What I Perceive as Weaknesses in the U.S. HealthCare System:
An Analysis from a Personal Point of View
By Samantha Bean, High School senior, Vermont
My mother has an autoimmune disorder and was diagnosed at 4 years old. There is still no cure for autoimmunity, so it has been a 46-year-long process of appointments, labs, tests, scans, procedures, and surgeries. Doctors she has seen have not given her a diagnosis or clear course of treatment, so she lives day to day, just trying to manage her pain and symptoms. From the experience of a daughter who has been along this journey with her, I have seen how inefficient and unaccommodating the healthcare system can be and want to share my insight and experience.
As a citizen wanting to take action with any issue, I believe it is important to first educate myself about what is already being done.
In July of 1965, President Lyndon B. Johnson signed the Medicare and Medicaid Act, also known as the Social Security Amendments of 1965. It established both Medicare and Medicaid health insurance programs for the elderly and people with low income. Next, the Affordable Health Care Act is a comprehensive health reform law enacted in March of 2010. Its goal is to make affordable healthcare available to more people, provide consumers with subsidies, expand the coverage of adults below 138% of the federal poverty level, and support innovative medical care delivery methods to lower the cost of healthcare.
An important program in place is the Hospital Readmission Reduction Program (HRPP). This program, under the Affordable Care Act Initiative, requires centers for Medicare and Medicaid Services to reduce payouts to care facilities that experience excessive patient readmissions.
Finally, an important foundation to recognize is the Commonwealth Fund. This foundation supports independent research on health care issues and makes grants to promote better access, improved quality, and greater efficiency in health care, particularly for society’s most vulnerable: people of color, low income, and the uninsured.
Overall, it seems that what is being done is not accessible to all people. The programs, acts, and foundations claim they reduce healthcare costs and give people access to health care, but a research study by the Commonwealth Fund showed that from “March 28 through July 4, 2022, 43% of working-age adults surveyed were inadequately insured. This figure includes “…23% that were underinsured where their benefits did not give them access to affordable care.” There are many reasons for this, but one includes how health care providers are unwilling to run into obstacles when trying to bill Medicaid or Medicare, leaving only a handful of doctors that accept this type of insurance. Various surveys, like one by the Medicaid and CHIP Payment and Access Commission (MACPAC), showed that providers are significantly less likely to accept Medicaid or Medicare. This specific study showed that physicians were less likely to accept new patients insured by Medicaid or Medicare, an average 64.75% acceptance, compared to private and much more expensive insurance, 90% acceptance (MACPAC June, 2021).
As a part of my research, I interviewed a physical therapist that works in the Sarasota, Florida area. He has worked as a private physical therapist who does not accept insurance and controls his own rates. But, he has also worked as a physical therapist at a hospital, where he often saw first hand how insurance coverage affected patients’ care. The therapist tries to make his practice more accessible for most people who may need his help. He keeps his prices at a level that he is comfortable charging, even though there are providers that charge significantly more in an attempt to attract high earning clients. He is also building a digital service into his practice that reduces costs without sacrificing quality of care for people who have undergone ACL* surgery. In doing so, he can charge lower rates while delivering a great outcome for his clients, which makes it a feasible option even for those who do not make a lot of money.
In my interview, the physical therapist said that a weakness of the healthcare system is that the quality of care seems to be highly variable from one hospital to the next, and even from one provider to the next. The quality of care, he says, is also dependent on your insurance coverage and your ability to pay for the care you need. He says that insurance companies make themselves a “middleman” in healthcare payments and make massive profits in that role. They have the ability to promote or approve certain procedures and reject payment for others, which takes some of the power of decision-making away from the provider and patient, sometimes with minimal regard for the best interest of the customer or patient. He also says that the added administrative workload that insurance places on the healthcare system comes with huge costs. He recognizes the need to ensure that the healthcare system is not overwhelmed with unnecessary services, but there are huge barriers and costs introduced in these processes. He has “more questions than clear answers, but when I see the profits that insurance companies pull in by acting as gatekeepers in healthcare, I have to wonder if all that money could be put to better use in other hands.”
I think this was a really important part of this interview. With any issue, progress will not occur without asking questions, doing research, and recognizing what is already being done. As an active citizen, it is important to recognize this. Like I mentioned before, I am not writing to propose a solution. I am writing to express my concerns and share some insight I have gained with my personal experience.
While I have been an active part of my mom’s experience, especially in the last few years, there are many elements of her story that I was unaware of. So, I asked her a series of general and personal questions about her experience and what she thinks the weaknesses in the healthcare system can be. Because of her extensive experiences, she provided insight on what she thinks would shift our healthcare system to being stronger, efficient, and accommodating for all people.
It is still undetermined what health, environmental, societal, cultural, or dietary factors can affect or cause autoimmunity. Her experience as a patient and the research she had done has informed her opinion that there is a mind-body connection that doctors could be overlooking. The Myth of Normal, a book by Dr. Gabor Maté, emphasizes how the problem is that doctors are not educated on the mind-body connection, as it would force them to go beyond medical history and break boundaries of treatment protocol. Currently, there are only short-term solutions to autoimmune symptoms, symptoms that are very diverse and unpredictable. This also results in duplicated tests that end up costing a significant amount of money. In her experience, autoimmune disorder patients are tossed around from doctor to doctor, not getting any closer to how the patient feels and what might be going on, making patients feel like their experience is not valid or real. In this way, doctors project their own inadequacy.
She made an interesting point about a “team approach” when it comes to doctors’ care. When someone is diagnosed with an autoimmune disorder, regardless of doctors understanding, there should be more communication rather than just sending patients to specialists who are unable to see the big picture behind what is going on in the body.
Next, we discussed the costs of insurance and treatments. She most often pays for tests and procedures with cash and she recognizes that this is a privilege, however; her insight shows her knowledge on both sides, as in recent months, she has had to use Medicaid for increased tests and procedures. Interestingly, when paying cash, she was scheduled right away because it guaranteed a direct payment. With insurance though, she first has to find somewhere that accepts her insurance and get authorization from the insurance company, even if the doctor orders it. Even after all of this, insurance companies have the right to say they will not pay for something. The medical system, unfortunately, has proved to be a money-making business where your level of insurance or ability to pay cash determines your level of care. Insurance costs only become expensive if you become sickly, as it is more profitable to keep people sick.
Who’s keeping the doctors accountable for their level of care based on your ability to pay? Micheal Pollan, the narrator of the documentary, Food Inc., said in his book, In the Defense of Food, that “much lip service is paid to the importance of prevention, but the healthcare industry, being an industry, stands to profit more handsomely from new drugs and procedures to treat chronic disease than it does from a wholesale change (Pollan, M., In the Defense of Food, 2008).”
Another point my mom made was that with no underlying illnesses and only regular checkups, a person may spend $2,000 a year on the care itself, but their insurance premium alone is probably close to $1,000 a month. Where is all that money going? When you pay cash, prices are significantly less than they pay with insurance. A fee should be a fee, but since insurance is a business, patients are often treated like business propositions, not human beings. Furthermore, why do pharmacies charge differently? With GoodRX, you can save up to 80% on your prescriptions. Where is the money difference being absorbed and who is getting paid?
My mother’s insight is significant because even outside of being an autoimmune disorder patient, she has noticed the weaknesses in the healthcare system as a whole. Talking specifically about food and nutrition, an interesting point she made was how health should be followed like a story. Doctors need to be educated to treat people from the very beginning about a healthy lifestyle. If we are what we eat, how can we be healthy if we are not taught from the beginning how to maintain a healthy diet?
Another point that Micheal Pollan made in his book was how chronic diseases are often affiliated with genetics or demographics, “however; the Western diet and lifestyle, and more specifically, industrialization, has heavily affected the rates of chronic disease like cancer and heart diseases.” This implicitly brings up the idea of how we might be too concerned with supporting a system that is broken rather than strengthening the system from the ground up to promote health and care for all people. Are we more focused on sustaining people’s health or short-term treatments for their medical problems?
There is clearly a problem, and I think it is my right to question what is being done, or more yet, what is not being done. I believe this is a critical issue that affects far too many people. But in order to progress, it is crucial that we look logically at what is happening in our healthcare system. It is time to strengthen the system and get to the root of the problem, rather than making short-term fixes that only support the system as it is.
By Samantha Bean, High School Senior, Vermont.
*ACL: The anterior cruciate ligament (ACL) is one of the key ligaments that help stabilize the knee joint. ACL is commonly torn during sports that involve sudden stops and changes in direction.
