President Donald J. Trump’s newly unveiled “Great Healthcare Plan” has drawn a mix of cautious optimism and sharp criticism from free-market advocates and libertarian think tanks, who argue the proposal remains a “skeletal” framework that fails to fully dismantle the regulatory infrastructure of the Affordable Care Act (ACA).
While the administration touts the plan as a way to slash prescription drug prices and maximize transparency, empowering patients over insurance companies, prominent voices at the Cato Institute and the Citizens’ Council for Health Freedom (CCHF) warn that the initiative may inadvertently expand government involvement in the medical marketplace.
One of the most praised aspects of the plan is the proposal to reclassify more prescription-only drugs as over-the-counter (OTC). Free-market experts argue this shift is essential for lowering costs and increasing consumer choice. Jeffrey A. Singer, a senior fellow at the Cato Institute, noted that moving medications to OTC status historically puts downward pressure on prices; for instance, the daily dose cost of the heartburn drug omeprazole dropped from $4.20 to $2.35 after its reclassification.
However, proponents of this reform urge the administration to go significantly further. Singer argues that the Food and Drug Administration (FDA) should remove barriers to hormonal contraceptives, HIV pre- and post-exposure prophylaxis (PrEP and PEP), and GLP-1 weight-loss medications.
“The potential for harm has never been a valid reason to treat adults as if they can’t make their own choices,” Singer stated, pointing out that many dangerous substances like acetaminophen and aspirin are already sold without a prescription. Expanding this list, he suggests, would return control to patients and promote active involvement in their own care.
“Obamacash” and the ACA Infrastructure
The most contentious element of Trump’s plan for libertarians is the proposed shift in insurance subsidies. Rather than sending billions in taxpayer funds to insurance companies, the plan seeks to send that money directly to eligible Americans to purchase the coverage of their choice—a move some have dubbed “Obamacash.”
Michael F. Cannon, a health policy expert at Cato, cautioned that this approach could actually expand the reach of the ACA rather than repeal it. Instead, Cannon advocates for “universal health accounts” that would allow workers to control the $1 trillion currently managed by employers, describing such a move as a tax cut larger than those enacted under the Reagan administration.
The Citizens’ Council for Health Freedom expressed similar concerns, stating that the plan “keeps in place the infrastructure that is hurting patients, doctors, and prices today.” Twila Brase, president of CCHF, argued that the plan fails to restore “real health insurance”—specifically, affordable major medical indemnity policies designed solely for catastrophic events, which are currently restricted under ACA regulations.
While Trump’s plan includes requirements for insurers to publish denial rates and overhead costs, free-market critics remain skeptical of the impact of such mandates. Brase noted that transparency alone does not create accountability if patients remain trapped in restrictive ACA networks. “Denial transparency does not prevent denials; competition does,” she remarked.
To address these distortions, CCHF has proposed that the administration require health plans participating in Medicare and Medicaid to pay the same price for the same treatment regardless of coverage, which they argue would reduce the “gaming” of government programs. Furthermore, they suggest giving Medicare recipients the option to take their funding and purchase private indemnity insurance instead.
Many in the libertarian community are pointing to Senator Rand Paul’s (R-Ky.) “Health Marketplace and Savings Accounts for All Act” as the necessary roadmap to flesh out Trump’s skeletal proposal.
Paul’s legislation would significantly expand Health Savings Accounts (HSAs), raising the annual contribution cap for individuals from $4,400 to $24,500 and making them available to all Americans. The bill also aims to de-link health insurance from employment by allowing membership entities—such as Costco or Amazon—to collectively bargain for lower insurance rates on behalf of their members.
The fiscal impact of the “Great Healthcare Plan” also remains a point of contention. The Committee for a Responsible Federal Budget (CRFB) estimated that while cost-reducing provisions could save $50 billion over a decade, the changes to ACA subsidies could increase the deficit by up to $350 billion, depending on the final design.
As the administration prepares to engage with Congress, the message from free-marketeers is clear: the plan contains “decent ideas,” but it must move toward a complete decoupling of the federal government from the healthcare market to be truly “great.”
“The Trump administration rightly recognizes that American health care needs reform,” J.D. Tuccille wrote for Reason, but added that the current plan needs to incorporate legislation that would “strip intrusive rules from medicine” and empower individuals over bureaucrats.