{"id":13676,"date":"2026-06-03T06:33:00","date_gmt":"2026-06-03T06:33:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=13676"},"modified":"2026-06-03T06:33:00","modified_gmt":"2026-06-03T06:33:00","slug":"you-call-this-a-system","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=13676","title":{"rendered":"You call this a system?"},"content":{"rendered":"
\n<\/div>\n

By TOMMY BEVERIDGE<\/p>\n

Just like the\u00a0Holy Roman Empire<\/a>\u00a0was none of those things, America\u2019s health care system is neither health care, nor a system. Both are in fact decentralized commercial arrangements clothed in things that sound good, like Holy-Romanness, or Consumer-driven Health Care. Rather than health care, we have a patchwork of consumer products and government subsidies designed to pay a vast cadre of individuals and interests to perhaps incidentally provide health care. To even call it a system would imply something centrally coordinated, which no one in their right mind would do.<\/p>\n

It feels hopeless. Health insurance is expensive, arbitrary, and capricious. It\u00a0profits off of slices of an ever-growing pie<\/a>, regardless of margins. The providers we cannot live without often charge\u00a0whatever the market will bear<\/a>. On top of this, the government, directed by laws written by politicians unwilling to upset\u00a0powerful interests<\/a>, has spent the past two decades pushing\u00a0complex payment ideas<\/a>\u00a0with\u00a0little result<\/a>\u00a0except a growing ecosystem of consultants specializing in gaming such incentives. Then there are the consultants\u2014 arms dealers in both sides of a war, selling\u00a0hospital systems<\/a>\u00a0software that helps them bill as much as they can for their work, and\u00a0health insurance companies<\/a>\u00a0software that helps them deny claims wherever they can.<\/p>\n

We all know this. It\u2019s the\u00a0learned helplessness<\/a>\u00a0about it all that gets me. Sometimes a sob story about\u00a0chemotherapy denied<\/a>\u00a0enters the zeitgeist, or the tale of a\u00a0lone vigilante<\/a>\u00a0taking out a health care executive, but mostly we just take the 7 percent annual\u00a0premium increases<\/a>\u00a0and deductible hikes with a stiff upper lip. Meanwhile, few of the players: payer, provider, government, or software slinger, put American\u2019s health at the top of their agendas. Customer satisfaction? Maybe. Public ire? Occasionally. Shareholder value? Certainly. But our actual health?\u00a0\u00a0<\/p>\n

Something that isn\u2019t health care or a system can\u2019t be a health care system. Not when\u00a0this how we pay for care<\/a>:<\/p>\n

<\/span><\/p>\n

People with steady work usually get employer-sponsored coverage. This is about 54 percent of America. These plans negotiate with providers in thousands of separate and discrete settings, with the natural incentive to maximize their own percentage in the deal.\u00a0A family facing a surgery or cancer diagnosis can easily shell out $10k or more<\/a>, on top of their growing monthly premiums.<\/p>\n

Old people, and certain sick and disabled people get Medicare. That\u2019s about 19 percent of America. It\u2019s federally run and it\u2019s a good deal, except that it covers only 80 percent of costs, and you need to buy a separate Medicare plan to cover prescription drugs whose prices are largely dictated by the sellers, plus a commercial plan that fills in all the gaps of its antiquated insurance coverage. Or a fully commercial Medicare Advantage plan that may or may not cover all your costs, but will make its money through a mix of\u00a0annoying-to-lethal administrative frictions<\/a>.<\/p>\n

Poor people, certain sick people, and some lower-middle-class people get Medicaid. That\u2019s about 18 percent of America. Low rates, coupled with the\u00a0administrative headaches<\/a>\u00a0common to all health plans lead to considerably fewer providers taking Medicaid.<\/p>\n

Ten percent of people buy individual coverage. All the claims of\u00a0impending socialist doom<\/a>, or a\u00a0coming golden age<\/a>\u00a0sixteen years ago were about this sliver of the population. The problem is that it\u2019s expensive, negotiates like employer-sponsored coverage (i.e., badly) and the\u00a0government just cut subsidies<\/a>\u00a0for a lot of people. And the\u00a0politics still burn<\/a>.<\/p>\n

People who are ineligible for coverage, can\u2019t afford it, or don\u2019t want it remain uninsured. This is about 8 percent of America (and\u00a0growing<\/a>, again). They show up at the ER and\u00a0cost us all<\/a>.<\/p>\n

Then there\u2019s the VA and Military Health System. About 1.2 percent of America is enrolled for health care with the VA. Active-duty military, their families, and retirees get TRICARE and the Military Health System. That\u2019s about 2.8 percent of America. They both own large portions of the care delivery as well. These programs barely communicate with one another, and are perennial\u00a0policy<\/a>\u00a0basket cases<\/a>.<\/p>\n

Each of these plan types have various subtypes, their own state and federal legal structure, their own billing and administrative procedures, and their own constantly churning client base. Each provider must individually contend with each of these complications with every claim or patient interaction. This is not a system, nor is it really health care. Against all this, how will small-ball, often voluntary payment reforms fix these problems?<\/p>\n

Market utopians imagine that the right economic incentives will create the just and rational distribution of health resources. Some people even believe that health care will be better if we expose the patient to more costs\u2014 give them high deductibles and they\u2019ll shop for care. I can\u2019t believe that I would be a better buyer of chemotherapy than an expert who works on my behalf. But hey, what do I know?<\/p>\n

This market conceit has been convenient for academics and politicians to dance around tough choices, hoping that the utopian\u2019s light touch will be enough. Well-meaning economists thought up complex incentive structures like\u00a0Accountable Care Organizations<\/a>; where providers willingly enter contracts with insurance plans to pay them less. If I hear about one more clever economist\u2019s approach to changing consumer or provider behavior, I\u2019ll invoke the spirit of\u00a0Uwe Reinhardt<\/a>\u00a0upon them.\u00a0<\/p>\n

In the end, the\u00a0only non-theoretical ways<\/a>\u00a0to control health care costs are things like negotiated fee schedules and global payments, and\u00a0we still act as if they\u2019re entirely novel<\/a>. The only way to improve health is to\u00a0restructure care towards prevention<\/a>, but that\u2019s a hard sell for committees of cardiologists and CEOs. The fact remains that market logic on its own has never and probably never will guarantee anything close to a \u201csystem,\u201d where health care is delivered on behalf of people.<\/p>\n

But there\u2019s a lot of good too. There\u2019s no better place on Earth for someone with a weird\u00a0cancer<\/a>\u00a0or in need of a\u00a0transplant<\/a>\u00a0(plus the\u00a0money<\/a>\/coverage<\/a>). Payers do good work too, when their incentives are aligned to helping the patient above all else.\u00a0Medicaid managed care<\/a>\u00a0is a good example. Then there\u2019s the drug industry, who\u00a0does amazing things<\/a>, but should be paid according to\u00a0the marginal value of their new products, just like\u00a0everyone else<\/a>\u00a0across the world does. Old power structures must be challenged, but they also need a role in the new order.<\/p>\n

That\u2019s a lot. Let\u2019s think big again. Big and different. Medicare for All is a good slogan for\u00a0a lot of different ideas<\/a>. Taken literally, what you really get is a\u00a0mid-1960s health plan design<\/a>, some\u00a0administrative simplicity, lower rates<\/a>, and tremendous\u00a0political baggage<\/a>. Matthew\u2019s\u00a0Concierge Care for All<\/a>\u00a0concept offers a robust rubric for reform, reorganizing how both payer and provider operate in a thoughtful way; sort of a laissez faire NHS that takes advantage of what already works here in America. Agree or not, it\u2019s an idea whose scale matches the challenge. Any way we do it, the road to reform is through prices and reorienting incentives away from hospitals, specialists, and pharma. The world is full of options:<\/p>\n

We could impose various forms of fee schedules and global budgets, reorienting providers to serve populations with heavy emphasis on primary care. That\u2019s how\u00a0much of Europe works<\/a>.<\/p>\n

We could abolish most private insurance, directing the government to set prices and process claims, leaving the care to provincial and regional authorities.\u00a0That\u2019s how Canada works<\/a>.<\/p>\n

We could change payer incentives so they\u2019re more interested in collectively bargaining on our behalf instead of taking a percentage of the ever-growing pie.\u00a0That\u2019s how Japan works<\/a>.<\/p>\n

We could attempt a\u00a0consultant\u2019s dream<\/a>\u00a0where heart surgery is just another consumer product. That\u2019s the consensus of what entrenched interests think would work.\u00a0<\/p>\n

Options abound, but no system will provide every service to everyone for cheap. Someone, whether it be government, a private insurance company, or ourselves, will need to judge that a particular back surgery is not necessary or too expensive for its value. The politics are\u00a0dark and full of demagogues<\/a>. But we can\u2019t say we have health care, a system, or a healthy civil society until we look at the whole thing and make some fundamental changes. Bring your own ideas, and let\u2019s get to work.\u00a0\u00a0<\/p>\n

Tommy<\/a>\u00a0Beveridge<\/a>\u00a0is a longtime health care policy wonk who has worked in the .org, .com, .edu, and .gov worlds. Due to present employment constraints, Tommy is sticking to a nom de plume.<\/em> His picture above is actually\u00a0Asclepius<\/a>, the Greek god of medicine. Because why not?<\/em><\/p>","protected":false},"excerpt":{"rendered":"

By TOMMY BEVERIDGE Just like the\u00a0Holy Roman Empire\u00a0was none of those things, America\u2019s health care system is neither health care, nor a system. Both are in fact decentralized commercial arrangements clothed in things that sound good, like Holy-Romanness, or Consumer-driven Health Care. Rather than health care, we have a patchwork of consumer products and government…<\/p>\n","protected":false},"author":0,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-13676","post","type-post","status-publish","format-standard","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13676"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=13676"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13676\/revisions"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=13676"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=13676"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=13676"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}