John W Beck, PhD

Problem Statement

The U.S. does not operate a true "universal healthcare" system today. What Americans experience instead is a patchwork of employer plans, public programs, and individual-market coverage that is expensive, unstable, and administratively hostile - so the "problems with UHC in the USA" that impact Americans are really the problems caused by the lack of universality + fragmentation.

1. The harms Americans actually feel
   1. Financial Harm: paying more, getting less security
      • The U.S. spent $5.3T on health care in 2024 ($15,474 per person, 18.0% of GDP) - yet still leaves millions uninsured and many more underinsured.
      • For working families, job-based coverage is increasingly unaffordable: average family premium ~$26,993/year (2025) with workers paying ~$6,850 out of pocket just for premiums (before deductibles/copays).
      • Medical debt remains widespread and destabilizing: 41% of adults reported some form of health care debt in 2022 (broad definition including debt on cards/loans/family).
        o Separate household-data research finds 36% of U.S. households had medical debt in 2024.
      Impact on the People: bills that do not match expectations, postponed care, drained savings, delayed retirement, delayed home ownership, and chronic stress.
   2. Coverage Harm: people fall through cracks-and many live on the edge
      • In 2024, 27.2 million people (8.2%) were uninsured; among adults 18-64, 11.6% were uninsured.
      Impact on the People: a job change, divorce, paperwork glitch, or income swing can mean losing access to doctors, medications, and continuity of care.
   3. Care delays and denials: "insured" is Not the same as "treated".
      • Prior authorization is a major driver of delayed care. In a national physician survey, 94% reported that prior authorization delays access to necessary care, and 24% reported it led to a serious adverse event for a patient (including hospitalization, permanent impairment, or death).
      • The HHS Office of Inspector General found that Medicare Advantage organizations sometimes denied or delayed services that met Medicare coverage rules-raising beneficiary access concerns.
      Impact on the People: cancer workups, imaging, surgeries, specialty referrals, and even basic therapies can get stuck in weeks of bureaucracy-or never happen.
   4. Geographic Harm: access depends on where you live
      • Rural hospital closures and conversions have been substantial; the UNC Sheps Center for Health Services Research reports 152 rural hospital closures/conversions since 2010 (with definitions separating complete closures vs. converted closures).
      Impact on the People: longer drives for emergency care, maternity services deserts, fewer specialists, and weaker local economies.
   5. Drug-price Harm: Americans pay far more for the same medicines
      • RAND Corporation estimates U.S. prescription drug prices average 2.78x those in peer countries (2022 data).
      Impact on the People: Rationing medications, worsening chronic disease, avoidable complications, and higher insurance premiums.
   6. Workforce/capacity Harm: even "coverage" can not fix shortages by itself
      • Association of American Medical Colleges projects a physician shortage of up to 86,000 by 2036 under multiple scenarios.
      Impact on the People: longer waits, delayed diagnoses, and overloaded primary care—especially in rural and low-income communities.
   7. Equity Harm: the system performs worst where it should protect people most
      • The Commonwealth Fund reports the U.S. ranks lowest overall among peer countries on measures including access, equity, and outcomes-despite the highest spending.
      • It also documents large state-by-state differences in access, affordability, outcomes, and equity.
      What that means for people: your income, race, and ZIP code remain powerful predictors of whether you get timely care—and whether you live longer.
2. Root causes (why these harms persist)
   1. Fragmented financing and eligibility (multiple payers + different rules) --> gaps, churn, and administrative burden.
   2. Weak price discipline in key markets (hospital prices, specialist pricing, drugs) → spending rises faster than wages.
   3. Administrative complexity as a business model (billing overhead, prior auth, denial management) --> time costs, burnout, delayed care.
   4. Coverage churn baked into program design (renewals, redeterminations, paperwork) --> interruptions in meds and care.
   5. Capacity constraints (workforce shortages, rural infrastructure fragility) --> coverage ≠ access.
3. 3. What these problems imply as UHC design requirements
   If a U.S. "universal" plan does not meet these, it will reproduce today's pain under a new label:
   • Automatic enrollment + no gaps (coverage is the default, not an application).
   • Portability (job change/divorce/income change does not break your care).
   • Continuous eligibility rules (especially for children and low-income adults) to reduce churn.
   • Standardized/admin-minimized operations: one eligibility interface, standardized claims, strong electronic standards, and strict timelines.
   • Prior authorization reform or replacement (narrow scope, real-time decisions, transparency, independent review).
   • Drug price discipline aligned with peer-country purchasing power.
   • Rural stabilization (facility support + transport + workforce incentives).
   • Workforce expansion plan (GME, loan repayment, scope-of-practice alignment, primary-care capacity).
   • Household protection: cap out-of-pocket exposure, reduce surprise billing risk, and eliminate medical-debt drivers.
4. Suggested "success KPIs" (testable, people-centered)
   Use these as acceptance criteria for a UHC transition:
   • Uninsured rate and underinsured rate (trend + subgroup equity).
   • Household medical debt prevalence and past-due medical bills.
   • Average family premium-equivalent burden (as % of median household income) and out-of-pocket max exposure.
   • Median time-to-appointment for primary care, mental health, and key specialties (by county).
   • Prior authorization denial rate, turnaround time, appeal reversal rate, and adverse-event reports.
   • Rural access metrics (distance/time to ED, L&D availability, closure risk).
   • Per-capita spending growth vs. wage growth (and administrative cost share).