The Price of an Appointment: What the New Congress and California Can Actually Change About Healthcare Costs

What the new Congress and California can actually change about healthcare costs

An American family can have insurance, pay substantial premiums, and still discover that an appointment is expensive or unavailable. A physician can be fully booked and still struggle to finance the staff, rent, technology, and unpaid administrative work needed to keep a practice open. An employer can spend more on health benefits without being able to demonstrate that its workers receive better care. These experiences are connected, but they cannot be explained by a single national spending number.

The incoming Democratic Congress and California's next administration will encounter several different healthcare cost problems: high negotiated prices, inadequate payment in selected settings, expensive drugs, administrative friction, weak competition, and insufficient primary care capacity. Each has its own legal instruments and political opponents. The most defensible forecast is therefore selective. Oversight, purchasing, payment design, and California implementation can change meaningfully during 2027–2028. A comprehensive federal reconstruction of healthcare financing would require agreements that the election itself does not supply.

This article distinguishes current law from announced policy and from the author's forecasts. Its election premise is the called incoming Democratic control of Congress and Xavier Becerra's victory in California; it does not assume certified final margins or that campaign priorities have already become programs. Its central question is practical: which public decisions could lower what households pay while preserving the capacity to deliver care?

Start with the bill, then ask whose bill it is

National health expenditures reached approximately $5.3 trillion in 2024, or $15,474 per person, according to CMS. That represented 18.0% of gross domestic product. Those figures describe all measured national health spending, including public and private financing. They do not mean every resident personally received a $15,474 bill. Nor do they establish how much spending was avoidable.¹

The distinction matters because a policy can shift a bill without reducing its underlying cost. A smaller patient copayment may be financed by higher premiums or taxes. A lower provider payment can reduce public spending but, in a financially vulnerable setting, also reduce available appointments. A negotiated reduction in a monopoly price can potentially improve affordability without reducing necessary service capacity. These are different mechanisms and should be evaluated separately.

A useful household framework has four components. First is the insurance premium, including the employer contribution that employees may not see directly. Second is the deductible, copayments, and coinsurance paid when care is used. Third is the tax contribution supporting public programs. Fourth is the time cost of obtaining care: travel, missed work, repeated authorizations, and unsuccessful attempts to locate a participating clinician. A reform that improves the first component while worsening the fourth may leave a family little better off.

A dated evidence table

Sources: CMS national expenditure facts, GAO's consolidation review, California HCAI's primary care benchmark, and the CMS 2027 physician fee-schedule final-rule materials.¹²³⁴

No single row is a verdict on a hospital, insurer, physician group, or drug manufacturer. The table identifies the scale and institutional structure against which individual policies must operate.

A century of financing choices brought us here

American healthcare financing developed in layers. Employment-based insurance expanded in the middle of the twentieth century. Medicare and Medicaid were enacted in 1965. Later federal laws changed hospital payment, physician payment, insurance-market rules, drug benefits, and the relationship between states and Washington. The result is a collection of purchasing arrangements rather than one national purchaser with a single price schedule.⁵

The last forty years are especially useful for understanding the next four. Medicare's prospective hospital payment and subsequent physician payment reforms showed how government can influence prices and incentives through reimbursement rules. The physician fee schedule has used relative values for work, practice expense, and malpractice expense since 1992. Managed care, preferred-provider networks, employer purchasing, and subsequent consolidation changed how private prices are negotiated. The Affordable Care Act altered coverage and insurance protections, while leaving multiple financing channels in place.⁴⁵

This history provides two warnings. First, changing the unit price can change behavior. Organizations may alter volume, service mix, location, or ownership structure. Second, an intended efficiency can become a new administrative burden if payment arrangements require extensive reporting without simplifying other obligations. The next administration should therefore be judged on the total work created by its reforms as well as their formal payment rates.

History also challenges the idea that ownership integration automatically produces coordination. A hospital and physician practice can share an owner without achieving timely communication, convenient scheduling, or consistent clinical management. Conversely, independent organizations can coordinate through well-designed contracts and information exchange. The policy test is measurable service performance, rather than the organizational diagram alone.

Congress has tools, but the tools are different

Current institutional position: Congress can legislate, appropriate funds, investigate, and request independent analysis. The president can veto ordinary legislation. Senate procedure may require a larger coalition to end debate, and budget reconciliation does not remove the presidential veto. These constraints make targeted agreements more plausible than assuming that a congressional majority can unilaterally rewrite the system.⁶

For healthcare prices, the most immediate congressional instrument is oversight. Committees can investigate payment incentives, insurer practices, consolidation, drug contracting, and whether public programs receive what they purchase. Oversight can expose a problem and create bargaining pressure, but a hearing does not itself change a private contract or a statutory payment formula. A forecast must identify the next legal step.

Some changes require legislation. Expanding a drug-negotiation program beyond its current statutory authority, changing a significant Medicare payment formula, or establishing a new federal benefit generally requires an enacted law. Other changes may fit within existing administrative authority, subject to rulemaking, statutory limits, and judicial review. Appropriations can support enforcement, data collection, and implementation, but a spending provision is not an unlimited substitute for substantive legislation.

A realistic bargaining agenda could include clearer purchasing information, narrower payment distortions, enforcement resources, and relief for demonstrably burdensome administration. The strongest prospects would arise where patient affordability, employer costs, and small-practice sustainability align. The obstacles would grow where a proposal imposes concentrated losses on organizations capable of blocking a coalition or where the administration views it as reversing a signature policy.

Forecast: Congress is likely to change the intensity and direction of scrutiny faster than it changes the entire architecture of healthcare financing. The practical importance of that scrutiny will depend on whether it leads to enforceable obligations, appropriated resources, or credible negotiated commitments.

California's primary care benchmark is a concrete starting point

California's Office of Health Care Affordability adopted a primary care investment benchmark in October 2024. It calls for annual growth of 0.5 to 1 percentage point in primary care's share of total medical expenses during 2025–2033, progressing toward 15% by 2034 for specified payer lines of business. The framework includes claims and nonclaims payments.³

This is unusually relevant to a physician office because it asks where the healthcare dollar goes. However, a benchmark does not guarantee that a particular practice will receive more money. Definitions, attribution, contract design, and reporting determine which services and payments count. An insurer could satisfy a measure through arrangements that do not improve access in every county. California therefore needs geographic and practice-level evidence alongside statewide averages.

The next governor can influence implementation priorities, appointments, administrative coordination, and budget proposals within the governing statutes. Becerra's published emphasis on primary care and workforce capacity supports an expectation that this framework will receive attention. It does not establish a new reimbursement appropriation or a guaranteed payment increase.⁷

An effective implementation would ask whether additional primary care investment buys observable capacity. Are more clinicians accepting new patients? Can practices hire medical assistants, nurses, and care coordinators? Are same-week visits available? Are complex patients receiving longer, useful encounters? Do smaller practices have contracts that allow them to participate without financing a large reporting department?

The cost question should remain explicit. More spending on primary care may be justified even if it does not immediately reduce total spending, particularly when it improves health and access. Savings should be measured rather than assumed. Prevention, continuity, and early treatment have different cost profiles across conditions and populations. A credible policy does not promise that every good service pays for itself.

The 2027 Medicare payment reset complicates the outlook

CMS issued the calendar-year 2027 Medicare physician fee-schedule final rule on November 4, 2026. Publication in the Federal Register was scheduled for November 9. At this article's cutoff, the rule should therefore be described as issued and final, with the later publication date identified—not as an entirely pending proposal.⁴

CMS reported conversion factors of $32.95 for qualifying alternative-payment-model participants, a 1.83% reduction, and $32.63 for nonqualifying participants, a 2.31% reduction, relative to 2026. The expiration of a temporary 2026 increase is part of the explanation. The conversion factor is only one component of payment; specialty mix, relative values, geography, participation status, and other policies determine a practice's actual result.⁴

For a primary care practice, this means the federal and California stories can move in different directions. State policy may encourage a greater primary care share while a federal payment input declines. Commercial contracts may change on another timetable. Rent, staffing, cybersecurity, and billing costs do not necessarily move in step with any of them.

A serious policy forecast should therefore avoid a sentence such as “the election will raise physician pay.” The meaningful questions are which payer changes, which services are affected, when contracts reset, and whether new obligations consume the additional resources. Congressional relief would require the appropriate legislative path and presidential agreement. Administrative adjustments have their own legal boundaries.

For readers, the practical watchpoint is the relationship between payment and access. If a practice reduces new-patient availability or closes a service, the policy response should examine its complete financial and operational circumstances. A national payment trend alone cannot establish the cause of an individual closure, but it can identify a pressure worth investigating.

Drug purchasing: implementation before reinvention

The Medicare Drug Price Negotiation Program already creates a scheduled sequence of negotiated prices. The first cycle applies to selected drugs for 2026; the second includes fifteen Part D drugs for 2027. CMS also selected drugs for the next cycle and issued additional program materials before this article's cutoff.⁸

The incoming Congress can scrutinize implementation, manufacturer behavior, beneficiary access, and whether savings reach patients or the program. A larger statutory expansion would require legislation. Existing negotiated prices should not be attributed to the new Congress merely because they take effect during its term.

The distribution of savings is central. A lower program price does not translate dollar-for-dollar into every patient's pharmacy payment. Benefit design, deductible status, coinsurance, formulary placement, and the specific drug determine the patient experience. A manufacturer can also change other prices or contracting strategies. An evaluation must distinguish the negotiated unit price, total program spending, patient spending, and access to alternatives.

California can act through its own purchasing and regulatory authorities, but it does not control every national pharmaceutical contract. State efforts to improve purchasing should be evaluated by delivered price, supply reliability, quality, and clinical availability. A low announced price has little value if the product cannot be obtained consistently or if the relevant patients cannot use it.

Forecast: During 2027–2028, the most reliable drug-policy story is continued implementation and political contest over an inherited framework. More ambitious changes remain possible, but their probability should rise only when legislation, administration support, and fiscal analysis begin to align.

Consolidation requires a precise diagnosis

GAO's 2025 review found that hospital employment or affiliation encompassed at least 47% of physicians in 2024, compared with less than 30% in 2012. Its review associated hospital-physician consolidation with higher prices and spending, generally without corresponding quality improvement; evidence concerning access was less clear. Evidence on insurer and private-equity consolidation was more limited.²

That finding supports scrutiny. It does not establish that every acquisition raises prices or that all organizational integration should be prohibited. Policymakers need to identify the relevant market, the services affected, the bargaining alternatives, and the efficiencies that can actually be verified. A struggling rural practice acquired by a larger organization presents different facts from a transaction that removes the only remaining meaningful competitor in a metropolitan specialty market.

Federal antitrust enforcement and California's transaction-review and affordability institutions operate through different authorities. Their work can complement each other, but a cost-growth review is not identical to an antitrust case. A merger can raise affordability concerns without satisfying every element of a particular competition claim. Conversely, the absence of a successful case does not prove that a market is competitive.⁹

The next two years could produce stronger demands for transaction information and post-transaction accountability. The difficult issue will be what remedy improves care. Blocking a transaction may preserve competition, but it may not solve an independent organization's capital needs. Conditions may be more useful in some circumstances, provided they are measurable, enforceable, and resistant to evasion.

The strongest industry counterargument is that scale finances information systems, recruiting, capital investment, and coverage of unprofitable services. Policymakers should require evidence for those claims while taking them seriously. The strongest public-interest response is to ask whether the promised benefit requires common ownership, whether it reaches patients, and whether a less restrictive arrangement could deliver it.

Fresno's cost problem includes distance and capacity

For Fresno County, the relevant policy unit is the actual care network: independent practices, health centers, hospitals, specialists, county programs, and referral relationships across the Central Valley. A statewide average can conceal a local shortage. A broad insurance network on paper can conceal long waits or providers who are not accepting new patients.

The county's Community Health Improvement Plan identifies access to medical, dental, and vision care alongside mental health, chronic disease, environmental conditions, and economic stability. Those priorities make clear why the local affordability question extends beyond the price printed on a claim.¹⁰

Consider a hypothetical family that must take unpaid time off and travel for a specialty consultation. Reducing the visit's copayment helps, but it may not remove the largest barrier. A policy that supports local consultation capacity, reliable referral coordination, or appropriate remote specialist support could have a different and substantial value. These are possible mechanisms, not claims about a documented individual case.

Fresno should therefore be visible in California's primary care and affordability reporting. The relevant indicators include participating providers by service, appointment availability, patient travel requirements, interpreter access, referral completion, and the financial stability of organizations serving large public-program populations. The denominator matters: a rate per resident, per enrolled member, and per clinician full-time equivalent describes three different things.

Local purchasing coalitions, public employers, health plans, and provider organizations could also compare contract terms and administrative demands within the law. Their opportunity is to identify duplicative processes and incentives that everyone pays for but no one values. Such cooperation should preserve competition and privacy rather than become a vehicle for coordinated price setting.

Who gains, who pays, and who may be overlooked

Patients with high medication costs may benefit from effective purchasing reform, while patients whose main problem is an unavailable clinician may need capacity investment. Small employers may benefit from lower negotiated prices, but the effect on premiums depends on the broader benefit and market. Independent practices may benefit from simpler administration and better primary care support while facing stronger disclosure or performance obligations.

Large provider systems may lose revenue from policies aimed at excessive prices or payment differentials. Some could absorb the change through lower margins; others might alter services. Policymakers should examine those responses with service-specific evidence. A generalized threat of closure should not end the inquiry, but an actual risk to a necessary service cannot be dismissed because the organization is large.

Taxpayers may finance transition costs before any savings emerge. Workers may experience benefit changes through wages, premiums, or employer decisions. People with disabilities, complex chronic conditions, limited English proficiency, or unstable work schedules may be overlooked if performance measures reward only easy-to-reach populations.

The distributional test should therefore ask who remains outside the improvement. If average spending growth slows while high-need patients lose access, the policy has not achieved a complete success. If a practice receives more funding but cannot hire in its region, the workforce constraint remains. An honest evaluation should allow several outcomes to be true at once.

Three paths through 2028

Base case: selective progress. Existing drug-negotiation and California primary care frameworks continue. Congress intensifies oversight and negotiates narrower measures. California emphasizes implementation within its fiscal constraints. Household gains are uneven because different financing channels and regions respond differently.

Improvement case: purchasing and capacity reinforce each other. A federal agreement addresses selected payment or administrative problems, while California directs primary care investment toward measurable access. Competition enforcement and transaction scrutiny constrain excessive prices without undermining necessary services. Fresno benefits if statewide policies explicitly measure local delivery.

Stress case: financial pressure outruns reform. Federal payment pressures, coverage disruptions, state budget constraints, and workforce shortages interact. Organizations respond through consolidation, reduced participation, or narrower services. Political attention produces more reporting but insufficient practical relief. This is a scenario to test, not an inevitable result.

The strongest argument against the base case is that affordability pressure could produce a larger bipartisan bargain than current institutional conflict suggests. Employers, patients, and public purchasers all have reasons to demand improvement. The forecast should be upgraded if a concrete package gains support from the actors needed for enactment, identifies financing, and provides an implementation timetable. Conversely, repeated breakdowns in funding negotiations or worsening local access would strengthen the stress case.

The scorecard that should replace campaign promises

A useful public scorecard would follow five results. First, measure what households pay, separating premiums from use-based payments. Second, measure appointment access and referral completion. Third, measure primary care investment using consistent definitions and show its geographic distribution. Fourth, track prices and service availability after significant transactions. Fifth, measure administrative work imposed on practices and patients.

Each indicator should identify its reporting period, population, and limitations. Changes should be compared with a current-law baseline and relevant economic conditions. If premiums rise more slowly, ask whether benefits or networks changed. If spending declines, ask whether health needs were met. If a payment increases, ask whether staffing and appointment capacity follow.

For California, the January budget proposal, May Revision, enacted budget, and OHCA implementation materials will be stronger evidence than general statements of intent. For Washington, enacted payment provisions, agency rules, oversight findings, and program performance will matter more than the number of hearings held. For Fresno, the essential evidence will be whether residents can obtain appropriate care with less financial and practical strain.

The election creates an opportunity to improve the terms on which Americans purchase healthcare. Whether that opportunity produces an affordable appointment will depend on the connection between purchasing power, legal authority, and local capacity. That connection is where the next phase of policy should be judged.

Sources and scope

Source notes

Numbered notes support the sentence that carries the number. A source supports the claim it is cited for, with its own date and scope; it is not an endorsement by the issuing institution.

1. CMS, National Health Expenditure Fact Sheet; 2024 historical expenditures. ↩↩

2. GAO, Health Care Consolidation: Published Estimates and Studies on Physician Consolidation, September 22, 2025. ↩↩

3. California HCAI, Primary Care Investment Benchmark, adopted October 2024. ↩↩

4. CMS, Calendar Year 2027 Medicare Physician Fee Schedule Final Rule, issued November 4, 2026. ↩↩↩↩

5. CMS, history of Medicare and Medicaid. ↩↩

6. U.S. Senate, Filibusters and Cloture; ordinary legislative procedure. ↩

7. Xavier Becerra campaign, healthcare priorities; evidence of stated agenda, not enacted law. ↩

8. CMS, Selected Drugs and Negotiated Prices; program-cycle records available by November 6, 2026. ↩

9. California HCAI, Office of Health Care Affordability; program authority and implementation. ↩

10. Fresno County, Community Health Assessment and 2024–2028 Community Health Improvement Plan, revised May 2026. ↩