Should American health care be tweaked, or overhauled?

If the former, then only modest, incremental policies may be needed to expand coverage at the edges and to lower out-of-pocket costs. If the latter, then more ambitious policies to fundamentally change how health care is financed, delivered, and covered would be needed.

Health care in the United States has become one of most hotly debated issues in the race for the 2020 presidential election. The leading Democratic candidates have been arguing over whether it's best to embrace a “Medicare for All” single-payer system, with no or a very limited role for private insurance, or advocate for a Medicare-like public option to offered along with heavily regulated private insurance. Some even suggest it's preferable to simply build on the Affordable Care Act by increasing premium subsidies, expanding Medicaid, and lowering deductibles, while keeping the current pluralistic system of public and private insurance mostly intact.

On the Republican side, President Trump and his re-election campaign argue (incorrectly, in my view) that all of the Democratic approaches will inevitably lead to socialized medicine. But socialism requires that the government own and control the means of production. In the context of health care, this would mean the government owning hospitals and employing doctors directly. None of the models being debated by Democrats would do this. The Republican alternative seems to be to give individuals and states more choice over insurance benefits and coverage, instead of the federal government dictating such decisions.

Such debates are important, for sure. But there is a more basic question that must be asked, which is, does the American health care system need to be tweaked, or overhauled? If the former, then only modest, incremental policies may be needed to expand coverage at the edges and to lower out-of-pocket costs. If the latter, then more ambitious policies to fundamentally change how health care is financed, delivered, and covered would be needed.

The evidence supports the need for fundamental overhaul. Simply put, U.S. health care costs too much, leaves too many people behind, and delivers uneven and suboptimal results, based in large part on where people live, how poor or rich they are, and personal characteristics like their race, ethnicity, gender, gender identity, and sexual orientation.


  • The United States spends more per capita on health care than any other industrialized nation, nearly 17% of its GDP. Overall system costs (and prices for health care services in particular) continue to rise at an unsustainable rate.
  • The U.S. allows tens of millions of people to go without any insurance coverage (the uninsured) and many millions more to have inadequate coverage (the underinsured). We are the only wealthy industrialized country in the world that does not have universal coverage.
  • Health care in the U.S. is increasingly unaffordable, even for those with insurance. Out-of-pocket costs have been rising for decades, as employers have raised deductibles and required employees to pay an ever-larger share of premiums to offset rising premiums charged by insurers. Insurers, for their part, claim that they are only passing on the rising costs of care, driven mainly by hospitals and prescription drug manufacturers, although most insurers are themselves quite profitable.
  • Patients routinely get hit with surprise medical bills, sometimes costing thousands of dollars, from out-of-network ED doctors, anesthesiologists, or ambulance companies, even though the hospitals where they received care are themselves in-network. Hospitals often charge uninsured patients more than insured ones and then use aggressive collection practices and lawsuits to collect payments from them for unpaid bills.

Is it any surprise, then, that the cost of health care is the number-one reason for personal bankruptcies in the U.S.?

The U.S. spends far more on administration than other countries do, more than 25% of hospital costs on average, according to one study. The U.S. has created a massive, unaccountable, and byzantine structure of claims reviewers, pharmacy managers, billing clerks, coders, and utilization managers to deny and limit patient access to needed care, along with clerical staff whose only purpose is to fight to get claims paid and to maximize reimbursement.

If higher spending meant better outcomes, that would be one thing, but it doesn't. The U.S. lags behind most other countries in reducing mortality from the leading causes of death, except for cancer, where we do better than most other countries. Longevity in the U.S. is on the decline, due to substance use disorders, prescription drug misuse, firearms deaths and injuries, suicides, and maternal mortality, among other causes.

And, while we spend more overall, the U.S. spends far less on primary care than other countries do, even though primary care is associated with better outcomes, fewer preventable hospital admissions, and lower costs.

These are systemic problems, unique to American health care. Like a house with a leaky roof or a cracked foundation, applying a patch here and there won't make the house strong and secure. It will only delay the day of reckoning when the house comes tumbling down from neglect, delay, and inaction.

This, I think, is the choice facing voters next year. Will voters insist that candidates offer concrete plans to address the reasons why our health care system is failing so many? Will we elect candidates who commit to universal coverage (recognizing there is more than one way to achieve it), lowering excessive prices and costs, reducing deductibles and copayments, realigning payment and delivery systems to support what's best for patients rather than the system (that is, everyone but the patient), understanding and addressing social determinants of health, ending discrimination and disparities in care based on personal characteristics, and redirecting the massive amount of money now being spent on administration and profit-taking to improving the care that patients receive?

Change won't be easy, because interest groups like hospitals, insurers, and drug manufacturers are spending millions of dollars to block reforms that threaten their economic interests (see my column in the September 2019 ACP Internist, “Time to Call Out Scare Tactics Blocking Needed Reform”).

Yet their cynical and self-serving opposition must not be allowed to carry the day. ACP will soon release its New Vision for American Health Care, which will offer comprehensive and connected solutions to coverage, cost, payment and delivery systems, and social determinants of care. It is clear to us that American health care needs to be overhauled to achieve better health care for all, not minor tweaks to a fundamentally broken system.