For the past twenty-four years, Sarah has operated a physical therapy clinic in a small town in Boulder County, Colorado. Her clinic is in-network with health insurance giant UnitedHealthcare (UHC), though Sarah’s reimbursement rate paid by the insurer for each patient visit has not increased once over the past quarter century. Meanwhile, the cost of running a business has skyrocketed.

Earlier this year, Sarah, who requested anonymity for fear of retaliation, asked the insurer for a raise. She was told there are plenty of in-network physical therapists in the area and therefore there’s no need for UnitedHealthcare to increase her reimbursement rate.

In an email, her contract manager told her that the insurer’s Boulder County outpatient therapy network “is robust and capable of handling therapy care needs of our UHC patient population” and that “we are under tremendous . . . pressures not to increase market rates in counties such as Boulder and surrounding areas when we do not have access to care concerns/needs.”