesses evolve. (For the record,
this view is also very stupid
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But it’s a much more practical problem for a Republican trying to
write a health care policy. Health insurance is straightforwardly
impossible to square with capitalist morality for reasons a child can
understand. Most obviously, people routinely get very sick or injured
through no fault of their own, and require care that is far more
expensive than they can afford out of pocket. Sometimes people have
chronic conditions that cost many multiples of what they could ever
possibly earn. Therefore, unlike the market for car or home insurance,
where each person is charged exactly what they are statistically
expected to claim (plus a margin of profit), any functioning health
insurance scheme must have systematic transfers from the young and
healthy to the elderly and sick.

With a pure market approach, only the very rich will be able to get
all the health care they need. Even people making well into six
figures will not be able to afford elaborate surgery or cutting-edge
therapies out of pocket. The poor—or really anyone living paycheck
to paycheck—will not get health care at all. Before Obamacare, that
was the reality for many
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with the only “insurance” available on the market being de facto
worthless if you ever actually needed it.

This is what led early socialists and social democrats to advocate for
national health insurance, run by the government. If the market is a
fundamentally stupid way to pay for medical treatment, then throw
everyone onto the same program, and fund it out of taxes. That way,
the risk pool and the funding base will be as large as possible,
people will be charged based on their ability to pay, and all citizens
will be permanently insured. And historically, the fact that both the
elderly and the poor were largely uninsured up through the early 1960s
was a major motivation for the creation of Medicare and Medicaid.

Republicans have hated Medicare and Medicaid since the moment they
were proposed, because they’re welfare programs. Ronald Reagan got
his start in politics with an unhinged mini-documentary
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lead to a totalitarian dictatorship. Historically, Medicare has been
too politically secure to touch—at least for now—but Republicans
finally took a trillion-dollar bite out of Medicaid in the One Big
Beautiful Bill.

Now, it is possible to set up a health insurance system based on
markets: It’s called the Obamacare exchanges. All you have to do is
set up an elaborate system of regulations to prevent the market from
doing the thing it normally does, namely ration health care by price.
You provide subsidies so people can afford premiums, and then forbid
insurers from discriminating against sick people (guaranteed issue),
or creaming off the healthy people (community rating), plus many, many
other regulations. It’s basically a highly inefficient pantomime,
but it does sort of work if it’s funded and regulated properly.

 

But Republicans hate this too. That’s why they voted dozens of times
to repeal Obamacare, and why they shut down the government and
illegally halted SNAP benefits rather than agree to Democrats’
demands to extend the enhanced Obamacare subsidies that were finally
set at a high enough level to make the system affordable.

Their replacement “ideas” consist of either shifting the subsidies
to people, who will then find out that they’ll have to use the money
to buy health insurance. As some Freedom Caucus members recently
floated
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that could translate into pre-Obamacare fake insurance, which does
nothing for people when care is actually needed.

It’s not impossible for conservatives to have a semi-workable health
care policy. In many European countries, conservative parties emerged
from a tradition of church and king, and are not so wedded to
capitalist morality. It was the German arch-reactionary Otto von
Bismarck, for instance, who set up Europe’s first national health
insurance scheme, in an attempt to steal a march on the German
socialists and win some support from the working class. The German
corporatist welfare system as it subsequently evolved is worse than
the Nordics’, but it’s better than America’s.

Absent a philosophical revolution that is nowhere in evidence,
however, American conservatives will never have a health care plan
worthy of the name. There is no way to improve the system without some
combination of regulations, subsidies, or expansion of public
programs. Rather than grappling with that obvious fact, and embracing
Obamacare as the most ideologically palatable option on offer—or
moving toward some Herrenvolk-style whites-only health care—under
Trump the party has doubled down on Reaganite tax and welfare cuts
that will gravely harm their own voters
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A handful of vulnerable Republican members of Congress might be
bullied
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supporting Obamacare subsidies, but that’s about it.

If Americans want better, cheaper health care, they should not vote
for the party of mindless cruelty and destruction for its own sake.

===

RYAN COOPER is the _Prospect_’s managing editor, and author of _How
Are You Going to Pay for That?: Smart Answers to the Dumbest Question
in Politics_
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was previously a national correspondent for _The Week_. His work has
also appeared in _The Nation_, _The New Republic_, and _Current
Affairs_.

 

* Afordable Care Act; Republicans;
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