Higher costs, lower quality, declining access, loss of primary care: How can Congress help health care?

As U.S. medical care gets more and more expensive, family physicians are firsthand witnesses to people deciding whether to put food on the table or get needed health care, according to the American Academy of Family Physicians (AAFP).

On March 18, 2026, the House Energy & Commerce Committee held the hearing “Lowering Health Care Costs for All Americans: An Examination of the U.S. Provider Landscape.” R. Shawn Martin, CEO and executive vice president of the American Academy of Family Physicians, and five other witnesses discussed the financial actors that, more and more, stop patients from seeking care, despite the nation spending $5.3 trillion, 18% of gross domestic product, on health care, in 2024.

The witnesses described a situation that is growing increasingly dire across the United States. The nation’s health care system has dedicated physicians and other clinicians using cutting-edge technology to treat and cure ailments, but patients can’t afford it. A good start would be to improve not just affordability or prices, but Americans’ health, Martin said.

That, in turn, starts with primary care.

“I suggest that the most effective way to lower health care costs for individuals and for our system as a whole is to improve the health of our population. And the best way to improve the health of our population is to strengthen primary care,” Martin said.

“Studies consistently show that primary care is the only area of health care that improves health outcomes while reducing costs on a per capita basis, and sadly, the number of Americans who have a usual source of primary care has decreased over the past decade,” he said. “These trends are certainly a by-product of consolidation, but also reflective of insurance design that places financial barriers between patients and primary care, particularly in the form of high deductibles and cost sharing.”

The hearing lasted more than 90 minutes as Democratic and Republican representatives asked questions and, at times, blamed the other party for the problems. Along with verbal testimony, the committee published the witnesses’ written statements online.

National change for the better

There are ways Congress could help, Martin and the other witnesses said in their written testimony.

Martin urged Congress to provide an annual inflationary update to physician payment. Hospitals and skilled nursing facilities already receive automatic annual updates, whereas physicians do not. Congress could reform the budget-neutrality requirements embedded in the Medicare Physician Fee Schedule (PFS), which force specialties to compete against each other for a fixed pool of money that has not meaningfully grown since 1992. Martin also recommended shifting toward prospective, per-patient monthly payments for primary care, which would reward health management rather than volume of billable visits.

Congress should waive patient cost-sharing for chronic care management services under Medicare Part B, and require all health plans to cover at least three primary care visits annually without any patient cost-sharing, Martin said. He also urged Congress to allow State Medicaid agencies to pay for direct primary care (DPC) arrangements — in fact, the Medicaid Primary Care Improvement Act is pending. Payers should also be required to publicly disclose how much they spend on primary care services annually, he said.

On administrative burden, Martin urged passage of the Improving Seniors' Timely Access to Care Act to codify prior authorization reforms in Medicare Advantage plans. Congress also should approve legislation that prohibits insurers from using automated algorithms to downcode physician claims without physician consultation or transparency into the methodology being applied, he added.

Physicians speak out

Two doctors were among the witnesses in the hearing, and they emphasized the importance of market competition through conditions that create a level playing field for independent physicians.

There is a widening gap between what Medicare pays physicians and what it actually costs to run a practice, said David Aizuss, M.D., chair of the American Medical Association (AMA) board of trustees. He is an independent ophthalmologist from California.

Payment cuts, market consolidation, and administrative burdens are eroding the financial viability of independent physician practices. Patients ultimately bear the cost through reduced access and higher prices, Aizuss said.

Medicare payment is hurting the situation, not helping it. Medicare physician payment has risen only about 10% over the past 25 years, approximately 0.4% per year. But practice costs as measured by the Medicare Economic Index (MEI), which tracks expenses such as staff wages, office rent and liability insurance, rose 63% over the same period. After adjusting for inflation, real Medicare physician payment has fallen 33% since 2001. Meanwhile, other Medicare Part B spending per enrollee grew 86% between 2015 and 2025, while physician fee schedule spending grew only 19%.

The AMA called on Congress to enact annual inflation-based updates to physician payment tied to the MEI, reform the budget-neutrality rules that trigger across-the-board pay cuts when new services are added to the fee schedule, and overhaul the Merit-based Incentive Payment System (MIPS) — a quality reporting program — which costs an estimated $12,811 and more than 200 hours per physician annually to administer.

On the workforce, the AMA warned that more than 75 million Americans already live in areas with too few physicians, with a projected shortage of up to 86,000 physicians by 2036. The AMA urged Congress to lift the cap on Medicare-funded residency training slots, which have not been meaningfully updated since 1996, and to protect visa pathways for international medical graduates who disproportionately serve rural and underserved communities.

Site-neutral payment and physician ownership

Anthony DiGiorgio, D.O., a neurosurgeon and assistant professor at the University of California, San Francisco, emphasized his support for strong hospital-based health care. At the same time, federal policy has systematically favored hospital consolidation over independent physician practices, and patients are paying the price.

DiGiorgio cited research showing physician ownership of medical practices has collapsed from 76% in the 1980s to just 35% in 2024. He argued this consolidation drives up costs: Prices at monopoly hospitals run 12% higher than in competitive markets, and when hospitals acquire independent physician practices, the cost of those physicians' services rises an average of 14.1% afterward. Since 1999, health insurance premiums have climbed by 342%, while worker earnings have risen by only 119%.

Another potential solution: site-neutral payment reform. Congress should require Medicare to pay the same rate for the same service regardless of whether it is delivered in a hospital outpatient department or an independent physician's office. Aizuss noted that performing procedures in hospital outpatient departments rather than independent ambulatory surgery centers costs Medicare approximately $38 billion more annually. Equalizing these payments, he argued, could reduce the federal deficit by $217 billion to $279 billion over 10 years.

DiGiorgio also called on Congress to repeal Section 6001 of the Affordable Care Act, which has largely frozen the expansion of physician-owned hospitals since 2010, and to reform the Stark Law, which governs physician self-referral, to stop treating independent physician arrangements as presumptively suspect while large hospital systems face fewer restrictions.

How can hospitals help?

Rick Pollack, president and CEO of the American Hospital Association, urged lawmakers to address rising health care costs through a multi-stakeholder approach rather than targeting hospitals alone.

Labor costs, which account for roughly 60% of hospital operating expenses, have surged due to persistent workforce shortages and lingering effects of the pandemic, Pollack said. Supply costs rose nearly 10% in 2025, while hospital drug expenditures climbed 13.6% in the same year, driven largely by high-priced specialty therapies. Meanwhile, Medicare payments fell more than $100 billion short of covering actual care costs in 2024, with Medicare margins for hospitals dropping to negative 12%.

As for outgoes, Medicare Advantage plans reported nearly 53 million prior authorization requests; that is a significant cost driver, Pollack said. Hospitals spent more than $43 billion in 2025 simply trying to collect payments that insurers already owed, administrative work that contributes directly to clinician burnout and staffing shortages.

On solutions, Pollack recommended expanding preventive care access, reforming medical malpractice laws, standardizing administrative processes across insurers and accelerating artificial intelligence tools to reduce documentation burdens.

His testimony also pointed to at least two issues that cause splits within health care. Pollack urged Congress to protect the 340B Drug Pricing Program, which allows safety-net hospitals to purchase drugs at discounted prices, and to reject Medicare site-neutral payment cuts that would reduce reimbursements for hospital outpatient departments. Those positions are split from assertions from physicians and other advocates.

Health insurance costs vs. health care quality

Elizabeth Mitchell, president and CEO of the nonprofit Purchaser Business Group on Health (PBGH), said her organization, which represents large employers and public purchasers, would support site-neutral payment. Additional reforms should include stronger price transparency enforcement, restrictions on anticompetitive contracting clauses and greater investment in advanced primary care, she said.

PBGH, a nonprofit, represents purchasers that collectively spend over $350 billion annually on health care for 21 million Americans. The annual cost of providing health care to an American family has risen an average of 6.1% per year over 20 years, now exceeding $35,000. Many PBGH members have seen double-digit cost increases since 2023, with no corresponding improvement in care quality or access. She argued these increases are not driven by greater utilization or sicker patients, but by unchecked market power wielded by consolidated hospital systems.

Serving patients with I/DD

The nation’s health care system provides care for patients with intellectual and developmental disabilities (I/DD). Medicaid-funded home and community-based services (HCBS) are a human necessity and a cost-effective alternative to institutional care, said Barbara Merrill, CEO of ANCOR, a national association that represents providers of community-based services for people with I/DD. Looming funding cuts threaten to unravel that system, she said.

Her primary recommendation was straightforward: Congress must maintain, and increase when possible, federal Medicaid funding for HCBS. She argued that these services are demonstrably less expensive than institutional alternatives, making adequate funding a fiscally responsible choice, not merely a humanitarian one.