The Washington Post printed a piece titled, "In Retooled Health-Care System, Who Will Say No?". Obviously a very tricky question to answer. The healthcare system without significant changes will generate costs out of control.
The federal government is loathe to do what England has done by indicating what is and isn't covered.
Patients certainly don't know what tests, imaging studies, or medications are needed to stay healthy or get better. Often they are fooled by slick advertising as well as the false belief that more is better (perpetuated by medical dramas like ER and House).
Insurance companies have tried, but given their past track record it is doubtful they can lead the change.
So who will say no? It's the doctors. Frankly it isn't as much as saying no as it is about refocusing what patients really want. What they really want is just the tests, imaging studies, and medications that they need to get better and well. They really don't want everything under the sun.
Research shows that we do too many tests, procedures, and interventions and the outcomes are actually worse! There is plenty of opportunity to still deliver high quality care without falling into the trap, which we are all victim to that newer is better. Don't buy this lie!
The problem is that the reimbursement system rewards doctors to do more. Until that changes, nothing will change. If reimbursement does change, then will doctors have the ability to counsel their patients on what the right care is when in the past, it was wrongly believed that more is better?