A Chicken Run: The Disintegrating Hen House of American Healthcare
Author's Note: This essay was written during the federal government shutdown of 2025, completed hours before the Senate voted 60-40 on November 9th to advance a spending deal ending the crisis. The analysis of Democratic “defections,” tribal warfare, and partisan dynamics in Section IV was written before the vote occurred, based on structural inference rather than hindsight. The henhouse metaphor, it turns out, was not speculative. It was descriptive.
The American healthcare system is a ramshackle henhouse perched on an eroding cliff. At dawn, you can hear the creaking—not of wood alone, but of fax machines cycling through prior authorizations, of billing codes updated overnight, of co-payment schedules revised without notice. The wind off the sea carries the sound of spreadsheets, of subsidy calculations, of deductibles reset each January 1st. Inside, twenty-four million hens shuffle and resettle, checking their coverage cards, comparing premiums. The ground beneath gives way a little more each year. Everyone agrees the structure is unsound. No one agrees whose eggs to break to fix it.
I. The Coop on the Cliff
The henhouse looks impressive from a distance. Record enrollment: 24.2 million Americans selected marketplace plans for 2025, more than double the number from 2021. Four out of five found coverage for ten dollars a month or less after subsidies. These are the numbers that make the evening news, the ones politicians cite when they talk about expanding access, about leaving no egg behind.
The gains were not evenly distributed, but they were real. Latino enrollment increased by 185% from 2020 to 2024, reaching nearly 5 million people on HealthCare.gov. Black enrollment increased by 204%, reaching nearly 3 million. American Indian and Alaska Native enrollment more than doubled. These were not incidental improvements—they represented targeted outreach, language-specific enrollment assistance, and subsidies generous enough to make coverage genuinely affordable for families previously priced out of the market.
But the uninsured rate tells a different story. Among working-age adults in 2024, 23% of Hispanic individuals remained uninsured—over three times the rate for white non-Hispanic adults. The Black uninsured rate was 12.3%, nearly twice as high. Among the non-elderly uninsured population, 62.9% were people of color, despite representing only 46% of that demographic. More than 80% of the uninsured had family incomes below 400% of the federal poverty level. The henhouse had more occupants than ever before. It was also more segregated by income and race than the enrollment numbers suggested.
Coverage is not care. Nearly one in four working-age adults with continuous insurance remained underinsured in 2024—facing deductibles and out-of-pocket costs high enough to make timely care functionally unattainable. Among the underinsured, 57% avoided necessary medical care due to cost. Forty-one percent reported their health worsened as a result. Nearly 30% carried medical debt, half owing $2,000 or more. They had insurance. They also had a $6,000 deductible and a narrow provider network that required a 90-minute drive to see a specialist who might or might not take new patients.
The "missing middle" has been redefined twice over. First, it meant those who earned too much for Medicaid but too little for employer-sponsored coverage and couldn't afford marketplace premiums. The Affordable Care Act built exchanges to reach them, then added subsidies to make enrollment possible. Premiums for a 40-year-old individual average around $500 per month before subsidies—roughly $6,000 a year. Employer-sponsored insurance costs nearly $9,000 annually. The subsidies closed the gap for millions. But the underlying cost structure—the reason premiums are so high to begin with—remains untouched.
Now the missing middle includes a second group: those with insurance they cannot afford to use. They are enrolled. They have cards in their wallets. They skip appointments anyway, ration prescriptions, avoid the emergency room until the pain becomes unbearable. The deductible is a cliff within the cliff, a psychological threshold that turns coverage into a kind of expensive permission slip you hope never to need.
Even among those with employer-sponsored insurance—66% of insured working-age Americans—higher deductibles and cost-sharing have made financial barriers to care increasingly common. Sixty-six percent of underinsured adults have coverage through an employer. The architecture of the henhouse looks solid in the enrollment reports. It feels different when you're inside, trying to figure out whether this month's symptoms are worth $200 you don't have, whether the specialist your doctor referred you to is in-network, whether the prior authorization will go through before the appointment you scheduled six weeks out.
That's assuming you can find a provider at all. Last week my spouse and I drove twenty miles across the Columbia River to Vancouver, Washington, because there wasn't an in-network provider in Portland accepting new patients with an appointment available within the next 60 days. We have insurance through my employer. We have coverage cards. We have a network. What we don't have is a doctor who can see us in a reasonable timeframe within our own city. The henhouse has occupants, but not enough nesting boxes, and the ones that exist are spoken for. According to the physician my wife saw, that scarcity is a "Pacific Northwest thing," a phenomenon that's been observed and catalogued, but yet to be addressed.
The wind picks up. Another plank loosens.
II. Leave No Egg Behind
The moral language of healthcare reform runs on a simple premise: everyone deserves coverage, and coverage is the pathway to care. This is the "leave no egg behind" framework, the one that animated the ACA's passage and every subsequent fight to preserve and expand it. By this measure, the system has made meaningful progress.
Subsidies work. Approximately 92% of 2024 marketplace enrollees received financial assistance. The average monthly premium after subsidies fell from $164 in 2021 to $111 in 2024. For many families, this was the difference between coverage and nothing. Silver plans with cost-sharing reductions—which lower deductibles and out-of-pocket maximums—became the most frequently selected plan type for Asian-American, Native Hawaiian, Pacific Islander, Black, and Latino consumers, representing over half of all plan selections for these groups.
These are not abstract policy victories. They are people who can now take their children to the doctor without choosing between the co-pay and groceries. They are freelancers and gig workers and small business owners who were previously uninsurable. They are the self-employed who no longer face $800-per-month premiums with no assistance.
People of color made up 54% of marketplace enrollees in 2024, up from 46% in 2021. Black and Latino enrollment grew by 186% and 158% respectively. Enrollment among people with incomes between 100% and 200% of the federal poverty level grew by 143% between 2021 and 2025. The uninsured rate hit historic lows.
These are not trivial victories. Being uninsured in America means delaying care until conditions become acute, facing medical bankruptcy over manageable illnesses, dying earlier from preventable causes. Coverage—even imperfect coverage—is better than none.
But 23% of Hispanic working-age adults remained uninsured in 2024. The subsidies reached millions. They did not reach everyone. And among those they did reach, 23% were underinsured—a category that includes 66% of people with employer-sponsored coverage, the supposedly stable foundation of American health insurance.
The feed distribution schedule depends on money pumped in at the consumer end, which does nothing to address why the feed costs so much in the first place. Health care in America is expensive because the prices of services, drugs, devices, and administrative overhead are all expensive. Insurance is expensive because it has to cover those costs. Subsidies make insurance affordable for individuals, but they don't reduce the total cost of care. They shift who pays.
When the subsidies expire—and they are set to expire at the end of 2025 without Congressional action—premiums for subsidized enrollees are projected to more than double, jumping from an average of $888 annually to $1,904. That's a 114% increase. Millions of people will find themselves suddenly unable to afford the coverage they have. Enrollment will drop. The uninsured rate will rise. The moral victory will collapse back into the moral crisis, and the cycle will begin again: emergency legislation, temporary extensions, last-minute deals that preserve access for another year or two while the underlying cost drivers churn on, unaddressed.
Inside the henhouse, the hens compare premiums. Outside, the wind carries another plank away.
III. Gotta Break Eggs to Make Omelets
The other narrative of healthcare reform is technocratic, not moral. It talks about efficiency, value, skin in the game. It says: the system is expensive because people overuse care when someone else is paying. The solution is cost-sharing—high deductibles, narrow networks, prior authorizations—mechanisms that make patients behave like consumers, rationing their own care to control utilization.
This is the "break eggs to make omelets" logic, and it has dominated benefit design for two decades. The theory is elegant: if patients have financial exposure, they'll shop around, compare prices, skip unnecessary tests, choose generics over brand-name drugs. The market will exert discipline. Costs will fall.
In practice, most patients can't shop. They don't know the price until after the service is delivered. They can't negotiate. They can't comparison-shop an emergency. They can't assess whether the specialist their doctor referred them to is in-network or whether the anesthesiologist who shows up in the operating room is employed by the hospital or contracted independently. The information asymmetry is total. The power imbalance is structural.
What actually happens: people delay care. They skip follow-ups. They don't fill prescriptions. Nearly 30% of adults with chronic illnesses skipped medications due to cost in 2024. They avoid the emergency room until the infection becomes septic, the chest pain unbearable, the mental health crisis acute. The deferred care costs more when it finally happens. The supposed efficiency generates waste.
The irony is that employer-sponsored insurance—the system's load-bearing pillar, covering 66% of underinsured adults—has itself become a source of financial exposure. High-deductible health plans spread through the employer market like a slow contagion, shifting risk from insurers to individuals under the banner of "consumer-driven care." The result: people with continuous employer coverage who still skip care because of cost, who still carry medical debt, who are functionally underinsured despite working full-time for companies that "offer benefits."
This is the distributional trap. You can't fix underinsurance in the employer market without either forcing employers to offer richer benefits (breaking the eggs of business margins and potentially employment itself) or subsidizing employer plans the way you subsidize marketplace plans (breaking taxpayer eggs). You can't fix it in the marketplace without reducing deductibles and out-of-pocket maximums, which requires either higher premiums (breaking enrollee eggs) or higher subsidies (breaking taxpayer eggs again). Every path forward breaks someone's eggs. The tribal warfare isn't irrational. It's the only rational response to a system with no non-distributional solutions.
But the deeper problem is not inefficiency. It's distribution. Every reform proposal—every attempt to make an omelet—requires breaking someone's eggs. The question is whose.
Medicare-for-All would break the eggs of 500,000 private insurance workers, every physician whose income depends on private-payer reimbursement rates 20-40% higher than Medicare, every hospital system that relies on well-insured patients to subsidize Medicaid and Medicare losses, every pharmaceutical company that prices drugs for a fragmented market, every investor in biotech who expects high returns.
A robust public option would break the eggs of private insurers through adverse selection, employers who use health benefits as retention tools, red-state governors whose refusal to expand Medicaid would be exposed as political rather than fiscal.
Mandatory price transparency would break the eggs of hospital systems that rely on price discrimination—charging more to patients with commercial insurance to offset lower Medicaid payments—and insurers whose negotiating leverage depends on contract secrecy.
Expanding Medicaid to close the coverage gap in non-expansion states would break the eggs of state budgets (even with 90% federal funding) and private insurers selling marketplace plans in those states.
Capping drug prices would break the eggs of pharmaceutical R&D budgets, biotech investors, and pharmacy benefit managers who profit from rebates tied to inflated list prices.
Reducing administrative complexity—simplifying billing codes, streamlining prior authorizations, standardizing claims processing—would break the eggs of the 375,000 Americans employed in medical billing and coding, the health IT vendors selling interoperability solutions to a fragmented market, the consultants who advise hospitals on revenue cycle management.
Even within the henhouse, the eggs aren't just in the nests; they cover the floor. Take a step, any step, and you break someone's egg.
This is what makes the tribal warfare inescapable. It's not that reform is impossible because special interests are too powerful or because politicians lack courage. It's that the system has distributed eggs so thoroughly across every constituency that no path forward leaves them intact. The 24 million marketplace enrollees are someone's eggs. The 500,000 insurance workers are someone's eggs. The rural hospitals operating on 2% margins are someone's eggs. The physicians whose student debt assumes private-payer income levels are someone's eggs. The employers who've structured compensation around health benefits are someone's eggs. The taxpayers funding the subsidies are someone's eggs.
You cannot rebuild the henhouse without walking. And you cannot walk without stepping on eggs.
The costs of reform are tribal. Every policy choice is a raid on someone's loot table. Urban hospitals can absorb Medicare-for-All rates; rural hospitals would close. Young, healthy people subsidize older, sick people in risk pools; changing the ratio shifts costs visibly. Employer-sponsored insurance is tax-advantaged; leveling the playing field means either taxing those benefits (breaking the eggs of the employed majority) or subsidizing individual coverage even more (breaking taxpayer eggs). Self-employed workers and small business owners rely disproportionately on marketplace plans; reforms that stabilize employer coverage do nothing for them.
You cannot make an omelet without breaking eggs. But you also cannot pass legislation if the eggs you're breaking vote, lobby, donate, and live in swing districts. So the fight is never really about outcomes or efficiency—those are rhetorical cover. The fight is about whose income, whose jobs, whose district, whose coalition takes the hit.
The henhouse stays rickety. The cliff keeps eroding. Every election cycle, someone proposes a new breakfast menu, while carefully avoiding the question of whose eggs they plan to scramble.
The wind gusts. The hens huddle closer.
IV. The Wind Off the Sea
November 2025. The federal government has been shut down for 40 days. Federal workers aren't being paid. SNAP benefits are delayed. Air traffic control is understaffed; Thanksgiving travel is in jeopardy. And at the heart of the shutdown: healthcare subsidies. Again.
The subsidies expire December 31st. Without them, premiums will more than double for 24 million enrollees. Democrats demand an extension before reopening the government. Republicans refuse to negotiate until the government reopens. The standoff is familiar, tribal, predictable.
Then eight Democrats break ranks. They cut a deal: reopen the government now, get a vote on subsidies in December. Two New Hampshire Democrats—Senators Maggie Hassan and Jeanne Shaheen—and an independent from Maine, Angus King, broker the agreement. Senate Minority Leader Chuck Schumer votes against his own caucus. Social media erupts. Pitchforks. Torches. Primary threats. They are called collaborators, cowards, traitors.
These “defectors” have calculated that the immediate pain—federal workers missing paychecks, food aid frozen, airports in chaos—outweighs the deferred pain of subsidy expiration. Their constituents need the government open now. The holdouts represent districts where 24 million people losing subsidies is existential, where surrendering the leverage now means Republicans will never negotiate in good faith later. Both groups are making rational calculations. Both are protecting their own eggs.
The 24 million enrollees whose subsidies are at risk are not an abstract number. They are disproportionately Black and Latino families who gained coverage only in the last four years. They are overwhelmingly low- and moderate-income—more than 90% earn less than 400% of the federal poverty level. They live in states that refused Medicaid expansion, in counties with thin provider networks, in regions where the marketplace is the only option. For many, losing subsidies doesn't just mean higher premiums. It means returning to the ranks of the uninsured, which in 2024 still included 23% of Hispanic adults and 12.3% of Black adults—rates that should be a national scandal but have been normalized as background noise.
The Democrats who broke ranks weren't wrong to worry about the shutdown's immediate casualties. But they were betting that Republicans would negotiate in good faith later, that a promise of a December vote meant something. Neither side was wrong to doubt the other’s good faith. Both were protecting different groups of vulnerable people. Both were making a triage decision about whose eggs to break first.
This is why the henhouse can't be rebuilt. Every reform requires someone to take a loss. And in American politics, taking a loss means losing your seat, your funding, your coalition. The only stable equilibrium is stalemate: patch the coop, defer the cliff-erosion, let the disease spread, and fight tribal skirmishes over who gets blamed when something collapses.
Meanwhile, President Trump proposes replacing the subsidies with direct payments to individuals, calling the current system a "windfall for Health Insurance Companies, and a DISASTER for the American people." It sounds populist. It also risks gutting the ACA's protections—guaranteed issue, community rating, coverage for pre-existing conditions—because direct payments without risk-pooling mean insurers can cherry-pick healthy customers and deny coverage to the sick. Trump's proposal echoes a Heritage Foundation white paper. It ends with the provision that "states may opt out of guaranteed-issue requirements." Translation: healthy people get $3,000 vouchers to shop for coverage. Sick people get a GoFundMe and the pre-ACA market, where insurers can deny coverage based on medical history. And Trump's Treasury Secretary says they won't negotiate until Democrats reopen the government.
So the Democrats are trapped. Surrender now and hope for a December vote that may never come, breaking the eggs of 24 million enrollees. Or hold out and get blamed for the shutdown, breaking the eggs of federal workers, SNAP recipients, and holiday travelers. Both options break eggs. The only question is whose.
The complexity is not incidental. It is load-bearing. The American healthcare system employs millions of people whose jobs exist to navigate the labyrinth: billing specialists, coding auditors, prior authorization nurses, appeals coordinators, formulary managers, network negotiators, compliance officers. Every reform that simplifies the system threatens those jobs. Every simplification activates an immune response.
A gamer can min-max a broken ruleset if the rules are at least knowable. Give them a 400-page splatbook and a weekend, and they'll find the infinite-damage combo by Monday. But you can't send a convention full of munchkins to optimize American healthcare. The rules are diffuse, obfuscated, changing at random—or rather, changing according to patterns you can't see because you're not party to the contracts, the rate negotiations, the utilization reviews, the formulary updates. You don't know what your surgery will cost until six weeks after it's over. You don't know if your prior authorization will be approved until the day of your appointment. You don't know if your doctor will still be in-network next month.
It's not that the system is too complicated to optimize. It's that it's designed to resist optimization by anyone except the incumbents. Complexity isn't a bug in the codebase. It's the core superstructure. The termites aren't stupid. They're just moving the dirt that other termites are eating. And the eggs aren't just in the nests—they're everywhere, covering the floor. You can't optimize a path through the henhouse without crushing something underfoot. The system knows this. It has weaponized it. Every reform activates a hostage crisis: move here and these workers lose jobs; move there and these patients lose coverage; stand still and the cliff keeps eroding.
The henhouse isn't just rickety. It's also diseased. The infection is systemic complexity itself, and it has learned to weaponize our inability to think in systems. Americans are famously bad at multivariable problems. We want a hero, a villain, a silver bullet. We want someone to blow up the Death Star. But this isn't a Death Star. There's no exhaust port. There's no architect. It's emergent, adaptive, parasitic. It endures not because it's sound, but because it's inhabited.
The disease is also profitable. Since 2021, private-equity firms have rolled up more than 30% of gastroenterology practices, 25% of dermatology practices, and 20% of urology practices nationwide. These aren't simple acquisitions—they're deliberate complexity factories. PE-owned practices are 40% more likely to add mandatory facility fees, 25% more likely to surprise-bill, and have begun requiring patients to sign "network deficiency waivers" that allow them to bill out-of-network rates even when the doctor is technically in-network. These eggs learned to lobby. The system didn't just resist simplification—it evolved new forms of extraction, layering fresh opacity over the old labyrinth faster than regulators could map it.
The wind off the sea strips another board from the siding. Inside, the hens carry on.
V. The Hens Keep Laying
The henhouse will not be rebuilt. Not because reform is impossible—other wealthy nations have managed universal coverage with controlled costs—but because the American version has metastasized into something that resists transformation at every scale. The moral language ("leave no egg behind") and the technocratic language ("break eggs to make omelets") both collapse into the same tribal calculus: whose eggs, whose jobs, whose coalition.
The ACA was never meant to be the final structure. It was a compromise, a patch, a way to cover more people without dismantling the employer-sponsored system or challenging the pricing power of hospitals, insurers, and pharmaceutical companies. It worked, partially. Millions gained coverage. The uninsured rate dropped. People with pre-existing conditions could no longer be denied insurance. These are not small things.
But the patch didn't fix the foundation. Healthcare costs continued to rise faster than wages, faster than inflation. National health spending hit $4.9 trillion in 2024—18.3% of GDP—and is projected to reach 19.7% by 2032. That's $15,000 per American per year, spread across premiums, taxes, and out-of-pocket costs, before anyone walks into a doctor's office. The subsidies masking marketplace premiums? They now represent roughly $2,500 per enrollee annually in taxpayer funding. We've built the most expensive Rube Goldberg wood chipper in human history, then taped a welfare program to the front of it so people don't notice the blades. Deductibles climbed. Networks narrowed. Administrative complexity multiplied. The subsidies kept premiums affordable, but only by transferring the cost to taxpayers—and only temporarily, subject to Congressional renewal every few years, hostage to shutdown politics and tribal warfare.
The system persists not because anyone designed it this way, but because everyone inside it is doing something reasonable in isolation. Hospitals charge high prices because they can, because insurers negotiate in secret, because patients can't shop. Insurers raise premiums because healthcare is expensive and they need to cover claims. Employers offer coverage because it's tax-advantaged and helps them compete for workers. Workers take jobs with benefits because individual-market coverage is unaffordable without subsidies. Doctors order tests because they're worried about malpractice and because fee-for-service rewards volume. Pharmaceutical companies price drugs high because the market is fragmented and no one can negotiate collectively. Pharmacy benefit managers carve out spread pricing because the opacity allows it. Billing specialists code claims because the system requires it. Every actor is responding rationally to the incentives in front of them.
The result is a structure that works for no one and can be escaped by no one. The hens are trapped not by a lock on the door, but by the fact that the door leads only to the cliff.
What would it take to rebuild? Not minor reforms. Not another patch. It would take deliberate decisions about distribution: who pays more, who earns less, which industries shrink, which jobs disappear. It would require political coalitions willing to absorb losses in service of a collective good that might not materialize for years. It would demand a shared understanding that the current system's complexity is not a puzzle to be solved but a condition that must be abandoned.
Other countries made different choices not because their politics were nobler but because they broke the eggs all at once, in a single legislative moment, and then defended that choice for a generation. They didn't "manage" universal coverage—they enacted it, often over fierce opposition, and made it politically untouchable before the industries being disrupted could mount an effective counteroffensive. Those nations didn't have better voters. They had voters who hadn't yet been told that breaking eggs was optional. They built systems where the underinsured rate is effectively zero, where medical debt does not exist as a category, where coverage is automatic and comprehensive. They did this not by eliminating trade-offs but by deciding them collectively and binding them into law: taxes are higher, wait times for elective procedures are longer, provider incomes are lower, pharmaceutical profits are constrained. But 23% of Hispanic adults are not uninsured. Twelve percent of Black adults are not uninsured. No one loses coverage because Congress failed to extend subsidies during a shutdown.
The American system could make those choices. But it would require accepting that 66% of underinsured adults have employer-sponsored coverage—the supposedly successful private model—and that fixing underinsurance means either regulating benefit design (breaking employer flexibility) or subsidizing everyone (breaking the fiscal compact). It would require admitting that 92% of marketplace enrollees need subsidies to afford coverage, and that this dependency is not a temporary bridge but a permanent feature of a system where unsubsidized premiums are unaffordable by design. It would require a level of political solidarity that does not currently exist, that may not be possible in a system where every constituency defends its eggs and every reform activates an immune response.
The American system breaks eggs continuously, randomly, without ever moving anywhere. The shutdown ends and premiums double. The subsidies get extended and the cliff erodes further. The eggs crack underfoot every day, but no one is walking toward a destination. They're just milling in place, trying not to be the one who steps wrong.
No one inside the henhouse believes the structure will hold forever. But no one can agree on what to build in its place, or where, or who should pay for it. The blueprint always looks the same: rebuild the coop on stable ground, using sound lumber, with room for everyone. But the stable ground is always someone else's land. The sound lumber is always someone else's trees. And the room for everyone is always funded by someone else's taxes.
The henhouse isn't going to be rebuilt. It's going to collapse, spectacularly, on a random Tuesday when the wrong spreadsheet cell turns red. And on that day, every politician who spent a decade saying "we can't rush this" will discover—live on cable news—that physics doesn't negotiate. Until then, the subsidies get extended for another year, then another. The premiums rise. The deductibles climb. The networks narrow. The shutdown ends, and six months later there's another one. The cliff erodes a little more. The boards creak a little louder. The wind picks up.
The sea below is patient. The hens, having forgotten the sensation of flight, go on laying into the wind.