AV福利社

Navigating Health Care.

It’s Complicated.

If you鈥檝e had to find a primary-care provider or pay a medical bill lately, you know that accessing and paying for health care can be very difficult. But why? What are the biggest problems? And how can we get the care we need in such a system?

By Patrick Luce 鈥�99

When the CEO of one of the largest health insurance companies in the United States was gunned down on a midtown Manhattan sidewalk in December, the public reacted with anger and exasperation, not a surprising response to such a brazen attack.

What was surprising was the target of that public ire.

In this case, the vitriol normally reserved for the perpetrator was largely directed at the victim, UnitedHealthcare CEO Brian Thompson, and all he represented: the most expensive health-care system in the world鈥攁 for-profit system that is complicated and inaccessible to many; a system that, ultimately, leaves many behind.

The universal right to health care is ingrained in many industrialized nations, but that is not the case in the U.S. More than 70 percent of U.S. adults feel the health-care system fails to meet their needs, according to a 2023 Harris Poll conducted with the American Academy of Physician Associates. The poll found 54 percent of Americans think the health-care system is going in the wrong direction, more than 25 percent feel it is completely broken, and 26 percent grade the system with a D or F, while just 10 percent give it an A. Those from traditionally underserved communities have a worse view. U.S. News & World Report鈥檚 State of Equity in America conference found that 75 percent of Black Americans believe their race negatively affects the care they receive.

More than a quarter of people polled cited cost and poor access to care and insurance as the key problems in the U.S. system. Even those with insurance say it鈥檚 difficult to get treatment, largely due to a shortage of primary-care providers. One-third say the health-care system does not meet their needs because it takes too long to get an appointment.

These problems add up to a worldwide ranking that is dead last among the top 10 wealthiest nations, according to a survey by the Commonwealth Fund, an international organization that promotes equitable health-care systems. Of the five categories measured in the survey, the U.S. ranks last in access to care and health outcomes, and ninth in equity and administrative efficiency. The American system performed well in just one category鈥攃are process鈥攔anking second, largely due to its emphasis on preventative services like mammograms and vaccinations.

鈥淓specially concerning is the U.S. record on health outcomes, particularly in relation to how much the U.S. spends on health care,鈥� the organization鈥檚 report reads. 鈥淭he ability to keep people healthy is a critical indicator of a nation鈥檚 capacity to achieve equitable growth. In fulfilling this fundamental obligation, the U.S. continues to fail.鈥�

The problems of cost and access were recurring themes when we asked AV福利社 alumni working in the health-care industry to provide their perspectives on the system. We asked practitioners鈥攊ncluding doctors, nurses, and pharmacists鈥攁s well as administrators, to share their impressions of the U.S. health-care system and offer advice for patients and caregivers.

The problems with U.S. health care are many, and there is no simple solution, says AV福利社 College of Nursing professor Betty Rambur, an expert on health-care cost and policy and author of Health Care Finance, Economics, and Policy for Nurses: A Foundational Guide. But among the myriad problems, two themes stand out: money and access.

鈥淚t鈥檚 too expensive,鈥� Rambur says. 鈥淐ost is well documented as Americans鈥� greatest concern with the U.S. system. We have the most expensive system in the world, yet we have real problems with quality. Structural racism is built into the system, and we have an enormous income divide.鈥�

Many point specifically at health insurance companies as the culprit when it comes to cost. Providers struggle to be reimbursed at a level that covers costs and allows them to make a living. Mental-health, maternity, pediatric, and primary-care providers are not well reimbursed by insurance or government payers like Medicaid, Rambur says. 鈥淎nd currently, only 5% of our total national health-care expenditure of $4.9 trillion is directed toward primary care, while high-performing nations have a robust focus on primary care.鈥�

Pharmacists鈥攅specially at the dwindling number of smaller, independent pharmacies鈥攁re often forced to operate at a loss, largely because of third-party middlemen known as pharmacy benefit managers, or PBMs, which maintain a stranglehold over pricing structures and reimbursement. PBMs frequently fail to pay what it costs pharmacies to acquire drugs, forcing them to take a loss to fill prescriptions they can鈥檛 refuse, according to Matt Olivier, Pharm.D. 鈥�06, who owns and operates Matt鈥檚 Local Pharmacy in Middletown, R.I.

鈥淎 lot of independents are closing because we can鈥檛 dispense medication without losing money. We can鈥檛 get medications for what they鈥檙e willing to reimburse,鈥� Olivier says. 鈥淭hey鈥檙e essentially forcing us out of business.鈥�

But reimbursement practices are only part of the problem in the complex, fee-for-service health-care system, Rambur says, noting that the first health insurance company, Blue Cross Blue Shield, was intended only to reimburse hospitals and doctors for illness care, not to be a health-care plan, coordinate services, support wellness, or contain costs.

鈥淭here is an intrinsic challenge with an insurance model, because insurance is supposed to be for rare events鈥攆loods, fires, etc.鈥攁nd we share the financial risk with others,鈥� Rambur says. 鈥淏ut we will all get sick; we will all need health care. People get upset with insurance companies, but the cost of insurance is largely a reflection of the cost of care, and our prices are higher than anyplace else in the world. It is difficult to assess the real value of health care.鈥�

Patients must rely on providers to advise them on what treatments they need. Even with their patients鈥� best interests at heart鈥攁nd possibly because they have their patients鈥� best interests at heart鈥攑roviders often fall victim to what Rambur calls the 鈥淕ucci effect鈥� of overtreatment and over-screening. Rambur points to prostate exams, which the American Medical Association recommends for men starting at age 45. Many wealthy countries do not do routine prostate screenings, unless there鈥檚 a particular reason to do so. Not doing a preventative screening might seem antithetical to quality care, but, she says, the prevalence of these screenings contributes to the low value of care Americans receive.

鈥淥ver-screening leads to overdiagnosis, which leads to overtreatment,鈥� Rambur says. 鈥淧rostate screening, for example, has been found to lead to overtreatment, and the treatment often has horrible outcomes鈥攍ike incontinence and impotence resulting from surgery. Some people might really need the surgery, but for others, the question should be, 鈥榃ould you die with it, not of it?鈥欌��

Furthermore, the fee-for-service system, in which providers charge separately for each procedure, is ripe for fraud and abuse. 鈥淲e do screenings on things for which there鈥檚 a lot of downstream revenue. We don鈥檛 do screenings on things where there isn鈥檛,鈥� Rambur says. 鈥淚 would challenge my colleagues to consider the value of what we鈥檙e contributing. What鈥檚 the cost, and what鈥檚 the outcome? Is there a way to do this better?

鈥淲hen we look at health care, we need to think about value, which is determined by the cost and quality of care鈥攁nd by outcomes. But there鈥檚 a lot of money in the illness industry. A lot of money,鈥� Rambur says. 鈥淧eople are starting to understand that we do not have the best health-care system in the world. The data has been very clear about that for a long time.鈥�

Short of a complete overhaul, there are things that could improve the system, Rambur says. More in-home care could reduce hospital costs, while also making patients more comfortable. Better reliance on nurse practitioners can expand the roster of primary-care providers, increasing access and potentially lowering costs.

The federal government could help by offering a public option, like the one proposed by Republican President Richard Nixon in 1971 or the more recent Medicare for All options, Rambur says. 鈥淩egardless of how health care is financed, we must stop paying for low-value care. It causes financial harm to individuals, businesses, and taxpayers, and often physical and emotional harm to patients and families.鈥� She adds that the government could follow other countries鈥� leads and regulate health-care prices, but that could face legal challenges in a free-market economy. There are no simple solutions.

So, faced with these obstacles, and few concrete solutions, how can consumers find the care they need? Rambur says: Be your own advocate. Don鈥檛 take what your provider or insurance company tells you on face value; insist that they involve you in your own health care, and make your voice heard.

鈥淚t鈥檚 important that people start questioning the recommendations,鈥� Rambur says. 鈥淭here鈥檚 a piece in the Affordable Care Act called shared decision-making. If you鈥檙e my provider, you and I鈥攖ogether鈥攖hink about my values, and what鈥檚 important to me. So much of the health-care system has revolved around the system, not the patients. That has to change.鈥�

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