Healthcare feels different because patients are insulated from costs. When out-of-pocket spending is low, price signals vanish, removing the pressure to compete or shop for value. This "ratchet effect" occurs as rising prices trigger larger subsidies, shielding consumers while insurers and providers face less resistance to hikes. True reform requires pairing access with actual price discipline.

The ACA’s subsidies made coverage affordable for millions but also shielded consumers from rising prices. When costs are invisible, demand stays high regardless of price hikes. Providers raise rates, insurers pass them on, and subsidies absorb the blow, weakening natural cost discipline. Combined with essential benefit mandates and system complexity, the corrective feedback loop is muted.

Most healthcare debates focus on intentions, but systems are driven by incentives. When the ACA changed how prices and risk work, behavior changed too. Take the 3:1 age-rating rule: by limiting charges for older adults, the cost was shifted to the young. Many healthy people opted out, weakening the risk pool and raising premiums. Similarly, profit caps tied to a percentage of premiums can nudge insurers away from cost reduction. The system simply responds rationally to the ru

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