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.

Mamdani, universal health coverage, and the scandal of profits over healthcare

First, let me offer congratulations to Zohran Mamdani and the people of New York who elected him. While the news focus is on him, and of course he merits it, it is the “them” that is more important. New Yorkers showed that they want someone who stands with and for them, for their needs, for their ability to afford rent, and healthcare, and education, and food, rather than for the developers and billionaires and financiers (overlapping groups) who have long controlled the city. It should be a wakeup call to the finance-oriented Democrats, not to mention the Republicans who only stand for the oppression of people. Maybe he will be able to deliver on his promise of universal health care in the city, and maybe not, but what he, and they, have shown is that this is something people want. People most assuredly do NOT want the interests of insurance company profit to even be in the same discussion as a value in comparison to their health and healthcare, and they shouldn’t.

What is remarkable is the number of people in positions of power who do. This can, accurately, be attributed both to the financial support insurers give to politicians (and pundits) and the fact that they hang around with each other. Polls have shown that large majorities of Americans support universal health care, and the NYC election was another important such “poll”. But, in fact, things are going in the opposite direction for healthcare and the health of the American people. The party of Snidely Whiplash (PSW) is doing everything it can to make people’s lives worse. They have made it eminently clear that they don’t think all Americans should have health coverage by keeping the government shut down rather than talk about continuing the subsidies for ACA demanded by the Democrats. 

And remember that lots of things besides healthcare coverage affect health – access to adequate food is one of the main ones. So, because, I guess, the PSW so enjoys being mean, they have cut SNAP (food stamps) benefits dramatically, so that more children can go hungry. Twirl that mustache, Snidely! In Tucson, as around the country, food banks that are already overwhelmed will see huge increases in need. We just loaded up the car with boxes of food for the community food bank donated by members of our HOA. They were particularly heavy because of the cans of beans, tuna, chicken, and peanut butter donated especially because the food bank is often out of protein. Which, you may recall, people, and especially growing children, need! You see, grants for the food bank to buy this food from local farmers, which benefitted the farmers as well, have been cut off. Just when you thought we couldn’t be meaner, har har har! 

Government policies that cut aid for food and healthcare are terribly damaging to Americans’ health. Rural hospitals are closing because so many of their patients are covered by Medicaid, which has been dramatically cut. Telehealth programs that might have helped fill that gap are ending. If anyone still believed the private, for-profit sector (as opposed to the volunteer non-profit sector, like food banks) might step into help, they are doing the opposite. Recent insurance company actions have doubled down on limiting access to care, paying for care, and of course caring. Just a few recent actions detailed by Health Care Un-covered include ‘Coverage Without Care: The Cruel Math of Health Insurance Open Enrollment’ and  ‘UnitedHealth CEO Says Company is Cutting Thousands of Doctors Out of Network to Boost Profits‘. You thought it was already hard to find a doctor? The largest health insurance company in the nation doesn’t care; it does care about making more money! Remember that when you see their ads on TV!

Many people – well, pundits, not actual people – say the problem is people need to have jobs, to contribute to the economy. Others, perhaps (?) more well-meaning suggest people need more education about how to choose and navigate the health insurance system so they are not (or are at least less) screwed. Baloney. Read this story on the KFF site about Dr. Lauren Hughes, whose car was T-boned 20 miles from her home. She had injuries including a broken ankle, but the hospital to which she was taken was “out of network” for her insurance, and she ended up with a $64K bill! Dr. Hughes is a highly-educated, knowledgeable, skilled and experienced family physician, who also leads a health policy research group at the University of Colorado. She knows way more about how the system works than most people – heck, than most doctors! And she still was screwed (not just with the ones in her ankle)! Because of her knowledge, role, and indeed clout, and the support of others she was able to get most of the insurance company decision reversed, but good luck if it is you, or someone else who has less of all of those advantages!

The KFF piece is full of phrases that should infuriate, and nauseate, any decent human being, like “out of network”, “surprise billing”, “uncovered care”, “observation status”. These are all strategies (“gimmicks” would minimize their significance) to make more profit for insurance companies by denying you health care. Another recent Health Care Un-covered piece discusses ‘Where Do Our Health Insurance Premiums Go?’, and the answer is profits, stock buy-backs, lobbying, executive salaries. Not increasing coverage or access, decreasing rates; indeed, quite the opposite: as profits go up, so does consumer cost, while access goes down! In any other country, these phrases would be anathema. Every other country that can possibly be considered “wealthy” or even “middle income” (an international classification that almost any American would still see as “poor”) has universal health care. The concept that any person, not to mention a “well-insured”, educated, professional – physician! -- would have such indignities heaped on them and not receive the care they need as a right of their citizenship (and in many countries, even non-citizens) would outrage them. I would like to remind folks of two pieces I wrote long ago, both coincidentally related to films. One thing to NOT worry about: paying for health care -- in France, is from 2012. It discusses the film Le Havre, and how amid the tribulations of being poor, worry about paying for necessary health care was not one of them. The other, from 2009, "Sick Around America": A little bit sickening, talks about TR Reid’s special “Sick around the world” and something from it that has stayed with me.

In each country he [Reid] asked how many of their citizens went bankrupt as a result of health care debts, and they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

It should be a national scandal here; indeed, it is a scandal that, for so many it is not. The American people know this, and increasingly will be punishing politicians who do not care, or who, with a total lack of not only empathy but any moral or religious compass at all, put the financial profits of insurance companies above the health of our people, when in fact it should have ZERO weight.

Back in 1958, Harry Golden, a writer, humorist, and published of the Carolina Israelite wrote the best-seller “Only in America”. At the time, reviewers’ comments focused on his being a Southern Jew, and on his support for integration (the moral issue of that age). But it is sad to think that nearly 70 years later, “Only in America” refers to the lack of a universal health care system, unique among the OECD (Organization for Economic Cooperation and Development, the rich) countries.

It is long past time to change that!

Access to healthcare: More primary care and no financial barriers for anyone

A recent study by Matthew Toth and Lauren Palmer from the Research Triangle Institute (RTI) evaluated the impact of the Center for Medicare and Medicaid Services (CMS) Financial Alignment Initiative (FAI) on access to primary care by those people who are eligible for both Medicare and Medicaid. These people are called “dual-eligibles” and represent about 13% of Medicare recipients. The FAI aimed to increase coordination of care, and the authors discovered that it did increase primary care access, to some degree, in 6 of the 9 states in which this demonstration project was implemented. In one state where it did not, Washington, eligibility for the program required people to have multiple morbidities (chronic diseases), and so the authors speculate that it increased access in other states for “healthier” dual eligibles.

There is nothing wrong with this study, or the program it studies, insofar as they go. But it raises two major issues. The first is that the program is yet another example of how the federal government continues to tinker around the edges of a completely flawed healthcare system by experimenting with one program after another that might possibly help, to some degree, a small portion of our population. This is not to say that the people who were studied, those eligible for both Medicare (by age or disability) and Medicaid (by poverty) are not deserving of better access to care and care coordination; certainly, they are. But we all are. Because we have some people who are eligible for Medicare and some people who are eligible for Medicaid and lots of people who are eligible for neither, and many people who are uninsured, and many more are grossly underinsured, we have fragmented our population and made financial access both unwieldy, far from comprehensive, and incredibly expensive. If this study (maybe) shows that the improvement in access was more for those “dual-eligibles” without multiple morbidities, is this bad? Well, it’s bad that they weren’t getting coordinated care in the first place!

Here I need to take a break, before going on to the second issue, to put in a word or two for our medical insurance companies and large hospital systems. They are not doing badly. Indeed, the outrageous excess cost of our health system, two to three times (or more) per capita than other OECD countries despite leaving large numbers of people uncovered, is due almost entirely to their profit-taking. They are doing well, thank you, along with the drug manufacturers, even while rural and inner-city safety net hospitals are going broke taking care of poor and uninsured (and sick) people, and millions of Americans go without care or receive inadequate care. The words – I’ll go with two – are rapacious thieves.

The second issue is that while financial access, being covered by adequate insurance, is very important, it is only part of the picture. The other part is having doctors (or other appropriate clinicians) who are available to see patients. This is the other area in which the US (and, in fairness, a few other countries including Canada) are failing. Have you tried to get an appointment to your primary care clinician lately? Maybe you can get in easily, but if so you are the exception. Most people have to wait weeks or months. If they go to the ER, they wait many hours, even for urgent or emergent problems. It would be good to be able to see a doctor who knows you, and knows your history, right? Instead of someone in an Urgent Care Center. I can answer all of these for people I know (or me) and the answers are not positive, and these are folks who are well insured and live in a major metropolitan area, not in a rural one or an inner-city health care desert! In Canada, there are suggestions that the way to fix the wait is to – wait – privatize health care! Hah! Come on down and see how that works here!

Why is it that people cannot get appointments to see primary care clinicians? Shouldn’t there be enough? Years ago on Saturday Night Live, Don Novello portrayed a character called Father Guido Sarducci who offered a “5-minute university”, where you were only taught what you would remember years later anyway. For Economics, it was “supply and demand”. So if there is so much demand for doctor visits, especially primary care visits, why is there not enough supply to meet it? This is, as you would guess, kind of complicated

Obviously, there are not enough primary care clinicians, either as a whole or as a percent of all physicians. If there were enough, you could call your doctor and get in today if you were sick or had a worsening problem. Like on TV (pick your favorite FP/GP show). So we don’t have enough. This is all about money. To some degree, it is about doctors wanting to make as much as they can. This results in far too small a proportion of graduates entering primary care, since they can make two or three times as much in some other specialties, which is enough to convince even many who liked the idea of primary care that, especially with their debt load, they liked anesthesiology more. We are at about half the percentage of primary care that we should be. For this I blame the system that pays other specialties so much more (or primary care so much less). In addition, the distribution is poor – not enough doctors in rural areas, or certainly poor urban areas, but all concentrated in more wealthy urban and suburban areas.

Ultimately this is all about the corporatization of health care, and the treatment of providers as widgets in a factory. Put this many in clinics, make sure that they are totally booked and have no room for anyone who needs to get in on short notice, put others in the hospital, put others in urgent care or ERs. Have no flexibility in the system because if you have the capacity to expand when needed, that means that at other times you have down time, and that is unacceptable for making maximum corporate profit. Of course, this is not good for your health, which is better when you can see a doctor who knows you, especially when you are sick and couldn’t plan two to eight weeks ahead of time (or more!) to make an appointment.

Creating doctors and other health professionals takes many years, and cannot change on a dime, but it will never change if that change doesn’t start. If we care about people’s health and healthcare, we need to dramatically decrease the difference between what primary care and other specialist income so it doesn’t discourage students from choosing primary care. We need to ban for-profit corporations (or ostensibly non-profit systems that act like for-profits) from being in our health system at all. All of health care and its components should be about ensuring better quality health for our people, not making money for businesses.

The usual pattern in the US is to have funding for public services cut by politicians who are receiving money from private corporations, to the point that they do not function well at meeting public needs. Then those same politicians say “privatize!” and they do and the cost goes way up and the public needs are still not met, because, well, that’s not what private enterprise is there for. (See this good video by Brittlestar on why privatization is not a good choice for Canadian healthcare.)

Jimi Hendrix said “Castles made of sand fall into the sea eventually”. But our health care system is not built on sand. It is built on rocks of intransigent corporate profit, and it is not going to change without a fight. You and your health don’t count as much as big business making money.  So there. Pick up the gauntlet, and fight for yourself, your family, your community.