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One tactic that insurance companies use to help contain costs is to require providers to seek approvals before actually performing specific operations (a practice known as prior authorization). It is not difficult to imagine how this practice can go wrong. KFF Health News published an article about one family's struggle with an insurer's delayed approval. The article notes "His family didn't expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life." and that "The insurer said the procedure wasn't medically necessary and that it was considered 'experimental and investigational.'" When the insurer finally did reverse course, "Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure." Notably, the procedure in question (histotripsy) "was a less expensive alternative to chemotherapy, which his insurer had already authorized."

The main question in this context is: who gets to decide whether the insurance company should authorize a procedure? The insurer authorized chemotherapy, but apparently, the family opted not to continue that treatment. Should the insurer be allowed to deny the histotripsy treatment, even if medical experts believe it would help? It appears that enough of the public has tired of challenges with the practice of prior authorization that "By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books." For the state in question for this article (West Virginia), the new law seems rather limited in scope. Presumably, if patients and providers continue to face challenges with prior authorization, stronger regulation will be considered.

A KFF Health News article highlights how a rise in premiums (and loss of subsidies) have prompted people to delay medical care. The article focused on older Americans who might be a few years away from Medicare eligibility, but the rise in effective premiums is quite alarming: "his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income." As another example, "her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum."

While subsidies provide some short-term relief, they do not address the underlying growth in medical costs. Subsidies might actually give providers less incentive to reduce costs, as they mask the cost (which eventually show up in higher premiums) to patients. Subsidies might make sense as a short-term policy, but ultimately, the underlying cost trend needs to be addressed.

KFF Health News outlined the struggles of some primary care physicians: "primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists." The lower salaries (relative to other specialties) has contributed to a shortage of primary care physicians. However, the article also points out that "primary care providers need time and money to manage or prevent illness ... and their insurance reimbursement rates should take that into account," meaning that declining or even stagnant reimbursement rates from insurance companies can have an outsized impact on primary care providers. The article also highlights why many of primary care physicians are keen to retain their independence, rather than, say, work at a large hospital system or for a practice owned by private equity.

One way that some primary care doctors have reacted is to adopt a business model known as "direct primary care," which "bypasses insurance altogether" (and is therefore less accessible to the average patient). However, some other doctors are banding together in what are known as independent physician associations (IPAs), which gives the doctors "power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies." IPAs can also be reimbursed for value-based care where "the medical practice is given a budgeted amount for each patient's care, which provides an incentive to keep them healthy so they need fewer treatments. ... If there is money left at the end of the year, it's split between the practice and the insurer." Many people in the industry have hopes that valued-based care will help slow the growth in healthcare costs.

The general sentiment from large medical associations seemed to be that as long as patients visited properly credentialed physicians, the patients would essentially not have anything to worry about beyond the standard risks. In the world of plastic surgery, however, it appears that botched surgeries have become so prevalent that even the "The American Society of Plastic Surgeons, which represents 12,000 doctors, is now warning patients to 'do their homework'," as reported by KFF Health News.

Although patients are entitled to lodge formal complaints to the state licensing boards, one member of such a board points out how "the disciplinary process is rigged in favor of doctors, mostly because of the power of medical groups in the state lobbying to thwart change." One tangible recommendation is that boards "should alert the public about doctors under investigation for alleged misconduct." As it stands, "complaints to medical boards about surgeons or other doctors can remain under wraps for years." While publishing allegations can have some negative consequences, not doing so and taking years to investigate the complaints seems to pose too great of a patient safety risk.

Insurers like to portray themselves as gatekeepers who help prevent runaway prices for medical procedures. After all, if they pay less for medical procedures, their costs are less, which theoretically should mean more profit. In this model, the insurers and patients are aligned in wanting low prices at clinics and hospitals.

KFF Health News published a piece explaining that the incentives that insurers face might actually tilt the other way. After providing examples of seemingly outrageous prices, the article explains that "Insurers aren't incentivized to lower prices, because high prices mean they 'get a slice of a bigger pie'... when prices rise, they can pass on the increase to customers in the form of higher premium costs... [which] mean less money for the patient and more profit for the insurer." The article notes that "Medical inflation has steadily outpaced general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars." Patients are affected by the high prices because even with insurance, they often need to pay the deductible or co-insurance, which can amount to several thousands of dollars.