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!

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!

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!

Healthcare and Public Health: Issues from 2024 will continue into 2025

As we end the year and begin a new one, what can we say was the most important health-related story of 2024, and what will be the biggest in 2025? Certainly, late in 2024 a huge story was the murder of Brian Thompson on the streets of New York. This was not in any way a random killing, but an assassination of someone the killer believed was responsible for hundreds or thousands of deaths in his role as CEO of UnitedHealthCare, the nation’s largest health insurer. As I discussed in my December 8, 2024 post ‘Murder of a Health Insurance CEO: People HATE the companies and the people who run them’, Thompson was guilty of presiding over a company whose role was to make money by collecting premiums and denying care. He also was guilty of having made this problem worse by bring in artificial intelligence algorithms, which had been shown to be wrong up to 90% of the time, to deny health care to his supposed customers – I say “supposed” because the only customers health insurance companies really have is their stockholders; the people they insure could be called “victims”. 

 Although much of the mainstream media tried hard to focus attention elsewhere – on the accused killer and his personality, on self-serving nonsensical essays like the one by Thompson’s boss, UnitedHealth Group’s CEO Andrew Witty run as a NY Times Op-Ed, etc. – the real story is the outpouring of fury at the health insurance industry from the great mass and majority of the American people. While most did not applaud the murder itself, virtually no one outside themselves and their paid punditry had anything good to say about US health insurance. Probably the overall public sentiment reflected that of Chris Rock: “He actually killed a family, a man with kids. I have condolences for the healthcare CEO. This is a real person, but sometimes drug dealers get shot.”

Another huge story, which will become even bigger in 2025, is the planned nomination by President-elect Donald Trump of profound enemies of public health to the positions responsible for ensuring that health. Foremost among these, of course, is Robert Kennedy, Jr. to be Secretary of Health and Human Services. Kennedy is well-known as a vaccine “skeptic”, which essentially means vaccine opponent, and if he is confirmed as Secretary and is able to implement policies reflecting the positions he has long advocated, we will see the resurgence of many diseases long gone from American life with accompanying deaths, as I discussed on November 15, 2024 in ‘Raw milk, vaccines, and RFK, Jr: Some dates worth remembering’. Remember polio? Measles? I do, but most do not. Check out the numbers on this picture. This is an incredible threat to the public’s health.

But, ultimately, the real story of 2024 – and probably 2025, and sadly beyond – is the fact that the American people remain the only ones in the developed, rich or really even middle-income, world that do not have universal health insurance or care. This is what would prevent the crises, delays, denials, and deaths that the private health insurance industry heaps upon our population and that engenders the wrath of so many. Indeed, that wrath continues to grow because the people who are affected, either personally or through someone they love such as a family member, who realize the inexcusable evil that the actions of these companies inflict, grows over time. While only a small percent of the ostensibly insured will have a terrible event each year, with more years more people and families experience such terrible events. Also, of course, the practices of the health insurance companies become more restrictive and more draconian, leading to both more delays and denials and deaths and more out-of-pocket costs for more people. In other countries, this happens, essentially, very little or not at all. The following chart presents the dates when other countries implemented universal health care, and when they got rid of it because it wasn’t working. Look at it carefully and you might discern a trend:

The US has a higher mortality rate than many of these countries. Jim Kahn, in the Health Justice Monitor, makes an effort to quantify the extent to which health insurance (or lack of it) contributes to this. It is an estimate, but as he notes, whether 170,000 or 220,000, it is too much. And, more, we spend much more than all these other countries on what we call “healthcare” despite so much of it going to corporate profit, that the fact that there is any excess mortality due to lack of health insurance is even more intolerable.

This might come as a shock to many Americans, especially those who have yet to personally experience the delays, denials, and deaths that the for-profit health insurance industry heaps upon its victims, because we are regularly and consistently told by politicians and pundits that a universal health insurance system would be a bad idea, that it wouldn’t work for Americans. That it would be too costly. That it would limit our freedom. We need to recognize that this is not true. Few of us want to have the freedom to choose which insurance company takes our money and then tries its best to limit our access to care (although, if we can afford it, we might choose the one that does it least). What we do want is the freedom to choose the doctors and hospitals that we believe will provide us the best care for our health needs and have our insurance pay for it. Of course, this is not the freedom that they are talking about; what they mean is the freedom of insurance companies (and to be fair, many health care providers) to make as much money as possible, which is what would be limited in a universal government-run health insurance system. And, oh, by the way, provide the funds to pay for it. Imagine that our health care dollars, from our pockets and those of our employers and our government (from the taxes we pay; the large corporations and billionaires who own them don’t) could be spent on providing us with health care rather than lining corporate pockets!

There are actual examples of “single payer” health care in the US. Military retirees and families are covered by government-funded health insurance through the VA or TriCare. In the military itself, for active duty service members, health care is not only single-payer, it is government run. The other big example of single-payer available to Americans is traditional Medicare, for those over 65 or disabled. Medicare. The most popular government program since…Social Security. Under traditional Medicare, health care services are approved for people who need them and have them ordered by a doctor, not micromanaged for each individual with people (or AI!) denying them willy-nilly. In an alternative to Medicare, people can opt for enrollment in an HMO/PPO like system run by the same insurance companies that insured (and often screwed) them before they became eligible for Medicare, and have it paid for by Medicare funds. This program, misnamed “Medicare Advantage”, takes away the guarantees of traditional Medicare and puts you back a the mercy of those for-profit health insurance companies that have treated you so well before!

This is exactly what we don’t need – erosion of Medicare. We need Medicare to be improved, to pay for 100% of all needed medical care, and expanded to cover every American, cradle to grave, paid for by the money now going to insurance company and pharmaceutical and device company and health system profits. The reason to do it is because it would benefit people, remove the major cause of heartache, loss and bankruptcy in the US, and make us more secure and happy people. The reason not to do it is that these huge corporations would no longer be making their exorbitant profits by taking premiums and denying health care, and thus would not be able to make such large contributions to the legislators who should be acting, instead, for the American people.

What do you want? Maybe in 2025 it is time to let your legislators know!

 

A final thought from Bernie Sanders: