By Reid Zeising, Co-founder of GAIN Servicing
Most patients can feel it the moment they walk into an exam room. The appointment is shorter than it used to be and the doctor seems rushed. The bill that shows up weeks later doesn’t match what anyone told you, and the treatment your doctor recommended may come back denied. It is easy to assume that is simply how healthcare works now.
I talk with healthcare providers every day, and the doctor on the other side of that exam table is under just as much pressure as the patient. Patients and providers are feeling the same squeeze from opposite ends. The one party that belongs in the middle of it, the healthcare insurance industry, has largely managed to stay out of the spotlight.
Why Providers Are Squeezed From Both Sides
Insurers pay medical groups a fixed amount for each procedure, and reimbursement from commercial and government payers has been falling. Medicaid rates often don’t even cover the cost of seeing the patient. Meanwhile labor, real estate and equipment all cost more every year, and nobody is having an orthopedic procedure over video.
Payers also want value-based care, where payment ties to patient outcomes. That works in theory, but in practice the doctor recommends the care and the insurer decides whether it happens. I still believe patient-centric care, delivered by knowledgeable doctors with patients making the final call, is what all of us want.
The result is more patients in fewer minutes and doctors pulled into HR and finance problems they never used to manage. Every doctor I know took an oath to act in the patient’s best interest, and none of them went into medicine to chase claims denials. Highly trained nurse practitioners can take on more routine care, but no amount of efficiency makes up for reimbursements that keep falling.
Patients feel the other side of that same squeeze. Premiums keep rising while insurers report strong profits, and it is fair for a patient to ask why their premium dollars are funding a denial for care their own doctor ordered.
Where the Pressure Lands
When financial pressure on patients meets operational pressure on providers, access to care is what gives. Roughly 28 million Americans were uninsured in 2025, according to the CDC. Many avoid care until it becomes urgent and end up in emergency rooms, which save lives but are an incredibly expensive place to treat a cold or the flu. Better use of urgent care would save money and get people seen faster.
The underinsured face a quieter version of the same problem. A 2026 U.S. News survey found that 43% of Americans don’t have enough savings to cover a $1,000 emergency. If someone in that position is injured through no fault of their own and faces a $10,000 deductible, that deductible might as well be $10 million. The money simply isn’t there, so care gets delayed or skipped.
Providers are adapting where they can, often by moving procedures into ambulatory surgery centers they own. That comes from thin margins, not greed. ASCs deliver care for far less than hospitals, yet many states are still slow to approve procedures like total joint replacements there. High-risk patients belong in the hospital, and everyone else should be treated at the most efficient point of care.
The cost of getting this wrong falls on patients. Someone I know went to the hospital fearing a stroke, and after an MRI the care team wanted to monitor them overnight. The insurer denied the stay, leaving that patient to weigh a surprise bill against their own safety.
Where Technology Should Be Helping
A huge share of healthcare spending never reaches patient care. One study in the Annals of Internal Medicine found administrative costs made up 34.2% of U.S. health expenditures. Technology can cut into that, and I have watched it happen at GAIN. By connecting provider EMRs with law firm case management systems and automating communication and document requests, we took our risk managers from about 450 cases at a time to 4,500.
Patients deserve the same kind of efficiency. Nobody should fill out identical intake paperwork at every new office or repeat an MRI another provider already ran. Patients should own their health information in one place and choose what to share, which would save insurers and practices an enormous amount of redundant work.
AI is already helping in radiology and dentistry, giving patients a second, third and fourth opinion on their findings. It won’t replace the doctor who walks into the room, but it catches what a busy human might miss. Providers should keep investing in these tools, and insurers should adopt the same technology to cut their own administrative waste.
What Patients Can Do Right Now
Until the system catches up, navigating it takes effort. I wish that weren’t true, but a little work up front saves a lot of stress later.
Start by understanding your plan before you need it. If your coverage comes through work, ask HR when your deductible kicks in and which providers are in network. If you buy on the marketplace, look past the monthly premium, since a few more dollars a month can significantly lower your deductible.
Stay in network whenever you can. Out-of-network costs often don’t count toward your deductible, and that is where denials and surprise bills pile up. There are highly qualified physicians in every network, even if it takes a few calls to find one who can see you quickly.
Talk to your doctor before anything gets denied, including whether they would write a letter supporting an appeal. If a denial comes, appeal it. Many patients give up after the first no, and I understand why after going through a denied claim with my own family. Appeals work more often than people expect. KFF found that 67% of appealed prior authorization denials in Medicare Advantage were overturned.
Finally, start building your own health record. Download your lab results, imaging and visit notes from each patient portal and keep them in one place. It takes time, but it gives you far more control over your care.
Final Thoughts
For all its frustrations, we have a fantastic healthcare system, with the greatest research hospitals in the world and dedicated professionals in every state. I would take it over single-payer models like Canada’s or the UK’s, where patients can wait so long for a procedure that they wonder whether they will live to get it. Ours is a capitalist system and it should stay that way.
What has to change is who absorbs the pressure. Healthcare insurance companies should be treated more like utilities. They should earn a profit, but they should be regulated, pushed to cut administrative waste and rewarded for expanding access and reducing denials. Delivering lower premiums for patients and higher reimbursements for doctors means insurers get squeezed at both ends, and they have more than enough room to absorb it.
Until then, advocate for yourself. Educate yourself about your coverage, keep your records, work with your doctor and appeal every denial that deserves it. You do not have to take no for an answer.
This article was inspired by a conversation I had on The Advisor with Stacey Chillemi, where we got into why healthcare feels harder for patients and providers and what both can do about it. Give it a listen here: https://www.spreaker.com/episode/why-healthcare-feels-harder-than-ever-costs-coverage-and-access–71503745.