America Has a Healthcare Cost Crisis. So Cut Costs, Not Access.

IPAK Has a Real Plan to Reduce U.S. Healthcare Costs

The United States does not have a patient-demand problem. It has price, coding, middleman, and administrative-waste problems. This article covers all four cost targets — national spending, federal outlays, employer premiums, and household medical bills — and prioritizes the policy levers that lower underlying system prices, cut administrative friction, stop payment gaming, and stop paying for care that does not improve or worsens outcomes.

The Diagnosis: Price, Not Demand

The United States spent $5.3 trillion on health care in 2024 — $15,474 per person and 18.0 percent of GDP.[1] CMS projects that share rising to 20.3 percent of GDP by 2033 if current trajectories hold.[2] That trajectory hits four balance sheets at once: national spending, federal outlays, employer premiums, and household medical bills. Any serious policy response must address all four simultaneously.

The comparative evidence is not ambiguous. Papanicolas, Woskie, and Jha (JAMA, 2018) found that the United States does not use radically more care than peer nations across the board; it pays higher prices for labor, drugs, and services while carrying far heavier administrative overhead.[3]Insurance premiums are not the disease. They are the invoice. That distinction changes the entire policy sequence.

Campaign-finance reform matters. It does not need to come first. Washington already has live instruments: hospital price-transparency enforcement, site-neutral payment authority, Medicare Advantage audit and recovery tools, PBM-reform pathways, antitrust enforcement powers, and a finalized interoperability and prior-authorization rule aimed at reducing administrative burden.[10] The obstacle is not the absence of tools. It is the refusal to deploy them in sequence, with enforcement teeth, before the next election cycle makes them radioactive.

The Ranked Agenda

Cost drivers are not equal. The following six targets are ordered by their measurable fiscal magnitude and the availability of federal instruments to address them. All-payer and global-budget models are addressed separately because they function as containment architecture for concentrated markets rather than as a universal solution.

Table 1. Ranked High-Impact Cost Drivers and Estimated Savings Potential in U.S. Healthcare

This table presents the six primary, evidence-backed cost drivers responsible for excess U.S. healthcare spending, ranked by fiscal magnitude and policy tractability. Estimates draw directly from Congressional Budget Office (CBO), Medicare Payment Advisory Commission (MedPAC), Federal Trade Commission (FTC), and peer-reviewed literature. Administrative overhead, Medicare Advantage overpayments, and commercial provider pricing dominate the cost landscape, while PBM extraction, site-of-service distortions, and low-value care represent substantial, measurable, and correctable leakages. The table underscores that the majority of excess spending is concentrated in identifiable, policy-addressable mechanisms rather than diffuse patient demand

1. Stop Paying for Low-Value Care

The system pays for a substantial volume of care that does not improve patient outcomes. Chalmers and colleagues (JAMA Network Open, 2021) measured overuse across 12 services in Medicare claims and found systematic variation by hospital type, with higher overuse scores in nonteaching and for-profit facilities.[15] The measured services included knee arthroscopy for osteoarthritis, vertebroplasty, inferior vena cava filters, renal stents, spinal fusion for non-specific back pain, EEG for syncope or headache, carotid imaging for syncope, and head imaging for uncomplicated syncope.

Shrank, Rogstad, and Parekh (JAMA, 2019) estimated total annual health-care waste at $760 billion to $935 billion, with overtreatment and low-value care accounting for $75.7 billion to $101.2 billion annually. They projected annual savings of $191 billion to $282 billion from combined waste-reduction interventions.[16] The low-value care category is not the largest slice, but it is among the most clinically actionable — and it produces direct harm in addition to financial waste.

Stopping useless care is not rationing. It is the first condition of ethical cost control.

The de-implementation agenda

• HHS should publish and update annually a national de-implementation priority list, drawing on AHRQ evidence reviews, claims-based overuse measurement, and clinical society guidance.

• CMS should tie a defined percentage of annual payment updates — applied to relevant services — to verified reductions in targeted low-value utilization, measured using validated claims-based indicators.

• Hospital-level overuse scores on priority-list services should be posted publicly alongside readmission rates and other quality measures.

• Value-based contracts should include explicit low-value-care reduction targets, with bonuses tied to verified performance rather than general process compliance.

Enforcement chain

• CMS action: Publish de-implementation list via rulemaking; finalize overuse measures in hospital quality programs.

• Congress: Authorize value-based payment models that explicitly penalize high-overuse outliers rather than only rewarding top performers.

• Audit trigger: Annual claims-based overuse measurement reported by CMS; automatic public performance disclosure.

2. Cut Commercial Provider Prices Where Competition Has Failed

The problem

Commercial hospital pricing is the largest private-sector pressure point on employer premiums and household out-of-pocket costs. Cooper, Craig, Gaynor, and Van Reenen (Quarterly Journal of Economics, 2019) found that monopoly hospitals charged prices 12 percent above those in markets with four or more rivals, and that prices rose more than 6 percent following geographically proximate mergers.[5] CBO has further established that inflated commercial prices increase federal subsidies, because employment-based insurance receives favorable tax treatment.[6]Commercial price inflation does not stay inside the employer market — taxpayers absorb part of it through higher subsidy costs.

Distinguish independent clinicians from consolidated systems

Independent primary care, rural obstetrics, community oncology, and solo-practice specialists are not the same policy problem as multihospital systems leveraging market dominance. Collapsing all providers into one rhetorical bloc punishes the wrong actors and kills the political coalition needed for reform. The tools below are targeted at consolidated health systems and private-equity rollups, not at independent practices.

The anticompetitive contract terms to ban

• All-or-nothing clauses that force insurers to include every system facility or none

• Commercial price-parity provisions that require insurers to pay no less than the system’s highest contracted rate

• Anti-tiering and anti-steering clauses that prevent insurers from directing patients toward lower-cost alternatives

• Cross-market leverage — using dominance in one geographic or service market to extract higher rates in another

• Most-favored-nation contracts that lock out price competition across payers

The enforcement chain

• Agency action: DOJ and FTC block new hospital mergers and private-equity rollups in concentrated markets; initiate civil investigations of all-or-nothing and anti-steering clauses.

• Legislation: Congress authorizes CMS to impose temporary commercial rate guardrails — tied to a multiple of Medicare rates — in markets where the HHI exceeds a defined threshold and competition has already failed.

• Regulation: HHS requires payers in ACA markets and ERISA plans to report anticompetitive contract terms; tie non-disclosure to market exclusion.

• Audit trigger: Annual HHI market surveys; automatic trigger if merger or acquisition raises HHI above threshold; mandatory rate-impact reporting.

• Penalty: Civil monetary penalties for prohibited contract terms; court-ordered rate rollbacks in adjudicated cases.

3. End Facility-Fee Arbitrage and Site-of-Service Overpayment

Medicare pays more for identical routine services when a hospital system owns the building. MedPAC’s March 2026 report documents the fiscal scale precisely: existing off-campus site-neutral policies reduced 2024 Medicare fee-for-service outpatient payments by $1.2 billion.[7]Extending site-neutral payment to on-campus clinic visits would have cut an additional $1.1 billion in 2024, and broader expansion to additional excepted off-campus settings would have cut roughly $2.1 billion more.[7] Over ten years, CBO scores versions of outpatient site-neutral reform at $6 billion to $157 billion in savings, depending on scope.[8]

Paying a premium for routine care because the sign on the door changed is a transfer, not a quality payment. Clinic-level low-complexity services should carry one rate regardless of ownership. This does not require dismantling the hospital system; it requires separating routine outpatient care from genuine high-cost standby capacity.

What to pay for explicitly

A well-designed site-neutral reform should explicitly fund what genuinely differs at hospital-based settings: emergency standby capacity, trauma and burn care, NICUs, behavioral health boarding, and other public-service obligations. Hiding those subsidies inside inflated routine outpatient prices makes them invisible to policymakers and unaccountable to taxpayers.

The rural and safety-net protection

MedPAC’s 2026 budget-neutral modeling shows that site-neutral expansion would shift revenue modestly toward rural hospitals, while urban and nonprofit systems absorb modest losses.[7] That finding undercuts the standard reflex claim that every site-neutral reform is anti-rural. Rural critical-access hospitals and verified safety-net institutions should receive transitional global-budget support tied to audited service obligations.

Enforcement chain

• CMS action: Extend site-neutral rates via rulemaking to on-campus excepted clinic visits.

• Congress: Codify broader site-neutral expansion and preempt hospital-system legal challenges.

• Audit trigger: CMS claims-based monitoring of facility-fee billing patterns post-acquisition; flag billing-code shifts that migrate services into higher-rate site categories.

• Penalty: Recoupment of differential payments found to lack clinical justification; escalating penalties for systematic misclassification.

4. Strip Out Administrative Waste

Administrative complexity is not a side effect of modern medicine. It is a business model. Himmelstein, Campbell, and Woolhandler (Annals of Internal Medicine, 2020) estimated that U.S. insurers and providers spent $812 billion on administration in 2017, equal to 34.2 percent of national health expenditures.[9] A 10 percent reduction in that administrative stack would free more than $80 billion annually. Billing complexity also functions as a competitive moat: it raises entry costs for smaller payers and independent practices while providing large system operators with revenue-cycle teams sophisticated enough to game complex rules.

A national simplification program

CMS’s 2024 interoperability and prior-authorization rule points in the right direction.[10]Congress and HHS should extend partial progress into a comprehensive national simplification program. The specific requirements:

• One standard prior-authorization transaction format across all commercial and government payers — mandatory electronic submission, defined turnaround windows, and automatic approval for high-evidence services.

• Universal credentialing data submission: one standardized file, submitted once, recognized by all payers and facilities in a market.

• One standard claims-attachment format replacing the current patchwork of payer-specific attachment requirements.

• One harmonized set of denial codes with mandatory definitions, preventing payers from using novel denial language to create ambiguity or delay appeals.

• One core set of quality-measure definitions, replacing the current proliferation of measure variants that forces providers to report the same underlying metric a dozen different ways.

• Mandatory public reporting of prior-authorization volume, average turnaround time, approval rates, appeal rates, and overturn rates — by payer, by service category, quarterly.

Enforcement chain

• HHS/CMS action: Finalize and enforce the prior-authorization rule; issue supplemental rules on attachment standardization and credentialing.

• Congress: Authorize civil monetary penalties for payers that fail to adopt required transaction standards within defined timelines.

• Audit trigger: Annual CMS audit of prior-authorization turnaround compliance; public dashboard updated quarterly.

• Penalty: Fines escalating with volume and duration of non-compliance; payer exclusion from federal programs for repeat violations.

5. Stop Medicare Advantage Overpayment and Coding Inflation

Medicare Advantage is the most measurable large-scale payment distortion in the federal budget. MedPAC estimates that Medicare will spend 14 percent more on MA enrollees in 2026 than it would spend on those same beneficiaries in fee-for-service Medicare — a projected $76 billion difference.[11] MedPAC also estimates that the MA premium subsidy raises Part B premiums by roughly $11 billion in 2026, adding about $175 per beneficiary per year.[11]

HHS-OIG found that diagnoses reported only on health risk assessments or HRA-linked chart reviews — with no corresponding treatment record in 2022 — generated an estimated $7.5 billion in MA risk-adjusted payments for 2023. Twenty MA companies drove 80 percent of that total.[12]MedPAC further notes that plan-submitted encounter data remain incomplete, which structurally limits oversight.[11] CBO scores versions of MA risk-policy reform at $124 billion to $1.049 trillion over 2025–2034 — the widest range in the entire federal health-care budget-options menu, reflecting how much policy design matters.[13]

The full anti-gaming architecture for Medicare Advantage

• Exclude unsupported HRA-only diagnoses from risk-score calculations unless confirmed by a treatment-relevant service encounter.

• Restrict chart-review-only risk adjustments to cases where the chart review reveals a new, actionable diagnosis that generates a documented clinical response.

• Accelerate RADV audit recoveries: shorten audit cycles, increase audit sample sizes, and apply extrapolation methodology consistent with existing HHS-OIG standards.

• Publish encounter-data completeness scores by MA contract, quarterly, publicly — and freeze rebate flows and bonus payments for contracts below a defined completeness threshold.

• Stop expanding rebate-pass-through and Quality Bonus Program payments into a payment environment that still cannot verify large shares of its coded disease burden.

• Recalibrate risk-adjustment factors using encounter data validated for completeness rather than diagnosis-only submissions.

Honest, well-documented care coordination should survive. Unsupported risk inflation should not. These two goals are not in conflict.

Enforcement chain

• CMS action: Issue final rule restricting HRA-only risk scores; accelerate RADV cycles.

• Congress: Codify completeness thresholds; authorize automatic suspension of bonus payments for non-compliant contracts.

• Audit trigger: Risk-based audit sampling using encounter-data completeness as the primary risk flag.

• Penalty: Clawback of risk-adjusted payments attributable to excluded diagnoses; civil monetary penalties for plans found to systematically manipulate encounter submissions.

6. Break the PBM Specialty-Drug Tollbooth

Drug-affordability debates habitually target manufacturers while leaving the distribution and payment architecture largely intact. The FTC’s January 2025 interim staff report documents what that architecture extracts. Pharmacies affiliated with the Big 3 PBMs received 68 percent of specialty-drug dispensing revenue in 2023, up from 54 percent in 2016.[14]In the FTC’s specialty-generic analysis, 22 percent of drugs dispensed through PBM-affiliated pharmacies to commercial plan members were marked up more than 1,000 percent over estimated acquisition cost; 11 percent of Medicare Part D dispensing at those affiliates crossed the same threshold, with a median markup of 2,105 percent in that subgroup.[14] The FTC also documented more than $7.3 billion in affiliated-pharmacy dispensing revenue above NADAC and another estimated $1.4 billion in spread-pricing income — a combined $8.7 billion in measurable extraction from the studied drug subset alone.[14]

The affiliated-pharmacy steering mechanism reinforces this: affiliated pharmacies were reimbursed at higher rates than unaffiliated pharmacies on nearly every specialty generic the FTC examined. Plan sponsors — including employer benefit funds and federal programs — are paying above-market rates while being steered away from lower-cost alternatives they do not know exist.

The corrective design

• Impose fiduciary duties on PBMs serving employer plans: require them to act in the financial interest of the plan sponsor, not the affiliated pharmacy or rebate revenue stream.

• Ban spread pricing in federal programs: require that the amount paid by the payer equal the amount paid to the dispensing pharmacy.

• Require full pass-through accounting: every rebate, fee, DIR fee, administrative fee, and other payment between manufacturers, PBMs, and affiliated entities must be disclosed to the plan sponsor.

• Prohibit affiliated-pharmacy steering unless the PBM can demonstrate a lower net price and equivalent patient access at the affiliated pharmacy compared to unaffiliated alternatives — verified by third-party audit.

• Require NADAC-based audit benchmarks for high-cost specialty generics, with automatic dispute rights for plan sponsors when dispensing fees exceed benchmarks by a defined percentage.

• Require public reporting of aggregate rebate flows, spread-pricing income, and affiliated-pharmacy revenue concentration — annually, by PBM and by federal program.

Enforcement chain

• FTC/DOJ: Continue and expand PBM investigation; refer adjudicated spread-pricing violations for civil penalties.

• Congress: Enact fiduciary duty, pass-through, and spread-pricing ban for federal programs; direct DOL to extend fiduciary standards to ERISA-governed employer plans.

• Audit trigger: Annual PBM audits by CMS for federal programs; third-party audit rights for large employer plan sponsors.

• Penalty: Disgorgement of undisclosed spread income; civil monetary penalties for affiliated-pharmacy steering violations.

7. Prevention: What It Can and Cannot Do

Prevention matters and must be part of any cost strategy. It is not a magic budget solvent, and treating it as one has done more harm than good to honest cost policy. Published reviews have long shown that many preventive services are highly cost-effective, but only a minority are clearly net cost-saving across the full program lifecycle.[17]Screening costs money, treatment triggered by detection costs money, and the time horizon to realize savings is often long enough that administrative regimes and insurance pools turn over before savings materialize.

The high-yield prevention investments are targeted rather than universal:

• Tobacco cessation programs with pharmacotherapy and behavioral support — among the few genuinely cost-saving preventive investments at scale.

• Hypertension screening and management in high-risk populations — strong evidence base for reducing downstream stroke and heart failure costs.

• Diabetes prevention programs targeting patients with documented prediabetes and high clinical risk scores — CMS has already piloted this; it should scale.

• Maternal risk reduction and early prenatal care access — strong evidence for reducing NICU costs and downstream complications.

• Aggressive primary-care management for the top 5 percent of utilizers generating recurrent avoidable admissions — the tightest loop between preventive investment and near-term spending reduction.

Prevention should sit inside a cost strategy. It should not replace one.

8. Use All-Payer Rate Setting Selectively, Not as a Talisman

All-payer rate setting and global budgets belong in the cost-control toolbox. They do not belong on a pedestal, and they do not substitute for the reforms described above. Maryland’s All-Payer Model achieved a CMS-reported 2.8 percent slower growth in total expenditures and $975 million in Medicare savings relative to the comparison group.[18] CMS later concluded that the model’s hospital-only focus constrained Maryland’s ability to sustain savings and quality gains over time — which is why the state transitioned to a broader total-cost-of-care model covering all settings.[18]

That is the correct lesson. Rate setting can work in concentrated hospital markets, in rural preservation contexts where global budgets protect access better than fee-for-service volume incentives, and in states with the regulatory infrastructure to operate across payers. Rate setting alone does not fix PBM spread pricing, MA upcoding, administrative bloat, or outpatient migration into unregulated channels. Any national rate-setting proposal that ignores those leakages will simply push the revenue game elsewhere.

Where all-payer models should and should not apply

• Apply in: Markets where hospital HHI is high and commercial rate benchmarks already exceed Medicare by 200 percent or more; rural states choosing global-budget models to stabilize access over volume; markets where antitrust remedies have failed to restore competitive pricing.

• Do not apply as a substitute for: PBM reform, MA payment accuracy, administrative simplification, or low-value-care de-implementation. A rate-setting model layered on top of intact payment distortions will be gamed faster than it can be calibrated.

9. Build an Anti-Gaming State, Not a Press-Release State

Every payment reform creates a new arbitrage opportunity. The history of Medicare and Medicaid is a history of policy-induced migration: DRG bundling shifted volume to outpatient; outpatient site-neutral policy shifted volume to off-campus facilities; MA encounter-data requirements shifted documentation investment toward chart reviews and HRAs. This is not an argument against reform. It is an argument that enforcement architecture must be built into every reform at inception, not bolted on after gaming is discovered.

GAO’s 2024 review of hospital price-transparency enforcement illustrates the problem precisely. CMS initiated 1,287 enforcement actions and issued more than $4 million in civil monetary penalties to 14 hospitals from 2021 through 2023. But GAO also found that CMS lacked assurance that published pricing data were sufficiently complete and accurate to serve program goals.[19] Enforcement actions without data quality validation produce published overcharges, not market discipline.

Required components for every major reform

• Claims-based auditing: mandatory, risk-stratified sampling of all large payment programs, updated annually.

• Encounter-data validation: independent verification of completeness and accuracy before data are used for payment, reimbursement, or quality scoring.

• Site-shift monitoring: automatic flagging when a service category’s billing-site distribution changes by more than a defined threshold following a regulatory change.

• Public dashboards: real-time performance metrics published for price transparency compliance, prior-authorization turnaround, MA encounter completeness, PBM fee disclosure, and low-value care utilization.

• Whistleblower intake: dedicated HHS-OIG channel for health-care payment fraud, with explicit qui tam provisions extended to MA and PBM programs.

• Automatic clawbacks: statutory authority to recover payments attributable to audited fraud or systematic error without requiring individual litigation.

• Civil penalties with repeat-offender escalators: first violation, penalty; second violation within five years, double the penalty; third violation, program exclusion review.

• Automatic statutory correction: if measured savings fall below a defined percentage of projected savings for two consecutive years, CMS triggers a defined policy adjustment without requiring new legislation.

Reform that cannot detect gaming will finance gaming. Reform that cannot recover overpayments will invite overpayments. Reform that does not publish its results will become press-release theater.

10. Make Savings Reach Households

Lower system costs must show up in family budgets, or the political coalition for cost control collapses. Two mechanisms currently prevent savings from reaching workers.

First, the tax exclusion for employer-sponsored insurance. CBO has estimated that the exclusion increases average premiums for employment-based coverage by 10 to 15 percent by encouraging employers to offer richer benefits — and compensation tilted toward tax-favored health spending rather than wages — without regard for the underlying price level.[20] CBO scores variants of limiting this exclusion at $521 billion to $965 billion in deficit reduction over 2025–2034, making it the single largest untapped revenue instrument in health-care reform.[20]Congress should cap the exclusion above a high premium threshold — say the 75th percentile of employer premiums nationally — and phase the change in over five years to avoid disrupting existing coverage.

Second, the transmission rule: savings must flow through. Any reform that reduces Medicare, Medicaid, or commercial payment rates should be paired with an explicit statutory requirement that aggregate plan-sponsor savings flow through to lower member premiums, reduced cost-sharing on high-value primary care, essential generic drugs, and preventive services — not into insurer margin, executive compensation, or hospital acquisition budgets. CMS should publish an annual household-dividend report measuring the share of documented payment savings that reached enrollee cost obligations.

What savings must not be used for

1. Bonus pay.

2. Premium increases offset by provider-contract savings (net consumer harm disguised as gross reform).

3. Insurer surplus accumulation beyond defined risk-based capital thresholds.

4. Hospital system acquisition of physician practices, imaging centers, or ambulatory facilities in markets where consolidation is already high.

11. A Timetable Matched to the Problem

Cost-control proposals without a sequenced implementation plan are editorials, not policy. The following timetable is organized by what agencies can do without new legislation, what Congress must authorize, and what multi-year structural reforms require.

First 100 days: administrative action without legislation

• CMS: Intensify hospital price-transparency audits; publish completeness and accuracy assessments for all hospitals with posted files.

• CMS: Publish MA encounter-data completeness scores by contract; notify plans below the 80th percentile that rebate and bonus payment eligibility will be linked to completeness thresholds starting in the next plan year.

• CMS: Accelerate active RADV audit cycles; announce expanded audit sample sizes for HRA-heavy contracts.

• CMS: Require public prior-authorization metrics from all payers participating in ACA exchanges within 90 days.

• FTC/DOJ: Issue joint guidance identifying anticompetitive contracting terms subject to per se challenge; open investigations of the largest all-or-nothing and anti-tiering arrangements.

• HHS-OIG: Activate dedicated whistleblower intake channel for MA and PBM payment fraud.

First year: Congressional action

• Enact site-neutral payment expansion covering on-campus clinic visits and additional excepted off-campus settings.

• Enact PBM pass-through pricing, spread-pricing ban in federal programs, and affiliated-pharmacy steering prohibition.

• Enact HRA-only diagnosis exclusion from MA risk scores and statutory RADV acceleration.

• Enact prior-authorization transaction standardization with defined turnaround timelines and automatic-approval provisions for high-evidence services.

• Enact a cap on the employer-sponsored insurance tax exclusion above the 75th percentile of national premiums, phased over five years.

Years 2–4: structural reform

• CMS and states: Deploy concentrated-market rate-guardrail models in hospital markets where HHI and commercial-to-Medicare price ratios meet defined statutory thresholds.

• FTC/DOJ: Bring adjudicated cases against the largest anticompetitive hospital contracting arrangements; challenge pending private-equity rollups.

• HHS: Launch national credentialing-data standardization and claims-attachment simplification program with mandatory adoption by federal-program payers.

• CMS: Publish first annual household-dividend report tracking whether documented payment savings reached enrollee cost obligations.

• Congress: Authorize global-budget pilot programs for rural hospital markets, tied to audited access and quality obligations.

Fiscal Summary: Official Estimates by Policy Area

The following figures are drawn from CBO, MedPAC, HHS-OIG, and FTC sources. They are not projections from this analysis.

Table 2. Fiscal Summary of Policy Interventions with Official Savings Estimates

This table consolidates official savings estimates across major healthcare cost-containment strategies using primary sources including CBO budget options, MedPAC reports, HHS-OIG findings, FTC investigations, and peer-reviewed analyses. Estimates span both annual and 10-year windows, reflecting variation in policy scope and implementation design. Notably, Medicare Advantage payment reform and limits on the employer-sponsored insurance tax exclusion represent the largest federal fiscal levers, while administrative simplification and low-value care reduction offer substantial recurring annual savings. These figures are not modeled projections from this analysis but are drawn directly from authoritative federal and scientific sources, establishing a grounded baseline for achievable cost reduction

The United States does not have a health-care cost mystery.

It has a payment, pricing, and oversight failure. That is fixable.

References

1. Anne B. Martin et al., National Health Expenditures In 2023: Faster Growth As Insurance Coverage And Utilization Increased, Health Affairs 44(1):12–22 (2025). PMID: 39693578. DOI: 10.1377/hlthaff.2024.01375.

2. Centers for Medicare & Medicaid Services, National Health Expenditure Projections 2024–2033, CMS Office of the Actuary (2024). Available at cms.gov.

3. Irene Papanicolas, Liana R. Woskie, and Ashish K. Jha, Health Care Spending in the United States and Other High-Income Countries, JAMA 319(10):1024–1039 (2018). PMID: 29536101. DOI: 10.1001/jama.2018.1150.

4. U.S. Government Accountability Office, Hospital Price Transparency: CMS Needs More Information on Hospital Pricing Data to Ensure Compliance, GAO-25-106995 (2024).

5. Zack Cooper, Stuart V. Craig, Martin Gaynor, and John Van Reenen, The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured, Quarterly Journal of Economics 134(1):51–107 (2019). PMID: 32981974. DOI: 10.1093/qje/qjy020.

6. Congressional Budget Office, Reducing the Deficit: Spending and Revenue Options, Health-Care chapters (2025). Available at cbo.gov/budget-options

7. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, Chapter 3: Hospital Inpatient and Outpatient Services (March 2026). Available at medpac.gov

8. Congressional Budget Office, budget options scoring outpatient site-neutral payment variants, 2025–2034 window (2025). Available at cbo.gov/budget-options

9. David U. Himmelstein, Terry Campbell, and Steffie Woolhandler, Health Care Administrative Costs in the United States and Canada, 2017, Annals of Internal Medicine 172(2):134–142 (2020). PMID: 31905376. DOI: 10.7326/M19-2816.

10. Centers for Medicare & Medicaid Services, Interoperability and Prior Authorization Final Rule (CMS-0057-F), Federal Register (2024). Available at cms.gov

11. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, Chapter 12: Medicare Advantage Program Payment (March 2026). Available at medpac.gov

12. U.S. Department of Health and Human Services Office of Inspector General, Some Medicare Advantage Organizations Use Health Risk Assessments and Chart Reviews to Increase Payments Without Ensuring Accuracy, OEI-03-17-00471 (2024).

13. Congressional Budget Office, budget options scoring Medicare Advantage risk-policy reform variants, 2025–2034 window (2025). Available at cbo.gov/budget-options

14. Federal Trade Commission Staff, Pharmacy Benefit Managers: Perspectives on Specialty Generic Drugs, Second Interim Staff Report (January 2025). Available at ftc.gov

15. Kelsey Chalmers et al., Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims, JAMA Network Open 4(4):e218075 (2021). PMID: 33904912. DOI: 10.1001/jamanetworkopen.2021.8075.

16. William H. Shrank, Teresa L. Rogstad, and Natasha Parekh, Waste in the US Health Care System: Estimated Costs and Potential for Savings, JAMA 322(15):1501–1509 (2019). PMID: 31589283. DOI: 10.1001/jama.2019.13978.

17. Joshua T. Cohen, Peter J. Neumann, and Milton C. Weinstein, Does Preventive Care Save Money? Health Economics and the Presidential Candidates, New England Journal of Medicine 358(7):661–663 (2008). PMID: 18256392. DOI: 10.1056/NEJMp0708558.

18. RTI International, Maryland All-Payer Model Evaluation Final Report, prepared for CMS Center for Medicare and Medicaid Innovation (2022). Available at downloads.cms.gov

19. U.S. Government Accountability Office, Hospital Price Transparency: Weaknesses in CMS’s Oversight Approach Need to Be Addressed, GAO-24-106995 (2024). [See also ref. 4.]

20. Congressional Budget Office, Private Health Insurance Premiums and Federal Policy (February 2016) and budget options on limiting the tax exclusion for employer-sponsored insurance, 2025–2034 window. Available at cbo.gov