Five Big Ideas to Help America's Struggling Health Care System

Ideas that could *actually* "Make American Healthy Again"

America's health care system faces numerous challenges, from skyrocketing costs (that are already quite high), to bad patient experiences, and limited access to care for certain populations. The population also experiences worse health outcomes compared to similarly wealthy countries, unfathomable frustrations with insurance companies, challenges obtaining coverage, and, to top it off, the health care workforce is plagued by burnout and are dropping out of the labor force.

The Commonwealth Fund’s Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System report authors state the following:

The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries [compared to the U.S. in the report] differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Most Americans know the health system is bad through their own lived experience, but many may not know, quantitatively, how much worse it performs compared to the systems of other countries. Most of the other countries do have a single payor system, also known as universal health care or Medicare-for-all in the U.S., and that can come with unintended consequences like longer wait times for services, but the data does not lie with regard to how much better these other countries perform.

Logically, one might say, “you won’t be worried about wait times if you don’t need as many services because you are healthier.” Its important to remember that the overarching goal for any society should be to reduce the need for medical services in the first place due to a healthier population. Nobody wants to sit in a waiting room all day.

However, while the data supports the clear merit of a single payor system, I do also understand the value of competition and the free market. In some health care markets and circumstances; the quality, cost, and experience of care may be improved through competition. However, this may not be the case for the bulk of services offered in health care as patient-consumers do not have the ability to assess value in many circumstances (see more on that here).

For the sake of this article, it is also important to note that the performance of a county’s health care system is not the only factor that affects the health of the population. Outside of health care services, other population factors contribute to the health of the American population. Lifestyles, diets, exercise, tobacco use, sedentary behaviors, environmental factors, genetics, and socioeconomic factors (e.g., poverty) all impact health. Most of these are not in the historical scope of medical care services (however that is changing).

So, in addition to solutions that solve systemic failures in health care service delivery, it is possible to improve health through other public health interventions. This article examines five transformative ideas that could fundamentally reshape and improve American health and health care systems.

1. Commit to Either Market Competition or Centralized Coverage and Payment

The current American health care system exists in an inefficient middle ground between free-market principles and centralized control. This hybrid approach combines the worst aspects of both systems: the misaligned incentives of for-profit business without the benefits of competition to manage quality and cost; and the lack of central price controls and universal coverage to manage access, individual affordability, and total costs.

Free Market-based Health Care Reform

A market-based solution would focus on increasing competition and transparency. Price transparency rules would be strictly enforced, insurance companies and health systems would be broken up to foster competition, and consumers would gain more control over where and how they spend their health care dollars. This would require the Federal Trade Commission, Department of Justice, and state Attorneys General to break up major health systems and insurance companies to foster competition. It would require aggressive enforcement of price transparency rules and the No Surprises Act to allow patients to understand the price of a service before purchasing. And, it would require an expansion of health savings accounts and flexible spending accounts and a potential expansion of direct primary care that could be carved out of insurance premiums.

This approach could further foster competition by allowing insurance sales and medical practice across state lines, and expanding telehealth services. Regulatory barriers that limit competition would be reduced. such as certificate of need laws, and antitrust enforcement in hospital markets would be strengthened to prevent monopolistic practices from reemerging.

Universal Health Care Reform

Alternatively, a centralized health care system would create a single administrative system for all health care coverage and insurance payments, eliminating the complexity and overhead of multiple insurance companies and profit motives from within the system. This approach would standardize pricing and payment methods across the health care system, significantly reducing the administrative burden on health care providers. Through price negotiation and unified payment systems, this model could enable more effective cost control. This cost control could be passed along to patients through reduced premiums compared to the current averages and reduced out-of-pocket costs.

This system could be modeled of of the United Kingdom’s NHS or Canada’s health system. While the competitive approach may work in theory, the real world evidence from the Commonwealth Fund report leans in favor of a single-payor health system to cure what most Americans would say are the problems with U.S. health care.

Either approach may be preferable to the current system, but it is clear that dramatic changes are necessary. The market approach could drive down costs through competition and consumer choice, while centralization could reduce administrative waste, regulate prices, and leverage economies of scale. The key is committing fully to one philosophy rather than maintaining the current inefficient hybrid.

I have another more detailed article on this topic here.

2. Invest in Public Health Services and Prevention

America's health care system focuses predominantly on treating illness rather than preventing it. In the U.S., the overwhelming majority of spending is on medical care delivery as opposed to public health. A significant investment in public health programs and infrastructure could reduce the burden of preventable diseases and lower long-term healthcare costs. Afterall, public health investments have strong returns on investment.

One study by Mays and Mamaril concludes with the following:

A 10 percent increase in local public health spending per capita was associated with 0.8 percent reduction in adjusted Medicare expenditures per person after 1 year (p < .01) and a 1.1 percent reduction after 5 years (p < .05). Estimated Medicare spending offsets were larger in communities with higher rates of poverty, lower health insurance coverage, and health professional shortages.

Importantly, I will note, for all you math people out there, that the ratio of U.S. public health spending and medical care spending is between 1:99 and 3:99¹. So, a ten percent increase in public health spending with a corresponding 1.1 percent reduction in Medicare spending is *probably* cost-saving.

What does this mean for the individual? Well, many of the avoided costs come from prevented hospitalizations, so that is a win for some people. Second, these investments in public health can improve the health of the population, so better health equates to a reduced need for expensive medical services, and, you know, better health (e.g., quality of life). A reduction in expenditures and medical risk across the board *should* result in lower premiums in some health insurance markets, however without adequate competition in the health insurance market that may not happen as readily.

Environmental health initiatives under this approach could focus on improving air and water quality monitoring systems while reducing exposure to environmental toxins. Food safety inspection systems would be enhanced, and communities could be increasingly designed with health in mind, creating environments that promote wellbeing.

Health education and promotion would be revolutionized through comprehensive programs and public awareness campaigns. Funding for school-based health and fitness education and community programs would be available. Efforts to improve the nutritional value of school lunches would be employed (which has shown the ability to improve child health). Workplace wellness initiatives would be supported and expanded, while communities would receive resources and support for implementing healthy lifestyle choices, parks, and walking paths. These efforts could empower individuals to take control of their health through informed decision-making.

Regulations on preservatives, ingredients, and other additives with known associations with chronic disease would be enhanced. One study , for example, examined the effect of regulating salt contents of food therefore reducing consumption by an average of 3 grams per day. The study suggests that this would result in 60,000 fewer cases of coronary heart disease, 32,000 fewer strokes, and 54,000 fewer heart attacks. This would result in $10 to $24 billion reduction in annual health costs. Maybe, RFK, Jr. should look closely at salt instead of vaccines?

Higher public health spending on the social determinants of health like food insecurity, housing instability, and transportation would also yield better health at lower costs.

In the realm of infectious disease control, we would benefit from stronger disease surveillance systems and expanded vaccination programs—with special care to garner trust from the population. Better outbreak response capabilities would be developed, supported by improved coordination between local, state, and federal agencies. We need better education and messaging to bring those who distrust public health practice and vaccines into the collective fold. This coordinated approach would enhance our ability to respond to public health emergencies quickly and effectively while ensuring trust and transparency.

The benefits of these investments would be substantial, including reduced incidence of preventable diseases and lower health care costs through early intervention. Population health outcomes would improve, and communities would be better prepared for public health emergencies. Perhaps most importantly, these initiatives would help enhance health equity across different communities and demographic groups.

3. Address the Diet and Exercise Crisis

The American obesity epidemic drives numerous health problems and billions in health care costs. Addressing this crisis requires a comprehensive approach that makes healthy choices easier and more accessible and provides medical support when necessary.

According to a study by Biener et al (2017):

“the share of total health care spending of noninstitutionalized adults that is devoted to treating obesity related illness has risen from 20.6 percent in 2005 to 27.5 percent in 2010 to 28.2 percent in 2013”

In 2010, the total expense associated with obesity was $315.8 billion, according to the study.

Dietary reform initiatives could begin in schools with stronger nutrition education programs, while agricultural subsidies could be reformed to favor healthy food production. Communities would receive support to attract grocery stores to food deserts, and stricter guidelines could be implemented for food marketing. Programs would be developed to make fresh produce more affordable and accessible to all communities.

Physical activity promotion would focus on designing communities that encourage walking and cycling, with expanded access to parks and recreation facilities. Safe routes to schools and workplaces could be created, and workplace fitness programs would receive support and resources. Community sports and activity programs would be developed to encourage regular physical activity across all age groups.

Cultural change would be addressed through programs promoting work-life balance to ensure people have time for exercise. Social determinants of unhealthy eating would be examined and addressed, while supportive environments for healthy choices would be created. Cultural norms around portion sizes could be challenged, and community-based wellness programs would be developed to support lasting lifestyle changes.

4. Build a Universal Primary Care System

Primary care serves as the foundation of an effective health care system, yet many Americans lack access to regular preventive care. Creating a universal primary care system could improve health outcomes and reduce costs.

The system would guarantee access to a primary care provider for all Americans, offering extended hours and same-day appointment availability when needed. Mental health services would be integrated into primary care settings, and comprehensive preventive care services would be readily available. Care coordination for complex conditions would ensure patients receive appropriate, well-coordinated treatment.

I discuss more about the details of a model like this in a past article.

Implementation could occur occur through the expansion of community health centers and the strategic use of telehealth technologies to reach rural areas. Mobile health clinics could bring care to underserved areas, while school-based health centers² would ensure access for children and adolescents. Team-based care models would be developed to maximize efficiency and effectiveness.

This transformed primary care system would enable earlier detection and treatment of health problems, while supporting better management of chronic conditions. Emergency department visits would decrease as people received appropriate care in primary care settings. Overall health outcomes could improve, and health care costs could decrease through prevention and early intervention. By making health insurance for catastrophic care only, this system may solve significant grievances experienced by Americans by reducing their interactions with for-profit insurers during routine care that represents the bulk of services.

5. Increase Healthcare Workforce Supply

Addressing the shortage of health care providers is crucial for improving access to care and reducing costs. This requires a multi-faceted approach to expanding the health care workforce.

One study by Macinko et al (2007) looking at this issue using data from 1980 to 1995 suggests the following:

“Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. This relationship held regardless of the year (1980–1995) or level of analysis (state, county, metropolitan statistical area (MSA), and non-MSA levels). Pooled results for all-cause mortality suggest that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year.”

Another recent study by Basu et al (2019) demonstrates similar results:

“Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.”

Medical education reform would focus on increasing medical school capacity and expanding residency programs. The educational debt burden for health care professionals would be reduced through additional public policy support programs and tax incentives. Training programs would be streamlined while maintaining quality, and alternative education models could be supported to create new pathways into health care careers.

Scope of practice regulations could be updated to allow non-physician practitioners to work at the top of their license, supported by team-based care models. The roles of nurse practitioners and physician assistants would be expanded, and new categories of health care workers could be created to meet evolving needs. Clear career advancement pathways could be developed to support professional growth and retention.

Importantly, burnout and workplace quality must be addressed to stem the loss of qualified health care professionals from leaving the workforce.

Conclusion

These five transformative ideas represent clear approaches to reforming America's health care system. While implementing them would require significant political will and resources, the potential benefits are substantial: lower health care costs, better health outcomes, improved access to care, enhanced prevention and public health, and more efficient health care delivery.

Success would require sustained commitment and coordination across multiple stakeholders, including government agencies, health care providers, insurers, and the public. However, the cost of maintaining the status quo – in terms of both financial resources and human health – makes such transformation important. The American public is becoming increasingly agitated with the lack of progress.

The path forward requires bold action and a willingness to fundamentally rethink how health care is delivered and paid for in America. By pursuing these five key reforms, we can create a health care system that better serves all Americans while controlling costs and improving the public’s health.

1. It is my humble opinion that, in addition to the Oxford Comma, we should be using the X:X ratio format more often because it is cool.

2. This is one of the most interesting areas to watch over the next ten years. This has been growing!