Originally published on FIERCE Healthcare, February 6, 2026
Health insurance CEO testimony on Capitol Hill followed a familiar structure: acknowledgment that costs are rising, reassurance that insurers want to be part of the solution and reminders that insurers do not set provider or drug prices.
Though technically correct, from a provider perspective, it is also incomplete—and Congress increasingly appears to start to understand why.
“We don’t set prices.”
True, but insurers shape the economics of care. Hospitals and physicians establish the cost of performing services, and drug manufacturers set list prices. Payer prior authorization requirements, denial management, contract complexity, coding rules and constant policy changes drive the operating cost within the healthcare ecosystem.
Providers must build extensive infrastructures just to deliver and get paid for care that is approved. Those administrative costs are structural, growing.
Denied care that is later approved still carries real consequences
One of the most underexamined dynamics in today’s affordability debate is the denial-and-appeal cycle.
A meaningful share of services denied under the guise of utilization management are ultimately overturned on appeal. From a provider and patient perspective, the impact is significant.
Appeals take time. During the time that care is postponed, conditions can progress, treatment often becomes more complex and expensive and patients experience avoidable disruption and stress.
When coverage is eventually granted, the entire ecosystem has already incurred higher cost and risk. Administrative friction does not merely shift expense—it often increases total cost of care and potentially decreases the quality of the outcome.
PBMs and vertical integration are no longer a fringe concern
Over the last several congressional sessions, lawmakers from both parties have introduced and debated legislation aimed at PBM transparency, rebate practices and the growing concentration of market power created by vertical integration.
That bipartisan interest reflects a shared concern: when the same parent company controls the insurance plan, the PBM, retail pharmacies and specialty pharmacies and, in some cases, employs providers, it becomes increasingly difficult to disentangle cost control from profit strategy.
PBM utilization rules, drug-specific prior authorization and formulary decisions directly affect site-of-care decisions, treatment timelines and administrative burden. Vertical integration shapes how care is accessed and how much friction patients encounter along the way.
Affordability, access and competition are harder to assess when accountability is diffuse by design.
When rhetoric and reality collide
While insurers largely spoke to the same themes throughout the hearing, two moments stood out.
One of those moments came from Elevance Health CEO Gail Boudreaux, who in written testimony argued that “some healthcare providers—most owned or backed by private equity and venture capital firms—are abusing the arbitration system … leading to inappropriate and excessive payment awards.”
The comment is notable because it comes as Elevance faces mounting provider backlash over a new policy affecting non-participating hospital-based clinicians. Critics say the policy undermines the principle of good-faith negotiation by penalizing hospitals when independent providers decline to accept financially unsustainable terms.
The No Surprises Act was designed to protect patients while preserving balanced negotiation between payers and providers. Policies that shift pressure away from negotiation and toward network penalties risk circumventing that balance—effectively reframing a provider’s decision to remain out of network as misconduct rather than economic necessity.
In that context, Boudreaux’s testimony does more than describe a cost driver. It helps justify a strategy that narrows negotiating room and reshapes network participation—with implications for access, staffing and the long-term sustainability of care delivery.
The second stand-out moment involved drug pricing—and who now controls it.
CVS Health emphasized that high drug prices are generated upstream and negotiated downstream—a framing that is increasingly difficult to reconcile with the company’s own structure. Its wholly owned subsidiary, Cordavis, manufactures biosimilar biologics, placing the company inside the very pricing ecosystem it describes as external.
When an organization operates simultaneously as insurer, PBM, specialty pharmacy, retail pharmacy and drug manufacturer, claims about where pricing power resides deserve closer examination.
Performative affordability does not equal structural reform
During the hearings, UnitedHealthcare highlighted a voluntary Affordable Care Act (ACA) rebate as evidence of its commitment to affordability.
As longtime insurance executive and industry critic Wendell Potter has noted, the individual ACA market represents a relatively small share of UnitedHealth Group’s overall revenue and an even smaller share of its operating margin. In that light, the rebate functions as a way to demonstrate responsiveness without materially affecting the company’s profitability or broader cost structure.
When a rebate affects only a narrow slice of a diversified insurer’s business, it leaves the underlying drivers of premium growth, administrative complexity and cost shifting untouched.
We have heard these promises before—and follow-through has been uneven
This is not the first time insurers have said they are committed to lowering costs, reducing friction and improving transparency. Payers reduced prior authorization lists but often removed authorization requirements for lower-utilized services.
Sustained follow-through has been harder to find. In many markets, complexity has increased even as insurers remain highly profitable and providers operate on ever-thinner margins.
What Congress should press on next
If lawmakers want these hearings to produce different outcomes, the next phase must go beyond restating positions.
Key questions remain:
- How much cost is introduced by lengthy denial-and-appeal cycles?
- Which utilization controls demonstrably reduce total cost of care versus deferring it?
- How do PBM incentives align with patient affordability and provider sustainability?
- What guardrails are needed when insurance, pharmacy and care delivery sit under the same corporate roof?
Patients and providers need fewer promises and more follow-through
Healthcare affordability will not be solved by testimony alone. Providers understand the system is complex and shared. Patients experience that complexity in far more tangible ways. ReShonda Young, a small business owner who testified before the committee, put that reality into stark terms.
Young told lawmakers that after the expiration of enhanced ACA tax credits, the premium for her health plan would have jumped from $94 a month to $592 a month, an increase of nearly $6,000 a year. She was forced into a lower-premium plan with a $7,500 deductible and a $10,000 out-of-pocket maximum. As she explained, this was not about luxury coverage, but about access to basic, lifesaving care.
That is what affordability looks like outside a hearing room. It is families and small business owners deciding whether to pay for health coverage or everyday essentials like groceries, rent or utilities.
When coverage decisions introduce unnecessary delays for care, the cost is not just administrative. It is borne by patients whose conditions worsen while they wait, whose treatment options narrow and whose financial stress compounds as care becomes more expensive and harder to access.
If insurers want to be credible partners in lowering costs, the next step is measurable reduction in administrative burden, fewer delays in care delivery and clearer alignment between cost controls and the real decisions patients are being forced to make.
That is when affordability stops being a policy concept and starts becoming something patients can actually feel.
