Problems

About 28 million people (8.2%) were uninsured in 2024. They delay care, use emergency rooms as a safety net, and leave hospitals with uncompensated costs that are shifted onto everyone else.

Coverage changes with jobs, income, age, marriage, and moves. Each switch can mean new networks, new deductibles, interrupted treatment, and paperwork. Medicaid redeterminations removed about 25 million people in 2023–24, many for paperwork reasons.

About 178.6 million people get coverage through work. Leaving a job, starting a business, retiring early, or cutting hours can mean losing insurance.

High deductibles and coinsurance mean many insured people avoid care. Average single deductibles in employer plans are about $1,800, and out-of-pocket maximums reach $9,200 single and $18,400 family (2025).

Plans cover only listed providers; directories are often wrong ('ghost networks'). Seeing an out-of-network doctor, sometimes without knowing it, can mean large bills.

Undocumented immigrants are excluded from most coverage; lawful immigrants face waiting periods. Care comes through ERs, community health centers, and Emergency Medicaid, often late and expensive.

About 3.5 million U.S. citizens and nationals live in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands. Federal Medicaid money there is capped each year instead of open-ended, Medicare works differently, and funding depends on temporary laws that keep expiring.

About 4 in 10 adults have health care debt. Debt leads people to skip further care, damages credit, and is a leading contributor to personal financial distress.

A family premium averages $26,993 (2025), the same whether the worker earns $50,000 or $500,000. Employers pay most of it out of compensation that would otherwise be wages.

The same service can cost wildly different amounts at different places, and the price depends on the insurer's secret contract. Price-transparency rules exist but are hard to use and inconsistently followed.

The No Surprises Act protects patients from many surprise bills, but the arbitration process for provider-insurer disputes exploded to 1.42 million disputes in 2024 (versus 17,000 expected), mostly filed by private-equity-backed groups, and providers win about 85%. Ground ambulances are not covered.

Nearly one in five insured adults had a claim denied in a year. Few appeal, though many appeals succeed. Denials shift costs to patients and providers.

Insurers require approval before many treatments. Physicians say it delays care and causes harm; practices spend about 12 hours a week on it.

Private Medicare plans are paid more when enrollees look sicker on paper, which rewards aggressive diagnosis coding. MedPAC estimates MA costs about 20% more than traditional Medicare for similar people.

The net cost of private health insurance (premiums minus benefits) was $176.5B in 2024, about 10.7% of private premiums of $1,644.6B. It covers claims processing, networks, utilization management, marketing, broker commissions, taxes, and profit.

Three PBMs handle about 80% of prescriptions. Rebates tied to list prices reward higher list prices, spread pricing hides margins, and PBM-owned pharmacies dominate specialty drugs.

The U.S. uses about as much care as peer countries but pays much more per unit: hospital stays, physician fees, drugs, devices, and administration all cost more.

Hospital systems have merged into regional near-monopolies and bought physician practices, raising commercial prices without clear quality gains.

Private-equity firms buy physician practices (anesthesia, dermatology, emergency medicine, gastroenterology), nursing homes, and hospices, often raising prices and cutting staff.

When a hospital owns a clinic, it can charge a facility fee on top of the physician fee for the same visit, which encourages hospitals to buy practices.

Nonprofit hospital systems are tax-exempt but pay CEOs about $1.3 million on average, and community-benefit spending varies widely.

Drug prices reflect market exclusivity, not production cost. Insulin costs roughly $2–6 a vial to make, yet U.S. list prices ran to hundreds of dollars before recent caps.

Manufacturers file many secondary patents to extend monopolies. Humira had 247 U.S. patent applications, 89% after approval; biosimilars reached Europe in 2018 but the U.S. only in 2023.

The industry spent $83B on R&D in 2019, about a quarter of net revenue, and developing a new drug costs roughly $1–2B+ including failures. Lowering prices lowers expected returns and the number of new drugs.

Shortages hit a record 323 in early 2024, about half sterile injectables such as chemotherapy and crash-cart drugs. Generic prices are so low that few factories make them, so one plant problem causes national shortages.

Independent and chain pharmacies are closing, squeezed by PBM reimbursement; rural and low-income urban areas lose access.

181 rural hospitals closed between 2005 and 2022, and hundreds more are at risk. Low volume, a high share of uninsured and Medicaid patients, and staffing shortages make them unprofitable under per-service payment.

Over a third of U.S. counties have no maternity care. Obstetric units close because births are low-volume and Medicaid (which pays for about 41% of births) pays little.

About 75 million people live in primary-care shortage areas, and about 137 million in mental-health shortage areas.

Missed appointments from lack of transportation are common; ground-ambulance bills are not covered by surprise-billing protections; rural EMS services are closing.

AAMC projects a shortage of up to 86,000 physicians by 2036. Residency slots funded by Medicare have been largely capped since 1997, and primary care pays far less than procedures.

Median medical school debt is about $200,000, and residents earn about $70,000 for 3–7 years. High debt pushes graduates toward high-paying specialties and away from primary care and rural practice.

There are 3.38M registered nurses and about 4.3M home health & personal care aides, but turnover is high, aides earn about $36,000, and nursing schools turn away qualified applicants for lack of faculty.

Clinicians spend hours a day on documentation, billing codes, and prior authorizations, which drives burnout and early retirement.

Nurse practitioners (323,000), physician assistants (162,000), pharmacists, and dental therapists are trained to do more than many states allow.

The U.S. has the lowest life expectancy among high-income peers and ranked last overall in the Commonwealth Fund's 2024 comparison, while spending about twice as much per person.

U.S. maternal mortality is the highest among wealthy countries, with large racial gaps; Medicaid postpartum coverage historically ended at 60 days.

Failures of care delivery and coordination waste an estimated $129–244B a year and cause preventable harm.

Access and outcomes differ sharply by race, income, and place, partly because Medicaid pays less and providers prefer better-paying patients.

Liability costs about $55.6B a year (2008 dollars), mostly defensive medicine, yet most injured patients are never compensated.

Roughly a quarter of spending is administration: billing, claims, coding, credentialing, prior authorization, and plan management across thousands of payers and plans.

Billing clerks, coders, insurance verification staff, claims adjusters, and brokers make up a large workforce. Simplification removes their jobs.

Tests and treatments with little benefit (imaging for routine back pain, some screenings, end-of-life interventions patients don't want) cost an estimated $76–101B a year.

Fraud is estimated at 3–10% of spending. Medicare's fee-for-service improper payment rate was about 7.7% in FY2024, mostly documentation errors.

About 137 million people live in mental-health shortage areas; many therapists and psychiatrists don't take insurance, and only about a third of psychiatrists accept new Medicaid patients.

Overdoses kill tens of thousands each year; treatment with buprenorphine and methadone is restricted, and coverage gaps interrupt treatment.

Medicare doesn't cover long-term care; Medicaid does only after people exhaust their savings. Hundreds of thousands wait for home-care services.

Many nursing homes are understaffed, increasingly private-equity owned, and paid below cost by Medicaid; quality and safety problems persist.

Medicare spent $25.7B on hospice in 2023 for 1.7 million people. Rapid entry of for-profit hospices has brought fraud concerns and patients enrolled who aren't dying.

Traditional Medicare excludes dental, routine vision, and hearing aids; adult Medicaid dental varies by state; dental is the care most often skipped because of cost.

Public health was $157.6B of $5.28T in 2024 (about 3%). Chronic disease (diabetes, heart disease, obesity) drives most spending.

Social conditions shape outcomes more than medical care, yet health systems have few tools or funding streams to address them.

Records are scattered across incompatible EHRs; tests are repeated and information is lost between providers.

The 2024 Change Healthcare ransomware attack disrupted claims nationwide for weeks and exposed data on a large share of Americans.

Health data is shared widely for payment, research, and marketing; sensitive data (reproductive, mental health, immigration) can expose people to harm.

When care becomes free and universal, use rises. If supply doesn't grow, people wait, as in Canada (median 28.6 weeks from referral to treatment) and the UK (7.4 million on the waiting list). People with good employer coverage today, who are seen fastest, notice most.

Where private insurance or cash practice exists alongside a public system (UK, Australia, Germany), those who pay get faster care, and providers' time shifts to them.

A publicly funded system competes with other spending every budget cycle. The UK's NHS waits rose sharply after a decade of slow funding growth.

Centrally planned capital budgets tend to under-invest; Canada has far fewer MRI and CT units per person than the U.S.

Systems with strict value assessment (UK NICE, Germany AMNOG, NZ PHARMAC) pay less but sometimes delay or refuse new drugs; lower U.S. prices would reduce global R&D.

Cutting payment toward Medicare levels would reduce revenue for specialists and commercially dependent hospitals; some may retire, opt out, or close.

Ending private insurance as primary coverage would displace about 975,000 administrative jobs (site estimate), end the core business of insurers and PBMs, and change coverage for about 178.6 million people with employer plans.

A single national payer concentrates fraud risk and cyber risk; improper payments of 7.7% at national scale would be about $300B.

With one public payer, people can't switch plans if they dislike how their coverage is run, and insurers no longer compete on service, care management, or extra benefits.

Public financing replaces premiums and out-of-pocket costs with taxes. Total spending may fall, but taxes become larger and more visible, change incentives to work and invest, and fall on different people than premiums did.

When employers pay a payroll tax instead of premiums, firms that used to offer coverage save money, but firms that didn't (often low-wage, small, or gig) face a new cost that tends to come out of wages over time.

Any point-of-care charge requires billing, collections, exemptions, and caps, and even small charges deter low-income patients more than others.

When one public body decides which treatments are covered or worth their price, every 'no' becomes a national controversy, and patients have no other insurer to turn to.

Global budgets cap spending, but if demand exceeds what the budget pays for, hospitals may limit operating-room time or slow elective work near the end of the budget year.

Capitation and bundled payments remove the incentive to over-treat, but create an incentive to under-treat, avoid sick patients, or refer costly cases elsewhere.

If a single buyer sets prices too low, manufacturers may not launch products, generic makers may stop producing, and providers may leave or limit services.

Publicly funded R&D or prizes put research priorities in government hands, which may underfund risky ideas or be swayed by politics.

Expanding what nurse practitioners, physician assistants, pharmacists, and dental therapists can do adds capacity, but some studies and physician groups raise concerns about over-prescribing, more referrals, and missed diagnoses.

Minimum nurse or aide staffing levels improve safety, but cost money and, during shortages, may force facilities to close beds or shut down.

If home care becomes covered, families who now provide care for free may switch to paid aides, raising costs far above today's spending (the 'woodwork effect').

Covering undocumented immigrants adds cost and, critics argue, could attract migration; leaving them out keeps emergency-room care and public-health gaps.

Wait-time guarantees, quality bonuses, and spending targets can be gamed: re-labeling referral dates, avoiding sick patients, or upcoding.

A national program takes over Medicaid from states, which changes who pays and who decides, and creates winners and losers between states.

The path costs more to run, or removes a limit on prices, spending, or use. This matters most when budgets are tight and the added care brings little benefit, and less when the extra spending buys care that is worth it.

Costs or disruption come first and benefits arrive later. This matters most when needs are urgent or funding may not last through the transition, and less when a gradual change is acceptable.

The approach depends on checking compliance and responding when rules are ignored or evaded. Its burden is greater when oversight is weak or affected organizations can readily change their behavior to avoid the rules.

The approach cannot deliver its intended benefit without complementary changes or sustained participation. This is a serious limitation when those conditions are absent and less so when they are already in place.

The path helps some people or places but not others, or offers partial relief. This matters most when it is treated as a complete fix, and less when it is one part of a broader response.

The approach can leave some plans covering a more costly mix of patients. This matters when payments do not account for those differences and is less serious when risk is shared adequately.

Eligibility rules and allocation measures may miss intended recipients or favor people who need less help. The cost is greater when these mismatches persist and smaller when rules can be corrected.

Affected groups may oppose the path, and it may invite legal disputes over authority or obligations. This matters when opposition blocks or weakens the policy, and less when there is durable agreement.

The approach reduces payments, earnings, or business for some participants. This matters most when they cannot readily adjust and less when the loss can be absorbed without disrupting needed services.

The path narrows options for patients, workers, or organizations, or sets one rule that fits some places poorly. This matters most when the remaining options don't meet people's needs, and less when adjustments are allowed.

The approach depends on building, integrating, or updating information systems. The burden is greater when implementation is difficult or failures interrupt the work those systems support.

The approach requires decisions where evidence is incomplete or outcomes are hard to assess. This matters most when mistakes are difficult to reverse and less when decisions can be reviewed as evidence improves.

The approach reduces the information available for oversight, research, or decisions. This matters most when missing or uneven data obscure important differences and less when the remaining information is sufficient.

The approach depends on people adapting to new roles or skills that may not match their previous work. This matters most when suitable opportunities or support are limited and less when workers can make the transition successfully.

The approach leaves funding exposed to budget pressure or ties resources to rules that can become unsuitable. This matters most when funding cannot adapt to changing needs and less when commitments remain adequate and flexible.

The approach narrows the compensation or routes to compensation available to injured patients. This matters most when serious harm leaves substantial unmet needs and less when adequate support remains available.

The approach can leave care responsibilities unevenly distributed within families. This matters most when caregivers lack support or choice and less when responsibilities are shared on acceptable terms.

The path adds rules, verification, accounting, or coordination between organizations, which can slow legitimate payments or confuse patients. This matters most when procedures are complicated or staff are scarce, and less when they are simple and well run.

The approach depends on monitoring activity or quality that is difficult to observe or interpret. This matters most when problems can persist without detection and less when oversight can identify and address them.

The approach weakens a signal or reward intended to influence behavior. This matters most when the behavior is essential to the policy and less when other motivations or safeguards are sufficient.