To the Editor:
Re “The Biggest Cause of High Health Care Spending,” by Zack Cooper (Opinion guest essay, May 7):
As a physician, a health care consumer and the former chief executive of a small rural hospital, I read Dr. Cooper’s essay with great interest.
While I think he is correct about how high hospital charges contribute to health care costs, I wondered about what else causes this. My hospital charged high prices for commercially insured patients so it could survive; we lost money on so many other patients that high prices for hip procedures for Blue Cross patients and others who were insured was the only way to keep the doors open to provide other care.
That other care — on which we lost lots of money — included providing emergency and primary care for 20,000 rural Mainers. It also included providing basic care to Medicare patients with pneumonia, congestive heart failure and other ailments.
Some expert insight into how hospitals juggle these demands would have been helpful.
Erik N. Steele Cumberland Foreside, Maine The writer is the former president of the Maine Medical Association and the former chief executive of Northern Light Blue Hill Hospital.
To the Editor:
This essay does not explore a fundamental truth of hospital care: Costs reflect inputs, and those inputs have risen sharply with inflation and other pressures.
In 2025, hospital expenses increased 7.5 percent, with sharp increases in labor, drugs and medical supplies. At the same time, patients are arriving sicker, requiring more complex care, driving up hospital costs. Meanwhile, Medicare and Medicaid routinely reimburse below the cost of providing services, and insurers increasingly use tactics that delay or deny payment — disrupting care and adding administrative cost and burden.
Hospitals are largely price takers, not price setters; government programs set rates administratively, and insurers negotiate payment terms. In 2025, expenses grew about twice as fast as hospital reimbursements for patient care, meaning hospitals absorbed much of the increase instead of shifting it to patients or payers. Federal government actuaries and other researchers have concluded that higher health spending is primarily driven by increased use and intensity of services — not hospital prices.
Hospitals are working to keep high-quality care affordable and accessible. Singling out any one actor will not solve the problem. Real progress requires all stakeholders — insurers, government, drug companies, providers and patients — to work together to address underlying cost pressures.
Rick Pollack Washington The writer is the president and chief executive of the American Hospital Association.
To the Editor:
Zack Cooper’s article was a timely and important contribution to the national dialogue about rising costs. However, one aspect of hospital charges that he did not mention: Rarely does anyone pay the posted rates.
Insurers negotiate their own rate schedules, as evidenced by his example of variability in the cost of a hip replacement by insurer. Self-pay and charity care are handled differently — billed partly to patients, with the rest usually written off.
If insurers were not working to generate returns for shareholders — their primary stated mission — a majority of hospitals would not need to post list prices nearly as high. The demands of for-profit health care, which prioritizes shareholders over patients, is a problem.
Treating health care as a right and a social good, not as an engine for shareholder value, would lower the cost most effectively.
Juliet L. Rogers Ann Arbor, Mich. The writer is a former faculty member at the University of Michigan School of Public Health.
To the Editor:
Zack Cooper makes the case that high hospital prices drive increased spending. The studies he uses to support this assertion are far more nuanced, in particular about the difference in higher costs for patients with private insurance compared with patients supported by Medicare. Dr. Cooper reports that the average hip replacement costs $29,000 with private insurance, whereas Medicare pays only $16,000. In Germany, where the public system covers 90 percent of the population, the payment to hospitals for a hip replacement is $9,400.
The American web of privately negotiated contracts and Medicare/Medicaid payments is difficult to untangle, but not impossible. Studies have shown that the administrative burden associated with private insurers adds 15 to 30 percent to health care costs; with Medicare, those costs are estimated at 2 percent.
If all hip replacements were paid at the Medicare rate, the savings would be more than $7 billion annually, for just one procedure. (Some 544,000 hip replacements are done in the United States every year, according to the American College of Rheumatology.)
Dr. Cooper’s proposed solution — to push back on hospital mergers and block a pending merger in Indiana — seems like a Band-Aid on a broken arm. The industry needs to embrace a “Medicare for all” plan. If Germany can figure this out, so can we.
Agatha Nolen Durham, N.C.
To the Editor:
Zack Cooper attributes high costs in health care to hospital mergers that create monopolies that control pricing. That’s part of the problem, but there are two others.
One is insurance itself. In economics, insurance creates a moral hazard. Because hospitals can pass costs on to insurance companies, they have no incentive to manage costs. If there were no commercial insurance market, and only Medicare, for example, hospitals would have to adjust their prices down, and lower internal costs.
President Bill Clinton proposed such a plan in 1993 during a joint session of Congress, as a national “health care security card.” It was aggressively resisted by the insurance industry and ultimately defeated.
The other problem is that hospitals increasingly function as “rental” facilities for surgeon partnerships that are separate from the hospital. This is prevalent in orthopedics, for operations such as hip replacements, in which a group of doctors forms a private, for-profit surgery company and then rents surgery facilities at hospitals.
These physicians’ private corporations have created a new layer of medical profiteering, which supports the insurance cartel. Hospitals like it because it reduces or removes their patient liability risk, while turning hospitals into real estate leasing companies.
Matthew G. Andersson Oak Brook, Ill.
To the Editor:
The biggest problem in American health care isn’t just costs — it’s that we keep pretending it’s a market.
Markets work when consumers can shop, compare prices, know what they are buying and walk away if the value is too low. Health care violates every one of those conditions. Illness is unpredictable and often urgent, so it’s difficult to shop for care. Patients don’t choose which emergency room the ambulance takes them to. They rely on physicians’ expertise and trust, but don’t fully understand what they are buying. Prices are invisible until after care is delivered, and outcomes come with no warranties or guarantees.
These aren’t flaws to be fixed with an app or more consumer choice. As the economist Kenneth Arrow argued more than 60 years ago, uncertainty, asymmetric information and ethical obligations differentiate health care from other commodities.
High costs are a symptom, not the disease. Diseases are cured when root causes are treated. Fixing health care is about defining value that lowers costs and improves care.
Jeffery Thompson Bainbridge, Wash.
To the Editor:
Zack Cooper’s essay underscores why it’s important to separate rhetoric from reality.
Too often, the affordability conversation relies on recycled claims that focus narrowly on pricing while overlooking the full picture of patient access to care. Patients today are sicker and require more complex treatment, while hospitals face sustained increases in labor, supply and infrastructure costs to maintain 24/7 readiness in every community.
At the same time, public programs like Medicare and Medicaid consistently reimburse providers below the cost of care, forcing hospitals, particularly in rural settings, to operate on increasingly thin margins just to sustain essential services.
The essay also gives insufficient weight to the role of corporate insurers. The growing use of prior authorization, payment delays and coverage denials adds administrative burdens, drives inefficiencies across the system and often delays or disrupts patient care.
Any serious effort to address affordability must account for these realities. Policies built on incomplete narratives risk undermining access to care, especially in the communities that rely most on local hospitals.
A more constructive path forward starts with acknowledging the full set of pressures across the system, not selectively placing blame on the providers working to keep patients healthy.
Lynn Falcone Cuero, Texas The writer is the chief executive of Cuero Regional Hospital.
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