Tag Archives: Health Insurance

More ACA Premium Spikes to Come in 2027 Amid Federal Policy Changes

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https://www.commonwealthfund.org/blog/2026/more-aca-premium-spikes-come-2027-amid-federal-policy-changes?utm_campaign=The%20Connection&utm_medium=email&_hsenc=p2ANqtz-8V3pn8EbkpgDcDV0THrnl3kHcJX4UdyLAkvhFzPVo_0k8AHyFzlLB8EIp7zjJSFaHP4LjRLbpbcLNDPqoruNT7EqyrxA&_hsmi=446033437&utm_content=446033437&utm_source=hs_email

For people who get their health insurance plans in the Affordable Care Act (ACA) marketplace, coverage became much less affordable in 2026. Insurers increased premiums by more than 20 percent; the average “benchmark” premium before tax credits jumped from $497 per month in 2025 to $625 in 2026.1 These increases were partly the result of actions federal policymakers took — for instance, slashing the tax credit some people received to reduce their health plan premiums and imposing new restrictions on enrollment. Predictably, as premiums rose and financial assistance shrank, consumers’ payments soared and enrollment dropped sharply.

Consumers will get no relief in 2027. Insurers have proposed a median 15 percent rate increase for 2027, with significant variation across insurers and states. These back-to-back double-digit rate increases are the highest we’ve seen in the marketplace since 2018 and follow five years of relatively flat premiums, with average increases of only 2 percent per year for the benchmark plan. Insurer rate filings for 2026 and 2027 reveal that the federal policy changes to the ACA are contributing to these significant rate increases.

What Are Rate Filings and What Information Do They Contain?

Each year insurers adjust their rates so that the premiums they charge will cover projected future health care costs, administrative expenses, and profit. To project future costs, insurers consider a range of factors, including how many people will enroll, how healthy or sick enrollees will be, how much the prices for health care services are likely to rise, and expected changes in how many medical services people will use. Insurers document how these various factors will impact their proposed rates in the annual rate filings. Under the ACA, these filings are subject to independent review from insurance regulators and portions of the filings must be made public.

https://flo.uri.sh/visualisation/30489845/embed?auto=1

Why Are Marketplace Insurers Raising Rates Again for 2027?

Rising health care costs are a key driver of 2027 rate changes. This is an issue for all private health insurance, and indeed, some analysts expect medical costs to grow faster in 2027 than they have in nearly two decades. The marketplace insurer rate filings point to a range of contributing factors, including higher provider prices, higher prescription drug costs, increased use of various services and medications, effects of health care workforce shortages, and general inflation.

But the marketplace rate increases are also the result of recent federal ACA policy changes. Most notable is Congress’ failure to extend ACA premium tax credit enhancements at the end of 2025. Enhanced subsidies were in place from 2021 to 2025, making coverage far more affordable and leading to record enrollment. Their expiration drove up rates in 2026; new rate filings signal ongoing effects.

Marketplace enrollment is expected to decline precipitously this year — by a range of 17 percent to 26 percent. As marketplace plans become less affordable, younger and healthier individuals are more likely to drop coverage. Remaining enrollees will be sicker on average and more costly. Many marketplace rate filings cite the end of premium tax credit enhancements and declining enrollment as further driving up rates in 2027, compounding 2026 increases.

Marketplace consumers will face additional barriers in 2027 that may also impact rates. New paperwork burdens will make it harder to enroll, and many lawfully residing immigrants will lose access to financial assistance that keeps premiums affordable. These changes will further drive down enrollment, leading to a smaller, sicker, and more costly marketplace risk pool.

How Will This Affect Affordability and Access for Consumers?

ACA premium tax credits provide a crucial buffer against insurers’ rate hikes. Policymakers’ decision to end the enhanced version of the credits caused that buffer to shrink for millions of people with modest incomes. For millions more (i.e., Americans with middle incomes), this cost buffer vanished completely. As a result, people with annual incomes of more than $63,840 for an individual or families of four with incomes of $132,000 or more will bear the full brunt of two years of double-digit rate hikes, with no financial help. For example, a 40-year-old individual with income just over this threshold who paid $445 per month after tax credits were applied in 2025 could owe $719 per month in 2027.2

As premiums become less affordable, marketplace consumers may continue to “buy down” to plans with lower premiums but higher deductibles. This would leave more enrollees underinsured, facing greater barriers to care and increased exposure to medical debt.

In addition, at least seven insurers — Baylor Scott & White Health Plan, CareSource, Cigna, Medica, Mending (formerly Taro Health), PacificSource, and Providence Health Plan — have announced they will no longer offer marketplace coverage in 2027. These insurers point to escalating costs, declining enrollment, and shifting regulations. Their exits will force consumers in 20 states to switch to new plans next year. With fewer coverage options, they may have a harder time finding plans that cover their doctors and prescription medicines. Less competition among insurers is also associated with higher premiums.

Looking Forward

Americans struggling to afford health care are concerned about the high cost of their health insurance premiums. They look to the federal government for solutions, yet recent actions by Congress and the Trump administration have made the problem worse. The ACA marketplaces have proven resilient, but the upheaval created by these recent policies could threaten their long-term stability. For now, with open enrollment around the corner, many marketplace consumers will soon face higher prices and fewer choices.

By Barring Profits on Basic Coverage, Switzerland Keeps Insurers from Denying Care

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https://www.linkedin.com/pulse/barring-profits-basic-coverage-switzerland-keeps-robqc

Roughly two-thirds of the U.S. population has health coverage through private insurance companies. Despite paying about $1,600 a year out of pocket on deductibles, copayments, and coinsurance, Americans have no guarantee their insurer will cover the cost of their care. Because insurance companies in the United States seek to maximize their profits, they have an incentive to deny payment for some services, even for recommended care, and to raise monthly premiums and out-of-pocket costs.

Switzerland has also struggled to make health care affordable for all residents, with one of the highest levels of out-of-pocket spending per person in the world, comparable to the U.S. average. Like the U.S., it relies largely on private health insurance, with residents choosing among competing insurers. But unlike the U.S., Switzerland bars insurers from profiting off basic plans. That difference helps explain why nearly a third of the U.S. population has medical bills or debt they are paying off over time, while only 2 percent of the Swiss population reports the same problem.

Regulating Private Insurers in Switzerland

Switzerland’s current system of mandatory basic health insurance (obligatorische Krankenpflegeversicherung, or OKP) was established in 1996 and requires all residents to purchase health insurance from authorized private insurers. Today, 100 percent of the population is covered through OKP, and everyone has access to the same nationally defined baseline benefits package, regardless of insurer. Because everyone is enrolled, costs are spread out across healthier residents and those who need more costly care.

Premiums are set by insurers but subject to federal approval. All plans include a minimum annual deductible of CHF 300 (USD 340), 10 percent coinsurance capped at CHF 700 (USD 794) annually, and a daily hospital fee; adults can choose plans with deductibles up to CHF 2,500 (USD 2,835) in exchange for lower premiums. The Swiss government also caps the price of services and what insurers pay providers to control costs.

While the federal government sets these baseline standards, it does not sell insurance directly. Residents choose among private insurers based on premiums, deductibles, provider restrictions, and networks, while guaranteed a core set of protections. Those who don’t enroll are assigned a plan by their local government and are responsible for late fees and past-due bills.

The most fundamental feature of the Swiss insurance market is that insurers are prohibited from earning a profit on basic health plans and must use a community-rating premium structure that shares costs between sicker and healthier individuals. Any surplus collected from basic premiums that exceeds paid claims must either be held in reserve to cover future costs or be returned to policyholders. Insurers also cannot deny coverage for any medically necessary care included in the basic package.

Insurance companies can, however, profit from supplementary private insurance, which covers services such as dental care and private or semiprivate hospital rooms. For these plans, insurers can reject applicants and vary premiums based on health status, age, and sex.

Despite federal regulations, affordability remains a major hurdle in the Swiss health system. Out-of-pocket spending is among the highest in the world, and premiums, which do not vary with income, can burden families who do not qualify for subsidies. Still, the system rests on a strong commitment to social solidarity, and some Swiss see these costs as the price of insuring everyone, even the most vulnerable. Because deductibles and coinsurance on basic plans are capped each year and claims for covered care cannot be refused, few residents fall into medical debt.

America’s Underregulated Private Insurance Market

The U.S. private insurance market is not entirely unregulated: the 2010 Affordable Care Act (ACA) prohibits insurers from denying enrollment based on preexisting conditions, age, or sex. The ACA also requires plans to cover essential health benefits and cap out-of-pocket spending, and it provides income-based subsidies for coverage bought through the marketplaces.

Since private insurers are permitted to operate for profit, they still have an incentive to limit what they pay out to maximize their earnings. While people cannot be denied enrollment, insurers can delay payment for doctor-recommended services or deny claims altogether by arguing the care was not medically necessary or by citing other technicalities.

In 2025, one in five U.S. working-age adults with private insurance said they or a family member had been denied treatment their doctor recommended in the past year, and about 40 percent of them said the denial led to delayed care. More than two in five adults whose claim was denied reported it led to medical debt they are still paying off. In one survey, most working-age adults with private coverage who were paying off medical bills or debt blamed insurance companies.

Fact: More than three in four adults in the U.S. who are underinsured — meaning their out-of-pocket costs are unaffordable relative to their income — are covered by private insurers.

While both Switzerland and the United States have an individual mandate requiring residents to enroll in a health plan — which is necessary for maintaining balanced risk pools — enforcement differs greatly. Since 2019, the ACA’s federal tax penalty for going without coverage has been reduced to $0, and only four states and Washington, D.C., impose their own financial penalties.

In both countries, a person’s insurer, out-of-pocket spending, and provider networks vary widely. But while federal regulation in Switzerland ensures all residents have robust minimum coverage standards, without fear of insurers creating obstacles to care in pursuit of their own profit, American patients have far fewer protections against companies that refuse or stall payment for care.

The Democrats Already Have a Healthcare Playbook for 2029

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https://www.aei.org/commentary/the-democrats-already-have-a-healthcare-playbook-for-2029/?utm_campaign=22139279-ECON_NLR%20Vital%20Signs&utm_medium=email&_hsenc=p2ANqtz-_y1mg21d3JknEciULh5_aXyPYC2iUEkirlIFOZ9Gq7-WaC9Uxh0h2XeaWIxenX7YPGM5M7S3SdtaH2mJHs5Nu6EPSOvQ&_hsmi=446383067&utm_content=446383067&utm_source=hs_email

As the midterm elections approach, politicians are debating healthcare within the broader context of “affordability,” or, more precisely, the challenge voters say they are facing in paying their regular bills. An interesting battle within the Democratic Party is underway over the appropriate response to this concern, with some favoring Medicare for All and others voicing skepticism about that approach.

Leading congressional Democrats, including Sen. Ron Wyden of the Finance Committee, are hedging their bets, but the most likely scenario is still one of incrementalism rather than sweeping reform.

Medicare for All has always been more effective as a rallying cry for the Democratic Party than as a roadmap for getting a bill through Congress. Although many voters are exasperated with the state of American healthcare, support for Medicare for All falls when its costs, which are considerable, are made clear to survey respondents. There is also a broad lack of confidence in the government’s ability to competently manage healthcare insurance for the entire country.

A potential guide for what Democrats might do in lieu of Medicare for All can be found in a document posted in July by Wyden on behalf of many of his Senate colleagues. It lists scores of ideas for reforming healthcare insurance and care delivery, including through the possible adoption of Medicare for All, although the balance of the paper points toward more public control and regulation than a major push for a monolithic public plan.

Wyden is following the playbook Democrats used to successfully advance the Affordable Care Act (ACA) from 2008 to 2010. In the months leading up to the 2008 election, then-Senate Finance Committee Chairman Max Baucus had worked with outside experts and fellow Democrats to draft a white paper on healthcare, which he released just days after then-Sen. Barack Obama won the presidency. That document would serve as the blueprint for the bill Baucus would draft and pass in the Senate in 2009, which later became the foundational ACA law.

Many healthcare concepts that are now familiar because of their inclusion in the ACA were promoted in the Baucus white paper, including the individual mandate, new premium subsidies for non-employer coverage for individuals with incomes below 400 percent of the federal poverty line, a large Medicaid expansion, and accountable care organizations, which are provider-led—as opposed to insurer-owned—managed care plans.

Wyden is explicit in his July release that he views the development work conducted by Baucus before 2009 as a model for what he hopes to accomplish in the run-up to 2029. However, he framed the ideas presented in the July release not as proposals he supports but as ideas for which he is soliciting feedback (responses to his “request for information” are due by October 2). It is possible, depending on what occurs in November 2028, that Wyden will publish a more prescriptive plan after the election to signal more clearly his intentions for 2029.

Wyden’s document zeroes in on consumer dissatisfaction with aspects of private insurance and divides the ideas under review into three categories: lowering costs for consumers and making enrolling in insurance easier, removing barriers to accessing care and lowering administrative costs, and regulating the for-profit companies providing insurance and care to patients.

Some of the more noteworthy concepts included in the document include:

  • reversing most of the budget cuts and regulatory changes implemented during the second Trump administration
  • developing transition plans that might allow Medicare for All to be approved with less immediate disruption to the current coverage of many Americans
  • creating an option for states to offer single-payer coverage
  • creating a nationwide “public option,” sponsored and run by the federal government, that would be offered to consumers buying individual coverage through the exchanges established by ACA and which might use Medicare’s regulations to set reimbursement rates for services or allow the government to negotiate rates with the providers of services in each market
  • developing new Medicare or Medicaid “buy-in” options that could be offered to all Americans regardless of their employment status and incomes
  • creating a single online entry point for enrolling in coverage that both those getting employer-sponsored and non-group coverage could use
  • allowing states to add to essential health benefits based on emerging evidence of effective services
  • stricter state oversight over premium increases requested by insurance plans, potentially including caps
  • eliminating deductibles and coinsurance for some “non-shoppable” services, and applying lower limits on total annual out-of-pocket costs based on a person’s income
  • reinstating the enhanced premium credits in place from 2021 to 2025 that the GOP Congress allowed to expire
  • allowing the ACA premium credits to go to lower-income workers enrolled in employer coverage, which the current “firewall” prohibits and which might be provided irrespective of the share of the premium paid by workers, and
  • restricting the business practices of for-profit companies participating in the healthcare industry, including insurance companies, private equity investors, and other “middlemen”

The connecting theme behind these ideas is a publicly regulated system, with the government taking on the responsibility of providing affordable coverage options for all Americans, with cost-sharing that is capped relative to household income. Wyden and other Democrats are willing to consider all manner of new controls and subsidies to ensure these objectives are achieved, but it is of course easier to promise these outcomes than to deliver them. An especially formidable obstacle is likely to be the service providers who believe Medicare and Medicaid’s payment rates are too low to serve as guides for private coverage too. Cutting payments to all providers is easier than designing reforms that more precisely target waste and inefficiency, but the ability of Democrats to overcome industry opposition to payment reductions in 2029, as they did when writing the ACA, is not assured.

In addition, even with some provider cuts, the aggregate federal cost of a plan that includes some of the more prominent ideas in the Wyden plan (not including Medicare for All), could be significant. For instance, the Congressional Budget Office has estimated that rolling back policies that tightened administration of the ACA credits, along with reinstating on a permanent basis the enhancement of the credits originally approved in 2021, would increase projected federal budget deficits by $662 billion over 10 years. Democrats are certain to favor tax hikes on well-to-do Americans in 2028, but it is not yet clear that those potential sources of new revenue would be sufficient to fully offset the most expensive ideas the Wyden document teases.

The heavy investment Senate Democrats are making in the development of their 2029 agenda for healthcare contrasts with the GOP’s approach, which is less focused. The Trump administration released a one-page framework earlier this year (“The Great Healthcare Plan”), but there has been little follow-up and no visible movement among congressional Republicans to approve new legislation.

Republicans should take the Wyden document seriously. If voters opt once again for change in 2028 rather than continuity, it is near certain Democrats will use the power voters granted them to prioritize passage of a major healthcare bill. The GOP could make that scenario less likely to occur if it developed, promoted, and tried to advance an alternative approach. There are multiple sound ideas they could embrace to make healthcare more affordable without excessive reliance on public regulation, such as by allowing consumers to keep the savings when they choose lower-cost insurance and care providers. Refining those ideas and putting them into legislation would put the party in a better position to compete with what is coming from their opponents in both 2026 and 2028.

Rising Employer-Sponsored Insurance Premiums Will Add to the Pressure for Reform

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https://www.aei.org/economics/health-care/rising-employer-sponsored-insurance-premiums-will-add-to-the-pressure-for-reform/?utm_campaign=22139279-ECON_NLR%20Vital%20Signs&utm_medium=email&_hsenc=p2ANqtz-8g6lt7Hk3NzQphj_eCzZIp60IBZq-hltXq3x0pLPKVdOXcilVfUTN56KoPSWkGceDBpsyWTTeyLdDahe9bGntortL1vQ&_hsmi=446383067&utm_content=446383067&utm_source=hs_email

The consultants agree: Healthcare premiums in 2027 for employer-sponsored insurance (ESI) are going up once again at an exceptionally elevated rate. As has been the case in all the years since the COVID-19 pandemic ended, the forces driving costs higher are overwhelming those working in the other direction. The added pressure from yet another year of significant premium hikes is likely to further intensify voter interest in a political response.

As employers get set to administer their open enrollment seasons for 2027 workplace benefit programs, a consensus has emerged among the outside firms monitoring trends in this sector that ESI is going through a sustained period of unusually rapid cost growth.

  • WTW (rebranded from Willis Towers Watson) projects that total costs for ESI will rise by 11.1 percent in 2027, which the firm says is the highest annual rate increase it has observed in two decades.
  • Aon forecasts a 9.5 percent increase for 2027, which would come on top of an 8.3 percent jump in 2026.
  • Marsh (previously Mercer) expects a modestly slower growth rate in 2027 of 8.2 percent after taking into account coverage adjustments, such as higher deductibles. The firm says the 2027 increase comes after a 6.7 percent rise in 2026 and 6.0 percent in 2025.
  • PricewaterhouseCoopers (PwC) predicts a 9.0 percent increase in covered medical expenses, on average, for ESI plans in 2027, which is the same rate it found for 2026 and slightly above the 8.5 percent rate it observed in 2025.

The PwC report points to multiple sources for ESI cost growth above general consumer inflation:

  • New AI Tools. Hospitals and physician groups are using artificial intelligence (AI) to maximize what they get paid for every interaction they have with patients. Insurers also have new AI platforms to better identify opportunities for cutting costs, but, to date, the provider-focused products are having more of an effect on total costs.
  • Provider Consolidation. Employers continue to struggle to hold down payment demands made by dominant health systems. With the industry already heavily consolidated, insurers have limited options to work around the major players.
  • Pharmaceutical Spending. Price increases for specialty therapies and expanded use of GLP-1s are pushing up drug costs.
  • Behavioral Health. Utilization of covered mental health services remains on a steep upward trajectory, with cumulative growth of 62 percent over the six-year period 2018 to 2024.
  • The Unintended Fallout from the No Surprises Act (NSA). Congress approved the NSA assuming it would lower overall costs for consumers, but it has had the opposite effect because physicians keep winning in arbitration. The added costs have grown to the point that they are noticeable in ESI premiums.

With cost pressures building, one might expect big employers to become more assertive in pushing for lower costs, yet WTW found continued reluctance among employers to take on the healthcare sector. In its survey, only 15 percent of the firms responding said they would be willing to back disruptive changes to secure a 5 percentage point drop in premiums. Further, 61 percent said they preferred to avoid upsetting their employees to securing meaningful cost reductions from disruptive ESI changes.

These findings confirm that the ESI market suffers from a collective action problem. Firms offering healthcare coverage want to attract the best workers possible within the budgets they allocate to labor costs. They do not want to develop reputations for offering less generous ESI than their competitors. Moreover, individual firms generally do not wield sufficient market power to change the business practices of major health systems.

The inability of employers to solve this problem on their own is certain to increase the pressure on Congress to provide a fix through legislation. In the coming years, many policymakers could get behind some version of additional rate setting in the ESI market to put a lid on premium growth.

Elected officials who might be wary of such remedies need to consider what they would offer as an alternative.

One option would be to force firms with ESI to run something like a premium support plan. Workers would get fixed levels of subsidization from their employers, which they would then apply to the plans they prefer rather than to the plans their companies choose on their behalf. The offered plans would need to be standardized (to a degree) to allow for apples-to-apples premium comparisons. This design would move responsibility from the firms to the workers to make economizing choices, with a strong likelihood of producing better results. Many employees might gladly accept coverage with market-disrupting changes if doing so would increase their take-home pay.

340B Rebate Fight Puts Hospital Cash Flow on the Line

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https://www.healthleadersmedia.com/cfo/340b-rebate-fight-puts-hospital-cash-flow-line

A new lawsuit from the American Hospital Association and four safety-net hospitals challenges a proposed federal drug rebate model, raising fresh concerns about liquidity, administrative spending and the financial stability of providers.

KEY TAKEAWAYS

Hospitals would pay wholesale prices for certain drugs upfront and seek 340B discounts through rebates.

Hospital groups estimate annual administrative expenses could exceed $1 billion, nearly double the federal government’s estimate of approximately $537 million.

The revised pilot is scheduled to begin January 1, 2027, but a new legal challenge could disrupt implementation.

The financial stakes of the federal 340B Drug Pricing Program are back in court. The American Hospital Association (AHA), the Maine Hospital Association and four safety-net hospitals filed a federal lawsuit October 9 seeking to block a revised rebate pilot that could change how participating providers obtain discounts on certain outpatient drugs.

The plaintiffs also requested a temporary restraining order to prevent the program from taking effect January 1, 2027. They argue that the Department of Health and Human Services (HHS) and the Health Resources and Services Administration (HRSA) failed to adequately assess the program’s financial consequences and consider less burdensome alternatives.

Under the current 340B model, eligible hospitals generally purchase covered outpatient medications at discounted prices. The revised pilot would instead require providers to buy participating drugs at wholesale acquisition cost, submit claims data and receive rebates for the difference between that price and the 340B ceiling price.

That change could create a significant working-capital challenge. Hospitals would have to front more money for medications and wait for rebates, while also managing claims submissions, payment reconciliation, potential denials and additional compliance work.

The cost estimates are the real disagreement. Hospital analyses cited by the AHA put annual administrative expenses above $1 billion, compared with the federal government’s estimate of roughly $537 million. The hospital groups contend that the government failed to fully account for startup costs, staff training, vendor expenses and the financial burden of advancing funds for drug purchases.

For hospitals operating on narrow margins, those expenses could have consequences well beyond the pharmacy department. Maine Hospital Association President Jeff Austin has said hospitals in the state average less than two weeks of cash on hand, underscoring how quickly additional working-capital demands could become a liquidity concern.

The HRSA, meanwhile, says the rebate model would improve transparency and program integrity by allowing individual transactions to be verified before rebates are paid. The agency also says the approach would help prevent overlapping discounts under 340B and the Medicare Drug Price Negotiation Program. The pilot is voluntary for manufacturers, and HRSA has approved plans from 10 manufacturers covering 18 drugs for the planned January launch, according to the lawsuit.

What CFOs should be watching

A shift from upfront discounts to retrospective rebates could increase cash-conversion-cycle pressure, require new investments in revenue-cycle and pharmacy systems, and expose hospitals to reconciliation delays. CFOs should therefore model potential cash requirements, assess vendor and staffing needs, and coordinate with pharmacy, compliance and legal teams rather than waiting for the litigation to conclude.

If the plaintiffs’ cost projections prove accurate, hospitals may have to redirect funds from patient assistance, specialty services and other community programs to cover administrative overhead and drug purchases. Smaller rural providers could be especially vulnerable because they have fewer reserves to absorb delays.

This is not the first legal challenge to the rebate approach. A federal judge temporarily blocked the original pilot in December 2025, and HHS later withdrew that version. HRSA announced the revised program in August 2026, but the latest lawsuit puts its planned launch back in question.

For now, CFOs should treat January 2027 as a planning deadline, not a settled outcome. The ultimate decision could shape how hospitals manage drug costs, liquidity and 340B-funded services for years to come.

Healthcare Is Still on the Ballot. But the Debate Has Changed.

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https://www.medpagetoday.com/opinion/second-opinions/123447?xid=nl_mpt_DHE_2026-10-18&mh=30d2d79f4357232a6a1236c866c0fe17&zdee=gAAAAABm4wli3fIz03mrmvZ196IZ7qiXDICmUr2x_v5Bie-ZePJsrTmL8XrZU6B1xohljjXg8La69mMLVEUrDycj0GAGgW4UPILdjxfuDCWMMIvHim5oQBk%3D&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Evening%20-%20Randomized%202026-10-18&utm_term=NL_Daily_DHE_dual-gmail-definition&lctg=5e4a6afa7e553f502501e525

As medical students in New York City, we spend our days witnessing firsthand how economics shapes patient care. Patients struggle to afford needed medications, battle insurance requirements, and wait months for specialty appointments. Rotating from Upper East Side hospitals to public safety nets in Queens, we also see how the precarious state of hospital finances makes care more difficult. So, as a consequential midterm election approaches, we’ve been following the news closely.

Since the 1990s, healthcare has been among the most important electoral issues. President Clinton proposed an ambitious restructuring of the system in the 1990s, Medicare Part D was born under President George W. Bush, and then came President Obama’s Affordable Care Act (ACA). In perhaps the most analogous election, healthcare became a top issue in the 2018 midterms during the first Trump administration, following dramatic “repeal and replace” efforts led by Republicans. Most recently, in 2020, “Medicare for All” was compared to a public option or the expansion of the ACA. These past policies differed tremendously, but they all asked a version of the same fundamental question: how should American healthcare be organized and provided?

Yet, in 2026, as we watch the midterms take shape, something seems different. Healthcare has hardly disappeared from American politics. But instead of grand structural reforms, candidates are particularly focused on individual affordability. The change may have more to do with voters than with politicians.

Healthcare affordability has become increasingly salient over the last few years: In 2024, when KFF asked voters about rising household expenses, food and grocery costs were the main concern. In January 2026, healthcare costs were voters’ top economic concern, with 31% saying they were “very worried.” Concern persisted across parties: 33% of Democrats, 36% of Independents, and 25% of Republicans were “very worried.” On top of that, 58% of voters said they expected healthcare to become less affordable next year.

While the issue is the same, the major parties are taking different approaches. Republicans are championing the Trump administration’s push for “most favored nation” drug pricing, reducing waste and fraud, and calling for direct subsidies for some Americans to purchase insurance. Democrats like Sen. Elizabeth Warren (D-Mass.) and Rep. Alexandria Ocasio-Cortez (D-N.Y.) have introduced a bill to make it illegal “for private equity funds, insurance companies, and other for-profit corporations to own or control medical practices,” with a co-sponsor, Sen. Ron Wyden (D-Ore.), saying explicitly in the bill’s announcement that “corporate medicine is making health care more expensive for everyone.” House Democrats have also created a “Cost of Living Healthcare Working Group” to highlight this issue as a campaign topic, alongside other household budget woes.

But these policies do not mean healthcare reform has stalled. Drug pricing, restricting corporate ownership, and shining a spotlight on the price of healthcare are themselves important reforms. What has changed is how both parties frame them: as solutions to the high cost of living.

Clearly affordability matters. However, from inside the hospital, we cannot help but wonder if something is lost when healthcare debates evolve into purely an affordability crisis. Healthcare is both a consumer expenditure and a social good — its success cannot only be measured by its price. As medical students, we see problems that don’t fit neatly into costs: avoidable cancer diagnoses due to shortages of primary care physicians, emergency departments overwhelmed with boarded patients, people in need of mental healthcare discharged to the streets, and re-emergence of infections due to eroding trust in public institutions.

Increasingly, clinicians themselves are left to compensate for these problems of healthcare delivery. When patients wait months to see a specialist, primary care physicians wind up managing niche, complex conditions. When beds are unavailable, emergency physicians care for chronically ill patients for days. When outpatient services are inaccessible, hospitals, like those we have rotated through, become the safety net instead. Patient care suffers.

Naturally, even those problems have financial roots, and prices are easy targets for politicians. Yet, while an insurance premium or prescription price can decrease, improvements in continuity, trust, and ultimately clinical outcomes are much harder to measure. And unfortunately, they may be even more difficult to campaign on in 2026.

Healthcare has not vanished from the midterms. Voters are increasingly concerned, candidates campaign on it, and parties disagree about how the government should address these issues. Yet, the foundation of the debate has changed. Increasingly the question is not how we should re-engineer the system, but rather, how we should make the system that we already have less expensive. In other words, instead of asking what kind of care Americans deserve, the 2026 debate is increasingly asking what Americans can afford.

Maybe that change is overdue. However, as medical students entering a system that these debates will shape, we hope that by confronting what healthcare costs, we do not stop asking what — and for whom — healthcare is for.

Health System Reform: The Two Areas where Support is Strongest

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Health System Reform: The Two Areas where Support is Strongest

As campaign 2026 nears its end in 15 days, polls show the potential for some surprising results and political pundits are already speculating about what to expect in the lame duck session and 120th Congress that convenes in January.

For healthcare, the realities are these:

  • Healthcare will be on local, state and national ballots in the context of affordability and costs of living. It’s a top-of-mind concern to voters along with housing, gas prices and groceries. A fourth of the population has an unpaid medical bill, and the majority worry about a surprise medical bill that could wipe them out.
  • Healthcare has lost much of the trust and confidence it enjoyed for decades. It has failed to navigate its positioning with voters because it lost control of its narrative. Among majorities of elected officials and voters across partisan aisles, the “system” is viewed as big businesses that put profits above all else. Reform is desirable to outside stakeholders but there’s no consensus about a ‘future state’ destination.
  • Healthcare is structurally flawed. Its tribalism is reinforced by laws and regulations that protect its status quo. Primary and preventive health is subordinated. For-profit and non-profit distinctions are artificial. Value is not defined. Business practices are opaque.

As a result, the industry will operate in limbo in the immediate future. Structural change is unlikely. For the near term, states will be the labs for healthcare innovation, and large (non- healthcare) employers might force a needed national discussion. Thus, in the 119th Congress’ lame duck session and 120th Congress next year, public policies in healthcare will center on low-risk efforts in two domains that enjoy widespread, Bipartisan support among elected officials and voters:

Program integrity: Fraud, waste and abuse in the U.S. health system is a soft target. According to CMS’ 2025 Improper Payment data, improper payments in Medicare, Medicaid, CHIP and other programs amounted to amounted to $96.16 billion. The largest categories include:

  • Medicare Fee‑for‑Service (FFS): 6.55% (≈ $28.83B)
  • Medicare Part C (Medicare Advantage): 6.09% (≈ $23.67B)
  • Medicare Part D: 4.00% (≈ $4.23B)
  • Medicaid overall: 6.12% (≈ $37.39B)
  • Children’s Health Insurance Program (CHIP): 7.05% ($1.37B)
  • Advance payment of the Premium Tax Credit (APTC) program: 0.89% ($657.46M).

It includes enrollees or actions for which the DOJ, FTC, FBI or HHS-OIG may seek redress on behalf of the public:

  • Billing for services not provided
  • Upcoding or unbundling
  • Billing for medically unnecessary services
  • Kickbacks or inducements
  • Duplicate billing
  • DME schemes (back braces, wheelchairs) — a high‑risk category highlighted by FTC.

Elected officials and the majority of voters support intensification of policies that reduce FWA spending.

Price transparency: Polls show large majorities of voters want unfettered access to accurate prices for the services they receive from doctors, hospitals, insurers, prescription drugs and everything else. They reject insider reasoning they’re not available today due to complexity and believe most price estimator tools currently in use of limited help to consumers. They believe of willful avoidance of price transparency is a calculated business strategy to protect margins, executive compensation and revenue growth.

There’s no doubt healthcare will significantly impact the results of the November 3 vote. There’s no doubt it will be a major focus in the 120th Congress. The major unknowns are (1) how states and federal policymakers will address the realities noted above, (2) how large employers and community leaders will participate (or not) in the design of a reformed system of health and (3) how voters will decipher reforms that promise offer accessibility, affordability and effectiveness.

Game on.

P.S. I grew up watching ABC’s Wide World of Sports that opened with Jim McKay’s infamous call “The thrill of victory, the agony of defeat”. Last week, we felt both. Pope Leo’s successful lung surgery was the victory; the mass murder of 3 kids and a teacher at Silver Rail Elementary the defeat. Our nation’s psyche is on edge along with many of the 8 billion inhabitants of planet earth. We need hope. We need victories. We need a break from bad news. I’m just sayin’.

ProPublica Wants to Hear About Your Prior Authorization Denial

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https://healthcareuncovered.substack.com/p/propublica-wants-to-hear-about-your?utm_source=post-email-title&publication_id=255152&post_id=222201228&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

Insurers promised to cut back on prior authorization. Now, ProPublica wants to know whether patients are still being denied or delayed care – and they need your help.

Last year, many of the country’s biggest health insurers promised to cut back on prior authorization. That’s the extra approval step insurers require before they’ll pay for a treatment, test, drug or piece of medical equipment. The pledge came after years of anger from patients, doctors and lawmakers in both parties.

I was skeptical then and I’m skeptical now. Prior authorization makes money for insurers. Every delay and every denial can mean care that never gets paid for. Companies don’t easily give up tools that pad their bottom line.

ProPublica is now trying to find out whether the promises meant anything. Reporters Max Blau and Brandon Roberts are investigating how insurers’ continued use of prior authorization is affecting patients. They want to know if people are still facing delayed or missed care.

I’m delighted they’re doing this. ProPublica can do the kind of reporting my small team can’t do yet – and they need your help.

If you’re covered by Medicaid, CHIP, an ACA marketplace plan or Medicare, and you’ve had a prior authorization request delayed or denied, they want to hear from you. That includes people in Medicare Advantage plans, where prior authorization is especially prevalent. It also includes people in traditional Medicare, where it has been rare until very recently.

The Trump administration is testing a program called WISeR that brings prior authorization into traditional Medicare for certain services in several states. Private tech companies are doing the reviews. As we have reported previously, this could be the start of turning traditional Medicare into something that looks a lot more like Medicare Advantage. If you’re in traditional Medicare and have run into WISeR, ProPublica wants to hear about it.

The reporters also want to hear from people who see the process from the inside. That includes doctors, nurses and office staff who fight these battles every day. It also includes regulators and people who work for insurance companies.

That last group matters. I know from my own years in the industry how much insiders know that the public never sees. If you work at an insurer and you’ve seen how prior authorization really works, please consider reaching out.

ProPublica says it will read everything submitted and won’t publish anything without your consent.

You can share your story here.

Why workers are giving up health insurance

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https://time.com/article/2026/10/22/us-health-care-costs-becoming-unsustainable/?utm_source=beehiiv&utm_medium=email&utm_campaign=newsletter-health-matters&_bhlid=c45aa2147e9223ce0a6186db43d0349c7193b7a1

Amber Kostka, who owns The Stockpot restaurant in Hampton Roads, Va., says she has tried to do right by her employees by offering them health insurance, alongside good wages and a 401k.

But as costs have risen—premiums have roughly tripled since the company first started offering health insurance in 2018—her employees are increasingly telling her they can’t afford health insurance. That’s even though she splits the cost of premiums with employees, which are roughly $400 a month.

Instead, employees are dropping out of the plan and going uninsured, she says. About 35% of her eligible employees now buy the employer-sponsored health insurance, she says, down from 50% prior to COVID. She wants to warn them about the risks of going without insurance, she says, but also knows their finances are extremely tight. “It’s just a cost thing, at the end of the day,” she says. “You can’t stop paying for groceries.”

Her employees aren’t alone. The share of working-age U.S. adults without health insurance rose to 11.2% in 2026, up from 8.9% in 2024, according to new research from the Commonwealth Fund. People don’t have health insurance because the costs of everything—including gasoline, housing, and food—are rising, and they’re deciding they can’t afford to pay for even employer-sponsored plans like Kostka’s. “The whole system just seems like a complete gamble with people’s lives,” she says.

Some people are looking at the price of plans on the Affordable Care Act marketplace and deciding they can’t afford health insurance. Premiums on the ACA marketplaces increased by an average of 58% in 2026 after Congress decided last year not to renew expiring subsidies.

Ironically, these uninsured Americans may be helping drive the cost of health care even higher, fueling a cycle in which health insurance gets more expensive, forcing more people to drop coverage. As hospitals field more uninsured patients, they have to pass the costs of uncompensated care onto someone. “When providers have to provide a lot of uncompensated care, how do they make themselves whole? They raise prices,” says Beth Umland, director of employer research for Marsh, the health benefits consultant company formerly known as Mercer.

Of course, having more uninsured Americans isn’t the only reason costs are rising. A Marsh survey of employers recently found that they expected total health benefit costs per employee to rise 8.2% in 2027, the highest increase since 2003. One reason was that the consolidation of health systems was leading to higher prices, as some systems had monopolies in certain markets. Another was that lower government spending for public health programs was leading to higher costs for private sector plans.

“This is starting to feel—’unsustainable’ is the word you hear,” she says.

Many of the reasons why health care costs are rising may seem minimal until you start adding them up, Umland says. For example, more doctors are using AI scribes in care, which are helping them bill for more services, making care more expensive, she says. A clause of the No Surprises Act, which was passed by Congress in 2020 to protect patients from surprise medical bills but which allows disputes to be settled by arbitration, has also added billions to costs, she says.

There are also increasingly more treatments available for patients, and those treatments are more expensive than the ones they’re replacing, she says. One example: GLP-1s, which may save insurers money in the long run on health costs but which are expensive upfront. “That’s just a whole new category of expense that didn’t exist before,” she says.

In its survey, Marsh found that many employers were planning to pass costs onto employees after years of trying not to do so.

Overall, workers are paying on average about $7,471 annually towards premiums for employer-sponsored family health benefits this year, up 9% from 2025, according to a new employer health benefits survey from KFF. Workers at small firms with less than 200 employees—like Kostka’s—are especially hard hit, paying about $9,687 towards family coverage: $2,847 more than workers in larger firms.

And even as they pay more for health care, the plans available to them are getting costlier to use. The average deductible for employer sponsored plans has increased 34% over the last 10 years, according to KFF.

What employers are doing

Kostka says there have recently been fewer health insurers in her area to choose from. Two years ago, she switched from just buying insurance outright for her employees, which many small businesses do, to self-funding the plan. She was able to do this because her employees are relatively young and healthy, she says, making her risk of incurring big medical costs for cancer or a catastrophic illness relatively low.

But she knows she’s just a major diagnosis away from being dropped from the self-funded plan, she says. “It’s a little bit of a gamble right now,” she says.

There are some things employers can do to push back against high health care costs, says Jim Winkler, chief strategy of the Business Group on Health, which published its own recent survey of employers which projected health care costs to rise 9% in 2027, the highest forecast the group has ever recorded.

Some employers are dropping coverage for GLP-1s for weight loss to save money, he says. Others are trying to drive employees toward what are called Centers of Excellence—essentially hospitals or medical practices with high ratings that may save money in the long-term since employees won’t need to return again and again for care. Some employers are also telling employees to try to find cheap, legitimate medications where they can—from sites like GoodRx, for example—and reimbursing them, rather than getting medications from a pharmacy benefit manager.

“We’re just painting a really challenging picture for health care costs,” he says, “which leads employers down the path of needing to find things to do to take action to mitigate them.”

A small number of employers are deciding not to offer health care at all and are instead offering employees cash to buy their own plans through the ACA marketplace. This option, called an ICHRA (Individual Coverage Health Reimbursement Arrangement) is pushed by Republicans, Winkler says, and was introduced during the first Trump Administration.

Small employers, though, often can only choose from available plans, and if there aren’t many, they don’t have much room to negotiate.

It’s a problem facing Mas Torito, owner of Kokoro restaurant in Denver. He spent close to $150,000 in premium payments for his employees in 2025 and is on track to spend $200,000 in 2026. That’s about 2.7% of revenues; most restaurants only have margins of 2-3%.

“Really since COVID, every single year feels like there are these extra pressures on us,” he says.

Kokoro has been in business for 40 years, and some of Torito’s employees have been working at the restaurant the whole time. He suspects that having an older pool of employees is part of what’s driving his health care costs up every year.

“I think they see the number of claims and costs every year going up,” he says, “and that translates into higher premiums.”

Like Kostka, Torito is committed to offering health insurance for his employees, even as his own costs rise. And like Kostka, he’s hearing from more employees that they can’t afford it. Now, only about 40% of his employees buy the insurance, he says.

“I get it,” he says. “The deductible keeps going up every year, the insurance keeps going up. It’s enough where people are really thinking, ‘Hey, do I want insurance or not?’”

Is AHA Right to be Concerned?

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Is AHA Right to be Concerned?

Last week, the American Hospital Association released a study by Kaufman Hall, its preferred data vendor, that took issue with methodologies used by critics of hospital consolidation:

“These findings suggest that a more comprehensive analysis of hospital M&A transactions, one that considers impacts on all patients served, broadens the focus to impacts beyond pricing, and considers the consequences if an M&A transaction is not permitted to proceed, would ensure not only competitive but also healthy hospital markets that can continue to provide the fullest possible range of services.”

The report discusses how hospital merger reviews should look beyond the potential impact on commercial insurance prices and consider what proposed transactions mean for all patients, particularly the nearly 60% of hospital patient days attributable to Medicare, Medicaid and Medicare Advantage beneficiaries whose payment rates are largely set by government programs.” Drawing on analyses of challenged and canceled transactions, the report also finds that hospitals seeking partners often serve more vulnerable communities and face greater financial pressures, and that when proposed deals do not move forward, struggling hospitals can experience significant financial deterioration that threatens services, workforce stability and access to care.”

Kaufman Hall added this disclaimer: “The findings contained in this document may contain predictions based on current data and historical trends. Any such predictions are subject to inherent risks and uncertainties. Past performance is not necessarily indicative of future results. Kaufman Hall accepts no responsibility for actual results or future events.

Also last week, a Health Affairs commentary “In 2026, States Are Leading On Health Care Affordability” noted that “Research has consistently shown that hospital prices are the largest driver of commercial health care spending growth. Hospital markets are dominated by monopolies, which enable hospitals to charge higher prices without improving quality or outcomes. State policymakers are increasingly looking for options to limit excessive hospital prices. Our research shows that capping the highest, most egregious prices charged by hospitals can meaningfully improve health care affordability while still allowing hospitals to generate a healthy margin…

A key driver of rising health care prices is consolidation in health care systems, including through hospital acquisitions of physician practices. These acquisitions, which are a form of vertical integration, increase hospital prices by 3 to 5%. This can be attributed to greater bargaining power, more intensive coding practices, and hospitals charging facility fees at what were previously independent physician practices but are now treated as “hospital outpatient departments.” To address these issues, states are increasingly considering facility fee bans or “site-neutral” policies that would cap prices for certain routine hospital outpatient services that could be provided safely in an office setting.”

Both positions are defensible.

Not for profit and public hospitals are at a disadvantage in managing their finances because they’re obligated to serve entire communities without regard to local economies or population health. Investor-owned hospitals and insurance companies have fewer restrictions and can exit markets at will.

And almost every hospital is dependent on reimbursement from commercially insured patients to offset what is the widely-accepted calculus that Medicare and Medicaid reimbursement doesn’t cover the total cost of care provided enrollees. Thus, across the hospital industry, the playbook has been straightforward: to optimize hospital finances….

  • Maximize the attractiveness of hospital services that attract privately insured patients via contracting with private insurers.
  • Negotiate favorable rates with private insurers to enhance cost-shifting to Medicare and Medicaid by private plans.
  • Optimize leverage (scale) over insurers by consolidating hospitals, acquiring physician practices, expanding ancillary activities and deploying capital to potentially profitable ventures.
  • Advocate for state and federal laws that dissuade hospital price caps, 340B cuts, site-neutral payments, unreasonable price transparency requirements and limits on private-equity partnerships.
  • Assert that hospitals are efficient stewards of the public’s trust but disadvantaged by corporate insurers and drug companies that are allowed to enter and exit markets at will, price at “what the market will bear” and put shareholder profit above all else.

This scheme has worked for 40 years to enable hospitals to control at least 50% of total health spending: 31% for traditional hospital services, 12% of total physician services, and ventures, partnerships, ancillary services and post-acute services in addition. In the aggregate, hospitals are the most important cog in the healthcare wheel. They’re labor intense, capital intense, complicated businesses that enjoy public trust that’s slipping away, especially among the 25 million who work in the industry.  Complicating matters, distinctions between rural and government safety net hospitals and highly profitable investor-owned and not-for-profit systems are attracting unwanted scrutiny from regulators and in media coverage.

While Kaufman Hall raises legitimate questions about current methodologies used by state and federal regulators to assess consolidation, it does not answer the bigger question: what role should hospitals play in the U.S. system as AI-derived clinical innovation proliferates, labor and supply costs accelerate and fewer people can afford services?

It’s not clear.

  • Should “hospital services” be redefined bifurcating facility-dependent inpatient services (Part A) and an expanded set of services inclusive of self-care provided in homes, schools, workplaces and virtually?
  • Should “community-benefits” and “charity care” be redefined so that methodologies are consistent and gaming to receive tax benefits eliminated?
  • Should hospital clinical performance be linked to improved outcomes and lower costs (affordability)?
  • Should local primary care and preventive health services (inclusive of nutrition, physical and mental health, prophylactic dentistry) be integrated with hospital services to improve population health and control demand for hospital services?
  • Should specialized tertiary and quaternary hospital programs be rationalized to optimize outcomes and improve efficiency?
  • Should consolidated hospital systems disclose administrative costs, functions and allocation methodologies publicly?
  • Should hospital boards be required to conduct scenario planning that’s comprehensive?
  • Should hospital administrative services and costs be standardized to facilitate caps on spending and management performance comparisons?
  • Should physician ownership of hospitals be enabled to increase competition?

And many others.

The American Hospital Association is right to be concerned about how regulators are addressing hospital consolidation and its impact on prices. And they’re right to challenge methodologies applied to questions about hospital prices and competition. But they fall short in offering a vision for the future of the health system that’s plausible, affordable and compelling. Rather, they offer a hospital-centric vision based on suspect assumptions and inadequate sensitivity to market trends not directly associated with traditional health services.

Every stakeholder in the health system—including hospitals and physicians—face heightened pressure to eliminate unnecessary utilization and costs due to willful or unknowing fraud. Just as insurer prior authorization practices have been frustrating to providers, unnecessary care is confounding to regulators and employers. The use of agentic AI tools to examine appropriateness of tests, procedures, medications and visits will exponentially change how “quality of care” is defined and regulated, and how its delivered. It’s a big deal everywhere, especially in Medicaid programs.