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Is our healthcare system broken?
- By Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
Here's a question that's been on my mind and perhaps yours: Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all. Below are 10 of the most convincing arguments I've heard that our system needs a major overhaul. And that's just the tip of the iceberg. Remember, an entire industry has evolved in the US just to help people navigate the maddeningly complex task of choosing a health insurance plan.
The cost is enormous
- High cost, not highest quality. Despite spending far more on healthcare than other high-income nations, the US scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality. And for all that expense, satisfaction with the current healthcare system is relatively low in the US.
- Financial burden. High costs combined with high numbers of underinsured or uninsured means many people risk bankruptcy if they develop a serious illness. Prices vary widely, and it's nearly impossible to compare the quality or cost of your healthcare options — or even to know how big a bill to expect. And even when you ask lots of questions ahead of time and stick with recommended doctors in your health insurance network, you may still wind up getting a surprise bill. My neighbor did after knee surgery: even though the hospital and his surgeon were in his insurance network, the anesthesiologist was not.
Access is uneven
- Health insurance tied to employment. During World War II, healthcare was offered as a way to attract workers since employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to healthcare.
- Healthcare disparities. The current US healthcare system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable healthcare disparities for people of color and other disadvantaged groups.
- Health insurers may discourage care to hold down costs. Many health insurance companies restrict expensive medications, tests, and other services by declining coverage until forms are filled out to justify the service to the insurer. True, this can prevent unnecessary expense to the healthcare system — and to the insurance company. Yet it also discourages care deemed appropriate by your physician.
This can make for shortsighted decisions. For example, when medications are prescribed for rheumatoid arthritis, coverage may be denied unless a cheaper medication is prescribed, even if it has little chance of working. A survey (note: automatic download) found that 78% of physicians reported that this led people to abandon recommended treatments; 92% thought it contributed to care delays. And because the expensive medication may prevent future knee or hip replacements, delay may ultimately prove more costly to insurance plans and patients while contributing to more suffering.
Investments in healthcare seem misdirected
- Emphasizing technology and specialty care. Our system focuses on disease, specialty care, and technology rather than preventive care. During my medical training, I received relatively little instruction in nutrition, exercise, mental health, and primary care, but plenty of time was devoted to inpatient care, intensive care units, and subspecialties such as cardiology and gastroenterology. Doctors practicing in specialties where technology abounds (think anesthesiology, cardiology, or surgery) typically have far higher incomes than those in primary care.
- Overemphasizing procedures and drugs. Here's one example: A cortisone injection for tendinitis in the ankle is typically covered by health insurance. A shoe insert that might work just as well may not be.
- Stifling innovation. Payment structures for private or government-based health insurance can stifle innovative healthcare delivery. Home-based treatments, such as some geriatric care and cancer care, may be cost-effective and preferred by patients. But, because current payment systems don't routinely cover this care, these innovative approaches may never become widespread. Telehealth, which could bring medical care to millions with poor access, was relatively rare before the pandemic, partly due to lack of insurance coverage. And yet, telehealth has flourished by necessity, demonstrating how effective it can be.
- Fragmented care. One hallmark of US healthcare is that people tend to get care in a variety of settings that may have little or no connection to each other. That can lead to duplication of care, poor coordination of services, and higher costs. A doctor may prescribe a medicine that has dangerous interactions with other medicines the person is taking. Medicine prescribed years earlier by a doctor no longer caring for a person may be continued indefinitely because other doctors do not know why it was started. Often doctors repeat blood tests already performed elsewhere because results of the previous tests are not readily available.
- Defensive medicine. Medical care offered primarily to minimize the chance of getting sued drives up costs, provides little or no benefit, and may even reduce the quality of care. Malpractice lawsuits are so common in the US that for doctors in certain specialties, it's not a matter of if but when they are sued. Though it's hard to measure just how big the impact of defensive medicine is, at least one study suggests it's not small.
No simple solution
Even insured Americans spend more out of pocket for their healthcare than people in most other wealthy nations. Some resort to purchasing medications from other countries where prices are far lower. The status quo may be acceptable to healthcare insurers, pharmaceutical companies, and some healthcare providers who are rewarded handsomely by it, but our current healthcare system is not sustainable (note: automatic download).
Other countries have approached healthcare quite differently, including single-payer, government-run systems, or a mix of private and public options. Perhaps some of the most successful can serve as a model for us. But, with so much on the line and competing interests' well-funded lobbying groups ready to do battle, it's far from clear whether reform of our healthcare system can happen anytime soon.
I haven't met many patients who think our current healthcare system is great. In fact, I don't know anyone who would design the system we currently have — well, other than those who are profiting from it.
The question going forward is whether there will be the trust, will, and vision necessary to build something better. It won't be easy, but the alternative — continuing to complain while waiting for the system to implode — is unacceptable.
Follow me on Twitter @RobShmerling
About the Author
Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
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No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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