Healthcare Reform Is Not Optional

By John Hood

RALEIGH — The top priority among voters this year is affordability. Various polls in North Carolina and other states ask the question in various ways — sometimes asking respondents about “affordability” explicitly, or using such terms as inflation or the cost of living, or allow respondents to volunteer their own responses — but the answers all converge. Voters want their leaders to do whatever they can to make essential goods and services more affordable. Candidates who appear blasé about affordability are about to lose competitive races and, even in safe seats, draw fewer votes than normal.

To the standard trio of food, clothing, and shelter, most voters would add healthcare and energy as essentials. In the 2026 midterms, politicians cannot afford to ignore any of these issues, regardless of which office they seek.

On healthcare, for example, Democratic candidates, activists, and policy professionals have long offered a coherent policy agenda. Republicans have not. By no means am I equating coherence with prudence. I consider the Democratic approach to healthcare reform — a mix of incremental expansions of Medicare and Medicaid into something akin to a single-payer system, incessant litigation against private hospitals and insurers, and price caps — deeply misguided. Still, you can’t beat something flawed with nothing in particular.

As I’ve observed many times over the years, the problem isn’t a lack of alternative ideas among Republicans. The problem is too many alternative ideas. Some GOP politicians, activists, and policy professionals want Washington to play a dramatically smaller role in healthcare. I sympathize, especially on constitutional grounds, but the inescapable fact of the matter is that over the past half-century, the vast majority of Americans have come to accept the existence of Medicare and Medicaid as inevitable. They may be open to substantial reforms, including crackdowns on fraud and greater cost-sharing by upper-income households, but nothing more dramatic than that.

On the other hand, many GOP politicians, activists, and policy professionals believe the healthcare issue is so fraught with peril, with inherently more downside than upside, that their best strategy is tinker around the edges, bargain for somewhat-smaller cost increases, placate conservative-leaning interest groups, and then change the subject as quickly as possible.

Neither strategy will suffice in the present moment. If Republicans want to succeed in 2026, 2028, and subsequent cycles, they’ll need to work out a coherent approach of their own, one consistent with their stated conservative principles — fiscal restraint, freedom, enterprise, and personal responsibility — while also offering the promise of making healthcare more affordable for more people in North Carolina and beyond.

If I were in their shoes, I’d describe this coherent alternative with four terms: choice, clarity, creativity, and commitment.

• Choice. Policymakers should maximize the opportunity for individuals and households to choose the health plans, providers, and treatments that best meet their needs. Any tax breaks or subsidies offered to defray the cost of care should be available regardless of where and how recipients secure it. States should eliminate limits on competition among hospitals, doctors, nurses, and other providers, again allowing customers and patients to make the final choice, not regulators or lawmakers.
• Clarity. Hospital and doctor bills are so convoluted as to be practically useless. Patients fill out too many duplicative forms. Simplify, automate, and otherwise ensure informed consent and a true meeting of the minds.
• Creativity. New products and technologies (especially artificial intelligence) promise to revolutionize the diagnosis and treatment of many medical conditions. Through tax and regulatory policies at all levels of government — from free trade in drugs to local openness to data centers — policymakers should encourage such innovation.
• Commitment. Through Medicare and Medicaid, government has implicitly promised to keep people from being bankrupted by high medical bills due to accidents, disabilities, or advanced age. Keeping this commitment without sacrificing other public commitments or economic growth will require combating fraud while limiting subsidies to upper-income households.

Some of these ideas are harder sells than others. Nevertheless, I see no alternative but to, in fact, offer an alternative.

John Hood is a John Locke Foundation board member. His books Mountain Folk, Forest Folk, and Water Folk combine epic fantasy with American history (FolkloreCycle.com).