As Congress quarrels over whether to extend enhanced Affordable Care Act (ACA) subsidies, millions of Americans face uncertainty.

Many Republicans support repealing or reforming the massively flawed Obamacare scheme. Democrats, meanwhile, warn about mass coverage losses.

Both sides have a point — but both are also missing the bigger picture.

The real crisis in American healthcare isn't who subsidizes insurance premiums.

It's why the underlying cost of care keeps exploding in the first place.

Whether subsidies are extended or allowed to expire, someone still pays the bill.

And increasingly, that bill is being driven astronomically higher by hospital systems demanding reimbursement increases that far outpace inflation, wages, and economic growth.

No matter how creatively Congress rearranges the subsidies, patients, employers, and American taxpayers ultimately pick up the tab for those massive costs.

Nationally, contract fights between insurers and hospital systems are exposing just how aggressive these demands have become.

Health insurer Aetna accused UConn Health in Connecticut of seeking annual rate increases "multiple times higher than the state cost growth benchmark."

When those negotiations fell apart late last year, about 15,000 patients found themselves scrambling to find care.

UnitedHealthcare, meanwhile, claimed that LCMC Health in Louisiana demanded a 40 percent price hike — enough to position its hospitals as the most expensive in the New Orleans market and siphon an estimated $80 million from local employers' budgets.

These aren't one-off disputes.

They are symptoms of a growing national pattern.

Anthem publicly criticized Mercy Health in Missouri for requesting rate increases five times higher than inflation.

In a separate contract dispute, the insurer claimed Colorado's CommonSpirit Health sought increases more than three times the rate of inflation — even though it already ranked among the most expensive systems in the state.

In North Carolina, UnitedHealthcare warned that UNC Health's proposal would add $570 million in costs over just three years.

The story is always the same: hospitals push for massive increases, insurers push back, and patients are caught in the middle — either facing higher premiums or the threat of losing access to their doctors.

Yet this cost spiral is largely absent from the ACA subsidy debate.

Rather than work to get prices under control, policymakers argue over how much taxpayers should pay towards the tab.

Subsidies don’t lower costs; they only shift them. When hospitals succeed in extracting outsized reimbursements, subsidies become a transfer from taxpayers to powerful health systems.

The situation is even harder to justify when many of these systems operate as tax-exempt nonprofits.

In theory, a nonprofit status reflects a commitment to benefit the community.

In practice, it often comes with multi-million-dollar executive compensation and posh perks that are indistinguishable from the corporate world.

Compensation disclosures show Texas-based "nonprofit" hospital system Christus Health pays its CEO $11.7 million a year and 22 executives more than $1 million each in annual salary and benefits.

Christus Health also provides first-class and private flights for executives and spent $5.3 million sending employees to conferences in 2023.

Montefiore Health System in New York also authorized first-class travel for senior leadership. Additionally, the nonprofit paid executives more than $32 million in a single year, including more than $16.3 million to its CEO, according to IRS documents — while simultaneously demanding higher reimbursement rates.

This spending isn’t just limited to executive perks either. For instance, Montefiore also paid a famous graffiti artist to paint a mural.

Elsewhere, Maine Medical Center acquired a pizza place in Portland as part of its $512 million expansion.

Further afield, Missouri’s Mercy Health has more than $13 million in unexplained investments in Antarctica.

None of this questionable spending squares with the claim that hospitals need ever-larger increases to keep the lights on.

When hospital systems spend lavishly at the top while pressing insurers and patients to pay more and more every year, it's hard to not reach the conclusion that keeping prices low for patients is not the priority.

Extending ACA subsidies may temporarily shield some consumers from the pain. But it won’t change the trajectory of health care spending, which has nearly doubled over the past decade.

Real reform means tackling the source of the problem.

That starts with greater transparency in hospital pricing and contract negotiations, policing anticompetitive mergers, and enacting stricter standards for nonprofit tax exemptions that truly reflect community benefit.

Employers, patients, and taxpayers deserve a system that’s affordable because costs are reasonable and rooted in reality — not because Washington keeps taking more money out of taxpayers’ pockets.

Until lawmakers confront that reality, debates over Affordable Care Act subsidies will remain exactly what they are today: a distraction from the real drivers of America’s health care spending crisis.

Drew Johnson is a government watchdog and health policy analyst. He was the Trump-endorsed Republican nominee for the U.S. House of Representatives in Nevada’s 3^rd congressional district in 2024. Read more Drew Johnson Insider articles — Click Here Now.