观点：医疗保健需要敢于说"不"的买单方

Right now, millions of workers are choosing their health plans for next year. The average family premium for employer coverage hit $28,303 in 2026, up 28% in the last five years. While employers appear to cover most of that premium, workers ultimately bear the full cost of those benefits through lower wages. Yet no one is really pushing back.

The industry’s major players have little appetite for change. Insurers record higher earnings when premiums rise. Insurance brokers and benefits consultants get a piece of those premiums. Large hospital systems use their bargaining leverage to demand high prices with little fear of losing patients. Physicians, who are commonly paid fee-for-service, earn more by doing more. Drugmakers, with patent protection, largely set their own prices. Each has good reasons to keep things as they are.

The most telling signal is health care prices: For the same service, prices vary enormously, even within the same market. An MRI or a knee replacement can cost several times as much at one hospital as at another across town, with little evidence that the higher-priced hospital provides higher quality care.

This violates a fundamental economic principle: the law of one price. In functioning market settings, price discovery and competition ensure this tendency. But in health care markets, such forces are obscured. Patients have little ability or incentive to shop for lower cost care, and insurers are content to pass on higher prices through as higher premiums.

Employers should be the natural check on this process, but few are engaged health care purchasers. They focus on the premium, while most benefit-design decisions are outsourced to insurers, brokers, and benefits consultants. Employers understandably worry that narrowing health benefits will anger workers. The result is a peculiar situation in which the employers paying the bill on behalf of employees rarely tell an expensive hospital, “No thanks. We’ll go somewhere else.”

A few purchasers have gone a different direction. They do the shopping ahead of time on behalf of their workers and reward them for following their advice.

Walmart offers employees with serious conditions treatment at designated centers of excellence, including the Mayo Clinic. Employees pay nothing out of pocket, and Walmart covers travel and lodging for the patient and a caregiver. This has had some unexpected benefits. Walmart reports that many workers referred for spine surgery ended up not needing it.

In 2011 CalPERS, California’s public employee plan, set a reference price for hip and knee replacements. Members who chose a hospital above that price paid the difference. The goal wasn’t to punish patients but to discipline hospitals, and it worked: High priced hospitals cut their prices sharply.

For two decades, consumer-driven health care mostly meant higher deductibles: When patients had “skin in the game,” the argument went, they would become savvy shoppers. But we know deductibles stop mattering once they are met, and for major surgery that happens almost immediately. Walmart and CalPERS turn the idea around. Instead, the sophisticated purchaser shops ahead of time, then tells employees where to go for high-quality, high-value care.

Small employers lack the heft of Walmart and CalPERS, but innovative solutions are available to them too. Self Fund Health brings the Walmart model to small firms in Wisconsin, where hospital prices are high. The company says it can be cheaper to fly patients to Johns Hopkins than to treat them locally. Members still have access to a broad network of doctors, but care from a preferred tier of low cost providers is free.

A plan doesn’t need to dominate a market to affect prices. When a hospital loses 10 lucrative cardiac cases to an out-of-state center, it notices. For example, CalPERS didn’t get all its members to change hospitals, but moving some patients made the threat credible. The key is to reintroduce price discovery by giving patients curated price information. This is how workers can be activated to vote with their feet.

The question remains: Why do so few employers use these methods? There are many reasons, but three seem most relevant.

First, the tax code is a huge obstacle. Because employer-provided health insurance benefits are excluded from workers’ taxable income, a dollar of health benefits costs employees less than a dollar of wages.

The result is a dulled incentive to save money on health care. While the Affordable Care Act’s “Cadillac tax” on high cost health plans was repeatedly delayed and eventually repealed in 2019, it was the only serious effort to limit the tax exclusion, albeit in a clunky way. It died because major beneficiaries of high spending pushed back, with an assist from public- and private-sector unions whose members often enjoy richly negotiated health benefits.

However, given that the current tax code is littered with caps and phase-outs of preferential tax advantages (think retirement benefits, mortgage interest, and the child tax credit), it doesn’t seem so outlandish to apply similar logic to the health insurance tax exclusion.

Second, small employers rely on brokers to help with plan selection and benefit design. But commissions influence their recommendations in complex ways. At a minimum, employers should proactively question their brokers about the commissions they earn; indeed, federal law requires brokers to disclose them.

Finally, big hospital systems can fight back even when engaged employers try to steer patients to cheaper providers. Recently, North Carolina’s State Health Plan built a tiered network that charges members more to use high-priced systems. Atrium Health didn’t like being placed in the costly tier, so it fought back by waiving cost-sharing requirements at its facilities, effectively neutralizing the tiering effort while keeping the plan’s high prices.

The answer is not to ban this behavior but to steer at enrollment rather than at the point of care. The employer can offer a lower premium that includes only lower-priced providers and let workers who want Atrium pay the premium difference. A hospital can waive copays, but it can’t pay your premium.

Workers are paying the bill for this largesse, and most would rather see that money in their paychecks than spent on bloated health care prices.

Anthony T. Lo Sasso, Ph.D., is a health economist and the Robert F. and Sylvia T. Wagner professor of public affairs in the La Follette School of Public Affairs at the University of Wisconsin-Madison.