The Price Is Correct

Forty-two thousand prices. Not one of them is real. But every single one of them is correct.

This piece was originally posted as a confession on X. @gothburz

Companion piece: The Claim Was Processed — a confession from the other side of the bill.

I. OPENER

I am the CEO of the largest for-profit hospital system in the United States. I operate 190 hospitals across 20 states and employ roughly 309,000 people.¹ I want to tell you about a spreadsheet.

The spreadsheet has 42,000 rows. Each row contains a price. The prices are for items you might need someday. A bag of saline. A chest X-ray. An hour in an operating room. A single dose of a drug that keeps your blood from clotting while a surgeon holds your heart in both hands. The spreadsheet is called the chargemaster. Every hospital in America has one. Mine has 190.

A bag of saline — one liter of salt water in a plastic pouch — costs my hospital roughly $1.² The chargemaster price for that bag is $137 to $800, depending on which of my hospitals you are unlucky enough to visit.³ A CT scan of the abdomen costs my facility approximately $100 to perform. The chargemaster lists it between $2,850 and $6,200. The ratio between cost ratio ranges from 28:1 to 62:1, depending on the scan, the facility, and the version of the spreadsheet loaded that quarter.⁴

The prices are not real. I need you to understand this before I explain anything else. They are not tied to the cost of the equipment. They are not tied to the nurses’ salaries. They are not tied to the complexity of the procedure, the severity of the illness, or the number of minutes a physician spent reading your chart at 2 a.m. The prices are not the cost of anything. The prices are the prices.

If you have insurance, your insurer has negotiated a different price. A private price. A price that is a percentage of the fake price, which makes the private price feel like a bargain, which is the entire point of the fake price. If you do not have insurance, you receive the fake price. The full one. The 42,000-row one. That price is for you.

The price is correct.

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II. CONTEXT

The chargemaster was not always fiction. It began as an inventory.

In the early 1950s, hospitals kept price lists the same way hardware stores did. You needed a procedure. The procedure had a cost. The cost included supplies, labor, and overhead, plus a margin. The price was higher than the cost but tethered to it. You could hold them both in your hand and see the rope between them.⁵

Then two things happened. Neither was an accident.

First, in 1965, Medicare began paying hospitals for the care of elderly patients. The government paid whatever hospitals charged. There was no ceiling, no negotiation, no counteroffer. Hospitals charged more. Costs rose. The spreadsheet grew. This was not fraud. This was an open checkbook and human nature.

Second — and this is the one that matters — on October 1, 1983, Medicare stopped paying whatever hospitals charged and switched to a flat fee per diagnosis. Public Law 98-21. The system was called the Prospective Payment System, and it grouped patients into Diagnosis-Related Groups (DRGs).⁶ If a patient arrived with pneumonia, Medicare paid a fixed amount for pneumonia, regardless of whether the patient stayed three days or thirteen. The incentive flipped overnight. Under the old system, more treatment meant more revenue. Under DRGs, less treatment meant more margin.

But here is what hasn't been fixed: the chargemaster. Medicare stopped using it. But nobody told hospitals to stop maintaining it. Nobody told them to make it rational. Nobody told them to tie the numbers to anything. The chargemaster floated free, untethered from the cost of care, untethered from what Medicare would pay, untethered from reality. It became an anchor — not for what things cost, but for what private insurers could be made to pay relative to a number that meant nothing.

Uwe Reinhardt, the Princeton economist, published a paper in Health Affairs in 2006 titled “The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy.”⁷ He called the chargemaster “incomprehensible.” He called the pricing system “chaos.” He was being polite. He was a Princeton economist. He used words like “opacity” and “administered pricing” when what he meant was: we made the numbers up. We have been making them up for forty years. The veil is not an accident. The veil is the product.

Steven Brill wrote 24,000 words about this in Time magazine in 2013. It was the longest article Time had published in its history. He used the word “chargemaster” fifty-three times.⁸ The New York Times had used the word three times in the previous year. Twenty-four thousand words. The country read them. The country was outraged. The chargemaster did not change. My spreadsheet has more rows now than it did in 2013.

The price is correct.

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III. ESTABLISHMENT

I want to walk you through twelve prices. Not because twelve is a meaningful number. Because twelve is all you can hold before the pattern makes you stop reading.

A single Tylenol tablet. Over-the-counter cost: roughly four cents. Chargemaster price at an American hospital: $15-$25. A markup of 37,500%.⁹

A pair of sterile gloves, the kind a nurse snaps on before drawing blood. Cost: pennies. Chargemaster: $53.

One liter of normal saline, the most common IV fluid in medicine, which is water and salt. Cost: roughly $1. Chargemaster: up to $800. In a country with municipal water systems and table salt at sixty cents a pound, the hospital charges $800 for water and salt. That is not pricing. That is poetry.

A chest X-ray. The machine is already paid for. The technician is salaried. The radiologist reads it on a screen that was amortized three years ago. Variable cost per image: less than $25. Chargemaster: $400 to $1,300.

Keytruda — pembrolizumab — an immunotherapy drug used for sixteen types of cancer. My hospital’s acquisition cost for one infusion: approximately $11,712.¹⁰ Chargemaster list price: $25,000 or more. The molecule does not know which spreadsheet it is on. The molecule does not know if the patient has insurance. The molecule does what molecules do. The spreadsheet does what spreadsheets do.

The average charge-to-cost ratio for American hospitals is 4.32-to-1. For-profit systems like mine average 6.31-to-1. For certain imaging procedures, the ratio exceeds 28 to 1.¹¹ That means for every dollar a procedure costs, we charge twenty-eight. Not because the procedure is twenty-eight times more valuable. Because the spreadsheet says twenty-eight, and nobody has ever been required to explain why the spreadsheet says what it says.

Now consider the same procedures outside this country. A hip replacement in the United States averages $40,364. In Australia: $14,884. In France: $15,460. In Spain: $9,354.¹² The titanium is the same. The surgical technique is the same. The difference is not medicine. The difference is geography, and geography is a spreadsheet with a flag on it.

An MRI in the United States: $1,119 average. In the Netherlands: $461.¹³ Same magnet. Same coil. Same image. A 2.4x gap that is not explained by labor costs, not explained by malpractice premiums, not explained by any input that enters the machine. The gap is the spreadsheet. The spreadsheet is the gap.

The price is correct.

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IV. THE TURN

The bill arrives at a kitchen table.

I never see this part. My office is on the top floor. The windows face a parking garage, my system was built for $60 million. From my window, I can see the emergency department entrance where the ambulances arrive. I cannot see the kitchen tables.

The bill is fourteen pages. The first page is a summary. The summary contains a number. The number is five or six figures. It has a dollar sign and a decimal point, and it sits in the upper-right corner like a verdict. Below it, in smaller font, is the phrase “Amount Due.” Below that is a payment deadline. Below that is a phone number. The phone number connects to a call center. The call center is in another state. The person who answers has a script. The script does not contain the sentence “This price is not real.”

There is $220 billion in outstanding medical debt in the United States.¹⁴

Hold that number. Turn it in your hand.

Two hundred and twenty billion dollars owed by patients to hospitals for prices set by spreadsheets untethered from cost in 1983. That is not a market failure. That is the market. The market is functioning. The price is correct.

Two-thirds of all bankruptcies in this country cite medical expenses as a contributing factor.¹⁵ Not the sole factor. A contributing factor. The medical bill did not cause the bankruptcy alone. The medical bill joined the mortgage, the car payment, the grocery bill, and the daycare bill and pushed the family past the line. The bill was the last weight. The chargemaster set the weight.

A 2024 study in JAMA Network Open found that medical debt is associated with higher mortality. Not a lower quality of life. Not worse outcomes. Higher mortality. The spreadsheet is connected to the cemetery by a chain of collection notices, deferred prescriptions, skipped follow-up appointments, and a decision, made at a kitchen table, that the family can afford the rent or the hospital bill but not both.¹⁶

One-third of GoFundMe campaigns in the United States are for medical expenses.¹⁷ A crowdfunding platform designed for creative projects and community causes has become the country’s largest supplemental health insurance program. Strangers on the internet have become the payer of last resort. That is not a glitch. That is the system working exactly as the spreadsheet intended.

Fifty percent of American adults cannot pay an unexpected $500 medical bill without going into debt.¹⁸ Not a $50,000 surgery. Not a $200,000 cancer treatment. Five hundred dollars. A single emergency room visit for a broken wrist. A single bag of saline and an X-ray and four hours on a gurney in a hallway. Five hundred dollars, and half the country borrows.

I set the prices. My chargemaster set the price of the saline. My chargemaster set the price of the X-ray. My chargemaster set the price of the four hours. None of those prices are real. All of those prices are owed. The debt is real. The bankruptcy is real. The mortality is real. The price that caused them is not.

The price is correct.

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V. ESCALATION

In 2021, the federal government did something unprecedented. It required hospitals to publish their prices.¹⁹

Not their costs. Their prices. The chargemaster prices. The negotiated prices. The cash-pay prices. All of them. In a machine-readable file. Online. For anyone to see.

I want to describe what we did next.

We published a CSV file. Nine thousand four hundred rows. You can download it from our website. This is a regulatory requirement, and we comply with it. The file contains charge codes, descriptions, and dollar amounts. It does not contain context. It does not contain the sentence “These prices are fictional anchors designed to maximize negotiating leverage with private insurers.” It does not contain the sentence “The cash-pay price is a penalty for not having insurance.” It contains numbers. The numbers are correct. The numbers are also meaningless without a medical billing certification and eight hours of free time.

As of November 2024, only 21.1% of American hospitals were fully compliant with the price transparency rule.²⁰ Four out of five hospitals had still not published their prices in full, four years after the requirement took effect. The maximum penalty for non-compliance is $5,500 per day.²¹ My system generates that much revenue in approximately twelve seconds. The fine is not a deterrent. The fine is a cost of opacity. We budget for it the way you budget for parking tickets.

In January 2026, the Centers for Medicare and Medicaid Services updated the rule. The CEO must now personally attest that the published prices are “true, accurate, and complete.” The CEO’s name must be encoded in the machine-readable file. The requirement was set to take effect on January 1, 2026. Enforcement was delayed to April 1, 2026.²²

I will sign the attestation. The prices are true. They are in the spreadsheet. The prices are accurate. They match our billing system. The prices are full. All 42,000 rows. The attestation does not require me to certify that the prices are fair. It does not require me to certify that the prices bear any relationship to cost. I don't need to explain why one hospital charges $137 for saline and another, 30 miles away, charges $800 for the same bag from the same manufacturer. The attestation asks if the numbers are the numbers. The numbers are the numbers.

In five years under the transparency rule, only 27 hospitals across the country have been fined.²³ Twenty-seven. Out of more than 6,000. The fines totaled less than what my system spends on cafeteria operations in a single quarter. There is a framed certificate on the wall of our compliance department. It says “Committed to Transparency.” The frame cost more than the average transparency fine.

Prices for the same procedure, at hospitals within the same state, can vary by a factor of 33.²⁴ Thirty-three times. An appendectomy at one hospital: $1,800. At another hospital in the same metropolitan area: $56,000. Same appendix. Same surgeon board certification. Same anesthesia protocol. Same twelve-inch incision or same three laparoscopic ports. But a different row in a different spreadsheet. Both rows are published. Both rows are attested. Both CEOs signed.

The price is correct.

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VI. THE WIDER PATTERN

A system this irrational should not survive. It has survived for forty-two years. I want to explain how.

My industry spent $713 million on lobbying between 1998 and 2024.²⁵ That is not a misprint. Seven hundred and thirteen million dollars to ensure that the people who write the rules have heard our perspective. We are the second-largest lobbying sector in the country, behind pharmaceuticals. We are ahead of defense. We are ahead of oil. We spend more money asking the government not to regulate our prices than most governments spend on hospitals.

In fiscal year 2024, my system reported $70.6 billion in revenue and $5.76 billion in net income.²⁶ I took home $23.8 million.²⁷ The median employee at my hospital system earned $60,820. The ratio is 391 to 1. The median employee changes bedpans and holds the hands of dying patients at 3 a.m. I hold the spreadsheet. The spreadsheet says the ratio is correct.

My predecessor’s predecessor paid $1.7 billion to the federal government to settle the largest healthcare fraud case in American history at that time.²⁸ The CEO was never criminally charged. The company was not shut down. The company was reorganized, renamed, and relisted. The stock recovered. The chargemasters were not deleted. They were updated. I update them. The company has appeared on Fortune’s “Most Admired Companies” list for twelve consecutive years.²⁹ including the years after the fraud settlement. Including this year. That is not resilience. That is immunity.

One point six trillion dollars. That is what the United States spends on hospital care annually.³⁰ Nearly 31% of all healthcare spending. More than defense. More than education. A third of it passes through spreadsheets that were unmoored from reality in 1983 and have been floating upward ever since, carrying prices that no one set rationally, that no one audits meaningfully, that no one can explain to the patient in the waiting room with a clipboard and a prayer.

Maryland is the only state that regulates hospital prices through an independent commission.³¹ One state. Out of fifty. The other forty-nine rely on the chargemaster and the fiction that a market exists where a patient having a heart attack can comparison-shop. Private insurers pay my hospitals 254% of what Medicare pays for the same services. For outpatient care: 279%.³² The chargemaster is the opening bid. The bid has never been rejected. Nobody has the leverage to reject it, because nobody can see the other bids, and the patient is already sedated.

The system is not broken. The system has a lobby, a legal department, and a compliance office with a framed certificate that says “Committed to Transparency.”The system works.

The price is correct.

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VII. KICKER

I have an executive health plan. It is not the plan we offer our employees. It is not the plan our patients receive. My plan has a $20 copay for specialist visits. My plan covers every procedure in the chargemaster at cost. Not at the chargemaster price. At cost. The actual cost. The $1 bag of saline. The $100 CT scan. The $11,712 infusion of Keytruda. I pay what things cost. You pay what the spreadsheet says.

My executive health plan is a benefit of my position. The position that sets the prices on the spreadsheet. I set the prices. I am exempt from the prices. That is not a contradiction. That is a perk.

Let me give you the numbers one more time.

$70.6 billion in revenue. $5.76 billion in profit. $713 million in lobbying. $23.8 million for the CEO. $60,820 for the median employee. 391 to 1. 190 hospitals. 42,000 prices. Not one of them tied to cost. 254% of Medicare. 33:1 price variation. $220 billion in medical debt. Two-thirds of bankruptcies. One-third of GoFundMe. Half the country cannot cover $500. Twenty-seven fines in five years. One state with price regulation. $1.7 billion in fraud, and the stock recovered.

I am the CEO of the largest for-profit hospital system in the United States. I have 42,000 prices and not one of them is real. But all of them are billed. And all of them are collected. And all of them are correct.

The price is correct. The price has always been correct.

I am the price.

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CODA

There is a moment, late at night, when the hospital is quietest. Not silent. A hospital is never silent. There is the beeping and the footsteps and the soft pneumatic sigh of a door closing on the ICU ward. But the administrative floors are dark. The compliance department is dark. The revenue cycle office is dark. The spreadsheets are still running on servers in a windowless room on the second sublevel, but no one is watching them. The spreadsheets do not need to be watched. They do what spreadsheets do.

I go home. I have a home in a neighborhood where the ambulances do not come often. I have a personal laptop. Sometimes, late, I open it. Not for work. For something else.

The CMS price transparency portal is public. Anyone can search it. I searched it once. I typed in my own hospital. I typed in a procedure I had last year — a routine thing, nothing serious, the kind of thing a man my age gets checked. I found the chargemaster price. I found the negotiated price my executive plan paid. I found the cash-pay price.

The cash-pay price was eleven times what my plan paid. For the same room. The same machine. The same technician who called me “sir” because she had seen my badge and knew my title.

I closed the laptop. I did not search again.

The spreadsheet is still there. It will be there tomorrow. It will be there when you need it — when the ambulance brings you to one of my 190 hospitals, when the nurse puts the saline in your arm, when the billing department generates an invoice fourteen pages long, when the number appears in the upper right corner like a sentence you cannot appeal.

The price is correct. I wrote it. I do not pay it. I go to sleep.

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FOOTNOTES

1. HCA Healthcare operates approximately 190 hospitals and roughly 2,400 sites of care across 20 states and the United Kingdom. As of FY2024, HCA employed approximately 309,000 people. Source: HCA Healthcare 2024 Annual Report (10-K); HCA Healthcare corporate website.

2. The wholesale cost of one liter of normal saline (0.9% sodium chloride) ranges from approximately $0.44 to $1.07 per bag. Source: Hicks and Adams, “IV Solutions: A Case Study,” Journal of Pharmaceutical Sciences (2015); multiple wholesale pharmaceutical pricing databases.

3. Hospital chargemaster prices for normal saline vary widely. A 2013 NerdWallet analysis of CMS data found hospital charges for one liter of IV saline ranging from $137 to over $800. Steven Brill’s “Bitter Pill” (Time, 2013) documented similar ranges. Source: NerdWallet (2013); Time Magazine; CMS hospital compare data.

4. Bai and Anderson, “Hospital Cost Shifting: The Hidden Surcharge Americans Pay for Health Care,” Health Affairs 35(9), 2016: average hospital charge-to-cost ratio was 4.32:1 nationwide. For CT scans specifically, ratios up to 28.5:1 were documented. For-profit hospitals averaged charge-to-cost ratios of 6.31:1 compared to 3.57:1 at nonprofits. Source: Health Affairs 35(9), September 2016.

5. The American Association of Medical Colleges (AAMC) and health economics historians place the origin of standardized hospital charge structures in the early 1950s, coinciding with the growth of indemnity insurance. Source: AAMC historical archives; Reinhardt (2006); Starr, “The Social Transformation of American Medicine” (1982).

6. The Prospective Payment System (PPS) using Diagnosis-Related Groups (DRGs) was enacted as part of the Social Security Amendments of 1983 (Public Law 98-21), signed April 20, 1983, effective October 1, 1983. It fundamentally changed Medicare hospital reimbursement from retrospective cost-based to prospective flat-rate per diagnosis. Source: CMS historical data; Congressional Research Service.

7. Reinhardt, Uwe E. “The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy.” Health Affairs 25(1):57-69, January 2006. Reinhardt described U.S. hospital pricing as a system of “administered prices” characterized by “chaos” and fundamental “opacity.” Source: Health Affairs 25(1), 2006.

8. Brill, Steven. “Bitter Pill: Why Medical Bills Are Killing Us.” Time, February 20, 2013. At approximately 24,000 words, it was the longest article Time had published in its history. Brill used the word “chargemaster” 53 times. The article was the basis for his subsequent book, “America’s Bitter Pill” (2015). The New York Times had used the word “chargemaster” only three times in the twelve months preceding Brill’s article (per NYT archives). Source: Time Magazine; NYT archive search.

9. Hospital markups on common items are widely documented. Tylenol (acetaminophen) markups of 10,000-37,500% have been reported across multiple analyses of hospital billing data. Source: Brill, “Bitter Pill” (2013); JAMA Internal Medicine; various CMS analyses of hospital charge data.

10. Keytruda (pembrolizumab) wholesale acquisition cost (WAC) for a standard infusion dose: approximately $11,712 per 200mg vial (current ASP per CMS Medicare Part B drug pricing file, Q1 2026). Hospital chargemaster prices for the infusion (including administration) routinely exceed $25,000. Source: CMS Medicare Part B ASP pricing file; Merck pricing; GoodRx.

11. Bai and Anderson, Health Affairs 35(9), September 2016. See footnote 4. Average charge-to-cost ratio: 4.32:1. For-profit average: 6.31:1. Imaging procedures (CT, MRI) showed some of the highest ratios, with CT scans reaching 28.5:1.

12. International hip replacement cost comparisons from the International Federation of Health Plans (IFHP) 2019 Comparative Price Report and OECD Health Statistics. U.S. average: $40,364. Australia: $14,884. France: $15,460. Spain: $9,354. Source: IFHP 2019; OECD Health at a Glance 2023. Note: IFHP data is from 2019, the most recent comprehensive international price comparison available.

13. MRI cost comparison: U.S. average $1,119 vs. Netherlands approximately $461. Source: IFHP 2019 Comparative Price Report; Anderson et al., “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries,” Health Affairs 22(3), 2003 (foundational pricing comparison, updated figures from IFHP 2019).

14. Peterson-KFF Health System Tracker: approximately $220 billion in outstanding medical debt in the United States. Source: Peterson-KFF Health System Tracker; Consumer Financial Protection Bureau (CFPB) research; Urban Institute.

15. Himmelstein et al., “Medical Bankruptcy: Still Common Despite the Affordable Care Act,” American Journal of Public Health 109(3), March 2019: 66.5% of all bankruptcies were tied to medical issues (medical bills and/or income loss due to illness). Source: AJPH 109(3), March 2019.

16. Han X, Hu N, Zheng Z, Shi KS, Yabroff KR. “Association Between Medical Financial Hardship and Mortality Among US Adults,” JAMA Network Open 7(3):e2354766, March 4, 2024: medical financial hardship is independently associated with higher mortality, controlling for income, insurance status, and baseline health. Source: JAMA Network Open 7(3), March 2024.

17. GoFundMe has reported that approximately one-third of its campaigns are related to medical expenses, making it a de facto supplemental health financing mechanism. Source: GoFundMe CEO statements; NBER working papers on medical crowdfunding; CBS News; NPR.

18. KFF Health Care Debt Survey, 2022: approximately half of U.S. adults would not be able to pay an unexpected medical bill of $500 without going into debt. 41% of adults carry some form of healthcare debt. Source: KFF, June 2022.

19. The Hospital Price Transparency Rule (CMS-1717-F2), effective January 1, 2021, requires all hospitals operating in the U.S. to publish their standard charges for all items and services in a machine-readable format and in a consumer-friendly display of 300 shoppable services. Source: CMS Final Rule; Federal Register.

20. PatientRightsAdvocate.org Semi-Annual Hospital Price Transparency Compliance Report, November 2024: only 21.1% of hospitals were fully compliant with the price transparency rule. Source: PatientRightsAdvocate.org, November 2024.

21. Civil monetary penalties for non-compliance with the Hospital Price Transparency Rule are tiered at $10 per bed per day, with a maximum of $5,500 per day for hospitals with 550+ beds ($300/day floor for small hospitals). CMS increased penalties from the original $300/day flat cap effective January 1, 2022. Source: CMS enforcement actions; 45 CFR 180.90.

22. CMS CY2026 Outpatient Prospective Payment System (OPPS) Final Rule, published November 21, 2025: requires the hospital CEO (or equivalent officer) to personally attest that published pricing data is “true, accurate, and complete.” The CEO’s name must be encoded in the machine-readable file. Effective date: January 1, 2026. Enforcement delayed to April 1, 2026. Source: CMS CY2026 OPPS Final Rule; Federal Register.

23. As of early 2026, CMS had issued civil monetary penalties to only 27 hospitals for non-compliance with price transparency requirements since the rule’s inception in January 2021. Source: CMS enforcement actions database; PatientRightsAdvocate.org tracking; KFF analysis.

24. PatientRightsAdvocate.org analysis found price variation of up to 33x for the same procedure within the same state. Source: PatientRightsAdvocate.org Semi-Annual Reports, 2023-2024.

25. OpenSecrets (Center for Responsive Politics): Hospitals & nursing homes sector lobbying totaled approximately $713 million from 1998-2024, making it the second-largest healthcare lobbying sector behind pharmaceuticals. Source: OpenSecrets.org lobbying database; CRP annual lobbying reports.

26. HCA Healthcare FY2024: revenue of approximately $70.6 billion, net income of $5.76 billion. Source: HCA Healthcare 2024 Annual Report (10-K); Q4 2024 earnings release.

27. HCA Healthcare CEO Sam Hazen’s total compensation for FY2024 was approximately $23.8 million per the 2025 proxy statement. Median employee compensation: $60,820. CEO-to-median-worker pay ratio: 391:1. Source: HCA Healthcare 2025 Proxy Statement (DEF 14A); SEC filings. NOTE: The narrator is a composite character; real CEO name used only in sourcing.

28. Columbia/HCA settled with the U.S. Department of Justice in two rounds: $840 million in December 2000 and $881 million in June 2003, totaling approximately $1.7 billion — the largest healthcare fraud settlement in U.S. history at that time. The fraud involved billing Medicare for costs of marketing and advertising, upcoding patient diagnoses to increase Medicare reimbursement, and paying kickbacks. CEO Rick Scott resigned in 1997 but was never criminally charged. Source: DOJ press releases (December 14, 2000; June 26, 2003); New York Times; Washington Post.

29. HCA Healthcare has appeared on Fortune’s “World’s Most Admired Companies” list for 12 consecutive years, most recently in February 2026. Source: Fortune; HCA Healthcare press release (February 2026).

30. CMS National Health Expenditure Data: hospital care spending represented approximately $1.6 trillion ($1,634.7 billion) in 2024, roughly 30.9% of total national health expenditures. Source: CMS Office of the Actuary, National Health Expenditure Accounts (NHEA) 2024.

31. Maryland is the only state with an all-payer hospital rate-setting system. The Health Services Cost Review Commission (HSCRC) was created in 1971; the all-payer system with Medicare waiver began in 1977. All hospitals in Maryland charge the same rate to all payers (Medicare, Medicaid, private insurance, self-pay) for the same service. Source: HSCRC; Health Affairs; Commonwealth Fund.

32. RAND Hospital Price Transparency Study, Round 5 (2020-2022 data, published 2024): private health plans paid hospitals an average of 254% of Medicare rates overall, and 279% for outpatient services. Source: RAND Corporation, “Prices Paid to Hospitals by Private Health Plans: Findings from Round 5 of an Employer-Led Transparency Initiative,” 2024.