A confusing quagmire of opaque financial relationships between insurers, providers and a new breed of middlemen has transformed how the health care system operates, driving higher prices, less competition, and more administrative complexity.
Employers, who provide health insurance to 147 million people, are largely unaware of these relationships and practices; those that are aware are hard-pressed to find alternatives.
Use this microsite to explore our analyses of these financial relationships as well as policy proposals that, when implemented together, would create a health care system that prioritizes consumers over profit.
| Title | URL as plaintext | Image as a URL | Publication Date | Author | 1-sentence Summary |
|---|---|---|---|---|---|
| Middlemen in the Commercial Health Insurance Market | https://georgetown.box.com/s/izb8ql7cq4rvls3fgwpgkp3ix37wj4w6 | https://chir.georgetown.edu/wp-content/uploads/emoji-money-with-wings.png | September 2026 | Kennah Watts and Abigail Knapp | Amidst an increasingly complex health care market, a tangled web of intermediaries has developed. These middlemen provide a variety of services, such as claims management and adjudication. Their clients include, but are not limited to, providers, insurers, third-party administrators (TPAs) and, sometimes, all of the above. Sometimes middlemen contract directly with their clients; in other instances they are direct subsidiaries of an insurer-TPA or health system. These companies advertise their ability to maximize revenue, cut costs, and drive efficiency. However, these entities often add additional administrative complexity and costs to claims and benefit management. Some also face conflicts of interest based on their fee structures, their work for clients with competing financial goals, or their ownership arrangements. |
| Hollowed Out: How Private Equity Destabilized Safety-Net Hospitals in Pennsylvania, Connecticut, and Rhode Island | https://georgetown.app.box.com/s/k1po5obmxf5o6jgv5uyb45kup33luc38 | https://chir.georgetown.edu/wp-content/uploads/emoji-money-bag.png | July 2026 | Karen Davenport and Kennah Watts | The extremes of the private equity playbook of asset extraction and profit maximization are on full view in Prospect’s recent bankruptcy. Prospect, as controlled by the private equity firm Leonard Green & Partners (LGP), used various asset-stripping and profit-maximization strategies across their multi-state hospital system with disastrous results. |
| Vertical Integration in Health Care: Implications for Consumers, Employers, and Clinicians | https://chir.georgetown.edu/vertical-integration-in-health-care-implications-for-consumers-employers-and-clinicians/ | https://chir.georgetown.edu/wp-content/uploads/emoji-hospital-office.png | May 2026 | Julia Burleson | With vertical integration driving up health care spending, CHIR’s Julia Burleson examines its effects on key stakeholders and highlights federal bills expanding antitrust enforcement. |
| Title | URL as plaintext | Image as a URL | Publication Date | Author | 1-sentence Summary |
|---|---|---|---|---|---|
| A 3-Part Strategy for Better Health Insurance | https://chir.georgetown.edu/three-part-strategy/ | https://chir.georgetown.edu/wp-content/uploads/emoji-3steps.png | September 2026 | Sabrina Corlette, Karen Davenport, Stacey Pogue | A pragmatic, 3-part package of federal policies built on two principles: (1) lowering direct out-of-pocket spending and administrative complexity for patients, and (2) constraining the underlying drivers of commercial market cost growth. |
| The Fair Pay, Fair Play TPA: A Proposal to Disrupt the Market for Plan Administration | https://chir.georgetown.edu/the-fair-pay-fair-play-tpa-a-proposal-to-disrupt-the-market-for-health-plan-administration/ | https://chir.georgetown.edu/wp-content/uploads/emoji-referee.png | August 2026 | Christine Monahan, Kennah Watts, Karen Handorf, and Kevin Lucia | A proposal to create an alternative TPA shielded from the profit motives and conflicts of interest that can drive traditional private ones to prioritize shareholder interests over their clients’ interests. |
| State Spotlight: New Massachusetts Law Enhances Oversight of Private Equity in Health Care | https://chir.georgetown.edu/state-spotlight-new-massachusetts-law-enhances-oversight-of-private-equity-in-health-care/ | https://chir.georgetown.edu/wp-content/uploads/emoji-police-woman.png | March 2026 | Stacey Pogue and Kennah Watts | Massachusetts recently enacted a law to increase transparency and oversight of private equity in health care following the collapse of Steward Health Care. |
| Title | URL as plaintext | Image as a URL | Publication Date | Author | 1-sentence Summary |
|---|---|---|---|---|---|
| Can Hospital Rate Setting Help Control US Health Spending | https://www.urban.org/research/publication/can-hospital-rate-setting-help-control-us-health-spending | https://chir.georgetown.edu/wp-content/uploads/emoji-capped-price.png | August 2026 | John Holahan and Michael Simpson | This cost and coverage analysis estimates the implications of price limits placed on hospital care provided to people with employer-based and private non-group insurance. |
| Skimming: How Complexity Raises Health Care Costs, and What Government Can Do About It | https://tcf.org/content/report/skimming-how-complexity-raises-healthcare-costs-and-what-government-can-do-about-it/ | https://chir.georgetown.edu/wp-content/uploads/emoji-mouse-maze.png | June 18, 2026 | Jeanne Lambrew and Joshua Varcie | This report gives examples of how the complexity of the U.S. health care system lets consolidated corporations exploit loopholes and skim profits, and proposes solutions. |
| Health Care Financialization | https://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1462&context=jhclp | https://chir.georgetown.edu/wp-content/uploads/emoji-bank-1.png | January 21, 2026 | Erin C. Fuse Brown and Hayden Rooke-Ley | Financialization manifests in three ways: governance moves from clinicians and community stakeholders to financial actors; profits derive from financial engineering and labor suppression rather than value creation; and accountability is obscured through consolidation, delocalization, and intricate corporate structures. |
- The Problems Learn how hidden fees, shared ownership, and conflicts of interest raise what everyone pays.
- The Solutions Explore federal and state policy strategies that could restore competition and oversight.
- Outside Resources Dig deeper with research and analysis on this topic from trusted organizations beyond CHIR.
The Problems
The last quarter century has seen extensive vertical and horizontal integration among providers, insurers, administrative entities, and middlemen, alongside a broader alignment of their profit-seeking financial interests even where the companies are unaffiliated.
- Many providers face no constraints on pricing in private markets and use a variety of tools to maximize revenue;
- Insurers have financial interests in keeping spending high;
- Many third-party administrators have financial interests that increase spending;
- Middlemen make money by unnecessary and repeated adjudication of claims and control over information.
The result is a web of cost-increasing incentives, money flows, and conflicts of interest with harmful consequences for consumers.
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The Solutions
The problems are systemic, and therefore the solutions must be systemic. Three sets of policy strategies are necessary for a comprehensive solution. These include:
- Rational pricing of payments to providers treating private insurance market patients and the uninsured.
- Elimination of conflicts of interest and cost-increasing behavior among stakeholders.
- Prohibition of extractive practices that increase costs, compromise quality, and threaten provider financial viability.
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Outside Resources
CHIR is not the only organization working on these relationships. The papers gathered here approach the same problem from different directions, such as: legal scholarship on how financial actors take over the governance of care, cost and coverage modeling on what rate regulation would actually do, and investigative work on how administrative complexity itself becomes a source of profit.