HJAR Mar/Apr 2026

HEALTHCARE JOURNAL OF ARKANSAS I  MAR / APR 2026 17 volume over value. Changing who holds the money does not immediately change what the system is engineered to produce — especially when profound asymmetry of information is baked into the transaction. The Great Healthcare Plan: A Familiar Bet on Consumerism The latest version of this idea has been recently formalized in the White House’s “Great Healthcare Plan,” which proposes shifting ACA-related subsidy dollars away from insurers and instead sending funds directly to eligible Americans to purchase coverage of their choice. It pairs that consumer-directed approach with several reforms that are broadly popular across the political spectrum: tightening expectations around price transparency, forcing insurers to disclose overhead and denial rates, targeting pharmacy benefit manager “kickbacks,” and expanding access to certain “verified safe” medications through over-the-counter availability. In isolation, many of these proposals are directionally reasonable. Transparency should be easier, not harder. Patients should not need a graduate education to understand what a plan covers. And PBM incentives deserve scrutiny because they can distort prices and obscure where dollars actually go. But it is important to separate reforms that improve consumer experience and visibility from reforms that change the production function of healthcare — the way the system generates utilization in the first place. The Great Healthcare Plan’s centerpiece — sending money directly to consumers — is best understood as a change in financial routing, not a redesign of healthcare delivery. Even if the money arrives in the patient’s pocket in- stead of an insurer’s ledger, the same supply- driven forces remain intact: fragmented care, specialist-dominated decision-making, pro- cedure-driven revenue, and a delivery system built to monetize illness more reliably than it produces health. Healthcare spending will not stabilize until we change the underlying struc- tures that generate preventable illness and re- ward volume over outcomes — not simply the pathway through which dollars are handed out. engines, because when you are insulated from marginal cost, efficiency stops being decisive. Automakers, responding rationally, would build exactly those vehicles. Over time, fuel efficiency would stop being a competitive advantage. Manufacturers would win by offering cars that feel safer, bigger, and more luxurious — because fuel costs would no longer be the consumer’s problem. The entire transportation system would drift toward higher consumption not because drivers are irrational, but because incentives would reward it. Healthcare behaves the same way. When patients are shielded from marginal cost and providers are paid on volume, utilization rises, intensity increases, and the system evolves toward overdiagnosis, overtreatment, and ever-increasing complexity. Spending doesn’t stabilize — it accelerates. The core problem isn’t that consumers are irresponsible. It’s that the market cannot function normally when the product is technically complex, the seller advises the buyer, and the seller is paid more when the buyer consumes more. TheWrong Fight, Again Every few years, Washington rediscovers the same argument: If healthcare is too expensive, we must be handing the money out the wrong way. Today that debate centers on whether ACA subsidies should be renewed in their current form or redirected straight to consumers. Supporters of consumer-directed subsidies aren’t entirely wrong: Moving dollars closer to patients can increase agency and transparency, and in a truly competitive market, it might exert some downward pressure on prices. But healthcare is not a truly competitive market — and pretending otherwise does not make it so. Simply transferring subsidies into consumers’ pockets does not redesign the healthcare delivery system any more than reimbursing drivers for gasoline would suddenly transform the automobile and transportation industries. The roads stay the same. The engines stay the same. The vehicles stay the same. In healthcare, the same specialists still practice, the same scanners still hum, the same hospitals still fill their beds, and the same incentives still reward Thus far in this series of trying to discern what’s wrong with healthcare, we meandered through the history of health insurance, indeed examining its very soul. We examined the role of providers in contributing to some of what is wrong. Then we debated the controversial issue of utilization management along with the current state of political polarization when it comes to healthcare’s woes before finally arriving at a diagnosis that asserts the most fundamental problem of what’s wrong with healthcare is that its economics do not align with rewarding those payers and providers who are most successful at improving health and health outcomes. And so, having come up with a diagnosis, we turn our attention to treatment. In this issue, we attempt to answer the question, “Where do we go from here?” by starting with current proposals that dominate the political debate. Some policymakers argue that giving Affordable Care Act subsidy dollars directly to consumers — as cash or health saving account (HSA) deposits — will lower total healthcare spending by turning patients into more prudent purchasers. The intuition is familiar: If people feel the cost, they will choose less. The problem is that this theory assumes patients, rather than the healthcare delivery system, are the primary drivers of utilization. Decades of work on unwarranted variation in healthcare service delivery by Jack Wennberg, MD and others suggest the opposite: Healthcare spending is dominated by supply-driven demand. More specialists lead to more procedures, more scanners lead to more imaging, and more hospital beds lead to more hospitalizations — often independent of patient preference or clinical necessity. In that environment, changing the path that subsidy dollars take does little to change what the system produces. To see why, imagine if gasoline worked the way healthcare does. Suppose we all paid monthly premiums into a third-party “fuel insurance” system, and that system reimbursed us every time we filled up our tank. Gas would feel cheap — maybe even free — at the point of use. We would not suddenly become more fuel-efficient consumers. We would buy bigger vehicles, heavier SUVs, and more powerful