It's clear that health insurance companies are awful, but I wish people weren't so quick to let medical providers off the hook. It takes two to tango, and health insurance companies have found medical providers are eager to protect the status quo.

Under our system, companies are highly incentivized to spend lavishly on employee health insurance plans since those dollars are not counted as taxable income on the employee's tax returns. By law, at least 80% of those tax advantaged insurance premiums must be passed on to medical providers [0].

Healthcare providers further benefit from having insurance companies act as a cut-out between consumers and them. Consumers have minimal price sensitivity since their care has already been paid for by their employer in the form of health insurance premiums. Under single-payer, providers would be unable to play insurance companies off one another in price negotiations.

So it's little wonder that the American Medical Association has been opposed to government-backed health initiatives throughout the 20th century [1]. Both the AMA and the American Hospital Association have joined with the pharmaceutical and health insurance industry to oppose Medicare for All [2,3,4].

Doctors have also lobbied to limit competition that could drive down their compensation. They have lobbied for caps on the numbers of doctors trained in the US and on Medicare reimbursements for resident physicians. A testament to the success of these limits is that in 2022, a quarter of US physicians were trained abroad [5]. The AMA has opposed expanding the scope of practice for nurse practitioners [6]. Resident physicians are subjected to grueling long hours in what amounts to an institutionalized hazing ritual, with residents working up to 28-hour-long shifts and 80-hour weeks under applicable duty hour regulations. Even these generous limits are routinely evaded by false reporting [7]. The Association of American Medical Colleges projects a shortage of up to 86,000 physicians by 2036 [8].

Meanwhile, despite most hospitals being nonprofit institutions and enjoying the concomitant tax benefits, they increasingly behave like rapacious capitalists. The Guardian reports [9]:

> Since the 1990s, hospital systems across the US – for and not-for-profit alike – have relentlessly chased after market power, executing nearly 2,000 mergers with little pushback from overwhelmed federal antitrust regulators and indifferent state authorities. Research from the American Medical Association found that by 2013, 97% of healthcare markets in the US had little competition and were highly consolidated under Department of Justice antitrust guidelines. By 2021, that figure had risen to 99%.

A 2023 Health Affairs study reported "substantial growth in nonprofit hospital operating profits and cash reserves" between 2012 and 2019 "but no corresponding increase in charity care" [10]. Direct-to-consumer advertising for health services ballooned from $542 million to $2.9 billion between 1997 and 2016 [11].

Stories have emerged of hospital staff steering patients toward unnecessary procedures and testing [9]; of exhorbitant charges, like $629 to put a bandaid on a finger [12]; and of fraudulent billing practices like upcoding [9]. ProPublica describes the case of Dr. Thomas C. Weiner, an oncologist at a Montana nonprofit hospital who was found to be routinely giving his patients unnecessary treatments. In one case, a patient died after 11 years of cancer therapy from treatment complications despite a biopsy in his medical record showing he never had cancer. An autopsy has confirmed the biopsy [13]. Over those 11 years, Dr. Weiner was paid over $20.1 million, billing up to 70 patient contacts a day [14].

Just last week, my wife had an otolaryngologist push to perform a closed reduction to straighten her broken nose despite a CT scan in her record showing that the fracture was not displaced. This was the third medical appointment she completed (ER, primary care, specialist) for an injury for which the ultimate treatment was OTC pain medication and ice.

Insurance executives make easy targets, and they earn their bad rap, but it would be a mistake to ignore the other players in the medical industry. Everyone is at the feast, and we're on the menu.

0. https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/

1. https://en.wikipedia.org/wiki/American_Medical_Association#O...

2. https://www.nytimes.com/2019/02/23/us/politics/medicare-for-...

3. https://thehill.com/policy/healthcare/482797-american-medica...

4. The New Yorker: Inside the AMA's Fight over Single-Payer Health Care - https://archive.is/u96Rn

5. https://en.wikipedia.org/wiki/American_Medical_Association#R...

6. https://www.ama-assn.org/practice-management/scope-practice/...

7. https://pmc.ncbi.nlm.nih.gov/articles/PMC3886449/

8. https://www.aamc.org/news/press-releases/new-aamc-report-sho...

9. https://www.theguardian.com/us-news/2024/oct/17/indiana-medi...

10. https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542

11. https://jamanetwork.com/journals/jama/fullarticle/2720029

12. https://www.vox.com/2016/5/13/11606760/emergency-facility-fe...

13. https://www.propublica.org/article/anthony-olson-thomas-wein...

14. https://www.propublica.org/article/thomas-weiner-montana-st-...