Rep. Barbara Bagshaw, R-Windham, represents House District 106 in the Maine House of Representatives.

The investigation into Gateway Community Services has rightly drawn attention across Maine. State audits found repeated overpayments from MaineCare, including billing for services that were allegedly not provided or not covered by Medicaid. After years of review, the state suspended payments following findings that more than $1 million in overpayments occurred during the most recent audit period alone.

The full facts are still coming out. But one thing is already clear: when billing abuse happens in health care, patients and taxpayers pay the price.

Improper billing, whether charging for services not delivered, upcoding or bending reimbursement rules, pulls money away from the people these programs are meant to serve. In Maine, where health care resources are already stretched thin, that means fewer dollars for children, seniors, people with disabilities and families who rely on MaineCare. When abuse goes unchecked, it shows up as tighter program rules, fewer providers able to participate and higher costs for everyone else.

The Gateway case matters not just because of what may have gone wrong, but because it shows how long problems can persist before oversight catches up. Slow and fragmented enforcement allows questionable billing to continue for years. By the time action is taken, public dollars are gone and patients may face sudden disruptions in care.

But this is not just a Maine problem, and it is not limited to one provider or part of the health care system.

Across the country, health care payment systems have become more complex, and more consolidated. Medicaid and Medicare now operate in a marketplace dominated by large insurance corporations that often own health plans, provider groups, pharmacy benefit managers and care management companies under one roof. These vertically integrated systems also work closely with group purchasing organizations that influence pricing and contracting throughout the supply chain.

When the same corporate entities control coverage decisions, provider networks, drug formularies, reimbursement rules and pharmacy payment flows, accountability breaks down.

Pharmacy benefit managers, for example, play a central role in deciding which medicines are covered and how much providers and pharmacies are paid, yet they operate with limited transparency. Vertical integration allows insurers to route payments internally, shift costs across subsidiaries and profit from complex pricing arrangements that are difficult for regulators and patients to see or challenge. These practices may be legal, but they often drive spending higher without improving care.

Health care financing has evolved faster than oversight. Billing rules, risk adjustment models and rebate structures have grown increasingly technical, while audits remain slow and enforcement is divided across agencies. That gap allows costs to rise quietly, not because care is better, but because the system rewards complexity and consolidation over efficiency and value.

Every dollar lost to improper billing or payment manipulation eventually shows up elsewhere: higher premiums, tighter state budgets and more pressure on Maine families and taxpayers.

That is why insurance reform must be part of any serious effort to make health care more affordable. Vertical integration gives insurers unprecedented control over how health care dollars move through the system, but too little responsibility for keeping costs down. Federal oversight must catch up by strengthening transparency around pharmacy benefit managers and group purchasing organizations, modernizing audits and examining how consolidation affects prices, access and patient outcomes.

Accountability should apply across the board. Providers who inflate claims should face consequences. But insurers and intermediaries that use ownership structures and opaque payment systems to drive up costs without delivering better care should face the same scrutiny.

The Gateway case is a local example with a national lesson. A health care system built on complex reimbursement and vertical integration cannot rely on outdated oversight tools. Without insurance reform, rising health care costs will remain baked into the system.

Insurance reform is not about pointing fingers. It is about restoring clear lines of responsibility so health care dollars are spent on care, not absorbed by a payment system that profits from its own complexity.

Mainers expect public dollars to be used carefully and honestly. Patients deserve affordable care. And our health care system should work for the people it was meant to serve, not for the middle layers that make it harder and more expensive to navigate.