You Gave Them Skin in the Game. Nobody Gave Them the Scoreboard.

A woman is standing in a parking lot with a paper order for a lumbar MRI without contrast (CPT 72148) and a phone at 41 percent.

She is not uninsured. She is a member. Of something. A health sharing ministry, maybe. An ICHRA-funded bronze plan with a deductible she will not touch until October. A reference-based pricing plan whose ID card says, in language her HR director practiced saying out loud before open enrollment, that the plan pays a defined percentage of Medicare and anything above that is “a conversation.”

Whatever the structure, the operative fact is identical: the first several thousand dollars are hers.

So she starts calling.

First facility: hold queue, then a scheduler who wants the CPT code, which she has, then an insurance ID, which is the whole point of the call, then a transfer that ends in a dial tone. Second facility: voicemail. Third facility: a number, quoted verbally, that does not include the radiologist’s read, a detail she will discover in three weeks when the second invoice arrives.

Ninety minutes. No comparison. She books the one that picked up.

Here’s the part that doesn’t make it into the enrollment deck: that was the system working exactly as designed.

The wager every organization in this market has already made

Health shares. Reference-based pricing administrators. ICHRA and QSEHRA platforms. Direct primary care networks. HSA and FSA administrators. Fixed-indemnity carriers and bill advocates.

Six different regulatory postures. Six different sales motions. One identical bet:

Give the member the money and the exposure, and they will make a better purchasing decision than an insurance company would make on their behalf.

That bet is defensible. In a meaningful share of cases it is demonstrably correct, and we’ll get to the data, because the data is more aggressive than the industry admits.

But the bet is also incomplete, and the incompleteness is structural rather than philosophical. You transferred the incentive. You did not transfer the information. And a consumer with full financial exposure and zero price visibility isn’t a consumer.

They’re a hostage with a checkbook.

The population just got very large, very fast

This stopped being a niche argument sometime in the last eighteen months.

The HRA Council’s fifth annual report, released August 12, found more than 20,000 U.S. businesses now offering ICHRA or QSEHRA as their health benefit in 2026, covering at least 500,000 employees, with applicable large employers the fastest-growing segment and adoption up 53 percent year over year. HealthSherpa’s transaction data puts ICHRA usage at 2.8 times last year’s level, with early signals pointing to another tripling in 2027.

Health care sharing ministries serve well over 1.5 million members, operating under explicit insurance-regulation exemptions in 30 states.

Direct primary care crossed 2,800 practices by early 2026, with membership up 837 percent since 2017.

Then Congress poured accelerant on all of it. Under the One Big Beautiful Bill Act and IRS Notice 2026-05, effective January 1: every marketplace bronze and catastrophic plan is now HSA-compatible regardless of whether it meets the traditional HDHP definition, and DPC arrangements at or below $150 a month for an individual ($300 for a family) no longer disqualify a member from contributing. Roughly 7.3 million people in bronze and catastrophic plans became HSA-eligible in a single stroke.

Meanwhile the ground shifted underneath everyone. Enhanced premium tax credits expired at the end of 2025. KFF found the average marketplace deductible grew by about $1,000 per person in 2026 as enrollees traded down into higher-deductible plans, with 9 percent of 2025 enrollees dropping to uninsured outright. Aon projects employer health costs up 9.5 percent this year, the third consecutive year near double digits.

Add it up. More people paying first-dollar. Higher first dollars to pay. And West Health-Gallup reporting that roughly one in three adults, about 82 million people, made a daily-life trade-off in the past year to cover a medical expense, with a record share saying they’re worried they can’t afford care at all.

That’s the addressable market. It is also a slow-motion accountability problem, and it is arriving on your member services line.

Follow the money, but keep your eye on the asymmetry

Here’s the structural insult at the center of all this, and it is worth sitting with.

Since January 1, 2022, uninsured and self-pay patients have held a federal right to a written, itemized Good Faith Estimate before scheduled care. Diagnosis codes. Service codes. Expected charge per line. NPI and TIN for each provider. If the final bill lands $400 or more above the estimate, the patient has 120 days to open a federal Patient-Provider Dispute Resolution proceeding for a $25 administrative fee.

Insured patients were promised something better: an Advanced Explanation of Benefits, showing expected cost-sharing before care. It has never taken effect. Four years and counting.

So the cash-pay member holds the stronger legal right. Congratulations.

Except read what that right actually delivers:

“So she has a federal right to a price.” “She has a federal right to one price.” “That’s a price.” “It’s a quote from the building she already called. It says nothing about the four other buildings. The right to an estimate is not the right to a comparison, and a market without comparison isn’t a market. It’s a menu with one item and no prices printed next to it.”

The GFE tells her what this facility intends to charge. It does not tell her that a freestanding imaging center eleven minutes away publishes a cash rate at a fraction of that number. Federal law gave her a receipt in advance. It did not give her a shelf to compare it against.

That shelf is the entire product category. And nobody in the enrollment chain is building it, because nobody in the enrollment chain is a data company.

The four failures, one per model

Reference-based pricing. The mechanics are unforgiving. The TPA reprices each facility claim against the plan’s benchmark and pays it directly. Because no network contract binds the provider to accept that amount, the provider can take it as payment in full or bill the member for the balance. A California court has affirmed the model’s legality: balance-billed amounts sit outside the ACA’s cost-sharing limits. Which settles the law and settles nothing about Tuesday. Post-service advocacy is triage; it is very good triage, and it is still triage. The only intervention that prevents a balance bill is a member who walked into a facility already priced near the benchmark. That is a pre-service problem wearing a post-service costume.

Health shares. The model runs on the member declaring themselves cash-pay, paying the bill, and submitting for sharing. The annual unshared amount (the IUA, the PRA, whatever the program calls it) runs $500 to $10,000 depending on the tier. Every dollar of that is member money, spent in a market with no posted prices, before sharing begins. And the ministry’s own math points the same direction: NBC News documented families who guessed wrong and got denied, which is a member-trust event. Meanwhile every dollar a member overpays above market rate is a dollar out of the share pool. Member protection and pool discipline are, unusually, the same intervention.

ICHRA and QSEHRA. The allowance is fixed and the plan is increasingly bronze. The HRA Council’s own framing is that employees are embracing a consumer mindset and selecting coverage that fits their circumstances. Fine. Consumers need prices. An employee spending a defined allowance against a deductible that just grew a thousand dollars is making purchasing decisions all year long, in the dark, and attributing the outcome to the employer who moved them off group coverage.

DPC and the HSA stack. DPC physicians are the highest-volume cash-pay referrers in American medicine. They negotiate labs down to wholesale, and then the referral leaves the building. Advanced imaging, outpatient surgery, anything the practice can’t do in-house: the doctor writes the order and the trust transfers to a facility nobody priced. Notice 2026-05 just made that stack tax-advantaged and legal at scale, which means the referral volume goes up.

Four models. Four different reasons. One identical gap between the moment a member is told what to do and the moment they have to figure out where to do it.

The uncomfortable finding: cash isn’t the consolation prize

Here’s where the received wisdom is simply wrong.

Researchers at Johns Hopkins and Michigan State compared hospital-disclosed cash prices against the same hospitals’ insurer-negotiated rates across 70 shoppable services at more than 2,300 facilities. Across those services, cash prices were lower than or equal to the median insurance-paid price roughly 47 percent of the time. Same procedure. Same hospital. Same service setting. Ge Bai, one of the co-authors, has noted that about 20 percent of hospitals set cash prices at or below their minimum negotiated insurance price.

Read that again, because it reframes the whole conversation.

The cash price is not the penalty a member pays for standing outside a network. In roughly half of shoppable encounters it is the better number in the building, and the member paying it has no way to know, because nobody assembled the comparison.

Which means the pitch to your members was never a compromise. It was the truth, delivered without the evidence attached.

So why doesn’t this data already exist?

It does. Legally, it has existed since January 1, 2021, when every hospital in the country became obligated under 45 CFR §180 to post a machine-readable file of standard charges, including discounted cash prices, plus a consumer-friendly display of 300 shoppable services.

Then reality.

PatientRightsAdvocate.org’s compliance audits found full compliance at 21.1 percent of 2,000 hospitals reviewed as of late 2024, down from 34.5 percent earlier that year, with backsliding, unusable JSON, encoded files posted without documentation, and more than 500 hospitals failing CMS’s own validator tool.

CMS is closing in. The CY 2026 OPPS final rule, effective January 1 with enforcement live since April 1, killed the “estimated allowed amount” field and replaced it with actual dollar figures: 10th percentile, median, and 90th percentile allowed amounts derived from 835 electronic remittance data. It requires the organizational Type 2 NPI for cross-dataset linkage. And it replaced the old affirmation with a named attestation, signed by a CEO or senior official, asserting the file is accurate and complete.

And here’s the part with a clock on it.

The CY 2027 proposed rule, published July 7, carries an RFI asking whether CMS should modify or eliminate the deemed-compliance policy for internet-based price estimator tools. That is the provision letting a hospital satisfy its consumer-friendly display obligation by pointing at an estimator widget instead of publishing a list. That widget is the reason your members hit a form asking for insurance information they don’t have. Comments close August 31, 2026.

If you administer a plan whose members pay cash, you have two weeks to tell the federal government what that widget does to them. Almost nobody in this segment will file. The hospital associations will.

The part where somebody has to actually build it

Which brings us to the unglamorous question underneath all of this.

Every organization in this category has the member relationship, the incentive alignment, and the trust. What none of them has, because it isn’t what they do, is a pipeline that ingests thousands of hospital files in inconsistent formats, resolves them to procedure and facility, verifies them against reality, and refreshes them before they go stale.

The objection is predictable, and it’s the right objection:

“We could build this internally.” “You could. What’s your plan for the four new MRF data elements that landed January 1?” “We’d map them.” “And re-map them when CMS finalizes the 2027 rule. And handle the 500 hospitals that don’t pass the validator, and the ones that post encoded JSON with no documentation, and the ones that were compliant in the last audit cycle and aren’t now. This isn’t a front-end problem. It’s a janitorial problem that never ends, and every quarter you spend on it is a quarter you didn’t spend on the thing your members actually pay you for.”

That’s the argument for SumHealth’s white-label cash price checker, and it’s the only argument we make for it.

A member searches once, by procedure and location. They see verified cash prices across imaging centers, labs, and outpatient surgery centers: ranked, comparable, ready to book. Not an estimate. Not a range. The number.

Your logo. Your color palette. Your domain or a subdomain of your choosing, embedded in the member portal they already trust, with SSO so nobody creates a second account to find out what an MRI costs. Underneath it, invisible to the member: our sourcing, our verification, our continuous refresh against files published pursuant to 45 CFR §180.

Three steps. Connect: portal embed, API, or SSO. Brand it: send a logo and a palette. Launch, and stop maintaining a data pipeline that was never your business.

The last thing

Whatever CMS does with that estimator loophole, it will take effect in 2027 at the earliest, and hospitals will have a year to interpret it creatively.

The woman in the parking lot has an MRI order in her hand today.

She trusted your organization enough to step outside the insurance system entirely: to take the allowance, join the pool, pay the membership fee, accept the exposure. That was not a small act of faith. Every model in this segment is underwritten by it.

Handing her a price is the cheapest way you will ever honor it.

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Ready to give your members a price they can trust? Request a partner demo and we’ll walk through a live build for your member base, or email us directly at contact@sumhealth.org.

SumHealth. Vertically integrated healthcare pricing transparency. Data sourced from hospital price transparency files pursuant to 45 CFR §180.