You’re Paying More for Worse Health Care. Everyone in Charge Knows It.

Your paycheck went up 3% this year. Marketplace health insurers want a median 15% more for 2027, on top of 20% for 2026. And for all that money, America ranks dead last among wealthy nations in health outcomes. The insurers know it. The regulators know it. Congress knows it. Nobody is fixing it.

Open enrollment for 2027 marketplace coverage starts November 1, two days before the election. Before you see your new rate, here’s what’s behind it, and who’s supposed to be stopping it.

ACA marketplace: the individual health insurance exchanges created by the Affordable Care Act, where people without job-based coverage buy their own plans, usually with a federal tax credit to help pay the premium.

Editorial: This Dispatch contains my opinion, clearly marked as such, alongside sourced reporting.

The Bill Keeps Outrunning the Paycheck

Here are the numbers side by side.

• Your wages: average hourly pay was up 3.0% over the past year, according to the Labor Department’s September jobs report.
• Prices in general: up 3.4% over the year through August.
• Marketplace insurance, 2026: insurers’ median increase was 20%.
• Marketplace insurance, 2027: In early filings, the median proposed increase is another 15%. Fifty-one insurers asked for more than 25%.

It isn’t just the marketplace. Last year, the average family premium for job-based coverage rose 6%, to nearly $27,000, while wages rose 4% and inflation 2.7%. Workers paid $6,850 of that straight out of their paychecks.

Here’s the part that should make you angry. Over the past year, the government’s measure of what medical care itself costs rose just 1.6%. The care isn’t what’s racing ahead. The insurance is.

What Your Money Is Buying

If you paid more and got better care, that would be one thing. You’re not.

In 2024, the Commonwealth Fund compared the health systems of ten wealthy countries. The United States spent the most, more than 16% of its entire economy, and ranked last overall. It ranked last in health outcomes, last in equity, and tied for last in administrative efficiency. The report’s verdict: the U.S. “continues to be in a class by itself in the underperformance of its health care sector.”

Then there’s what happens when you try to use the coverage you paid for.

• Denied claims: Insurers on HealthCare.gov denied about 19% of in-network claims in 2024. Fewer than 1% of those denials were appealed.
• Prior authorization: In the American Medical Association’s latest survey, 95% of doctors said insurer pre-approval requirements delay care, and 26% said those requirements led to an adverse event for a patient.
• Who your doctor works for: UnitedHealth Group, the nation’s largest insurer, disclosed in 2023 that it employs or is affiliated with about 90,000 doctors, roughly 10% of all physicians in the country.

I’ve written about what this does inside the exam room. In Your Doctor Didn’t Choose Fifteen Minutes. Their Employer Did., I covered the billing model behind the rushed visit. In Malpractice by Design, I covered why your specialists don’t talk to each other. Each one treats the symptom in their own lane. Nobody is paid to ask what’s causing all of them.

That isn’t a theory for me. I’ve spent the past several months watching specialists handle my own case one organ at a time while I carried the full picture between appointments myself. I’ve been writing that story on Substack. The short version: the questions I brought in on paper kept turning out to be the right ones, and nobody’s job was to ask them first.

The Watchdogs Who Watch

Every part of this system has someone assigned to oversee it. Look at what they’ve done with the job.

Medicare is overpaying the insurers it’s supposed to police. Medicare’s own independent advisers, MedPAC, estimate that the government will pay private Medicare Advantage plans about $76 billion more this year than it would spend on the same seniors in traditional Medicare, after an estimated $84 billion last year. Most of that, MedPAC says, comes from plans attracting healthier enrollees and coding patients as sicker than they are.

The denials were documented years ago. In 2022, the Department of Health and Human Services’ own inspector general reviewed Medicare Advantage denials and found that about 13% of denied prior authorization requests met Medicare’s coverage rules. In other words, the care Medicare would have covered was denied anyway. Four years later, those same insurers still collect the overpayments.

The insurer owns the doctors. UnitedHealth Group, the nation’s largest health insurer, disclosed in 2023 that it employs or is affiliated with about 90,000 doctors through its Optum division, roughly 1 in 10 physicians in the country. Think about what that means: the company that profits when care is denied now also employs many of the doctors deciding what care you need. That empire was built largely by buying up doctors’ practices one at a time, and most of those purchases were too small to trigger a federal antitrust review.

Editorial: These agencies aren’t failing for lack of information. Their own reports are where I got most of it. They’re failing because publishing the problem has become a substitute for stopping it.

The Congress That Goes Home

And then there’s the branch that writes the rules. This is where the Uniparty earns its name again.

Democrats wrote the expiration date. The enhanced premium tax credits that kept marketplace coverage affordable were created in 2021 and extended in 2022, on party-line votes, through the end of 2025. Democrats chose a sunset date instead of making them permanent.

Republicans let them expire. In December 2025, as part of the deal that ended the government shutdown, the Senate held two votes on the credits. Both failed. Even a health advocacy group tracking the votes noted that neither was expected to pass and that they were “largely for messaging purposes.” In January, the House passed a three-year extension by a vote of 230–196, with 17 Republicans joining Democrats. The Senate never passed it. Bipartisan talks fell apart, with each side blaming the other.

The result: the credits expired. Average monthly premium payments for marketplace enrollees rose 58% in 2026, the average deductible jumped 37% to a record $3,786, and effectuated enrollment is projected to fall by roughly a fifth. Insurers now say the healthier people who left will add about 4 more percentage points to 2027 premiums.

The bill that passed unanimously, then vanished. In 2022, the House passed a bill to rein in Medicare Advantage prior authorization without a single objection. It never became law. This July, two House committees approved it again. It still isn’t law.

In fairness, Congress did act on one front this year. In February, after years of false starts, it passed reforms to the pharmacy benefit managers, the drug-pricing middlemen. Some of the biggest changes don’t take effect until 2028.

Editorial: One overdue reform in a decade isn’t a record. It’s an exception. Both parties have held the White House and both chambers of Congress at some point in the past ten years. Both have had the votes to fix pieces of this. Each time, the expiration dates, the messaging votes, and the bills that pass once and vanish land the same way: the industry keeps its money, and you keep paying.

What This Doesn’t Mean

It doesn’t mean your doctor is the villain. Most doctors I’ve dealt with are capable people working inside a system that pays them to move fast and stay in their lane. It doesn’t mean every insurer denial is wrong, either; some claims should be denied. And not every agency has done nothing; their reports are the reason we know the numbers.

What it means is that the people paid to supervise this system can see it failing, have the authority to act, and keep choosing to write it down instead.

Call to Action

1. Shop your plan on November 1. If you buy marketplace coverage, don’t auto-renew. Compare plans, deductibles, and networks at HealthCare.gov. Rates and plans change every year.
2. Appeal your denials. Fewer than 1% of denied in-network claims get appealed. Ask for the denial in writing, ask why, and appeal. You have the right.
3. Ask your doctor the whole-patient question. “Could anything you’re seeing be connected to what my other doctors are treating?” Write down the answer.
4. Ask your senators and representative three questions. Will they vote to restore or replace the premium tax credits? Will they pass the Medicare Advantage prior authorization bill that already passed the House once? And will they press Medicare to stop overpaying private plans?
5. Read the background. The Insurers Pledged Reform. One Year Later, Some Still Deny Care 80% of the Time. covers what the insurers promised and didn’t deliver.
6. Become your own best advocate, and use the tools available to you. One of my own doctors told me to use AI to keep track of my health, and it was good advice. Write down your full medical history: past surgeries, diagnoses, medications, symptoms, and when they started, and family history. Keep a log of every visit: who you saw, what they said, what was ordered, and what’s still unanswered. An AI assistant can help you organize all of it, explain lab results in plain language, spot patterns across specialists, and turn your concerns into a written list of questions to bring to your next appointment. Bring that list, and don’t leave until it’s answered. AI isn’t a doctor. It can be wrong, and it can’t examine you or write a prescription, so check what it tells you with your doctors. And remember that health information you share with a consumer AI app generally isn’t protected by HIPAA, the federal medical privacy law, so read the privacy settings before you share it. But in a system where nobody else is paid to connect the dots, it can help you do it yourself.

You’re paying more every year for a system that ranks last. Everyone with the power to change has seen the numbers. The only one still surprised by the bill is you.

V64OTD // YOU PAY MORE. YOU GET LESS. NOBODY’S IN CHARGE.

Sources

1. Peterson-KFF Health System Tracker, “How much and why ACA Marketplace premiums are going up in 2027,” updated Aug. 3, 2026 — https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2027/
2. U.S. Bureau of Labor Statistics, “Employment Situation Summary — September 2026,” Oct. 2, 2026 — https://www.bls.gov/news.release/empsit.nr0.htm
3. U.S. Bureau of Labor Statistics, “Consumer Price Index Summary — August 2026,” Sept. 11, 2026 — https://www.bls.gov/news.release/cpi.nr0.htm
4. KFF, “Annual Family Premiums for Employer Coverage Rise 6% in 2025,” Oct. 22, 2025 — https://www.kff.org/health-costs/annual-family-premiums-for-employer-coverage-rise-6-in-2025-nearing-27000-with-workers-paying-6850-toward-premiums-out-of-their-paychecks/
5. Commonwealth Fund, “Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System,” Sept. 19, 2024 — https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024
6. KFF, “Claims Denials and Appeals in ACA Marketplace Plans in 2024,” March 24, 2026 — https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
7. American Hospital Association, “AMA survey shows physicians, patients continue to be heavily burdened by prior authorization,” May 14, 2026 — https://www.aha.org/news/headline/2026-05-14-ama-survey-shows-physicians-patients-continue-be-heavily-burdened-prior-authorization
8. STAT News, “UnitedHealth Group now employs or is affiliated with 10% of all physicians in the U.S.,” Nov. 29, 2023 — https://www.statnews.com/2023/11/29/unitedhealth-doctors-workforce/
9. Healthcare Dive, “Medicare Advantage overpayments will total $76B this year: MedPAC,” Jan. 16, 2026 — https://www.healthcaredive.com/news/medicare-advantage-overpayments-76b-2026-medpac/809859/
10. HHS Office of Inspector General, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care” (OEI-09-18-00260), April 27, 2022 — https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
11. Medicare Rights Center, “Senate Fails to Extend ACA Subsidies; Price Hikes Loom,” Dec. 11, 2025 — https://www.medicarerights.org/medicare-watch/2025/12/11/senate-fails-to-extend-aca-subsidies-price-hikes-loom
12. Ballotpedia News, “House passes three-year extension of expanded ACA subsidies,” Jan. 12, 2026 — https://news.ballotpedia.org/2026/01/12/house-passes-three-year-extension-of-expanded-aca-subsidies/
13. NBC News, “Senate ACA funding talks fizzle as higher premiums for millions take effect” — https://www.nbcnews.com/politics/congress/senate-aca-funding-talks-fizzle-higher-premiums-take-effect-millions-rcna254227
14. KFF, “What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles,” May 19, 2026 — https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/
15. Rep. Suzan DelBene, “House Unanimously Passes Bill to Improve Care for 28M Seniors, Cut Red Tape,” 2022 — https://delbene.house.gov/news/documentsingle.aspx?DocumentID=3221
16. American Occupational Therapy Association, “House Committees Pass Bill to Improve Prior Authorization in Medicare Advantage,” July 27, 2026 — https://www.aota.org/advocacy/advocacy-news/2026/house-committees-pass-bill-to-improve-prior-authorization-in-medicare-advantage
17. Pharmacy Times, “PBM Reform Within 2026 Appropriations Bill Signed Into Law,” Feb. 2026 — https://www.pharmacytimes.com/view/pbm-reform-within-2026-appropriations-bill-signed-into-law
18. V64OTD, “Your Doctor Didn’t Choose Fifteen Minutes. Their Employer Did.,” July 22, 2026 — https://v64otd.com/dispatch/doctor-didnt-choose-fifteen-minutes/
19. V64OTD, “Malpractice by Design: Why Your Specialists Don’t Talk to Each Other,” Aug. 21, 2026 — https://v64otd.com/dispatch/fragmented-specialist-medicine-malpractice-by-design/
20. V64OTD, “The Insurers Pledged Reform. One Year Later, Some Still Deny Care 80% of the Time.,” July 28, 2026 — https://v64otd.com/dispatch/health-insurance-denial-pledge/