“You can’t come in for your steroid injections without scheduling an extra appointment because your insurance isn’t paying us enough.” That’s what I was told at my most recent visit to an orthopedic surgeon I’ve seen for years. I expected relief from my pain, not a surprise medical bill—or as I learned later, “cost-shifting.”
My physician explained he could no longer afford to offer injections unless I paid for an additional appointment. Why must I pay extra for a service I’ve been receiving and paying for the past four years? Because insurance wasn’t reimbursing the clinic enough to cover the cost. In the end, I paid the extra cost of $86 per knee because I was in too much pain to wait another month.
At first, I was angry and blamed the clinic for overbilling me. After the appointment, I reviewed my insurance’s previous billing statement from the last injections, and I realized this wasn’t entirely the clinic’s fault. This was the result of insurers practicing what is known as cost-shifting-by-design, and Texans are unfairly and unknowingly caught in the middle.
Insurers know physicians want to help their patients and will do whatever they can to continue providing care. Therefore, as my experience has shown, when clinics are underpaid by insurance, they often require extra appointments, administrative fees, or cash payments, all of which are factors of cost-shifting. Patients end up paying more out of pocket, and those payments may not count towards their deductible. This is not because physicians or clinics are greedy, but because insurers leave them no alternative. Insurers have effectively shifted the cost to patients and clinics. Clinics either must charge more or go out of business, and patients must either forgo treatment or pay the bill.
My story is not an isolated case; it’s happening all over Texas and the United States. People often assume high health care costs originate from physicians, clinics, and hospitals. That is an easy assumption, but the reality of the problems is much deeper and more complex. To implement cost-shifting, insurers are underpaying clinics and using their market power to force physicians to accept contracts that are often referred to as “take-it-or-leave-it” payments. Clinics, such as the one I went to, then face the dilemma of continuing to provide treatment and losing money, saving their clinic by stopping services altogether, or practicing cost-shifting by adding additional fees for patients to pay.
Critics may argue that if insurers pay more, premiums will rise. But that is missing the point. The issue isn’t just the amount being spent; it’s that patients lack the freedom to choose. Even those willing to pay out of pocket often can’t. Networks dictate which providers we see, where we go, and what treatments we receive, even when it’s not in our best interest.
But once patients have options, insurers will reform. That’s how free markets work.
As someone who has spent years navigating doctors’ offices, this problem is more than just frustrating as a patient; it’s an anti-competitive market that prioritizes bureaucracy over people.
Patients should be able to shop for high-value care without monopolistic restrictions, whether at an independent clinic, hospital, or through a direct-pay or health-sharing model. If we reformed or eliminated network restrictions, insurers would finally have to compete based on value, not contracts and gatekeeping. That would open the door for alternatives like Crowd Health or health-sharing ministries, thereby restoring price transparency and personal liberty and agency.
Other states are leading the way. Colorado, New Hampshire, and Florida have passed strong network reform and transparency laws. Georgia’s Surprise Billing Consumer Protection Act sets fair reimbursement standards. Arizona has expanded direct primary care to help patients bypass insurance entirely. Texas should follow their lead, not by expanding bureaucracy, but by restoring competition and choice.
But reform alone isn’t enough. Most Texans are unaware that they can demand to know cost up front, request cash-pay pricing, utilize health sharing, or appeal to network denials. If I hadn’t known this, I would have been over-billed and left untreated. Patients need clear guidance, easy-to-use tools, and public education to avoid unfair situations like mine.
Lawmakers should build on recent transparency reforms, such as HB 1314, and pursue policies that eliminate restrictive networks that trap patients, upfront cost estimates for all clinics, and empower patients to explore cash-pay and health-sharing options. Enforcing absolute network transparency, not just a list of unavailable physicians, is critical, as is promoting public education to allow Texans to know their options and rights.
Most importantly, we must put patients, not insurers, back in control of their health care decisions.