Why Aren’t More Health Policy Commentators Libertarians?

This is the sort of essay I love. I had no idea what to expect. I wanted to object to nearly every sentence until the following sentence made me reconsider my objections. I’m still not sure my opinions have changed, but I am certainly better for having read this.

Adam Cifu

“The history of public control should not lead anyone to think that government can deliver health care efficiently.” Two coauthors and I wrote those words in February. Since then, the many downsides of centralized governmental control of the healthcare system have become even clearer. The federal government is shut down because Republicans and Democrats disagree about extending the ACA super-subsidies. Patients are having telehealth appointments cancelled because Congress let Medicare coverage lapse. The NIH’s staff has been reduced by 75 percent, and “almost all administrative activities” have been halted. The FDA has stopped accepting new applications for drug and device approvals. And CMS is keeping doctors guessing as to whether they will be paid for treating Medicare patients.

Even before the shutdown, the news was bad. President Trump exacerbated the shortage of primary care services in rural areas by defunding many clinics. “More than 700 rural hospitals—one-third of all rural hospitals in the country—are at risk of closing because of the serious financial problems they are experiencing.” “[E]mployers … are facing the stiffest increase in health costs in more than a decade” and are expected to pass much of the burden onto workers. Californians, Pennsylvanians, Michiganders, and residents of other states who purchase ACA-compliant insurance policies are about to be hit with double-digit premium hikes. Federal employees who participate in the government’s insurance program “will pay an average of 12.3% more” in 2026, this after premiums were raised 13.5% in 2025. The FDA was mired in controversy as the rate of drug approvals slowed and the agency’s efforts to raise scientific standards spawned a backlash. Etc. Etc. Etc.

The government’s incompetence was also on display at the recent press conference President Trump and HHS Secretary RFK Jr. held on autism. Arthur Caplan, a professor at NYU Langone, had this to say about the presentations.

The announcement on autism was the saddest display of a lack of evidence, rumors, recycled old myths, lousy advice, outright lies, and dangerous recommendations by anyone in authority in the world claiming to know anything about science that I have ever witnessed…

There is no point in refuting the entire flood of nonsense released during this pathetic event. What has to be said is that given this performance, given the unhinged behavior of Kennedy, given the president’s total lack of knowledge about health and science, and given the sycophantic behavior of his top medical and science officials, one thing is clear: Americans cannot trust their government…

Other mainstream commentators are also aghast. One wrote that “[m]edical professionals can no longer fully trust federal health guidance, and our patients are the ones who will suffer the most.” Another urged doctors to ignore the recommendations of the CDC’s Advisory Committee on Immunization Practices (ACIP) after RFK Jr. stacked it with “handpicked vaccination opponents.” In June, months before the autism program, more than 6,000 health professionals signed an open letter accusing the Trump Administration of dismantling the “agencies and programs that protect medical care and public health in our country.” “[M]ore than 400 NIH scientists signed an open letter … criticizing the Trump administration over recent actions that undermine the institutes’ mission and threaten to harm the public’s health.” “Across the country, policymakers, scientists, health professionals, and advocates are calling to remove politics from vaccine policy, to promote evidence-based health policy, and to remove [RFK Jr.] as health secretary.”

Yet, as far as I have been able to discover, the widespread desire to “remove politics” from health care policy has not led a single mainstream commentator to call for downsizing the government’s role.

That includes Arthur Caplan. After the shutdown started, he came out in favor of extending the ACA super-subsidies, a policy that would increase federal spending on health care by $450 billion over the next decade. Despite thinking that Trump, RFK Jr., and their cronies are worse than incompetent, Caplan would give them almost a half-trillion dollars extra to play with.

The scientists and medical professionals who condemned RFK Jr.’s handling of ACIP are not demanding less government involvement either. They want ACIP to be restaffed, not eliminated. They are urging state governments to intervene too, as if the way to “remove politics” from health care policy is to bring in more politicians.

As a student of government, I know that many politicians are venal, ignorant, scheming, corrupted by special interests, unprincipled, and incapable of managing complex systems. Because I expect the worst from them, nothing the Trump Administration does surprises me. Others may have been shocked to learn that the One Big Beautiful Bill Act will add $8.8 billion to Medicare spending rather than the $4.9 billion Americans were told because drug makers convinced Congress to exempt certain pharmaceuticals from price negotiations. But knowing how Congress works, I am happy that the original estimate was off by only 80%. “A 1967 estimate by the House Ways and Means Committee predicted that, in 1990, Medicare’s total cost would be $12 billion. The actual cost was $98 billion—eight times as much.”

What I fail to understand is why mainstream commentators expect better. To me, the doctors and academics who support the ACA, Medicare For All, the public option, and other government-centric policies seem to be as ignorant of politics as Trump & Co. are of medicine.

Continued support for public control seems even harder to explain when one considers the frequency and intensity with which the parties and their proxies clash over health care policy. In 2010, the Democrats rammed the ACA through Congress without the support of a single Republican. Since then, “Republicans have tried [to weaken or kill the program] more than 70 times.” Wars have been waged over the constitutionality of the ACA; repeal of the statute itself; state adoptions of the Medicaid expansion; funding for abortions, contraception, and gender-supportive therapy; the propriety of the FDA’s approval of mifepristone; work requirements for Medicaid; the make-up and ideological leanings of the USPSTF; coverage for preventive services and end-of-life consultations; religious exemptions to vaccination requirements; stem cell research; Medicare drug price negotiations; etc. etc. etc. Just this week, Trump fired 1,100 HHS employees who worked on programs that were “Democrat-oriented.” The battle over the ACA super-subsidies is just one more fight in a never-ending partisan conflagration.

Do we really want a health care system that encourages lawsuits and political skirmishes more efficiently than it treats patients? Mainstream health policy commentators must, because that is what a system run by politicians will always do. The system’s major defects, including provider shortages, excessive spending, absurd prices, surprise bills, ever-rising insurance premiums, site-of-service differentials, annual fraud losses exceeding $100 billion, and perpetual political turmoil, are all traceable to public control. The retail health sector, in which consumers pay for services directly, experiences none of these shortcomings. Consumers get what they want at prices they can afford. And because the retail sector is privately run and financed, it contributes nothing to the national debt.

The title of this essay asks why so few health policy commentators are libertarians. I can pose the question but not answer it. I’m ready to be enlightened, but if you think the answer has something to do with the moral responsibility to help the poor or the problem of market failure, please think again before responding. We can help the poor, as we do through Social Security and the Child Tax Credit, without putting the government in charge of the health care system. And the fact that markets are imperfect does not imply that public control is better. Economists coined the phrase “government failure” to describe the many instances in which public intervention makes things worse. That is what happens when the government controls the health care system.

Charles Silver holds the Roy W. and Eugenia C. McDonald Endowed Chair in Civil Procedure at the School of Law, University of Texas at Austin. He is also an Adjunct Scholar at the Cato Institute.