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ANTHEM VS. MT. SINAI FIGHT AFFECTS OUR MEMBERS

Volume 126, No. 4April, 2026

Martha Hyde

Many members who use the Local 802 health plan — particularly those who live on the Upper West Side — have noticed that Mt. Sinai doctors and providers have fallen out of the Anthem network.

The reason for this is a contract dispute between the two behemoths who are battling it out while patients are forced to watch from the sidelines. Mt. Sinai claims Anthem doesn’t reimburse at a high enough level and Anthem claims Mt. Sinai wants to raise its rates by 50 percent and this will hike costs for patients as those increases are inevitably passed down.

According to the Centers for Medicare and Medicaid, total healthcare spending in the U.S was $5.3 trillion in 2024. The Peterson KFF healthcare tracker projects it to increase to $5.6 trillion in 2025. The biggest slice of that pie is hospitals at 31 percent. Some hospitals like Mt. Sinai and New York Presbyterian have expanded into enormous networks. Mt. Sinai has eight hospital campuses, the Icahn School of Medicine, over 400 outpatient practices and much more. It is also the creator and investor in the Center for Blockchain Technology. This giant network has a lot of leverage in negotiations with a health insurance company that pays for the medical services the network delivers. Moreover, as healthcare systems expand, there are fewer of them and less competition.

Anthem is an even bigger giant. It offers Medicaid and Medicare plans in over half the states, DC and Puerto Rico. It covers one in eight Americans and is the largest publicly traded Blue Cross Blue Shield affiliate. This positions it to push back on the demands for higher payments from hospital networks.

On average, private insurance companies pay Mt. Sinai 231 times what Medicare pays. From 2016 to 2020, there was a 31 percent overall increase in inpatient hospital prices in New York City, doubling the increase in outpatient services and quadrupling the increase in doctors’ prices.

The main drivers of healthcare costs in the U.S. are the rapidly rising prices for services, the fee-for-service system (which is an incentive to do more services) and an arms race between health networks to have the latest in technology. Innovative new gadgets are expensive and tend to be booked many hours a day to pay for themselves, whether or not patients truly benefit from them.

Health insurance companies are a symptom of the problem. They are obligated to pay 85 percent of what they take in on medical services which means there’s an additional 15 percent cost on top of the cost of services.

One way to counter this problem would be greater transparency in pricing. Instead of opaque contracts between health networks and insurers, the prices negotiated would be public knowledge. In New York, the Health Equity and Affordability Legislation (HEAL) would prevent the hiding of prices from the public. (This is Senate bill 7199 and Assembly bill 8169.)

Additionally, NYC Council Speaker Julie Menin helped pass legislation that created the Healthcare Accountability Office, which fosters transparency in health plans for city employees. She is now pushing for expanding that idea into transparency for everyone by creating an Office of Insurance Accountability and an Insurance Accountability Advocate.

The only state that regulates healthcare pricing is Maryland. Several other states are looking at other methods. New York State, unfortunately, went the other way, deregulating prices in 1996 and leaving it to the various payers, both public and private, to negotiate price controls.

Meanwhile, we patients are sidelined in a battle between titans until there is enough political will to change how care is paid for. Please watch this space for information on how to join the push to pass HEAL in Albany.

Martha Hyde is a longtime Local 802 member and Broadway woodwind doubler. She’s a member of Local 802’s Executive Board and serves on the Local 802 health fund and the AFM pension fund.

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