For most Americans with private health insurance, hospital prices are not set by the government. Instead, they are set by hospitals and insurers who negotiate over how much an insurer will pay when one of its members receives care.
Threatening to end that relationship — and taking the threat to de-participate public — can give either side additional leverage in those negotiations, but it can also create weeks or months of uncertainty for patients. Looming threats of coverage loss may even force some patients to change health systems in order to be sure they will receive in-network care.
“It's difficult to quantify anxiety, but aggressive negotiating tactics have clearly led to profound alarm,” said Jason Buxbaum, an assistant professor in the Department of Health Services, Policy and Practice who led a new study looking at the use of publicly announced threats to leave networks in hospital and insurer negotiations.
According to the study, published in Health Affairs, the negotiating tactic is relatively common in recent hospital-insurer contract disputes and is more likely to be used by some of the most financially strong players in healthcare, including large national insurers and hospitals already commanding relatively high prices.
The team from Brown’s Center for Advancing Health Policy through Research (CAHPR) examined 14,918 relationships involving 3,772 hospitals and 92 commercial health insurers from August 2021 through July 2025. They also sifted through news reports, public notices and press releases for cases in which either side publicly announced plans to end a contract or threatened to do so unless certain demands were met.
The research team — which also included CAHPR director Andrew Ryan and former research assistant Neil Mehta ’25 — identified 1,249 cases in which a hospital or insurer publicly threatened to end a contractual relationship, totaling about 8% of the relationships studied. Only 28% of those episodes of brinkmanship actually resulted in the hospital leaving the network while roughly 72% were resolved without an actual network exit.
“You see these stories of brinkmanship—and actual de-participation—quite regularly in local media,” Buxbaum said. “It's rare these events make waves outside the local area. But when you gather all these isolated disputes, add them together and quantify how often these tactics are deployed, it’s clear that there’s a real national issue. Patients and families are regularly caught in the middle as hospitals and insurers negotiate better deals for themselves.”
For instance, the paper describes a North Carolina patient who feared an insurance dispute could disrupt access to potentially life-saving care, as well as a patient in New York who said the uncertainty was causing people significant pain and suffering.
The analysis also breaks down which hospitals were most likely to engage in public-facing brinkmanship. The team found that brinkmanship occurred in 12% of relationships involving for-profit hospitals, nearly twice the rate than among nonprofit hospitals. The tactic was also more common among hospitals with positive operating margins and those already receiving relatively high prices from commercial insurers. It was less common among public hospitals and independent hospitals that were not part of larger health systems.
National insurers were involved in 991 of the disputes and were more likely to engage in brinkmanship than regional or single-state insurers.
Buxbaum said brinkmanship was especially common when both sides had substantial — but not overwhelming — local market power. The paper described this as a “Goldilocks zone,” where both the hospital and insurer have enough leverage to credibly threaten to walk away, but neither side is dominant.
The findings ultimately raise questions about whether aggressive, public-facing negotiations are a desirable way of restraining healthcare spending or if an alternative system is needed, such as government pricing.
“In commercial health insurance, prices are generally set with little public sector intervention,” Buxbaum said. “Other than aggressive negotiations, health plans have few tools to control prices, and higher prices generally mean higher premiums. So ultimately, there is this real tension between affordability and drama.”
Ongoing work is now looking at the incidence of brinkmanship in Medicare Advantage, where early work suggests these disputes play out differently.
Health Affairs
Data/statistical analysis
Real-World Brinkmanship In Hospital-Insurer Negotiations
23-Sep-2026