HJNO Jan/Feb 2026

WHAT’S WRONG WITH HEALTHCARE 20 JAN / FEB 2026 I  HEALTHCARE JOURNAL OF NEW ORLEANS   only one social responsibility of business — to use its resources and engage in activities de- signed to increase its profits so long as it stays within the rules of the game.” 3 Under this doctrine of shareholder primacy, health plans optimize for return on capital, not return on member health. Their board struc- tures, executive incentives, product designs, utilization management strategies, and admin- istrative processes all flow from this foundation- al principle. And in an industry where healthier patients often mean lower revenue, publicly traded insurers face a structural tension that cannot be solved by goodwill alone. When shareholder value becomes the dominant cus- tomer value proposition, patients cannot ever truly be the customer. As policymakers and politicians continue to struggle to solve the affordability crisis of healthcare, I am quite certain that both sides of the ideological spectrum will continue to point fingers at the other. Caught in the middle are the patients and providers who are working within a complex system that is not helping us realign in such a way that maximizes value cre- ation for patients. As an example of how government is current- ly failing to address the root causes of dysfunc- tion in healthcare, news headlines in the last months of 2025 were dominated by the loom- ing premium spikes expected to occur for mil- lions of patients who depend on the Affordable Care Act’s enhanced subsidies. As these de- bates intensified, one of my former instructors, and a man I deeply respect, Sen. Bill Cassidy, emerged as one of the more vocal Republican policymakers offering an alternative lens on the looming premium shock if the enhanced ACA subsidies were allowed to expire. Rather than supporting another multiyear extension of these subsidies — which were originally enacted as temporary pandemic re- lief — Cassidy proposed redirecting much of the federal spending on enhanced premium tax credits into individual Health Savings Ac- counts (HSAs). In his framing, the goal was to push purchasing power directly to individuals, allowing them to control more of their own healthcare dollars rather than subsidizing premiums through insurers. These HSA funds could be used for deductibles, copayments, medications, imaging, and a wide variety of out-of-pocket expenses, though not for premi- ums themselves. Cassidy argued that this structure empowers patients as true consumers while reducing the federal government’s role in propping up insur- er-based premium subsidies that he believes distort the underlying cost structure. In short, his proposal attempted to blunt the impact of rising premiums by shifting financial agency to individuals rather than continuing large direct subsidies to insurance companies. More broadly, Cassidy’s approach reflects a longstanding Republican mindset around healthcare economics: that affordability im- proves when individuals, not intermediaries, are placed at the center of financial decision- making. From this perspective, government subsidies — even those designed to help mid- dle-class families afford coverage — risk mask- ing the underlying price inflation and entrench- ing insurer-driven market dynamics. Republicans who support this approach ar- gue that continually expanding subsidies sim- ply pours more federal dollars into a system that has failed to address cost growth at its root. They view HSAs, price transparency, ben- efit redesign, and consumer-directed tools as mechanisms to realign incentives, increase in- dividual responsibility, and allow market forces to exert downward pressure on prices. Critics of this view counter that healthcare is too com- plex and too consolidated for consumerism alone to stabilize premiums. Understanding this ideological divide is cru- cial: One side believes the government should stabilize premiums by renewing enhanced sub- sidies; the other believes that doing so merely feeds an inflationary system and that empower- ing individuals directly — rather than insurers — offers a more durable economic path. Both are trying to solve the same problem, but from fundamentally different theories of change. Both approaches might soften the blow of premium spikes in the short run, but neither fundamentally rewrites the rules of how care is delivered and paid for. And as much as I respect Sen. Cassidy, I would maintain that such thinking falls into a short-term mindset of prob- lem-solving, lending itself to a whack-a-mole approach to healthcare dysfunction rather than a completely new way of thinking about how to solve the problems of healthcare at its core. Only by completely reenvisioning the structure of healthcare delivery and reengineering the system to be built directly and explicitly around improving health and health outcomes will we ever solve the affordability crisis of healthcare. Overcoming the Courage Gap at the Heart of Reform If I had to name a realistic starting point for change, it would be the large public purchas- ers of healthcare — especially the Centers for Medicare & Medicaid Services — which already writes many of the rules for how money flows through the system. When CMS, large self- insured employers, and a critical mass of com- mercial payers begin to pay explicitly for health and outcomes rather than units of service, de- livery systems will reorganize faster than most people expect. In the end, our problem is not a shortage of ideas, subsidies, or slogans; it is a shortage of structural courage. We keep rearranging the financing — more subsidies, fewer subsidies, bigger HSAs, new plan designs —while leaving intact a delivery system and economic architec- ture that were never built around improving health and health outcomes per dollar spent. As long as hospitals, health plans, employ- ers, and government agencies are rewarded primarily for managing transactions, shifting costs, and winning zero-sum battles over who pays, patients and frontline clinicians will con- tinue to feel like collateral damage. The real breakthrough will come only when we insist that every major actor in healthcare competes on a single, shared customer value proposition: creating better health and better lives for the people we serve at a sustainable and afford- able cost. Until we redesign the rules of the game to re- ward that kind of value, our debates will remain noisy, our fixes will remain temporary, and our frustration will remain justified — because at its core, what’s wrong with healthcare really is the economics. n REFERENCES 1 Wikipedia. “It’s the economy, stupid.” Last modified November 8, 2025, 14:57 (UTC). https:// en.wikipedia.org/wiki/It%27s_the_economy, _ stupid. 2 Porter, Michael E., and Elizabeth Olmsted Teisberg. Redefining Health Care: Creating Value- Based Competition on Results. Boston: Harvard Business School Press, 2006. 3 Friedman, Milton. “The Social Responsibility of Business Is to Increase Its Profits.” The New York Times Magazine, September 13, 1970.