October 2, 2026 

Re: Request for Information on Policy Proposals to Improve Access, Quality and Affordability of Health Coverage for All Americans

Dear Senate Committee on Finance:   

The Center for Individual Freedom (hereinafter CFIF) writes in response to your July 30, 2026, Request for Information (RFI) regarding Policy Proposals to Improve Access, Quality and Affordability of Health Coverage for All Americans.^{1 2}      

The Committee’s RFI identifies genuine problems confronting American patients, physicians, providers and employers.  Such headwinds as excessive prior authorization requirements, opaque claims denials and convoluted financial relationships among insurers, pharmacy benefit managers (PBMs), providers and other intermediaries interfere with competition and inhibit patients’ access to the physicians and treatments that they need.  Those problems merit serious attention.  

Affordability and access concerns, however, do not mean that even more federal government control of healthcare financing, insurance design or prices provides the appropriate remedy.  

To the contrary, as both experience and scholarship repeatedly confirm, the opposite is true.  Many of the problems identified by the RFI illustrate the need for market competition, greater transparency, stronger intellectual property rights and more patient control, not more government regulation and control than already exists.  

SECTION 1:

In that vein, Section 1 of the RFI addresses legitimate concerns regarding healthcare affordability, deductibles, out-of-pocket expenses and access to coverage.  In so doing, it also raises broader proposals ranging from a federal public option and Medicare or Medicaid buy-ins to single-payer healthcare.  

Those proposals must be considered against the massive scale of existing federal healthcare commitments that already exists.  

According to the Congressional Budget Office (CBO), for instance, federal health insurance subsidies will already total approximately $33.6 trillion between 2026 and 2036.³   The CBO projects those subsidies to rise from approximately 7.4% of gross domestic product in 2026 to 8.4% in 2036, and Medicare alone accounts for approximately $16.1 trillion of that projected total.  

Meanwhile, private employer-sponsored insurance remains the principal source of coverage for approximately half of the American population, and the CBO projects that nearly 50% of Americans will continue to receive employment-based coverage through the 2026 – 2036 time period.  That remains the overwhelming preference for Americans, with surveys consistently showing 90% happy with their employer-provided coverage.⁴   Moreover, the same 90% level of Americans prefer health coverage provided by employers over plans offered through other means.⁵  

Accordingly, any proposals for a federal public option, Medicare or Medicaid buy-ins, or a single-payer system implicate tectonic and disruptive questions objectionable to the overwhelming majority of American consumers.  Given the budgetary numbers referenced above, such proposals also necessarily implicate broad questions relating to federal spending in an era of unsustainable federal deficits and debt, and ultimately patients’ range of coverage choices.  

It must also be emphasized that any proposal to increase federal government control over health coverage would threaten the innovation on which Americans rely.  

Pharmaceutical and biotechnology innovators, for example, face enormous burdens in the form of protracted, expensive and uncertain research and development processes, including governmental approval and testing uncertainties.  Most experimental medicines never reach patients, meaning that the comparatively small number of successful medicines must finance not only their own development but also the many unsuccessful compounds that preceded them.  

Consequently, the magnitude of disruption contemplated by the RFI, including “Medicare for All,” or drug price controls in any form, would introduce even more uncertainty to pharmaceutical and other medical technological innovators.⁶  

That detrimental impact upon innovation deserves particular attention whenever policymakers contemplate extending government-administered payment systems or price-setting mechanisms, and the consequences that they would have.  As experience both at home and overseas repeatedly confirms, government price regulation inevitably reduces the availability of treatments, particularly for seniors and patients suffering from complex or rare conditions.⁷  When governments artificially suppress reimbursement rates, manufacturers face diminished incentives to introduce new therapies into the U.S. market.  That in turn means delayed product launches, limited distribution and elimination of certain offerings altogether.  The result is fewer options for patients who often cannot afford to wait. 

SECTION 2:

Next, Section 2 of the RFI appropriately focuses attention on an area of growing bipartisan concern: administrative barriers that separate patients from physician-recommended care.  

Although utilization-management tools can serve legitimate purposes, including reducing fraud, waste and unnecessary care, inefficiencies inhibit healthcare access and become an obstacle between patients and physicians.  

The American Medical Association’s 2024 survey of practicing physicians illustrates the magnitude of the problem.⁸  Fully 93% reported that prior authorization delays access to necessary care, 82% said it can cause patients to abandon treatment and 94% associated it with negative clinical outcomes. Most disturbingly, 29% reported that prior authorization had resulted in a serious adverse event for a patient, including hospitalization, disability or death.  

Those numbers justify the Committee’s attention, and potential reforms can be evaluated according to whether they reduce needless administrative friction while preserving appropriate safeguards against fraud and unnecessary expenditures.  Transparency is particularly important.  A patient who receives a denial should be able to determine promptly what was denied, why it was denied, what evidence supported that decision and how to appeal it.  Physicians likewise should not have to divert extraordinary amounts of staff time merely to discover why a treatment prescribed according to their medical judgment failed an insurer’s administrative test.  

SECTION 3:

Section 3 of the RFI addresses another important component of healthcare reform:  reducing the degree to which opaque middlemen and bureaucratic complexity stand between healthcare solutions and American patients.  

Today, modern health insurers increasingly bear little resemblance to the traditional company that simply collected premiums and paid medical claims.  Conglomerates can now encompass insurance operations, PBMs, pharmacies, physician practices, clinics and other healthcare businesses.  

PBMs merit particular scrutiny.  Too often, negotiated rebates and discounts on particular pharmaceuticals fail to reach the patients whose prescriptions generated them.  Even when insurers or PBMs pay substantially less for drugs, patients still face prices calculated from drugs’ higher list prices, and that disconnect deserves Congress’s attention.  Employers and plan sponsors should ideally possess sufficient information to ascertain whether their PBMs actually secure the savings promised to them, and patients should in turn benefit from those negotiated savings.  

Congress should accordingly pursue greater PBM transparency and accountability, and remove artificial barriers to direct contracting, where greater competition can reduce costs.  The ultimate goal shouldn’t be yet another level of federal price-setting, but rather a more transparent and competitive marketplace in which intermediaries actually compete on the basis of price and value delivered to patients and plan sponsors.  

Employers purchasing coverage, patients selecting plans and independent providers negotiating contracts benefit when prices, rebates, fees and financial relationships can be meaningfully evaluated and compared.  Contractual arrangements that conceal compensation, spreads, rebates or payments to affiliated businesses can make it difficult for employers and consumers to determine what they are actually purchasing and what parties are actually being paid.  

The Committee’s RFI thus identifies genuine sources of frustration for American patients and physicians.  Patients should not wait weeks while an insurer bureaucracy decides whether to approve physician-recommended treatment. They should receive understandable explanations when claims are denied and meaningful opportunities for prompt appeal.  Employers purchasing health benefits should be able to determine what middlemen such as insurers or PBMs charge them.  Independent physicians and pharmacies should be able to compete without hidden contractual or financial arrangements tilting the marketplace toward vertically integrated conglomerates.  

At the same time, those concerns exist alongside other important considerations.  Namely, current and future federal healthcare obligations already measure in tens of trillions of dollars, and Americans overwhelmingly prefer and rely upon employment-based insurance, not alternative government options.  Additionally, continued pharmaceutical and medical innovation rely upon expected returns in financing medical innovation, based largely in reliance upon strong intellectual property rights, which must be safeguarded.  Meanwhile, the potential detrimental effects of public options, buy-ins and administered prices on private coverage and provider markets would create more harm than benefit.  

Accordingly, CFIF respectfully urges the Committee to focus upon real-world data and evidence referenced herein to benefit consumers and more effectively address the concerns raised by the instant RFI.  Transparency, competition, patient choice, innovation incentives like strong patent protections, reduced administrative burdens and federal budgetary sobriety all bear directly upon whether potential federal reforms ultimately improve patients’ access to affordable care.  

Thank you very much for your focus on this important matter, and please contact me at your convenience with any questions or comments.   

Sincerely,   

-----------------------------------------------------------