America Pays the Healthcare Bill. The Patient Still Needs Permission

The United States spends public-scale money on medicine while Congress leaves private institutions in control of who receives care, what it costs and how long patients must wait.

The Rehabilitation Bed Was Ready

On the morning of Memorial Day 2022, Dr. Gary Dean Bent told his wife, Gloria, that something was wrong. He was bumping into walls and could not remember how to tie his shoes.

A scan at the University of Connecticut Health Center found a bleeding lesion in his brain. Surgeons removed the lesion and a hematoma on June 1st. Pathology confirmed that the cancer Gary had fought for years had returned as metastatic melanoma.

He survived the operation, but he emerged confused and severely impaired. He could not stand or walk without assistance, and his brain no longer fully recognized the left side of his body.

His medical team knew what should happen next. Gary’s neurosurgeon, physical therapist, and occupational therapist recommended acute rehabilitation. Gaylord Hospital for Specialty Care had accepted him, a rehabilitation bed was available, and his family expected the transfer on June 8th.

It never happened. UnitedHealthcare, acting through its naviHealth subsidiary, denied authorization. According to Gloria Bent’s later testimony before the Senate Permanent Subcommittee on Investigations, the company concluded from Gary’s records that he would not be able to withstand the intensive therapy schedule.

The doctors who had examined him believed he needed the rehabilitation. Someone reviewing his chart from somewhere else decided the plan would not pay for it. The doctors existed. The treatment existed. The facility existed. The rehabilitation bed was ready. What Gary did not possess was permission from the institution responsible for paying the bill.

That is the bargain millions of Americans are told to accept as healthcare. They work, pay taxes, surrender part of each paycheck for premiums, and enroll in plans approved or subsidized under federal law. When illness arrives, the physician’s judgment may still be placed beneath the decision of a payment system that has never examined the patient.

Gary Bent’s denial was not merely a dispute between one family and one insurance company. It occurred inside Medicare Advantage, a federal program created by Congress, financed with public money and administered substantially through private corporations. Congress built a system in which the public carries the cost while private gatekeepers retain the power to decide whether the promised care reaches the patient.

America does not suffer from a shortage of healthcare spending. It suffers from the absence of a guarantee strong enough to carry that spending through the final gate.

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America Built a Payment System, Not a Healthcare Guarantee

The United States does not operate one healthcare system. It operates several overlapping systems that leave people moving among different rules, networks, and eligibility categories.

A working-age adult may receive insurance through an employer. An older American may enter Medicare. A qualifying family or person with a disability may receive Medicaid. A veteran may obtain care through the Department of Veterans Affairs. A family without job-based coverage may purchase a private policy through an Affordable Care Act marketplace.

Each program protects people who might otherwise go without care. Together, they still do not create one national promise that every person will be covered and able to obtain medically necessary treatment.

Congress entered healthcare repeatedly. It wrote tax preferences, created programs, subsidized premiums, authorized private plans, and divided responsibility among agencies, states, employers, and insurers. Medicare and Medicaid closed enormous holes in American economic security. Later reforms protected children, people with disabilities, families purchasing individual coverage, and patients with preexisting conditions. Every reform answered a real need, but Congress answered those needs by opening separate doors.

Which door a person may enter can depend on age, income, employment, disability, military service, family status, and state of residence. A change in one circumstance can alter the insurer, network, deductible, physicians, and rules governing care. The result is not a national guarantee with several methods of delivery. It is a collection of payment arrangements with different admission qualifications.

Congress did not lack the power to build something coherent. It repeatedly used that power to protect another population without deciding what every person should be entitled to receive.

The programs became indispensable, but the gaps remained. America built a system for moving the money, but it never completed the promise at the other end.

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The Job Became the Insurance Office

For millions of Americans, access to doctors and hospitals begins inside the employer’s benefits department. The company selects the carrier. The carrier establishes the network. The plan determines the deductible, drug formulary, prior-authorization rules, and the worker’s share of the bill.

That arrangement is familiar, but it was never inevitable. Employer-sponsored insurance expanded during World War II, when wage controls limited businesses’ ability to compete for scarce workers through higher salaries. Health benefits offered another way to attract labor. Federal tax policy later entrenched the arrangement by excluding employer-provided coverage from workers’ taxable income. A wartime labor response became the country’s principal method of financing care for working families.

That tax advantage helps millions obtain coverage, but it also obscures the cost. Employer contributions are part of total compensation. Money absorbed by rising premiums cannot as easily become higher wages, additional hiring, or investment elsewhere.

The system also forces businesses to serve as healthcare purchasing offices. Large corporations may have consultants and bargaining power. Small employers must compare networks, deductibles, and premiums while trying to operate their businesses. When prices rise, they may shift more costs to workers, reduce benefits, or stop offering coverage.

The arrangement burdens the employer and binds the employee. A worker may remain in an abusive or exhausting job because a spouse needs medication. A parent may hesitate to start a business because a child requires continuing treatment. Losing a job can mean losing income and medical security during the same crisis.

Even workers who remain employed do not own the coverage. The employer can change carriers, the insurer can change networks, and a hospital covered this year may become unaffordable the next.

This is not an argument against employers that provide good insurance. Many spend substantial money trying to protect workers within a market they possess little power to control. It is an argument against making employment carry an obligation that should never have depended on a job.

The American employer did not apply to become the nation’s insurance office, and the American worker did not consent to making employment the admission requirement for medical security. The law assigned both of them those roles and left the patient dependent on whether the next paycheck also carried permission to see a doctor.

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The Cost Is Already Socialized

Americans are often told that universal healthcare would require the country to begin paying for other people’s medical care.

We already do. We pay through federal, state, and local taxes. Workers pay through payroll taxes, premium deductions, deductibles, copayments, and coinsurance. Employers pay premiums as part of compensation. Families pay prescription bills, uncovered charges, and debts that may follow them for years. The cost is already collective. What America lacks is a collective guarantee in return.

According to the Centers for Medicare & Medicaid Services, national healthcare spending reached approximately $5.3 trillion in 2024, about $15,474 for every person in the country and 18% of the American economy. The federal government sponsored 31% of that spending. Households carried 28%. Private businesses accounted for 18%, while state and local governments carried another 16%.

Those categories make the money appear to come from separate places, but it does not. Government money comes from taxpayers. Household spending comes from wages, savings, and retirement income. Business spending is part of the cost of employing people and producing goods. State and local spending comes from communities whose residents are also paying federal taxes, premiums, and medical bills.

A premium paid by an employer is not free healthcare. It is compensation redirected toward an insurance plan. A deductible is not proof of personal responsibility, but another bill imposed after the premium has been paid.

Even unpaid medical bills do not disappear. Hospitals, governments, creditors, families, and other patients eventually absorb the consequences. The cost travels. It does not vanish. America has not chosen individual responsibility over collective financing. It has chosen collective financing without collective clarity.

The country sends healthcare money through enough institutions that patients cannot easily determine what they have paid, what they are entitled to receive, or who is responsible when care does not arrive.

America already pays enough to treat healthcare as a shared national obligation. What it has refused to share is the promise. The cost has already been socialized. The guarantee has not.

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“Socialized Medicine” Was a Warning Label, Not a Description

The American people were not merely asked to reject one healthcare proposal. They were taught to fear a phrase.

“Socialized medicine” collapsed every form of national healthcare into one threatening image: government officials owning hospitals, employing doctors, and dictating treatment. However, that description does not fit every universal system.

Other developed democracies combine public insurance, private insurers, nonprofit funds, private physicians, and publicly or privately operated hospitals in different ways. Their shared principle is not identical government ownership. It is that people belong to the healthcare system before they become sick.

During President Harry Truman’s campaign for national health insurance, organized opponents portrayed federal coverage as politically controlled medicine and a threat to American freedom. The warning label changed the question.

Americans were no longer being asked whether every family should be protected from the medical and financial consequences of illness, but whether they trusted the government. That allowed the institutions already controlling healthcare to disappear from the frame.

The public was warned that a government bureaucrat might interfere with the doctor-patient relationship. It was not asked whether an insurance reviewer, restricted network, or payment algorithm might do the same thing without democratic accountability.

The country was warned that public financing would limit choice. It was not asked how much choice a worker possesses when an employer selects the plan, the plan selects the network, and the network determines which doctors remain affordable.

Americans later accepted Medicare, Medicaid, veterans’ care, public medical research, and enormous tax subsidies for employer coverage. Public money was never the forbidden ingredient.

The real boundary appeared when public financing threatened to create a public obligation stronger than the authority of the institutions controlling access.

The debate was never only about who would own the hospital. It was about who would own the promise. America did not reject collective payment. It rejected collective power over what that payment must provide.

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The Gate Is Larger Than the Insurance Company

The insurance company is the easiest gatekeeper to see. Its name appears on the card and denial letter. Yet before care reaches a patient, money may pass among an employer, insurer, hospital system, physician network, pharmaceutical manufacturer, pharmacy benefit manager, claims administrator, billing contractor, or private-equity owner.

Each institution may perform a legitimate function. The problem is not that money changes hands. It is that every institution may claim a share of the money, while no institution accepts final responsibility for ensuring that the patient receives care.

The system has also become more concentrated. Government Accountability Office research has found substantial growth in hospital affiliation and physician employment, often accompanied by higher spending and prices without consistent improvements in quality. The Federal Trade Commission has also described how major pharmacy benefit managers operate inside vertically integrated companies that may own insurers, retail pharmacies, and specialty pharmacies.

The patient sees one appointment or prescription. The system sees several opportunities to negotiate, classify, redirect, and collect before the service reaches them.

The healthcare system does not require a villain at every desk to produce an unjust result. It only requires each institution to protect its balance sheet, while no institution is required to protect the patient’s entire path.

The insurer blames the hospital. The hospital blames reimbursement. The manufacturer blames the pharmacy benefit manager. The employer blames rising premiums. The government blames market complexity. The patient still needs the treatment.

Profit may reward lifesaving innovation and efficient care, but it should not reward the construction of another tollbooth between the patient and treatment. The gate is not one insurance company. It is a system that allows everyone to collect before anyone is required to guarantee the care.

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The Doctor Treats the Patient. The Machine Reviews the File.

Prior authorization begins with a defensible idea. Healthcare systems should not pay for unnecessary procedures, duplicative tests, or treatments unsupported by evidence. The question is who performs the review, what standards govern it, and who carries the harm when the first answer is wrong.

The physician examines the patient, reviews the history, and accepts professional responsibility for the recommendation. The payment system receives a file.

That file may be evaluated by an insurer, contractor, or internal criteria. The decision may rely on clinical evidence, but it is made inside an institution whose financial obligation changes depending on the answer.

The doctor remains responsible for the illness. The payer possesses the power to stop payment for the treatment.

A 2025 Government Accountability Office review found that most of the selected Medicare Advantage organizations it examined required prior authorization for inpatient behavioral healthcare. A 2026 inspector general report found that the three largest Medicare Advantage organizations denied certain post-acute-care requests at comparatively high rates. When patients appealed, the plans collectively overturned substantial shares of long-term acute-care and inpatient-rehabilitation denials.

For skilled nursing care, patients and providers appealed only a minority of denials. When they did, the organizations reversed nearly all of them. A successful appeal may demonstrate that a safeguard exists. It also demonstrates that a sick person, family member, or clinician had to fight for care that was ultimately found to be covered.

The strongest patients do not necessarily have the strongest cases. They may simply have more time, education, professional assistance, or a family member capable of continuing the fight.

An overturned denial also does not return lost time. A rehabilitation bed may be given away, a condition may worsen, and a family may accept lesser care because the preferred facility cannot wait.

The file may eventually record that the patient won. The body still carries what happened while the answer was no.

The doctor treats the person. The machine reviews the file. Congress must decide how much power the second should possess over the care prescribed by the first.

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The Bureaucracy Did Not Disappear. It Changed Employers.

Opponents of universal healthcare warn that public coverage would place bureaucracy between the patient and doctor. Americans should take that warning seriously, but they should also look at the bureaucracy already standing there.

It appears in the insurance portal, drug formulary, network directory, billing code, referral requirement, peer-to-peer review, and appeal deadline. Instead of one publicly accountable set of rules, clinicians and patients may confront different requirements for every insurer, plan and contract.

The doctor must learn medicine. The office must learn every payer.

American Medical Association surveys have found that physicians and their staff spend hours each week completing prior-authorization requests. Many practices employ workers dedicated entirely to navigating those demands.

The patient performs unpaid work too, determining whether the doctor, hospital, anesthesiologist, and medication are covered, then collecting records and learning an appeals process while sick. The system calls this consumer responsibility. No ordinary consumer designed the product.

Administration cannot be eliminated from healthcare. Records must be maintained, fraud detected, and payment standards enforced. The question is whether those rules are understandable, accountable, and designed primarily to deliver care rather than protect separate payment systems.

America did not choose between bureaucracy and freedom. It chose bureaucracy divided among institutions with separate contracts, incentives, and rules. Then it handed the patient a telephone number and told the sick person to sort it out.

The clinician became its data-entry worker. The family became its appeals department. The patient became its clerk.

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Illness Should Not Be an Employment Test

Illness does not ask whether the patient worked enough hours. Cancer does not wait for enrollment. A stroke does not check the network. A premature birth does not postpone itself until the deductible has been met. The body does not recognize the categories Congress built around it. The healthcare system does. That makes healthcare insecurity a labor problem as well as a medical one.

A worker dependent on a job for a spouse’s cancer treatment does not negotiate with the same freedom as someone whose care follows them. An employee may remain in an unsafe or abusive workplace because leaving could interrupt medication or treatment. For some workers, employer-sponsored coverage becomes employer-sponsored confinement.

The same dependency discourages entrepreneurship. A skilled worker may have customers and the ability to work independently but remain attached to an employer because someone in the family has a chronic condition.

Healthcare is infrastructure. It allows people to work, raise children, care for parents, start businesses, and live with dignity when work is no longer possible. A system that depends on healthy workers cannot abandon them when they become patients.

Illness is not a moral failure. It should not be an employment test, and medical security should not disappear at the exact moment a person becomes too sick to keep earning it.

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Universal Does Not Require One Imported Model

The United States does not have to copy another country’s healthcare system. It has to decide whether every person will belong to its own.

Britain uses a national health service financed largely through taxation. Canada uses provincial public insurance for medically necessary hospital and physician services, many delivered by private providers. Germany relies heavily on statutory insurance funds. Switzerland requires residents to purchase a legally defined basic package from authorized insurers.

These systems have problems. Universal coverage does not automatically create enough nurses, specialists, rural hospitals, or appointments. A guarantee must still be financed, administered, and enforced. Yet those countries begin with a principle America continues to avoid: a person does not have to earn admission by finding the correct employer, reaching the correct age, or fitting the correct eligibility category.

Congress does not have to nationalize every hospital, employ every physician, or prohibit every private insurer. The legitimate debate concerns how public and private institutions should operate beneath a national guarantee. It asks whether there should be a guarantee at all.

America does not need to import another country’s healthcare system. It needs to adopt the promise those different systems share: Every person belongs before illness arrives. Universal coverage is the obligation. The delivery model is the choice.

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Congress Built the Patchwork and Then Hid Behind It

The American healthcare system is often described as though it became complicated by accident and now lies beyond the control of any elected institution. While that description is convenient, it is not true.

Congress established Medicare and Medicaid and wrote the tax treatment supporting employer insurance. It enacted federal laws governing benefits, cost sharing, appeals, reporting, and much of the private insurance market.

States retain important authority. Employers choose plans. Insurers administer benefits. Hospitals negotiate payment. The boundaries separating them were written in law. That fragmentation makes responsibility easy to pass.

The insurer blames the contract. The employer blames the insurer. The hospital blames reimbursement. The state blames federal restrictions. The agency says it must administer the statute Congress enacted. Congress then points to the resulting complexity as evidence that comprehensive reform would be too disruptive. Complexity became the place where responsibility went to disappear.

The people’s branch cannot claim helplessness before a structure assembled from laws it enacted, programs it funded, and divisions it preserved. For generations, lawmakers responded to exposed failures by attaching another patch. Those patches are important, and millions depend on them, but dependence on the patchwork cannot become an excuse for preserving every hole between its pieces.

Congress built a healthcare system in which every institution can identify the limits of its own responsibility. The patient is the only person expected to survive all of them.

The people’s branch wrote the divisions. It must now write the guarantee.

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Congress Must Write the Guarantee

Congress does not need to promise that every illness will be cured. Instead, it must guarantee that every person can enter the healthcare system without first proving the right job, age, income, disability category, or insurance history.

Coverage must follow the patient. It cannot disappear when a company closes, an employer changes plans, a marriage ends, or a sick worker becomes unable to continue earning the benefit.

That guarantee must mean more than possessing an insurance card. A person is not meaningfully covered when the deductible makes treatment unaffordable, the specialist is outside the network, or an insurer can delay urgent care until the medical opportunity has passed.

Congress should establish a national floor of necessary care and meaningful protection from financial destruction. That floor should include primary and preventive care, emergency treatment, hospitalization, maternity care, mental healthcare, prescription medicine, rehabilitation, and chronic-disease treatment.

When a treating clinician recommends covered care, that judgment should carry a rebuttable presumption in the patient’s favor. A denial should identify the medical reason, supporting evidence, and qualifications of the reviewer. Urgent cases should receive rapid independent consideration. Institutions that repeatedly issue improper denials should face penalties larger than the savings produced by delaying care. The burden cannot remain entirely on the sick person.

Congress should also establish a federal out-of-pocket ceiling tied to income, protect medically necessary care from collection practices that threaten a family’s home or wages, and require prices to be understandable before treatment whenever an emergency does not make advance disclosure impossible.

Healthcare workers must be protected inside the guarantee. Universal coverage cannot be built by exhausting nurses, underpaying caregivers, or closing rural facilities. A promise of care is dishonest when the country refuses to maintain the people and institutions capable of providing it.

Private participation may remain extensive. Private physicians may practice medicine, private and nonprofit hospitals may deliver care, companies may develop drugs, devices and technologies, and insurers or nonprofit funds may administer portions of the system.

However, participation in a publicly supported necessity must carry obligations. An institution receiving public reimbursement, tax preferences, subsidies, or the benefits of publicly funded research should accept enforceable standards of transparency, access, and stewardship.

Congress has spent generations deciding which institutions may move healthcare money. It must finally decide what the American people are entitled to receive when that money reaches the other end.

Private institutions may deliver healthcare, but the American people must own the guarantee.

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The Country Already Pays the Bill

Gary Bent did not need Congress to promise that medicine could save him from every consequence of cancer. He needed the healthcare system to deliver the rehabilitation his doctors believed could help him recover from the surgery he had survived.

The medical knowledge, facility, rehabilitation bed, and public money supporting Medicare Advantage all existed. What failed to exist was a guarantee stronger than the institution empowered to deny the care.

Across the country, Americans pay taxes, premiums, deductibles, and prescription costs. Employers administer benefits they were never created to manage. Doctors and nurses surrender clinical hours to authorizations and appeals. Families become claims departments while someone they love is sick.

The country already pays the bill. America has not refused to treat healthcare as a shared obligation. It has refused to make the institutions receiving that shared money answer to a shared promise.

Private institutions can continue practicing medicine, operating facilities, developing treatments, and administering portions of the system, but no institution should be allowed to collect public-scale money while the patient remains outside the protection of a public guarantee.

The American people have already supplied the money. They have already carried the risk. What they have not received is ownership of the promise.

America already pays for sickness collectively. It simply sends the money through enough institutions that no one is required to guarantee the care at the other end.

The American people already carry the cost. Congress must finally give them ownership of the guarantee.

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Sources:

• American Medical Association. 2025 AMA Prior Authorization Physician Survey. May 13, 2026.

• Bent, Gloria. “Testimony of Gloria S. Bent.” Testimony before the U.S. Senate Permanent Subcommittee on Investigations, Examining Health Care Denials and Delays in Medicare Advantage, May 17, 2023.

• Centers for Medicare & Medicaid Services. “History.” Accessed August 2, 2026.

• Centers for Medicare & Medicaid Services. “NHE Fact Sheet.” Accessed August 2, 2026.

• Federal Office of Public Health, Switzerland. “Health Insurance: Key Points in Brief.” Accessed August 2, 2026.

• Federal Trade Commission. Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies. Interim Staff Report. July 9, 2024.

• German Federal Ministry of Health. “Statutory Health Insurance.” Accessed August 2, 2026.

• Health Canada. “About Canada’s Health Care System.” June 25, 2025.

• HealthCare.gov. “Affordable Care Act.” Accessed August 2, 2026.

• Harry S. Truman Presidential Library and Museum. “President Truman’s Fight for National Health Insurance, 1949–1953.” Accessed August 2, 2026.

• NHS England. “Structure of the NHS.” Published November 9, 2022. Last updated March 12, 2024.

• Organisation for Economic Co-operation and Development. “Population Coverage for Healthcare.” In Health at a Glance 2025: OECD Indicators. Paris: OECD Publishing, 2025.

• U.S. Congress. Joint Economic Committee. How the Tax Exclusion Shaped Today’s Private Insurance Market. December 17, 2003.

• U.S. Department of Health and Human Services. Office of Inspector General. Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns about Initial Denials. OEI-09-24-00331. June 8, 2026.

• U.S. Department of Health and Human Services. Office of Inspector General. The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates. OEI-09-24-00330. June 8, 2026.

• U.S. Department of the Treasury. Internal Revenue Service. Publication 15-B (2026): Employer’s Tax Guide to Fringe Benefits. 2026.

• U.S. Government Accountability Office. Health Care Consolidation: Published Estimates of the Extent and Effects of Physician Consolidation. GAO-25-107450. September 22, 2025.

• U.S. Government Accountability Office. Medicare Advantage: CMS Oversight of Prior Authorization Criteria Should Target Behavioral Health Services. GAO-25-107342. May 29, 2025.