Reforming the healthcare system in the United States

Political circumstances are not favorable for making fundamental changes in our healthcare system, but I propose that we consider the problems generated by our current system and think about the benefits that would be derived with sensible changes.

With adoption of universal health insurance coverage, as with Medicare for all, we would save billions, even trillions of dollars; make our population healthier; benefit distressing social problems; and slow the relentless increase in our national debt. A survey of small business owners indicates that their number one problem is cost of healthcare. 

Our nation continues to spend more on healthcare than other countries and we get worse results. Healthcare expenditures in the US are about twice that of other industrialized nations whether measured in absolute dollars or as a percent of GDP. We are now close to 20% of GDP and our collective results are drifting further behind as measured by life expectancy, preventable deaths, infant mortality, or maternal mortality. Since 2017, average life expectancy in this country has decreased while it has advanced elsewhere. Our maternal mortality rate is 3 to 10 times higher. Even for the white population in this country, the infant mortality rate is more than in other nations.

About 35% of US healthcare funding is through commercial insurance, yet in the US we spend more tax dollars on healthcare than do other nations. Even so, we have more than 27 million people with no health insurance. It is projected that another 10-15 million people will lose their insurance with the effects of the “big, beautiful bill “ passed last summer. For those with insurance, co-pays and deductibles have tripled since 2006. 

Many politicians continue to emphasize individualism and the principle that people should work to earn the benefits of healthcare. Such a strategy is counterproductive to making healthcare cost-effective. It fails to accept that people have a wide variation in abilities and in starting opportunities. Unfortunately, there are many genetic disorders causing lifelong problems and healthcare expenses. 

For us to adopt a single party payer system we would decrease our expenses and improve our collective health. Polls show that the majority of people in the USA favor such a system, and recently most physicians do as well. The proposed system is not socialized medicine, and the doctors could retain their independence. In contrast to commercial insurance, patients would be free to choose their hospital and their doctor. 

Such a system would need to confront budgetary reality and limit coverage for some aspects of healthcare. It would provide basic care for all, but have some care paid for by either supplemental insurance or out-of-pocket.

Other industrialized nations have health insurance for all their citizens by different methods. Some have government-owned hospitals and salaried physicians, but other nations require citizens to have health insurance, with doctors and hospitals retaining a degree of independence. None of these countries have for-profit health insurance. None of them have healthcare CEOs with annual compensation ranging up to $450 million, as we do in the USA.

Administrative expenses in the US are 30–35% of healthcare dollars. In Taiwan it’s 1.6%. Duke Hospital with 957 beds has 1600 billing clerks. In Canada the University of Toronto Hospital with 1272 beds has 7 billing clerks. To expand the existing Medicare program to cover all people can be done with less overall administrative burden.

Current political debate focuses on whether the subsidies for health insurance should go to patients or to the insurance companies. Other aspects of the political arguments also avoid some fundamental changes that are needed. 

We could take steps to diminish the profit motive involved in our system. For-profit health insurance creates a moral contradiction. Why should a company derive its profits and pay its executives millions of dollars annually by limiting healthcare for its insured clients? Certainly, capitalism has made major contributions to the success of our nation, but in some aspects of healthcare it is contrary to professional ethics and should be reined in. 

We resist learning from the experience of multiple other nations with a fraction of our cost, yet better health outcomes. Most notably they do not have for-profit health insurance. Another consideration is to recognize that only two countries in the world, the US and New Zealand, allow direct to consumer advertising. Pharmaceutical companies spend significantly more on marketing than they do on research and development. In 2025 American pharmaceutical companies spent more than $30 billion advertising their products.

An independent appraisal in North Carolina done a few years ago verified that having patients established with a medical home (that is, a primary care provider) generates significant cost savings and better health quality metrics than do large national managed care organizations.

We currently spend about 25% of our healthcare funds on inefficient healthcare for homeless people. A recent analysis in Wake County revealed that with a homeless population of 1,258 (0.1% of the population) their healthcare costs consumed 27% of healthcare dollars for the county. The homeless utilize emergency departments for their medical home and are admitted to the hospital much more frequently. An emergency room visit costs more than 10 times that of a medical office visit, and hospitalizations typically range in the tens of thousands of dollars or sometimes much more. If homeless people had insurance and a primary care provider, we would derive tremendous savings in the funds spent for emergency room visits and hospitalizations for the homeless. 

Another aspect of care with the potential for significant savings is at the end of life. So often we resort to highly expensive technology in a futile effort to delay death. Far more humane and even comforting is hospice care which contributes to death with dignity and savings of a huge amount of money.

Analysis of data shows that the outcome for our health is about a 20% impacted by the healthcare system, with the other 80% by social determinants of health. Such social factors include housing, access to healthy foods, and poverty. If we used a small portion of tax dollars to ensure adequate housing for all people in our country, we would generate savings in healthcare costs with dramatic improvements in health metrics. We already allocate tax dollars generously to home owners through tax deductions for mortgages and property taxes. 

A system of universal insurance coverage, as with Medicare for all, would have a highly beneficial effect on the incidence and the pain of poverty. About 60% of bankruptcies have medical expenses as a causative factor. About 100 million Americans are making monthly payments on their medical debt. 

Since 2017 the average life expectancy in the US has been declining. Such a sad phenomenon has not been the case in other industrialized countries. Health economists have determined that such a tragic trend is attributable to an increase in deaths of despair in our country. These deaths are from overdoses with recreational drugs, alcoholic liver disease, and suicides. If all of our citizens had health insurance and connectivity with a primary care physician, the incidence of these tragedies should decline sharply. 

To accomplish major improvements in our current system, we need to make some fundamental adjustments. We could learn from other nations’ more effective use of healthcare expenditures. Our democratic country could make changes to provide universal insurance coverage, decrease costs for health care, and improve health outcomes. Such measures would also make for a better quality of life and more collective happiness.

R Robert Bilbro has had a career practicing internal medicine and cardiology in Raleigh, being a cofounder of Raleigh Medical Group. He has served as president of the medical staff at WakeMed and was president of the Wake County Medical Society. He currently serves as coordinator of the clinics at Healing Transitions, in which volunteer physicians help with medical care for the clients of Healing Transitions.