The other day, I was asked for a one-pager on what’s wrong with the U.S. health system. “Just one page.” To my amazement, with our thousands of fact sheets and policy briefs and even our Health Policy 101, we didn’t have anything short or current, nor could I find one elsewhere to send along. The closest we came was this 2022 policy brief. So, while this isn’t my usual column about current issues, and it’s only about problems, not the reasons for them or solutions, it might be useful to some of you.
First, our health system is not affordable, either for people or for the country. About a quarter of the public struggle with their medical bills and the numbers rise sharply for people with chronic illnesses or major diseases who need a lot of care. About 100 million deal with medical debt. We spend almost twice per capita what other wealthy nations spend, putting pressure on other national priorities and for employers on wages.
Despite progress, we still have 27 million people who are uninsured, and according to projections from the Congressional Budget Office, cuts in the One Big Beautiful Bill will bring that total to about 40 million if the cuts aren’t reversed.
The system is beyond complex and challenging to navigate. The poster child of this is prior authorization review, which almost everyone hates. People tell us on surveys that it’s their single greatest problem getting care.
As is well known, although we spend much more than other wealthy nations, our health outcomes lag behind theirs in most cases. There are a lot of different ingredients in that stew, but our well-heeled health system has not lifted our health outcomes.
Trust in health professionals remains strong, but trust in critical agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration is at a low point. The agencies take it on the chin for different reasons from both Democrats and Republicans. If we have another COVID-like crisis, we’ll pay a big price for that; national emergencies, like wars, cannot be handled state by state.
If I were to nominate one more item for the list, it would be the “crisis” in primary care. In many parts of the country, it’s just not easily available, and in some, like the Silicon Valley where I live, much of it has been skimmed off to expensive concierge practices with long waiting lists.
Finally, the politics of health care are as broken as the system (and are a reason it is broken). For decades, Democrats and Republicans have not been able to agree on any major solutions to our health care problems and disagree sharply on the role of the federal government in health, forcing us to gravitate to smaller incremental changes where there might be some agreement. They also blow their importance out of proportion. I won’t name names in this short piece.
The result: we have neither a competitive health care system nor a regulated one—we have a fragmented, micromanaged health system that fails to control costs and makes both patients and health professionals more miserable than they should be.
Of course, if you have a problem requiring a world-renowned specialist or the very latest drug and can get to and afford her, him, or it, it can be the greatest health system in the world.
