Testimony: Practical steps Congress can take to bring down health care costs
On Wednesday, December 10, 2025, Yale Professor Zack Cooper testified on Capitol Hill that subsidies for ACA individual marketplace plans should be extended and encouraged Congress to do more to rein in health care spending.
This testimony was delivered before the House Judiciary Subcommittees on Oversight and Antitrust on December 10, 2025.
Zack Cooper is an Associate Professor of Public Health and Economics at Yale University and the Director of Health Policy at Yale's Tobin Center for Economic Policy.
Opening Remarks
Good afternoon, Chairman Jordan, Chairman Van Drew, Chairman Fitzgerald, Ranking Members Raskin and Crockett, and Members of the Subcommittees.
My name is Zack Cooper1. I am a health economist and a professor at Yale University, where my research focuses on understanding the drivers of health care spending growth in the United States and how health spending impacts the wider economy.
I greatly appreciate the opportunity to testify before the Committee.
A decade ago, in my health economics class, when I taught my students about what the literature suggested about the relationship between health insurance, health, and mortality, I told them that I thought health insurance was a financial tool that did not impact health outcomes.
A decade later, my views have changed.
The clearest evidence we have is that enrolling an American in an Affordable Care Act Marketplace plan makes them less likely to die.2
The enhanced ACA subsidies that help approximately 22 million people purchase those plans are set to expire at the end of the year. The people getting health insurance on the exchanges are farmers and ranchers; they’re cooks in small restaurants; and they’re contractors who run their own businesses.
If those subsidies end, the premiums people pay will skyrocket, and approximately 4 million people will lose coverage.3 Extending them matters.
But if we focus only on whether the subsidies remain in place, we are having the wrong conversation.
The real problem we’re facing in this country is the underlying cost of health care.
The growth in health spending is what makes the subsidies necessary in the first place. It is driving up premiums for employer-sponsored insurance, and it is driving up premiums on the exchanges.
Rising health care spending is crushing families; it’s slowing wage growth; and reducing employment for Americans earning less than $100,000 a year outside the health sector.4
Next year, premiums for employer plans are expected to increase by 10%.5 Premiums on the exchanges are projected to rise 18%.6 This premium growth is largely being driven by the growth we’re seeing in hospital and provider prices—think mergers, staffing shortages, and the impact of tariffs on medical devices—and then there is increasing use of GLP-1s.
As the Congressional Budget Office notes, exchange plans are seeing a sharper increase than employer plans because of the uncertainty over the expiration of the subsidies.7 Insurers had to factor in the risk that, if the subsidies expired, healthier people would be less likely to buy insurance, which would lead to a sicker insurance risk pool.
Price growth is our core problem. Over the last two decades, prices in the hospital sector, for example, have grown faster than prices in virtually any other sector of the economy.8 We have seen huge numbers of hospital mergers, mergers of hospitals and physician practices, and mergers of pharmacy benefit managers.9
There are practical steps Congress could take to address this.
The first is introducing so-called site-neutral billing.10 Medicare often pays more—sometimes double—for the same service when delivered in a hospital versus an independent physician’s office. That encourages consolidation and drives up premiums.
A second is increasing funding for antitrust enforcement. Increasing enforcement budgets is cost-effective and makes a difference.11
Finally, we should begin serious exploration of larger health care reforms that could be implemented over the next decade. During the shutdown, one idea that briefly surfaced was a bipartisan commission to study ways to lower health care spending. That commission shouldn’t be a footnote—it’s essential.
Now, a brief word on fraud. As the GAO report makes clear, there is a fraud risk on the exchanges.12 And in 2024, CMS took action to suspend 850 agents and brokers from the federally run marketplaces because they had reasonable suspicions of fraud. We shouldn’t tolerate fraud and should work to stop it.
However, my read of the literature is that fraud is not a primary driver of the growth we’re seeing in health care spending. What’s really driving the premium growth is growth in providers’ prices.
We, as a country, have failed to take the steps necessary to make health care affordable. My insurance coverage is good. I’m going to assume most people in this room have good insurance coverage.
The reason I think the subsidies are important is because lower- and middle-income Americans shouldn’t be left uninsured or be stuck paying astronomical premiums because policymakers and health care purchasers, like large employers, have failed to make tough choices and rein in health care spending.
Subsidies alone aren’t a solution; they buy us time. The point is to use the time they provide to build a system where coverage is affordable because care is affordable.
In what follows, I provide a more detailed summary of the consolidation that has occurred in the US health industry and described how it has impacted domestic health spending.
1I am testifying on my own behalf, not on behalf of Yale University, and the views expressed are my own.
2Jacob Goldin, Ithai Z Lurie, Janet McCubbin, Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach, The Quarterly Journal of Economics, Volume 136, Issue 1, February 2021, Pages 1–49, https://doi.org/10.1093/qje/qjaa029.
3 See Phillip Swagel, “Re: The Estimated Effects of Enacting Selected Health Coverage Policies on the Federal Budget and on the Number of People With Health Insurance,” CBO, September 18, 2025 and Matthew Buettgens, Michael Simpson, Jason Levitis, Fernando Hernandez-Lepe, and Jessica Banthin, “4.8 Million People Will Lose Coverage in 2026 If Enhanced Premium Tax Credits Expire,” (Washington, DC: Urban Institute, 2025). The Congressional Budget Office (CBO) estimates that 3.8 million will lose their insurance coverage. The Urban Institute, using a similar approach, estimates that eliminating the Premium Tax Credits would lead 4.8 million people to lose coverage.
4Brot-Goldberg, Zarek, Cooper, Zack, Craig, Stuart, Klarnet, Lev, Lurie, Ithai, Miller, Corbin. Who Pays for Rising Health Care Prices? Evidence from Hospital Mergers. NBER Working Paper No. 32613, June 2024, revised Dec. 2024. National Bureau of Economic Research, 2024. https://doi.org/10.3386/w32613.
5 Anna Wilde Mathews. “Health Insurance Costs to Rise by Most in Years.” The Wall Street Journal, 10 Sept. 2025, www.wsj.com/health/healthcare/health-insurance-costs-rise-6cc1b934.
6Ortaliza, Jared, et al. “How Much and Why ACA Marketplace Premiums Are Going Up in 2026.” Peterson-KFF Health System Tracker, 6 Aug. 2025, https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2026/.
7 Congressional Budget Office. The Estimated Effects of Enacting Selected Health Coverage Policies on the Federal Budget and on the Number of People With Health Insurance. Report No. 61734, 18 Sept. 2025, cbo.gov/system/files/2025-09/61734-Health.pdf.
8 Mike Cummings. “Lax antitrust enforcement linked to rising hospital prices.” Yale News, April 24, 2024. https://news.yale.edu/2024/04/24/lax-antitrust-enforcement-linked-rising-hospital-prices. Cooper Z, Craig S, Gaynor M, Harish NJ, Krumholz HM, Van Reenen J. Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007-14. Health Aff (Millwood). 2019 Feb;38(2):184-189. doi: 10.1377/hlthaff.2018.05424.
9 Brot, Zarek, Zack Cooper, Stuart V. Craig, and Lev Klarnet. 2024. "Is There Too Little Antitrust Enforcement in the US Hospital Sector?"American Economic Review: Insights 6 (4): 526–42. Zack Cooper, Stuart V. Craig, Aristotelis Epanomeritakis, Matthew Grennan, Joseph R. Martinez, Fiona Scott Morton, and Ashley T. Swanson, "Are Hospital Acquisitions of Physician Practices Anticompetitive?," NBER Working Paper 34039 (2025), https://doi.org/10.3386/w34039.
10Cooper, Zack, Elizabeth Jurinka, and Daniel Stern. Review of Expert and Academic Literature Assessing the Status and Impact of Site-Neutral Payment Policies in the Medicare Program. Tobin Center for Economic Policy, Yale University, 30 Oct. 2023. https://tobin.yale.edu/sites/default/files/2023-10/Site-Neutral%20Payment%20Literature%20Review%2010302023.pdf
11 Cooper, Zack, and Martin Gaynor. Addressing Hospital Concentration and Rising Consolidation in the United States. 1% Steps for Health Care Reform, Feb. 2021, onepercentsteps.com/wp-content/uploads/brief-hc-210208-1700.pdf. Brot, Zarek, Zack Cooper, Stuart V. Craig, and Lev Klarnet. 2024. "Is There Too Little Antitrust Enforcement in the US Hospital Sector?"American Economic Review: Insights 6 (4): 526–42.
12 U.S. Government Accountability Office. Patient Protection and Affordable Care Act: Preliminary Results from Ongoing Review Suggest Fraud Risks in the Advance Premium Tax Credit Persist. GAO Report No. GAO-26-108742, 3 Dec. 2025. https://www.gao.gov/assets/gao-26-108742.pdf