致罗恩·怀登参议员及参议院财政委员会民主党成员的备忘录

Philip Alvelda and Thomas Ferguson* Working Paper No. 252 August 4, 2026 ABSTRACT On July 30, 2026, the Democrats of the Senate Finance Committee put forward an eighty-six pagerequest for outside evidence and proposals that could become a basis for future legislation. They requestresponses by October 2. We think their critique of theAmerican health care insurance system has manymerits. But their proposals in many cases will not work even to fix insurance and they do not reach mostof the system at all. The Senate Democrats are building an Archimedean lever that will not move anymajor part of the health care world. We think this is a sure-fire path to further disappointment andpopular anger. https://doi.org/10.36687/inetwp252 This is our submission in response to the Committee's request for information.Full identification ofthe source document, the four value labels and their definitions, the method, the verification protocol,the working notes and the limitations of this analysis are set out in Appendix A. Webeginwith an executive summary of our full argument and a detailed Table of Contents. Executive Summary Senate Finance Committee Democrats have described, more honestly than any committee before them,how insurers profit by denying care—then proposed a plan that misses 68 to 76 percent of the problem,$382 billion a year, most of it hospital pricing. Reform has toincludehospitals, and has to raise theaudited share of each dollar reaching care across whole conglomerates, not one subsidiary. This 86-page request for evidence (July 30, 2026; responses due October 2) will draft the next healthbill. What it omits now stays omitted (p002—page cites refer to that document). The diagnosis is right, and the Committee's own numbers convict.Denying care is how insurersmake money, not bad administration (p059-060). Insurers keep "nearly $1,000 per enrollee annually inoverhead and profit" (p071); the rule written to claw that back returned "approximately $200" (p077).Nineteen percent of 2024 claims were denied—85 million, on care already agreed to—and0.3percentwere appealed (p055).SOURCED. But the proposals regulate insurers and nothing else, which is 24 to 32 percent of the money thatdoes not buy care. Hospitals are the largest untouched piece,$306 billionESTIMATED, paid254percent of Medicarefor identical inpatient care.SOURCED18. Across 86 pages, "facility fee,""provider consolidation," "market power," "monopoly" and "antitrust" appear zero times.How insurersbehave decides how the dollars get fought over. What hospitals charge decides how many dollarsthere are. And a rule aimed at one company in a group moves money rather than saving it.The Medical LossRatio "applies only to the insurance entity rather than the parent company" (p077)—the Committee'sown proof that a conglomerate escapes a cap by overpaying the physician group it also owns. This report rates all 71 proposalson care-dollar share, usable access, and gameability (Exhibit 1), andourExhibit 7names where each gameable one sends the money.Seein this order: benchmark affiliatepayment rates; bar utilization management from counting as quality improvement; measure the parentbefore capping the subsidiary; cap what hospitals charge commercial plans. The largest absences arevolumetric liabilityfor wrongful denials and a provider-side price instrument (Section 7). One number settles whetherthe proposalswork:the audited care-dollar share across the parent andeverything it owns, required to rise5 percentage points in five yearsagainst a baseline that does notyet exist. It drifts±2 pointsa year unaided, so insurer-only reform isindistinguishable from doingnothing(Section 12). Extend these proposals to hospitals and to whole companies, and the Committee goes frominconveniencing a quarter of the money to recovering most of it for care. +5 ptsT H ET E S T A N Y R E F O R MM U S TP A S Scare-dollar ratio, whole company,five years Contents Part I—Two-Page Brief •The Committee's diagnosis is right, and the damning numbers are its own•The plan does not reach 68 to 76 percent of the problem•A rule aimed at one company in a group moves the money rather than saving it•Three measures that would actually move money back to care•What the plan cannot see at all•One number decides whether any of it worked Part II—Introduction (standalone) •The plan leaves out 68 to 76 percent of the problem it is trying to solve•Squeeze one part of a company and the money moves to another part of the same company•Three things the plan gets wrong about its own subject•Three measures that would actually move money back to care•Nine components, and the one number that decides whether any of it worked•What to submit by October 2, and in what order Part III—Full Critique •1. The verdict•2. Three questions to ask of every proposalo2.1 Axis 1—Care-dollar ratioo2.2 Axis 2—Accessibility and affordability, nominal versus effectiveo2.3 Axis 3—Gameability •3. Exhibits oExhibit 1—Three-ax