Why is it so hard to get medical care? And what should we do about it?

You may have noticed, should you or a family member or a friend have had a health problem recently, that it is difficult to get care. It is difficult to find a doctor (or a nurse practitioner, or any health care provider) who is available to add you to their panel. If you are lucky enough to have one, especially one who practices primary care (a family physician or general internist or geriatrician for adults), it is still difficult to get an appointment. If you think you just have a simple question, it can be difficult to get through to them to ask it. Sometimes you can get a nurse, or a medical assistant, or perhaps the desk clerk who may be familiar with some things enough to answer, but often they cannot. Many practices now have “patient portals” (e.g., MyChart ®) where you can post a question for your doctor (often in the form of “I have these symptoms but I can’t get an appointment; do you think I need to be seen?”) that, hopefully, they will answer before you are in extremis.

When all these methods fail, and you are still sick, you can visit an Urgent Care Center, sometimes run by local health systems and sometimes by private chains. They can care for many problems and do some tests, but a lot of things will lead to them sending you to the local Emergency Department. That is, of course, what you were trying to avoid, if for no other reason than the long wait (often hours, even if you have a severe problem that, once they diagnose it, can truly be an emergency; I wrote in the past about a close family member who waited 7 hours to be found to have appendicitis). Not all ED waiting rooms look like “The Pitt”, but it is not uncommon, especially in those centers who have the facilities to care for really dire problems needing urgent intervention (heart attacks, strokes, acute abdominal issues needing surgery, etc.) 

A big part of the problem is that there is a shortage of primary care physicians. This is worse in the US than in other countries but is becoming a problem elsewhere as well, as discussed by Dr. Kenny Lin in “Primary Care Supply and Access Challenges Around the World” on his substack CommonSenseMD. There are also shortages of other physicians (thus the line out the door of the cardiologist’s office), exacerbated by distribution problems (specialists tend to group in major cities and wealthier suburbs). But much of the delay in getting into subspecialists would be mitigated by having more family doctors and other primary care physicians. This works in 4 ways:

1.      The primary care doctor can take care of lots of the problems that people otherwise seek out subspecialty care for. Because you have a heart, it doesn’t mean you need a cardiologist.
2. If the primary care doctor identifies a problem that they think does require a subspecialist (say, a cardiologist) they can refer you to one who is less backed up because primary care doctors have done an assessment and identified that there is a problem requiring a subspecialist. This also makes the subspecialist more effective, because the people they see have already been assessed by a physician and they have a clearer issue on which to focus their attention.
3. Once the subspecialist does their assessment, makes their treatment plan, and initiates it, much of the follow-up can be done by the primary care doctor, freeing the subspecialist from needing to see so many follow-ups and having more appointments for new patient assessments.
4.  Many people (especially older people) have more than one health problem. Not only is going to a separate subspecialist for each potentially inefficient and possibly unnecessary, but can result in “communications problems” between them. This can be dangerous for the patient, in part because treatments for one condition sometimes worsen another. Having a primary care doctor who cares for the whole person, not just one organ system or disease, and is in possession of the assessments and plans from all the subspecialists, means the patient receives care that is coordinated and managed appropriately.

This model is understood and often utilized by subspecialty physicians who understand that their time and effort is best spent in the narrow area in which they are expert. The problem is that it requires a sufficient number of primary care doctors (about 40-50% of physicians), and, in the US, we don’t have them, and are not even moving in the right direction. As I have discussed before, a big reason that students do not choose to become primary care doctors is money…that their incomes are far less than subspecialists, and this needs to be addressed (see, for example, Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people, Sept 28, 2023).

Another part of the reason people do not access care is cost; the American Academy of Family Physicians (AAFP) newsletter Family Medicine Today reports on a survey by West Health-Gallup that 1 In 3 Americans Are Making Basic Living Sacrifices, Borrowing Money To Afford Health Care. Of course ‘…the “need to make these trade-offs was far more common among the uninsured, Gallup found, with 62% saying they made at least one sacrifice to afford their care. However, 29% of those with insurance also said they were forced to make a trade-off to cover their health care costs.” So…a big problem.

The cost issue may seem to be one that is more clearly related to my contention, in a recent blog (Feb 26, 2026), that The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., but in fact so is the shortage of primary care physicians and the difficulty getting appointments. On Feb 18, Health Care Un-covered addressed “The Economic Exploitation of Independent Physicians by Insurers”. It is also a result of practices being owned by profit-making private equity companies (or sometimes by insurance companies, such as UnitedHealth owning Optum) that determine the practice parameters and character, including the speed-up (seeing more patients more quickly) and other business approaches that are good for making money but not for people’s health. In addition, this includes the practice of replacing primary care physicians with less-trained non-physicians, such as nurse practitioners and physician’s assistants. I don’t mean to disparage these professionals, and indeed they can be very good and effective in the roles they are put in – seeing acute minor illnesses or checking on the status of chronic illness such as diabetes and hypertension. But being the coordinator, the “quarterback” – of care for the whole person that the primary care physician can fill, as I described above, requires more, not less, training. It makes care better; not the “most profit” or the “most efficient” but the “most likely to maintain and improve the patient’s health”. Even when for-profit companies don’t own the practices, “A wave of coordinated lawsuits is transforming the No Surprises Act’s arbitration system into a battlefield where insurers seek to intimidate physicians, rewrite the law and consolidate control” (How Insurers Are Using the Courts to Rewrite the No Surprises Act, Health Care Un-covered, Mar 11).

The health of the US population has long been worse, using generally accepted health parameters and measures, than in comparable countries. The situation is not improving, as insurers decrease access by increasing premiums and co-pays and deductibles, forcing a significant percentage of Americans to cut back on other necessities, as well as often denying coverage for important care. These practices control not only patients but physicians, along with the control exerted by hospital systems are for-profit ownership of physician practices. It also contributes to a downgraded role and lower pay for primary care physicians, who are key to maintaining health in the US and other countries. It is not a good situation, and it is getting worse, if Americans’ health is the measure.

It is past time for us to ensure that this is the measure, and not maximizing the profit of corporations!

The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That the US health system is (to quote the opening of an important book*) “broken”, is obvious to almost everyone. It’s a mess. Even calling a “system” is probably incorrect. It costs a tremendous amount of money, generally 2-4x per capita what any other wealthy country spends, and generates far worse public health outcomes (even before the wackadoodle RFKJr became Secretary of HHS) such as longevity, disability-adjusted-life-expectancy (DALE), infant mortality, cancer survival, and almost all other measures. It also is very difficult to access, just getting to see a doctor, as well as financially. This situation has long been true for the poor and much of the working class. It is getting worse as low-income people lose access to Medicaid because of cuts to ACA subsidies or because they live in a state that never expanded Medicaid, and for rural people who are both, on average, older (and thus more likely to have health problems) and poorer. Over time it has increasingly become something that affects working class people, as insurance companies raise their rates, employers become stingier with paying premiums, and, very importantly, as the power of unions has been dramatically eroded by a society concerned only with corporations making the most possible money. It is critical to remember that the health insurance benefits employed workers gained resulted from the struggles of unions, never from the generosity of corporations.

The days of “Cadillac health plans” for unionized workers are long gone, and they are finding themselves in the same pool of too many people seeking too unavailable health care at too unaffordable costs. The new Trump administration plan for the ACA will make things much worse; it may offer lower-cost plans in terms of premiums but with enormous deductibles (‘New A.C.A. Plans Could Increase Family Deductibles to $31,000’, NY Times, Feb 26, 2026). So if you get sick and need care, you’re really screwed, and if you don’t you’re paying insurance premiums for nothing!

And now even those in privileged economic positions, who have money and sometimes even personal access because they are doctors, are finding themselves struggling to access care. People can’t find doctors, especially primary care doctors like family physicians and general internists who can manage their health and the input from various specialists. When they can find them, it is hard to get an appointment. It is very difficult to talk to them, or get a message to them, or speak to anyone who works for them who has any clinical knowledge or understanding. Some people say “I have a good doctor, they respond to my calls, or I can communicate on a health portal,” but these grow fewer. I know physicians who have real difficulties! They need supplies for their insulin pumps, but the insurance companies require notes from their doctors, and it is almost impossible to reach them. I know health care professionals who have heart problems requiring them to wear machines recording their heart rhythm over time, who must wait in lines stretching out the door to see their cardiologists. This is bad, not because they are better educated, wealthier, or health care professionals, but because it is bad for everyone. These people, at least, be able to afford to get a “concierge” doctor who they pay out of pocket, but clearly this is not a solution for most folks. 

We are in the grips of a perfect storm, with insurance companies raising their rates and finding reasons to deny care, a shortage of doctors in many areas, both geographic and by specialty, especially including primary care, with doctors having such speed-up of their work that they scarcely have time to see their patients not to mention respond to calls or notes. We have federal and state governments cutting back public benefits, including not only Medicaid but also Medicare and the VA. Doctors no longer work for themselves where they can make decisions about how to run their practice, and balance work and income, but for giant hospital “healthcare” systems and private equity investors interested only in profit.

Well, you know, maybe “perfect storm” is the wrong analogy. That phrase implies that the bad situation you find yourself in is the result of several unrelated events that come together coincidentally at the same time. This is not the case in the health care crisis. While a lot of things seem to be happening together, they are all manifestations of one single thing:

THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That's it. That is 100% of the problem. A lot of effort is spent trying to transfer blame between blameworthy players, with insurance companies saying providers are too greedy, providers saying insurers don’t pay enough. And everyone blames the pharmaceutical industry and even components of that industry – drug manufacturers, giant retail pharmacies, and “PBMs”, the middlemen between drug companies and insurers – blaming each other. But this “it’s not me, it’s them” is all a load of crap. Yes, sometimes one part of the “healthcare” industry is doing better financially than another, sometimes one corporate behemoth puts another out of business, but what is never a major consideration – and I put forward it should be the only consideration – is what improves the health of the American people, as individuals and as a whole. You, the “patient”, the sick person who needs care, is the one player in this whole thing whose interests are not getting the consideration they deserve – which should be ALL of it.

The growing trend, which is the proof of all of this, is the “vertical integration” of the components of the system. This means that the same company is the insurance company, the provider, the drug supplier. It feeds itself sucking out your money at every turn while denying you the care that you need. Several recent posts on the “Health Care Un-covered” substack detail aspects of this, including ‘The Economic Exploitation of Independent Physicians by Insurers’, and recently ‘2025: Big Insurance’s $1.7 Trillion Year’ which shows that while they ARE making these outrageous amounts (from YOUR pocket, whether directly in premiums, co-pays, and deductibles or premiums paid by your employer in lieu of higher wages) the bosses THEY answer to, the sharks on Wall St., are harassing them to do more, charge more, deny more care, because it isn’t enough; they aren’t making enough  profit! They need more!

I said at the beginning of this piece that “almost everyone” realizes that our healthcare system is a mess, and I think this is true. Certainly, those profiting from it, all those insurance companies and health systems and private equity companies and drug companies, know it. They love it. They’re making out like bandits, one might be tempted to say, if only bandits could begin to compete with them in cupidity, heartlessness, and immorality.

The truly infuriating thing is that our governments are in the practice of enabling them, of enhancing their power, of increasing their profits (see, for example, the gargantuan efforts to move US seniors out of traditional Medicare, an efficient and cost-effective single-payer plan to Medicare Advantage, which puts them back at the mercy of insurance companies; see for example Medicare re-enrollment: Time to consider being dissatisfied with a new plan!, Oct 25, 2025). Most legislators and their health pundits who are not the out-and-out-on-the-take corporate enablers that characterize the Republican party are the somewhat-less-but-really-still-on-the-take corporate enablers of the Democratic party!

We regularly hear from even somewhat progressive (not to mention the right-wing) think tanks and academics and legislators that it would be impossible to change the system to truly benefit the health of the American people, and not the pockets of big corporations, even though it has been done in every other wealthy (and many less wealthy) countries in the world. The key change here is to take the profit (or most of the profit, or the possibility of generating ever more profit) out of the health system. The problem is simply NOT that people use “too much” health care and cost too much money; the problem IS simply that insurers and big health systems and Wall St. and drug companies MAKE too much money and are taking the money we pay for health care out of health care!

The only people who are going to speak for the health care needs and interests of the vast majority American people are those people themselves. Demand of your politicians that they commit to single-payer improved and expanded Medicare for All, demand that they pursue policies that actually get more primary care doctors out in practice by decreasing the payment prejudice for subspecialists and banning completely the corporate practice of medicine.

And if they don’t, vote them out!

 

*Joshua Freeman, Health, Medicine, and Justice: Designing a fair and equitable healthcare system, Copernicus, 2015.

Red, Blue and Purple Redux: Don't let them divide and conquer!

I wrote Red, Blue, and Purple: The Math of Health Care Spending back on Oct 20, 2009, and have referred to it several times since. It is important because not everyone is sick at the same time, so the percentage of sick people in any given year is relatively low.

I included these charts:

 

The colors represent more or less the same groups of people; in any given year 5% of the population accounts for 50% of the health care costs, while half the population accounts for only 3%. This means that, in any given year, a large percentage of our population (generally younger, and mainly healthier) does not have significant medical problems and thus does not incur significant medical expense. This is good for them, but it also can make them relatively happy with their health insurance. When you don’t need it, insurance of any kind is great, except that you continue to pay premiums. Ignorance is bliss. But when you get sick is when you find out how good your health insurance is – or is not. Does it cover the treatment that your doctor recommends? Does it say it will, but require prior authorization that, while not medically indicated, can delay your treatment. Maybe for too long ()? Does it cover your doctor? Does it cover the hospital they use? Does it cover the other doctors in the hospital you will be billed by (e.g., ER, radiology, laboratory, anesthesiology, etc.)? Does it require big co-payments? Or any?

It is also the basis for a lot of the decisions that health insurance companies make. In a recent post on the “Health Care Un-covered” substack, Ron Howrigon (Feb 3, 2026) demonstrates how insurance companies can use these numbers to their advantage (i.e, to not pay):

So, you have been named the new CEO of UnitedHealth, and you have this wonderful idea. Put policies in place to deny, delay or refuse to pay for care. These policies are going to upset 5% of your membership. The members impacted by these policies are expensive members with chronic diseases like MS, cardiac disease or cancer. Let’s say that half of those members get so upset that they leave UnitedHealth and join one of your competitors. That means you take a 2.5% reduction to your revenue but a 25% reduction to your medical expense. Profits go up and life is good. Well, unless you are one of those patients that didn’t get the medication or treatment that you needed that is.

You see? They don’t get screwed – you do. They don’t care if you leave their insurance company if you are costing them money. Ideally, insurance companies want to collect premiums from people (or their employers, or the government for programs like Medicare and Medicaid) who will never use them! Indeed, one tactic that Medicare “Advantage” (MA) plans use is urging people who get sick to consider leaving their program and going on to regular, traditional Medicare (TM). Those “free” glasses and hearing aids and gym memberships that the MA plans offer seemed great at the front end, but actually having them cover the cost of your being sick and in the hospital and needing procedures would be better.

It is too bad if people do not realize that, while they may be in the purple or even blue groups today, not needing too much health care and not costing that much, that could change tomorrow. Much of that “purple” group is made up of people with one or more chronic diseases, predominantly older, who go to the doctor a few times a year and maybe have a short hospitalization or two. But when those chronic diseases worsen, when you need surgery or other procedures, or need to be in an ICU, then you can quickly become “red”. The shifts can be even more dramatic for young, healthy people. One car accident and a teenager can need multiple surgeries and become a very high-cost patient. One premature baby who needs to be cared for in the neonatal ICU and your young family skyrockets into the high-cost group. Or cancer – a new and unexpected diagnosis can change anyone of any age into a high-cost high utilizer.

Since I wrote the original piece in 2009, many more people have cottoned to the truth of the situation, because they, or their family members, or their friends have experienced movement into the high-need, high-cost group. It may be only 5% of people in any given year, but those years mount up, and they are not the same people year-to-year. For starters, a significant percentage of those who were in that 5% last year are no longer with us this year. It is commonly noted that end-of-life care accounts for a huge percentage of the cost associated with someone’s care in their lifetime, but when that lifetime is over, others move into the 5%. The fact is that we are all in this together (well, except for the insurance company executives and really wealthy folks) and policies that don’t hurt us individually this year can hurt us very much next year.

In the substack post cited above, Ron Howrigon raises the specter of a major economic event, “correction” or recession à la the housing bubble of 2008, except maybe worse because the health sector of the economy is three times as large. The problem identified above is only one of three major problems with the health insurance industry that he identifies, as he makes the case that it is built on flawed economic assumptions just as the housing industry was. Such economic implosions are not, in themselves, good for us, but continuing the way we are is also not. For many years, the “economy” has grown, but all that growth has gone to corporations and multi-billionaires and not to regular people (indeed possibly more than all the growth, since the imbalance is worse). While there may be some hard-working people who are fine with this even though they are struggling to pay the rent and buy food and gas – it takes all kinds – most of us are not. If the health care industry “fails” and then must be rebuilt to actually take care of Americans’ health, that would be a good thing. Although, judging by the response of the government to the financial crisis of 2008-09, that would be a dubious outcome; they’d probably bail out the health insurers. Unless we all can get together to stop them!

Divide and conquer has long been a strategy used by rulers and the powerful. It still happens and, so far, it still works. On Dec 30, 2025 I published on this blog Yes, Rep. Van Drew, there IS a solution!, which had appeared 3 days earlier as an Opinion piece in my local paper, the Arizona Star. I note that Medicare for All is a solution to a huge part of this problem, that there are bills in both the Senate and House (S. 1506 and HR. 3069) to create it, and that a large majority of the American people, in poll after poll, support it.

While the people are increasingly understanding how they are being screwed for the benefit of the rich and powerful, in this important case insurance companies, legislators seem to have not gotten the message. This could be in part the result of money being given to them and their campaigns for re-election by those same companies! This cannot be understood as anything but – graft! And, to overcome this, our voices – and our votes – need to be loud and clear so they can be heard by those legislators and policy makers. Pass laws and make policies that benefit the health and pocketbooks of the mass of the American people, and do not pay attention to the enrichment of health insurance companies, their executives, or their billionaire private equity owners. In the balance between the health of the people and the wealth of corporations, the latter should get NO weight!

Write to them, tell them, call them daily!