What’s Wrong with Medicine Today: My Perspective After Forty Years in the System

The State of American Medicine: A Physician’s Account | Part One

OPINION PIECE

Medicine is a sacred covenant between a person in need and a person with the knowledge and the willingness to help.

For most of human history, that relationship was the entire architecture. A patient came in, the physician examined, reasoned, and acted. Payment was direct. Accountability was personal and immediate. If the physician failed the patient, the patient knew it, and so did the community.

That system had limitations. Costs fell entirely on individuals. People without means went without care. Medicine before the mid-twentieth century had far less to offer, so that risk was lower than it would become.

The Accident That Became the Architecture

During World War II, the federal government imposed wage controls to contain wartime inflation. Employers, competing for scarce labor, found a way around it: offer health insurance as a non-wage benefit. The IRS eventually ruled these benefits tax-exempt. Congress codified the arrangement. Within two decades, employer-sponsored health insurance became the dominant model of coverage in the United States.

The structural consequence was this: the patient was no longer the payer, the employer was. And when the employer became the payer, the insurer’s client became the employer, not the patient. The insurer’s financial incentive shifted accordingly. Its obligation was to the entity writing the premium check. That entity’s primary interest was cost containment while optimal patient outcomes were sometimes secondary.

The patient, the only person whose health was actually at stake, became the party with the least power, the least information, and the least direct recourse in a transaction that existed to serve them.

The Physician as Buffer

When an insurer denied coverage for a treatment I believed was medically necessary, I was the one sitting across from the patient. I was the one who had to explain why a decision made by a reviewer I had never met, whose compensation was structured to reward denial, was going to override my clinical judgment. I was the one who absorbed the patient’s fear, confusion, and anger; not the insurer.

The physician was conscripted as the human buffer between financial decisions and their human consequences. The insurer retained the authority and externalized the moral weight. The physician retained the relationship but surrendered the authority.

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Fifty Years of Bipartisan Failure

Both Republicans and Democrats controlled Congress and the White House during periods when the insurance industry consolidated power and administrative costs expanded. Multiple attempts at reform addressed symptoms while leaving the incentive structure intact, because the financial interests that benefit from that structure fund both parties.

The Affordable Care Act extended coverage to millions of Americans. While this was not a trivial achievement, it did not restructure the three-party transaction. It did not change who the insurer’s client is. Administrative costs, documented by Himmelstein and colleagues in a 2020 analysis published in the New England Journal of Medicine, consume approximately 34% of total US healthcare expenditure, the highest proportion of any developed nation measured. That figure did not improve after 2010, it got worse.

The system’s failure is bipartisan in origin and bipartisan in persistence.

The Single-Payer Premise and What I Actually Saw

The standard response to everything I have described above is a version of the same proposal: remove the private insurer, have the government pay, and the misaligned incentives disappear. The argument has surface logic, and I understand why it is appealing.

Before you decide, let me tell you a story.

I trained in Puerto Rico’s public health system in the 1980s and 1990s. What I experienced was a single payer system on American soil, serving American citizens, and I watched it operate from the inside during my clinical training there.

Puerto Rico operates under a hybrid public model: Medicaid finances a large portion of the public system, the territorial government funds the remainder. For millions of residents the public system is the only option available.

What I witnessed during my training was a system where the promise of universal access and the reality of care delivery diverged. Understaffing was common, equipment was outdated and frequently non-functional. Specialist access required long waits that in a mainland private system would have been unacceptable. Patients who could find any other option used it. Those who could not waited, sometimes for care that arrived too late to matter.

The physicians and nurses I trained alongside were skilled, committed, and working under constraints imposed by the system. The government entity responsible for funding the public health system had finite resources and unlimited demands. The rationing that resulted was the unescapable consequence of an underfunded mandate.

After Hurricane Maria in 2017, the system’s deterioration became worse. Ayala-Rodríguez and colleagues writing in the American Journal of Public Health in 2018, described the collapse of public health infrastructure.

The VA system offers a parallel. It is the closest operational analogue to single-payer healthcare serving a defined American population. The Inspector General’s audit record on VA wait times, resource allocation failures, and administrative overhead is not contested. A 2020 audit by the VA Office of Inspector General on management of consult requests found systemic failures in how the VA tracked and fulfilled clinical referrals, resulting in care delays with direct patient harm implications.

I am not arguing the current system is preferable, but that replacing private insurance administration with government simply relocates where rationing decisions are made. It adds new bureaucratic structures with their own resource consumption. It introduces political oversight as a rate-limiting step on clinical and administrative modernization.

The Conversation We Have Never Had

Every healthcare system rations care. The United States rations by ability to pay, by insurance status, by geography, by the negotiating leverage of the employer writing the premium check. Single-payer systems ration by wait time, by formulary restriction, by the political priorities of the government administering the program. There is no system in which everyone receives every intervention that might benefit them. While resources are finite, demand is infinite.

The honest conversation this country has avoided is not whether to ration. It is how, by whom, and according to what values. Until that question is engaged directly, every proposed reform is avoidance dressed as solution. We argue about the mechanism of payment and leave the underlying question untouched, because the underlying question is genuinely hard and the political cost of engaging it is high.

I practiced medicine for forty years. I entered the profession because I believed that the patient in front of me deserved my full attention, my best judgment, and my unambiguous advocacy. I spent a significant portion of those years navigating a system that made each of those things harder than they needed to be, because of a structural architecture that was never designed by intention, honestly examined, and never seriously reformed.

I do not claim to have a solution. I am one physician, with one vantage point, and the problem is larger than any single vantage point can resolve. What I have is an account of how the system works, grounded in forty years of operating inside it.

Here is Part One of this series of assays, the entry point for a conversation we all need to have, leaving feelings, ideology and party politics out. By examining the data and the facts with an open mind and full intellectual honesty we will gain an understanding of the magnitude and complexity of this problem.

What you make of it, is the part I cannot write alone.

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