Comments from Richard Besser, MD, on Health Insurance Reform

The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) President and CEO, in response to a request for information (RFI) from Ron Wyden, United States Senator Ranking Member, Committee on Finance. The RFI requested comments regarding opportunities to fix America’s for-profit private health insurance system.

The Robert Wood Johnson Foundation (RWJF) appreciates the opportunity to respond to your request for information (RFI), “Health Coverage That Works for Everyone,” published on the Senate Finance Committee website on July 30, 2026. We share your goal to make health insurance coverage “universal, comprehensive, easy to get, and easy to use” for all people in the U.S.¹

RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work alongside communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.

Our comments are grounded in the perspectives and expertise of our grantees, who include grassroots organizers, policy analysts and researchers, consumer advocates, lawyers and other legal advocates, public health leaders, and direct care providers committed to promoting health as a human right, advancing racial justice, centering dignity, and driving toward collective wellbeing. They are also informed by RWJF’s investments over the past 50+ years in research and programs to identify and close key gaps in healthcare coverage and access and achieve a healthcare system that is fair, just, and built for everyone.

As a private foundation, RWJF is nonpartisan and cannot comment on specific or proposed legislation in direct communications to legislators. In this response, we provide resources to inform the Committee’s understanding of the current barriers to universal, comprehensive healthcare; information on the ways that RWJF and our network of hundreds of non-profit grantee organizations focused on healthcare can contribute to future health insurance reform efforts; and recommendations and frameworks for facilitating an inclusive policymaking process. In this response, when we refer to “universal, comprehensive coverage” or “universal coverage,” we are referring to the goal of ensuring that every person in the U.S. has high-quality health insurance; we are not referring to any specific or proposed legislation that contains these phrases or that is designed to achieve that goal.

Executive Summary

Access to quality healthcare is essential to everyone's ability to be as healthy as possible—and access to quality healthcare is not possible without affordable, high-quality health insurance coverage. However, that coverage is not equally accessible to all people in America.

We urge you to consider transformative changes that disrupt the status quo and build toward a more just healthcare system that works for everyone.

The nation needs bold change to reimagine healthcare as a public good that benefits all, shift the public’s expectation of what government can and should provide to its people, improve health outcomes for all, and uproot structural racism in our healthcare system.

Through this RFI process and beyond, the Senate has an opportunity to engage communities—especially those most affected by structural racism, health inequities, and profiteering—in the design of a fair and just healthcare system. RWJF stands ready to support an inclusive policymaking process where government entities and communities work together to make decisions on policies and programs.

1. Comprehensive health insurance that enables meaningful access to affordable, high-quality preventative and curative healthcare is foundational to a healthcare system that works for everyone.

A healthcare system where everyone has comprehensive health insurance would save the federal government over a trillion dollars and save more than 100,000 lives annually.²

U.S. households are more worried about paying for healthcare than food, housing, transportation, or utilities.³ Nearly half of working-age adults in the United States reported difficulty paying for their healthcare in 2025, and more than one-third reported that a family member had an unmet healthcare need due to costs.⁴

Even families with health insurance struggle to pay for care due to high deductibles, coinsurance, and copayments. For those who seek care, the financial risk is real—more than four in ten adults have medical debt, which increases the risk of bankruptcy and homelessness.⁵ Affordability challenges fall particularly hard on Black and Hispanic adults and people living in the South and in rural areas.⁶

Achieving coverage for everyone will not be easy. Over 28 million people ages 0–64 were uninsured in 2025.⁷ Enrollment in Medicaid, the Children’s Health Insurance Plan, and the Affordable Care Act Marketplace has declined by millions of people since the passage of the One Big Beautiful Bill Act (OBBBA) and the expiration of enhanced premium tax credits for the Affordable Care Act Marketplace last year.^{8, 9} An estimated 5 million to 10 million fewer people are expected to enroll in Medicaid coverage in 2028 due to the combined impacts of work requirements and more frequent paperwork requirements—both of which will result in people losing their health insurance through Medicaid even when they meet the work requirement or otherwise remain eligible.¹⁰

When fewer people have health insurance, hospital and healthcare providers face more “uncompensated care,” or care that is neither paid for by a patient nor reimbursed by an insurer. This can place significant financial strain on hospitals and healthcare providers, particularly those in rural communities and those that serve a high share of patients covered by Medicaid.¹¹ About 80% of uncompensated care is financed by federal, state, and local governments, with the federal government bearing the largest share, while the remaining 20% is absorbed by healthcare providers as charity care, covered by private sources, or shifted to other payers in the form of increased health insurance premiums.¹²

RWJF is working with our grantees and partners to create more  community-rooted, equitable anti-racist healthcare systems, developed and governed by the people most affected by structural racism and other harmful systems. For example, Black and Indigenous midwives across the country have been building more holistic models of care in communities and hospitals that are rooted in traditional practices and prioritize autonomy, respect, and equitable care practices. We aim to shift who holds power, how financial and other resources flow, how care is delivered, and perceptions of what people deserve and can expect from healthcare. Further, we seek to shift from an extractive model that concentrates wealth and power to one rooted in community wellbeing, democratic accountability, collective care, and the understanding that health and healthcare are shared public goods essential to a just society. We believe universal coverage is one critical element of this transformation process.

2. The United States needs a healthcare system that prioritizes health over profit.

The federal government has a responsibility to make sure everyone in the United States has the opportunity to live the healthiest life possible. This goal will remain out of reach as long as the U.S. healthcare system continues to prioritize corporate profits over people’s wellbeing. Despite spending twice per capita on healthcare compared to other wealthy nations, health outcomes in the United States lag far behind our peers, especially among lower-income people; those living with disabilities; and Black, Hispanic, Indigenous, and other people of color.¹³ Changing that requires recognizing healthcare as a public good that enables good health and serves everyone, rather than a profitable commodity.

The status quo of high-cost, low-value healthcare is driven by several intersecting factors:

• Private equity, corporate investors, insurance companies, pharmaceutical companies, and hospital systems prioritize increasing profits for investors, rather than creating healthy communities with access to quality care.¹⁴ Historically marginalized groups are hit hardest. For example, private equity investors target safety-net hospitals and other healthcare facilities that serve patients who are disproportionately people of color and uninsured or covered by Medicaid. Medical debt disproportionately affects lower-wage workers. The conflict between short-term profits and the long-term investment needed for high-quality patient care is most visible in the hospitals taken over by private equity investors. They deploy financial strategies—including debt loading, sale-leasebacks, and asset stripping—that jeopardize hospitals’ financial stability and compromise patient care.¹⁵ Private equity investments in healthcare have skyrocketed from $5 billion in 2000 to $104 billion in 2024.¹⁶ This growth has been driven in part by private equity investors justifying their aggressive acquisitions, particularly in primary care practices, as necessary to advance value-based care.¹⁷ In reality, research shows prioritizing profit obstructs the delivery of evidence-based patient care.¹⁸
• Healthcare services are becoming more consolidated, which stymies competition, increases prices, reduces affordability—and reinforces a  focus on profit over care. Hospital mergers over the last 25 years have resulted in nearly half of the nation's approxiately 5,000 hospitals operating with little or no competition—21% are monopolies, and another 24% face just one competitor.¹⁹ The financial challenges facing independent medical practices are further fueling consolidation. Over 80% of physicians are employed by hospitals, insurers, private equity firms, and other corporate entities, up from 62% in 2019.²⁰ Vertical integration—whether driven by health insurance plans or health systems acquiring healthcare provider practices or payers integrating with pharmacy benefit managers and pharmacies—has given rise to healthcare conglomerates of enormous scale.^{21, 22} Consolidation increases healthcare spending without improving the quality of care or in some cases making the care worse.²³
• Middlemen extract substantial profit by maximizing revenue and minimizing insurance claims payments through coverage denials, prior authorization, step therapy, and other tactics.²⁴ This growing industry includes revenue cycle management companies, claims re-pricers, and independent dispute resolution management companies, among others. The impacts on patients can include delayed or forgone care and increased insurance premiums and out-of-pocket expenses.

The harms of a profit-driven healthcare system are felt at multiple levels. In a survey of over 1,200 physicians, 47% reported often or always feeling unable to provide optimal care due to inadequate time, and 44% reported being unable to deliver medically necessary treatment because of insurance barriers such as prior authorizations and coverage denials.²⁵ This erosion of physician autonomy drives “moral injury,” or psychological harm caused when a healthcare provider is forced to compromise medical judgment.²⁶ Cost-cutting measures frequently deployed by private equity, such as staffing reductions and underinvestment in resources, leave healthcare professionals overextended, more prone to error, and without the tools they need to deliver adequate care.²⁷ In highly concentrated markets, lower wages and limited job mobility compound poor working conditions, particularly for nurses and pharmacy workers.²⁸ For patients, these dynamics translate to worse health outcomes, including increased falls, more infections, and higher mortality rates.²⁹ Communities experience worker turnover, deteriorating infrastructure, reduced essential services, and closed facilities.^{30, 31}

The RFI’s focus on making health insurance more affordable, easier to use, and free of corporate greed is crucial to the success of universal coverage and a more just healthcare system.

3. The path to comprehensive healthcare reform starts with an inclusive process.

To have a strong democracy, it is imperative to center the voices of people long excluded from decisionmaking and most harmed by current systems. A future where our healthcare systems are trustworthy and accountable to their communities—delivering high-quality care for all—is possible through policymaking that prioritizes the needs of historically marginalized communities from the start. We cannot afford to repeat the mistakes of our nation's previous healthcare reform efforts, which relied on policy insiders more than the people closest to the problem, and thus to the solutions.

In an era when decisionmaking authority is increasingly wielded by a privileged few, an inclusive policymaking process is central to collaborative governance (co-governance), in which governments and communities work together to make collective policy decisions and programs.³² That is why RWJF is investing in grassroots leaders and community-based organizations to build collective power to fundamentally change the systems that shape people’s health, not just improve them at the margins.

This year, RWJF kicked off a national grassroots movement called One Nation, Overcharged to inspire people to start conversations and participate in community organizing and cultural activities about the urgent need to address America's healthcare affordability crisis.³³ More than 130,000 people have joined the One Nation, Overcharged movement and advocates collected 1,000 stories at over 100 events across the country. The stories have reinforced the national consensus that our healthcare system is broken, costs are too high—and we're all paying the price. Our partners in the One Nation, Overcharged movement include organizations that bring different constituencies and valuable perspectives to healthcare affordability and civil rights conversations.³⁴

We urge the Committee to make its process for engaging with interested parties as inclusive as possible. Achieving this requires building relationships with grassroots and community-based organizations an networks committed to a more just healthcare system, removing structural barriers to participation, offering multiple pathways for engagement, and establishing standards and practices for transparency and accountability. These appraoches are grounded in a growing body of research on the use of co-governance to advance health equity and racial, gender, and other forms of justice.^{35, 36, 37}

To start, RWJF recommends the Committee take stock of who participates in the RFI—who is underrepresented and who is missing. Hearing the concerns and ideas from a wide range of interested parties—including people who rely on Medicaid and subsidized Marketplace plans and those who face the greatest barriers to accessing care—is essential to counterbalance profit-driven interests. Our grantees and partners can support the Committee in its listening and learning process in reaching people who might not otherwise engage with policymakers about their experiences with the healthcare system. 

A key to co-governance is building long-term relationships through sustained collaboration. This can include establishing multiple checkpoints by returning to a diverse set of community voices at important junctures as well as offering a range of accessible ways for individuals to track and provide feedback on the policymaking process. Further, community engagement does not end when legislation passes. The commitment to an inclusive process must be carried forward to implementation and oversight.

Thank you for the opportunity to provide ideas and feedback to inform potential legislative solutions to improve health insurance coverage. If you have questions about the information in this letter, please reach out to Alyson Northrup, RWJF senior policy officer, at .

1.  Sen. Ron Wyden, Ranking Member, S. Comm. on Fin., Health Coverage That Works for Everyone: Request for Information (July 30, 2026), https://www.finance.senate.gov/imo/media/doc/073026_sfc_health_coverage_rfi.pdf.

2.  Matt Kristoffersen, Universal Health Coverage Could Save $1 Trillion and 114,000 Lives Every Year, Yale Study Projects, Yale Sch. of Pub. Health (Aug. 13, 2026), https://www.medrxiv.org/content/10.64898/2026.07.22.26358689v1.full-text.

3.  Grace Sparks et al., Kaiser Fam. Found., Americans' Challenges with Health Care Costs (last updated Sept. 11, 2026), https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/.

4.  Michael Karpman et al., Urban Inst. & Robert Wood Johnson Found., Nearly Half of Working-Age Adults Struggled to Afford Healthcare in 2025 (June 10, 2026), https://www.urban.org/sites/default/files/2026-06/Nearly%20Half%20of%20Working-Age%20Adults%20Had%20Difficulties%20Affording%20Health%20Care%20in%202025%20.pdf.

5.  Grace Sparks et al., Kaiser Fam. Found., Americans' Challenges with Health Care Costs (last updated Sept. 11, 2026), https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/.

6.  Michael Karpman et al., Urban Inst. & Robert Wood Johnson Found., Nearly Half of Working-Age Adults Struggled to Afford Healthcare in 2025 (June 10, 2026), https://www.urban.org/sites/default/files/2026-06/Nearly%20Half%20of%20Working-Age%20Adults%20Had%20Difficulties%20Affording%20Health%20Care%20in%202025%20.pdf.

7.  Robin A. Cohen & Elizabeth M. Briones, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2025, Nat’l Ctr. for Health Stat. (May 2026), https://www.cdc.gov/nchs/data/nhis/earlyrelease/Health-Insurance-Coverage-Early-Release-of-Estimates-2025.pdf.

8.  Matt McGough et al., What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles, KFF (May 19, 2026), https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/.

9.  State by State Medicaid and CHIP Enrollment Data, Georgetown Univ. Ctr. for Child. & Fams., https://ccf.georgetown.edu/feature/state-by-state-medicaid-enrollment-data/ (last visited Oct. 2, 2026).

10. Matthew Buettgens et al., Urban Inst., Projected Reductions in Medicaid Expansion Enrollment under OBBBA's Work Requirements and Six-Month Redeterminations: National and State Estimates for 2028 (Mar. 25, 2026), https://www.urban.org/sites/default/files/2026-03/Projected%20Reductions%20in%20Medicaid%20Expansion%20Enrollment%20Under%20OBBBA%E2%80%99s%20Work%20Requirements%20and%20Six-Month%20Redeterminations_325.pdf.

11. Eva H. Allen et al., Urban Inst. & Robert Wood Johnson Found., How Will the Changing Federal Policy Landscape Affect Hospitals? (July 29, 2026), https://www.urban.org/sites/default/files/2026-07/How_Will_the_Changing_Federal_Policy_Landscape_Affect_Hospitals.pdf.

12. Teresa A. Coughlin et al., Kaiser Fam. Found., Sources of Payment for Uncompensated Care for the Uninsured (last updated Aug. 9, 2025), https://www.kff.org/affordable-care-act/sources-of-payment-for-uncompensated-care-for-the-uninsured/.

13.  Katherine Hempstead, Robert Wood Johnson Found., Marketplace Pulse: Overcharged and Shortchanged. (Aug. 27, 2026), https://www.rwjf.org/en/insights/our-research/2026/08/marketplace-pulse-overcharged-and-shortchanged.html

14. Erin C. Fuse Brown & Hayden Rooke-Ley, Health Care Financialization, 29 J. Health Care L. & Pol'y 1 (2026), https://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1462&context=jhclp.

15. Karen Davenport & Kennah Watts, The Outpatient Pivot: How Prospect Exploited Facility Fees While Inpatient Care Crumbled, CHIRblog, Georgetown Univ. Ctr. on Health Ins. Reforms (July 28, 2026), https://chir.georgetown.edu/the-outpatient-pivot-how-prospect-exploited-facility-fees-while-inpatient-care-crumbled/.

16. Cherry Bekaert, Renewed Optimism: Private Equity 2024 Year-in-Review and 2025 Industry Outlook (Feb. 12, 2025), https://www.cbh.com/insights/reports/private-equity-report-2024-trends-and-2025-outlook/.

17. Adasina Soc. Cap., The Financialization of Value-Based Care: Who Benefits and Who Pays the Price When Financial Interests Drive Healthcare Transformation? (n.d.).

18. Physicians for a Nat'l Health Program, Moral Injury in Medicine: The Human Costs of Practicing in a Profit-Driven System (Mar. 17, 2026), https://pnhp.org/moral-injury-in-medicine.

19. Andrea Harris & Christina Ramsay, Health Care Affordability Lab at Yale, Just the Facts on Health Care Consolidation (June 9, 2026), https://www.healthcareaffordabilitylab.org/commentary-press-release-posts/just-the-facts-on-health-care-consolidation.

20. Physicians Advocacy Inst. & Avalere Health, PAI-Avalere Health Report on Physician Employment Trends and Practice Acquisitions: 2018–2026 (Apr. 2026), https://www.physiciansadvocacyinstitute.org/PAI-Research/PAI-Avalere-Health-Report-on-Physician-Employment-Trends-and-Practice-Acquisitions-2018-2026.

21. Zack Cooper et al., Health Care Affordability Lab at Yale, Review of Expert and Academic Literature Assessing Vertical Integration in Health Care (June 9, 2026), https://cdn.prod.website-files.com/682cf1c625625bb1fcf9efa1/6a282ed7091dec7b1685a522_JTF_Vertical%20Integration.pdf.

22. Victor Roy, Beyond Insurance: Financialization and the Politics of Healthcare Conglomerates, J. Health Pol. Pol’y & L. (forthcoming).

23. U.S. Gov’t Accountability Off., Health Care Consolidation: Published Estimates of the Extent and Effects of Physician Consolidation, GAO-25-107450 (2025), https://www.gao.gov/products/gao-25-107450.

24. Linda J. Blumberg et al., Untangling the Complex Web: Summary of a New Expert Perspective, CHIRblog, Georgetown Univ. Ctr. on Health Ins. Reforms (Nov. 19, 2025), https://chir.georgetown.edu/untangling-the-complex-web-summary-of-a-new-expert-perspective/.

25. Physicians for a Nat'l Health Program, Moral Injury in Medicine: The Human Costs of Practicing in a Profit-Driven System (Mar. 17, 2026), https://pnhp.org/moral-injury-in-medicine/.

26. Physicians for a Nat'l Health Program, Moral Injury in Medicine: The Human Costs of Practicing in a Profit-Driven System (Mar. 17, 2026), https://pnhp.org/moral-injury-in-medicine/.

27. Brian Keyser et al., Ctr. for Am. Progress, 5 Consequences of Private Equity's Expansion in Health Care Services (Oct. 30, 2025), https://www.americanprogress.org/article/5-consequences-of-private-equitys-expansion-in-health-care-services/.

28. Amy Phillips, Wash. Ctr. for Equitable Growth, The Consequences of U.S. Hospital Consolidation on Local Economies, Healthcare Providers, and Patients (Nov. 15, 2023), https://equitablegrowth.org/research-paper/the-consequences-of-u-s-hospital-consolidation-on-local-economies-healthcare-providers-and-patients/.

29. Brian Keyser et al., Ctr. for Am. Progress, 5 Consequences of Private Equity's Expansion in Health Care Services (Oct. 30, 2025), https://www.americanprogress.org/article/5-consequences-of-private-equitys-expansion-in-health-care-services/.

30. Brian Keyser et al., Ctr. for Am. Progress, 5 Consequences of Private Equity's Expansion in Health Care Services (Oct. 30, 2025), https://www.americanprogress.org/article/5-consequences-of-private-equitys-expansion-in-health-care-services/.

31. Karen Davenport & Kennah Watts, The Outpatient Pivot: How Prospect Exploited Facility Fees While Inpatient Care Crumbled, CHIRblog, Georgetown Univ. Ctr. on Health Ins. Reforms (July 28, 2026), https://chir.georgetown.edu/the-outpatient-pivot-how-prospect-exploited-facility-fees-while-inpatient-care-crumbled/.

32. Kesi Foster et al., P'ships for Dignity & Rts. & Race Forward, Co-Governing Toward Multiracial Democracy (Feb. 25, 2023), https://dignityandrights.org/resources/co-governing-report/.

33. Robert Wood Johnson Found., One Nation, Overcharged, https://onenationovercharged.com/ (last visited Sept. 24, 2026).

34. Partner organizations of One Nation, Overcharged include American Cancer Society Cancer Action Network, Americans For Financial Reform, Asian & Pacific Islander American Health Forum, Black Voters Matter, Black Women's Health Imperative, Center on Budget and Policy Priorities, Community Catalyst, Families USA, NAACP, National Immigration Law Center, National Health Law Program, National Urban League, New Disabled South, Popular Democracy, Patients Union Hub, People’s Action Institute, Private Equity Stakeholder’s Project, UnidosUS, and many more national, state, and local organizations. See full list of partner organizations at https://onenationovercharged.com/partners.

35. Kesi Foster et al., P'ships for Dignity & Rts. & Race Forward, Co-Governing Toward Multiracial Democracy (Feb. 25, 2023), https://dignityandrights.org/resources/co-governing-report/.

36. Ashley Gallegos et al., Othering & Belonging Inst., Univ. of Cal., Berkeley, Governing for Belonging: Case Studies and Strategies for Collaborative Governance (Aug. 31, 2026), https://belonging.berkeley.edu/governing-for-belonging.

37. Jamila Michener & Tiffany N. Ford, Engaging Voice to Support Racially Equitable Policymaking, Commonwealth Fund: To the Point (Oct. 4, 2022), https://www.commonwealthfund.org/blog/2022/engaging-voice-support-racially-equitable-policymaking.

About the Robert Wood Johnson Foundation

RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work side-by-side with communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.