Introducing a New Series: A Decisionmaker's Guide to Competing Health Evidence
AcademyHealth CEO Aaron Carroll announces our monthly series designed to help policymakers and journalists make sense of conflicting health policy evidence.
Health policy debates are full of experts who seem to be saying opposite things. But the reality is, they’re asking different questions, working from different data, or making different assumptions about what matters most. AcademyHealth is launching a new series to help policymakers, journalists, and other decisionmakers sort through those competing claims: what the research actually shows, where the tradeoffs are real, and which questions remain genuinely unsettled. We’re not here to tell you what to think. We’re here to help you think it through.
What a New Proposal to Lower Health Costs Gets Right. And Where the Evidence Gets Complicated
If you’ve ever waited weeks for your insurer to approve a treatment your doctor already ordered, or opened a medical bill that bore no relationship to anything you were told in advance, you’re not alone. A February 2026 KFF poll found that 34 percent of insured adults named prior authorization their single biggest burden with their health plan. Meanwhile, employer premiums have risen steadily, and deductibles have outpaced wages for years.
The Center for American Progress stepped into that frustration this month with “A Patients’ Bill of Rights to Lower Health Care Costs.” The proposal has three main parts: ban prior authorization and replace it with independent clinical review, cap hospital prices in concentrated markets at three times Medicare rates, and impose new limits on insurer profits. State legislatures in Delaware, Vermont, and Maine are already debating similar hospital price-cap bills. CAP’s proposal takes those state-level pressures and packages them as a federal agenda.
So what does the evidence actually say?
On prior authorization, the case for reform is strong. The AMA’s 2024 physician survey found 93 percent of physicians said prior authorization delays necessary care, and 29 percent reported a serious adverse event, including hospitalization or death, linked to those delays. A 2026 systematic review found associations with disease worsening and preventable hospitalization across multiple clinical areas. Physicians spend roughly 13 hours per week on prior authorization paperwork alone. Almost no one, including insurers, defends the current system in its entirety.
The harder question is what replaces it. CAP proposes independent clinical review with decision support. That’s a reasonable direction, but it hasn’t been tested at scale. A March 2026 study in JAMA Health Forum examined what happened when 19 states removed prior authorization requirements for buprenorphine, a treatment for opioid use disorder. Utilization didn’t improve as expected. Patients also needed available providers, counseling access, and sustained support, removing the paperwork barrier alone wasn’t enough. The lesson isn’t that reform is wrong. It’s that the replacement model matters as much as the reform itself.
On hospital price caps, Oregon’s experience is the most useful data point we have. In 2019, the state capped hospital prices for its employee health plan at 200 percent of Medicare rates. Over 27 months, the state saved $107.5 million. Out-of-pocket spending fell 9.5 percent. No hospitals left the network.
CAP sets its cap at 300 percent. The problem is that commercial prices nationally already average around 250 percent of Medicare rates, according to RAND and CBO. A cap at 300 percent mostly affects outliers in the most concentrated markets. For example, places like San Francisco, where prices for the same procedure vary by a factor of nearly three within a single city. That’s a real problem worth addressing. But it may not deliver broad affordability relief for most insured Americans, which is what the proposal promises.
There’s also a legitimate question about whether savings would reach patients. CAP directs insurers to pass savings through as lower deductibles, but the ACA’s medical loss ratio, which requires insurers to spend at least 80–85% of premiums on actual care rather than overhead and profit, was designed to do something similar and, by CAP’s own acknowledgment, hasn’t worked particularly well.
The deepest issue in this debate isn’t prices, it’s consolidation. The evidence that hospital consolidation raises prices is among the strongest findings in health services research. Studies find mergers increase prices from 6 to 18 percent. The FTC challenged roughly 1 percent of hospital mergers over two decades, and the unchallenged anticompetitive ones produced price increases of 5 percent or more. CAP’s proposal correctly identifies consolidation as the root cause, but addresses primarily its consequences, not its structure. Price caps set a ceiling. They don’t change the incentives that drove consolidation in the first place.
None of this means the proposal is wrong. The diagnosis is sound. Prior authorization causes real harm. Hospital prices in concentrated markets are hard to justify on quality grounds. The debate is about whether the prescription is sized to the problem and whether savings, if achieved, would actually reach the people who need them.
Those are exactly the kinds of questions health services research exists to answer. The problem is we need more of those answers before the next round of legislation, not after.
Read the full guide here.