Georgetown report calls for capping hospital prices, reforming prior authorization and curbing medical debt

A patient walks into a primary care visit already carrying $3,000 in unpaid bills from a hospital stay six months earlier. Her insurance is fully active — she has coverage through her employer — but a high deductible and a facility fee she never saw coming left her owing more than she can pay in 30 days. Multiply that scene by tens of millions, and you have the everyday reality behind a new federal policy brief that argues America's commercial health insurance system is broken in ways that hurt physicians and patients in the same breath.

That brief, "A 3-Part Strategy for Better Health Insurance" was published in September 2026 by Georgetown University's Center on Health Insurance Reforms, with support from the Robert Wood Johnson Foundation. Authors Sabrina Corlette, Karen Davenport and Stacey Pogue argue that the roughly 161 million Americans with commercial coverage — through an employer or the ACA Marketplace — are squeezed by three interlocking problems: costs rising faster than wages, unnecessary administrative complexity and a health care system increasingly dominated by consolidated, profit-seeking corporate actors. Their proposed fixes range from capping hospital prices and deductibles to overhauling prior authorization to cracking down on private equity's role in health care.

The cost squeeze is a consolidation story

Commercial insurers now pay hospitals more than two-and-a-half times what Medicare pays for the same care, according to the report — a gap that widens further once facility fees get tacked onto an outpatient bill. Among the report's sharpest proposals: ban facility fees for routine outpatient visits and adopt "site-neutral" payment, so a service costs the same whether it's delivered in a hospital-owned clinic or an independent physician's office.

That dynamic is accelerating, not slowing. Medical Economics reported in January on an analysis from the hospital and corporate ownership of physician practices climbing from 39% in 2019 to 59% by 2023, with independent practices in rural areas losing ground fastest. Prices, the report found, rose an average of roughly 14% after hospitals acquired a practice — and by 30% or more in markets where a hospital system already dominated.

Yale health economist Zack Cooper, who has studied the trend for years, told Medical Economics in January: "One of the big drivers of integration is the way Medicare pays physicians. The program pays for more physicians in hospital-owned practices than for comparable care delivered in independent practices, and that's a real thing that we've got to change." Kelly Kenney, CEO of the Physicians Advocacy Institute, put the stakes in blunter terms, telling Medical Economics in April: "These small physician practices — we call them the onesies and the twosies — have been a critically important part of the infrastructure of care for patients in rural America. Consolidation equals less competition equals higher prices for everybody." That's the dynamic Georgetown's site-neutral payment proposal is explicitly designed to break.

Complexity that costs physicians their week — and patients their care

Self-insured employer plans — which cover most workers — still operate under prior authorization timeframes that haven't been updated since 2000, according to the report, even as Medicare Advantage and ACA Marketplace plans move toward faster, more transparent standards.

Physicians aren't waiting patiently for that gap to close. Medical Economics reported in May on findings from the 2025 AMA Prior Authorization Physician Survey: 95% of physicians said prior authorization delays necessary care, and 79% said patients had abandoned recommended treatment altogether because of the hassle. Only a third of physicians believe a June 2025 pledge by roughly 60 commercial insurers to streamline the process will make any real difference — skepticism the AMA says is grounded in history, since a nearly identical 2018 industry pledge produced little measurable change.

The report's proposed fixes echo several of the state-level reforms physicians have already been pushing for: honoring prior authorization approvals across payers for chronic conditions, requiring that only clinicians with relevant expertise issue denials, and barring insurers from retroactively rescinding care they already approved. Extending those protections — plus updated federal timeframes — to the commercial plans that cover most working Americans is, the report argues, a change insurers are largely already equipped to make, since many are implementing similar systems for their Medicare and Marketplace business anyway.

When "corporate abuse" shows up as a patient's bill

Health care "middlemen," financialized private equity ownership and the No Surprises Act's dispute-resolution process are driving up costs without adding anything to patient care, the report argues. Among its most pointed proposals: a Hospital Fair Billing Certification program to curb the medical debt that results.

That debt problem isn't confined to the uninsured, as a survey makes clear. Medical Economics reported in September on Commonwealth Fund findings showing that 32% of working-age adults with private insurance are paying off medical debt over time — nearly half of them owing $2,000 or more. Hospital care was the single biggest driver, the origin of 64% of that debt, but routine visits mattered too: 43% of affected adults cited a doctor's office visit and 39% linked their debt to an ongoing chronic condition.

Commonwealth Fund senior scholar Sara Collins, a co-author of the survey, told Medical Economics in September: "Medical debt is often viewed as a problem limited to people who are uninsured or who face a major medical emergency. But this survey shows that it is also widespread among Americans with private insurance. Moreover, it often stems from more routine care, including doctors' office visits and treatment for chronic conditions. When insured people are left owing thousands of dollars for their care, coverage is falling short of its most basic purpose: protecting people financially when they get sick."

The human cost was visible throughout the survey. Sixty-eight percent of respondents with unpaid medical bills said the debt caused them worry or anxiety, and more than a third said they couldn't cover an unexpected $1,000 bill within 30 days — a share that jumped past half among Black and Hispanic respondents and those near the poverty line. Commonwealth Fund President Joseph Betancourt, a primary care physician himself, told Medical Economics in September: "As a primary care physician, one of the most difficult things is seeing a patient who can't afford something they truly need, whether it's important testing, a critical follow-up visit or necessary treatment. This can have real clinical consequences and be incredibly demoralizing for caregivers. No patient should have to avoid or delay care or experience anxiety about medical bills and debt. We can and should do better. There are clear steps policymakers, insurers and hospitals can take to ensure people can get and afford the care they need, when they need it most."

Tellingly, the survey's own respondents pointed toward remedies that mirror the Georgetown report almost exactly: its authors highlighted eliminating deductibles in commercial plans and capping the rates insurers pay providers as ways to address medical debt at its source, rather than just managing the collections aftermath.

The stakes for physicians

What ties these three threads together isn't just policy symmetry — it's the fact that physicians are absorbing the fallout from all three problems at once. Consolidation drives up the price of care physicians didn't set. Prior authorization steals hours physicians could spend with patients. And medical debt lands, eventually, in physicians' own collections queues and difficult conversations at the front desk.

Whether Congress moves on any piece of this roadmap remains an open question. The report's authors, Corlette, Davenport and Pogue, acknowledge that a quantitative projection of the full package's costs and savings is beyond their scope, and that reforms like eliminating cost-sharing would need to be paired with hospital price caps to avoid pushing premiums higher. But pressure for some kind of federal action isn't coming from Washington alone. As experts told Medical Economics this year, it's also coming from exam rooms, billing departments and physicians who are increasingly vocal about a system that asks them to deliver care inside financial incentives they didn't design and can't control.