A friend posted on Facebook about the difficulty he and his wife had finding new primary care physicians after their long-time PCPs retired. They ultimately decided to join a concierge medicine group, an expensive choice, but one that suits their circumstances.
Their experience helped me consolidate my thoughts on U.S. health care and its economics. I’ve been ruminating about these points for months, even years. It’s time I got my thoughts organized and in print, as it were.
As we age, we encounter increasing care needs, and they can be many and varied. My wife is a retired medical professional. I worked in the health insurance industry in one capacity or another for decades. So we both know medical and we know, most of the time, how to navigate our own very complicated care environment. But not always.
I now have three MyChart accounts and at least six logins for medical practices. My wife also has three MyChart accounts, two of them different from mine. She declines to participate in medical practice logins. Instead, she spends all sorts of time on the phone seeking answers to her questions.
While we might hope that our various practitioners can immediately see our medical records, that is not the case. They don’t have logins to the MyChart or to medical practice accounts that they are not part of.
My wife would benefit greatly by having someone – a practitioner or a practice – coordinating and guiding her care. This is impossible. So, no matter how she feels, she is the coordinator. This works, pretty much because she is knowledgeable. It does not work at all when she’s having difficulty, is in pain, is highly anxious, or is just plain ill. My own breadth of knowledge helps only part of the time. So she will call the on-call doc. Almost always, the advice is: go to the ER – by far the least efficient and most expensive option.
And here’s the rub. As I’ve said, we’re both knowledgeable and capable of navigating the “system” when any system is there to navigate. But too often it’s not. I despair for people who don’t have our knowledge or experience, never mind our medical insurance. What can they do? Unfortunately, one of their major options is to suffer; another is just to die.
We could choose to engage in concierge medicine as my friends decided to do. But it’s highly unlikely we would. We could pay for it, at least for a while. But that sort of expense would deeply offend my wife, who is, at heart, a pure socialist. Me? The whole thing enrages me. And that’s not a good place to be.
So what’s the answer? Is there one?
Not in the current climate. The thing we call a health care system looks like a jigsaw puzzle dumped out of several boxes. It’s no wonder that people are perplexed, sometimes to the point of just not participating.
The most talked about health care solution, the “Affordable Care Act” known as Obamacare, is a massive deflection from fixing the many problems. It isn’t even a Band-aid. It’s a mirage. It is a very expensive, deeply inadequate way to place all of the responsibility for care on the individual, no matter that person’s resources. Except for the most expensive options, it provides inadequate services if services can be found; and even the expensive options have far too many exclusions and limitations.
I’m sure some readers will see the above as agreement with the trolls who have tried for years to repeal the Affordable Care Act. It is not. I’m saying that the A.C.A., while laudable as a first step, is only that: a first step, and it’s not a true solution.
It’s often said that we’re the only developed country without something that might be termed “Universal Health Care.” Instead, our politics demand, ostensibly, that we rely on our capitalist process to provide competition and, therefore, best-priced, best-quality service to all.
A nice sentiment. Doesn’t work.
For one thing, no “marketplace” for medical care exists. It is impossible to compare hospital services, doctor services, prices, or quality in any meaningful way. Such comparison is not what anyone with medical needs can or should have to engage in. Certainly with “elective” care, such as surgery, most of us who are able will get recommendations from primary care docs or friends about who is best at, say, knee replacement. In an emergency, though, the ambulance generally takes you to the nearest ER (or you go yourself) for evaluation and care. If you have insurance, that hospital ER will take you in and the doc caring for you is the in-service person. If you’re admitted to inpatient care, you don’t usually choose who cares for you, other than having your primary care provider manage your case if that provider works at that hospital.
Our “system” is highly inefficient in far too many ways. The process I just described is one that can occur only if your community has medical care facilities. It’s great if your facility has multiple departments such as urology, ophthalmology, orthopedic medicine, gastroenterology, and the like. In less affluent or rural areas, it’s very possible that the hospital ER you used to go to is gone because the hospital closed. If your hospital is still operating, it is highly likely that it has constant problems recruiting adequate numbers of staff at a pay scale that is attractive, never mind a cardiology or obstetrics department that can treat you.
For decades in the U.S., the form of our medical “system” was decided entirely by doctors, particularly the American Medical Association. The AMA has been highly protective of the economics of medicine, of individual doctors and of how hospitals are organized and operate. They have, sometimes in panic-attack mode, inveighed against anything that, to them, had the odor of “socialized” medicine. They have vigilantly opposed state regulation of hospitals, hospital equipment, staffing levels, and any other sort of governmental oversight. It is rather ironic that they are forcefully protecting a capitalist model that does not exist and has never existed. In many ways, their adamant championing of individual practitioner rights, as opposed to what is best for society as a whole, has perpetuated a concentrated landscape of medical care that is intentionally understaffed (they mostly control how many medical schools we have, for example). The AMA and its sister state organizations have, also with intention, strongly opposed the training and licensing of different sorts of caregivers such as nurse practitioners, reluctantly bending to the efforts of various state legislators to grant licensing to such trained people. They are behind the recent declaration of our federal Health and Human Services Department that nursing is “not a profession,” proving once again that certain sorts of conservatives never give up.
The success of the AMA lies in the massive amounts of money certain medical practitioners earn in a year. This benefice does not accrue, by the way, to your gerontologist, your family care doc, your internist. Generalists don’t get the respect or the money their specialist friends realize – which is one reason that such generalists are in short supply.
Years ago, our ‘system” had dozens of companies providing health insurance. Many states had Blue Cross – Blue Shield organizations, which were mutual companies owned by their policyholders. Other insurance companies large and small had health insurance departments selling both individual and group insurance plans. In the 1970s entities called “Third Party Administrators” arose. Some industrial, service and financial corporations were tired of constantly rising health care insurance premiums. So they decided to self-insure, hoping that they would be eliminating the overhead of insurance company staffing in their costs, instead paying only direct medical costs, lower administrative costs and reinsurance premiums to cover excessive losses. Several such third-party administrators still operate, managing health plans for small to medium sized businesses.
Over time many of the larger private health insurance companies merged, creating larger and larger corporate entities. Connecticut General Insurance Company and Insurance Company of North America, for example, combined to form Cigna Group. CVS acquired Aetna, along with multiple other companies. At the same time, Blue Cross – Blue Shield organizations changed their structures to allow them to buy each other. Blue Cross – Blue Shield of Illinois, operating as Health Care Service Corporation, acquired the Blues plans of Montana, New Mexico, Oklahoma and Texas and is now the largest customer-owned health insurer in the U.S.
Two highly important elements of health care are Medicare and Medicaid. They are significant factors in the consolidation of health insurance companies. Aetna/CVS, Cigna and the Blues plans are major contractors for Medicare and state Medicaid plans.
I mention all of these players – AMA, Blues plans, insurance companies, Medicare and Medicaid – as parts of a totally fractured medical care environment. They are illustrative of the huge mess that our “system” is. But it’s also salient that eliminating this hodgepodge in favor of “Universal Health Care” would be massively disruptive to our economy and would likely mean the loss of millions of jobs, never mind the closure of some very large businesses. Sure, managing a health-care-for-all actual system would shift a lot of companies and workers into that world, but in the best scenario, a lot of duplicate overhead would be wiped away and not all of those who are part of that overhead would see new opportunities.
So is universal health care (termed by some advocates “Medicare for All”) feasible? Of course it is. But we need the political will even to discuss it rationally and thoroughly. And this does not include bashing the systems of other countries. Such bashing is always fact-free and tinged with the sort of fear that engenders purely fantastic doom-saying. See this short bit of Senate testimony for examples: https://www.facebook.com/share/v/18Fm4k7QRV/?mibextid=wwXIfr
To see how much of an outlier we are in the U.S., note this map.
Courtesy Wikimedia Commons
An entrenched cadre of the far right would see any universal system as a deadly attack on personal rights and they would loudly oppose even discussing it. The more rational people on the right simply do not believe that health care is a right; that millions of people don’t have adequate or even any health care coverage is not something for government to fix on their dime. These beliefs currently dominate the majorities in both houses of Congress. Other involved interests – insurance companies in particular – would initially stonewall the discussion out of their sense of existential threat. Their deep concerns would have to be heard and included in the discussion.
The key is to establish an objective and place it on the wall. This has been attempted but has been shouted down in the past. However, more and more strong opponents of the past have recognized that their constituents, their friends, their allies, even their families are hurting. We need to find the wall on which to place our overall objective and to agree on that objective.
The overall objective must be to provide health care for every person living in our country and to make the care the best in the world. Are we professionally staffed for that right now? Of course not. Are we structured for this? Are our medical care facilities in the right places and all properly equipped? No. Do we understand the real economics of such a change? Definitely not. But we must begin seriously talking about it, analyzing it, understanding it, and agreeing on what the problem is and what its solutions entail. Those are the first steps. We can’t shy away from fixing these real problems by concentrating on improving the Affordable Care Act and doing only that. Yes, in the interim that coverage needs improvement and proper funding. But its improvement must be viewed as a stopgap measure while we face the real problems.
What I’ve detailed here is a view from above high the landscape. There’s much more history and background, but a detailed history lesson is not my purpose. It’s important to take that view from above to get things started.
It’s also important to keep the overall objective as a lodestar and not to spend any time making that objective somebody’s perfect design. Make the objective clear and find ways to make it achievable. But get going and don’t stop, Congress. Lives depend on it.
Edmund J. McDevitt
© March 2026