Library
Vertical Integration in Health Care
Insurance Denials
When Insurance Fails: Patient experiences navigating insurance barriers to care
- This March 2026 report highlights real-life stories of insurance failing to meet patient needs
Insurer Profits
The Lever: Health Insurers’ $371 Billion Windfall
- The three largest health insurers have earned more than $371 billion in profits since the Affordable Care Act was enacted.
KFF: How Much and Why ACA Marketplace Premiums Are Going Up In 2026
- Since COVID, the average Affordable Care Act benchmark premium increased by 30%, from $452 in 2021 to $586 in 2026.
KFF: Deductibles in ACA Marketplace Plans, 2014-2026
- The average deductible across benchmark silver plans without Cost Sharing Reductions increased 92% over the last 10 years, from $2,556 in 2015 to $4,902 in 2025.
Insurer Cost-Shifting
- Millions of Americans are in high-deductible plans that expose them to substantial cost-sharing.
IQVIA: The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028
- Patient out-of-pocket costs in the commercial market increased $5B in 2023, up 5.8% over 2022 and 11% over the last five years.
- Increasing cost sharing above $100 was associated with up to a 75% abandonment rate for certain specialty drugs.
Federal Spending On Insurance
CMS: National Health Expenditures Projections Through 2030
- The federal government is expected to pay health insurance companies and PBMs $16 trillion to administer health benefits over the next decade. If the cost to the federal government of subsidizing insurance premiums through the tax code, that number increases to over $21 trillion.
KFF: Estimated Total Premium Tax Credits Received by Marketplace Enrollees
- The value of Premium Tax Credits increased 153% since the COVID-19 pandemic, from an estimated $57 billion in 2021 to $144 billion in 2025.
Waste and Low Value Care
JAMA: Measuring Low-Value Care in Medicare
- Health insurers pay for hundreds of services that are considered low value and the Medicare system spends $8.5 billion a year on low-value care.
WFAE 90.7: U.S. Health Care Administration Costs Are Responsible For At Least 25% Of Medical Bills
- Up to 33 cents of every health care dollar in America are spent on administrative services and paperwork (source).
Utilization Management
KFF: Health Tracking Poll: Public Finds Prior Authorization Process Difficult to Manage
- Of those who have dealt with prior authorization in the past two years, more than half (51%) report difficulty in navigating the process.
KFF: Claims Denials and Appeals in ACA Marketplace Plans in 2023
- ACA marketplace plans denied 19% of in-network claims in 2023 and 37% of out-of-network claims.
- Insurers offering plans in ACA marketplaces denied 73 million claims for in-network services in 2023, over 4 claims denied per enrollee.
Commonwealth Fund: Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S.
- 45% of insured, working-age adults reported receiving a medical bill or being charged a copay in the past year for a service they thought should have been free or covered.
KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024
- 99% of enrollees in Medicare Advantage plans are required to obtain prior authorization for some services.
- Insurers fully or partially denied 3.2 million Medicare Advantage prior authorizations in 2023.
- 81.7% of prior authorization appeals were overturned in 2023.
- Among coverage denials that Medicare Part D beneficiaries appealed in 2017, sponsors fully overturned or partially overturned 73%. HHS OIG noted that denials could have been avoided if plan sponsors correctly received and processed information at the first request.
AMA: 2024 Prior Authorization Physician Survey
- 93% of physicians report care delays associated with PA.
- 82% of physicians report that PA can at least sometimes lead to treatment abandonment.
- 29% of physicians report that PA has led to a serious adverse event for one of their patients.
PBM Business Practices
- PBMs are each part of massive vertically-integrated healthcare conglomerates that are highly consolidated and wield enormous power of patients.
- PBMs steer patients to affiliated pharmacies. The report found that one drug cost $97 at an independent pharmacy but $19,200 at PBM-preferred home delivery pharmacy.
- The parent companies of the three largest PBMs and Humana (including Humana Pharmacy Solutions) comprised 22 percent of all national health expenditures in 2024.
- PBMs can reimburse owned pharmacies at higher rates than community and independent pharmacies and engage in spread pricing (where a PBM charges a payer more than what the PBM reimburses the pharmacy).
- Rebates may incentivize PBMs and plan sponsors to favor higher cost drugs, which can increase costs for beneficiaries.
- Part D beneficiaries paid 4 times more than their insurers and PBMs for 79 of the top 100 highly rebated medicines (insurers paid $5.3 billion and Part D beneficiaries paid $21 billion out of pocket).
CBO: Estimate of Modernizing and Ensuring PBM Accountability Act
- Part D delinking reforms and PBM transparency disclosure requirements would save the federal government more than $700 million over 10 years.
- In 2011, plans excluded 20.4% of drugs from their formularies, which grew to 30.4% in 2020.