Congress just preserved a narrow window of enhanced Affordable Care Act subsidies. That matters. For many families, it will mean lower premiums, fewer impossible tradeoffs, and a little breathing room.

But let’s be honest: breathing room is not the same as stability.

The ACA was never designed to fix what’s actually broken about American health care. It expanded coverage. It made the system more humane. It prevented insurers from denying care for pre-existing conditions. Those gains are real — and worth defending.

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But the ACA did not make health care prices rational. It did not make them fair. And it did not make them predictable.

In Hawaiʻi, that failure is especially visible.

Under federal law, hospitals are supposed to publish their prices so patients can make informed decisions. In practice, that “transparency” is a joke. Hospitals release massive machine-readable files — tens of thousands of lines of data — that no ordinary person can understand. That’s not transparency. That’s concealment by complexity.

When some of this Hawaiʻi hospital data was recently translated into plain language using AI tools, what emerged was startling. An additional vaccine shot — same nurse, same syringe — can cost $4 under one plan, $12 under another, $28 if you pay cash, and $71 if you’re billed the hospital’s so-called “gross” price. A basic pregnancy test can range from under $9 to more than $60.

Nothing about the care changed. Only the insurance card did.

That is not a market. It’s a shell game.

This chaos hits harder in Hawaiʻi because of our geography and limited choices. On many neighbor islands, there is only one hospital. Specialty care is centralized on Oʻahu. Patients often have to fly for treatment, adding airfare, lodging, childcare, and missed work to their medical bills. Rural clinics are fragile. Provider shortages are real. Burnout is constant.

Even in a “high coverage” state, many people are functionally uninsured. High deductibles delay care. People ration prescriptions. They skip follow-ups. They show up in emergency rooms when problems become critical — an expensive and inefficient way to deliver care.

This isn’t personal failure. It’s system failure.

And right now, that failure is being locked in through consolidation — most notably through the proposed partnership between HMSA, Hawaiʻi’s dominant insurer, and Hawaiʻi Pacific Health, one of our largest hospital systems. When an insurer and a major provider network align this closely, power concentrates. Control over pricing, networks, referrals, reimbursement, and care pathways collapses into fewer hands. Competition shrinks. Transparency fades. Patients lose leverage.

In a small, isolated market like Hawaiʻi’s, this matters enormously. We don’t have endless alternatives. We can’t just “shop around.” When power concentrates here, it sticks. What is framed as “efficiency” today can become dependency tomorrow.

We’ve seen this pattern elsewhere. On the continent, vertically integrated health care giants now dominate entire regions — owning insurers, clinics, pharmacies, and data systems — while costs rise and access shrinks. Hawaiʻi is not immune to that trajectory. In fact, we are more vulnerable to it.

That’s why the ACA — even at its best — can only ever be a stopgap.

The ACA makes an unjust system more survivable. It does not make it just.

Universal health care is not a radical idea. It’s a basic one: everyone should be able to get care when they need it, without financial terror. Prices should make sense. Care should not depend on employment status. Coverage should not disappear when you change jobs, move islands, or get sick.

In most advanced democracies, this is not controversial. They spend less per person. They cover everyone. They get better outcomes. They don’t pretend that a hundred different prices for the same service is “choice.”

They recognize what we refuse to: health care is not a consumer good. It is infrastructure. And like roads, schools, and clean water, it only works when it is governed in the public interest.

That’s the real conversation we need to be having — especially now.

The temporary ACA subsidy extension should be seen for what it is: a narrow reprieve in a system that still leaves people one illness away from financial crisis. It buys time. It does not buy security.

We can keep patching holes in a leaky boat, or we can build a better one.

Universal health care isn’t just about how we pay for care. It’s about who the system is for.

No one in Hawaiʻi should have to choose between rent and insulin. No parent should delay care for a sick child out of fear of a bill. No kupuna should ration treatment after a lifetime of work.

Health care should not feel like roulette.

The window Congress just preserved is small. But it reminds us of something important: when we organize, we can protect people.

Now we need to go further.