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american health care remains broken.

  • Writer: Josiah Pearlstein
    Josiah Pearlstein
  • 6 days ago
  • 4 min read

Updated: 3 days ago

chatpastel art for 'american healthcare remains broken.'

Most Americans don’t avoid the doctor because they misunderstand health care. They avoid it because they understand it. They know what follows an appointment: a bill that arrives weeks later, a charge insurance declines, an explanation of benefits that obscures more than it clarifies. Over time, that pattern teaches people something practical. Seeking care comes with financial and administrative risk.


That reaction follows from how American health care is organized and how risk is distributed inside it.


It became easier to see during a recent congressional hearing, when Alexandria Ocasio-Cortez questioned executives from CVS Health. In a short exchange, she pointed out something patients are rarely told directly. CVS operates across insurance, primary care, pharmacy access, and the pharmacy benefit manager that decides which medications are covered and how they’re priced.


When insurance approval, drug pricing, pharmacy access, and primary care sit inside the same corporate structure, patients move through a tightly managed system. The confusion people experience reflects how consolidation shapes their path through care.


American health care runs through overlapping providers, rules, and billing systems. Those layers pull patients into paperwork, phone calls, and approvals, while the organization of power stays mostly out of view. What patients experience as chaos is actually a system that operates with a high degree of internal consistency.


One reason for that consistency is the role of pharmacy benefit managers. PBMs decide which drugs insurers will cover, which pharmacies patients are steered toward, and which medications suddenly become unaffordable. When the same company controls the insurer, the pharmacy, and the benefit manager, those decisions follow financial logic first. Medical judgment arrives later, translated through coverage rules and cost controls.


A doctor writes a prescription, insurance steps in, and an alternative is approved instead. Patients experience this as a clinical decision because that’s how it’s presented. What’s actually happening is a cost decision made earlier in the chain, long before the patient is involved.


For people inside the system, the effects add up quickly. A delayed refill turns into multiple phone calls. A prior authorization stalls care for weeks. Eventually, an appointment that was meant to prevent a problem starts to feel optional, not because the care isn’t needed, but because the process surrounding it has become exhausting and unpredictable.


Health care is structured like a market that assumes people have time, flexibility, and energy to spare. It works best for patients who can delay care, compare options, and switch providers without consequence. For anyone managing ongoing treatment or something urgent, that assumption falls apart. Choice narrows into compliance as the room to maneuver disappears.


Framing outcomes as personal choices shifts responsibility onto patients. Missed care looks like a failure of follow-through rather than a rational response to friction. Harm becomes individualized, while the structure that produces it stays insulated from scrutiny.


From the system’s perspective, none of this registers as failure. Rising prices, delayed care, and patient confusion don’t interrupt operations. They help maintain them. As people abandon appeals, postpone treatment, or stay with familiar providers because alternatives feel risky, resistance fades. Improvement becomes unnecessary because the system continues to function as designed.


Vertical integration is often sold as efficiency. In practice, it allows profit to be collected at multiple points along the same patient experience. Prior authorizations expand, formularies narrow, and prices change without warning, leaving patients to absorb instability while corporations collect the revenue. The incentives reward delay and cost shifting, not care.


Health care also operates differently from other consumer spaces. People enter it while sick, injured, exhausted, or aging, when their leverage is already limited. Administrative burden compounds that vulnerability. Time spent on hold, navigating portals, filing appeals, and tracking paperwork quietly determines who keeps moving forward and who falls behind.


Even insured patients begin delaying appointments, rationing prescriptions, or avoiding questions because the process drains more energy than they have. Medical debt builds the same way. Not in a single moment, but through repeated friction that wears people down until pushing back stops feeling possible.


Surprise billing and unaffordable medication are now routine. Less visible is the structure beneath those experiences. Many people still don’t know what a pharmacy benefit manager is, or that the same organization denying coverage may also benefit from the alternative it offers. The system gets labeled complex, but it operates through a consistent pattern of extraction.


The congressional hearing helped clarify a structure that has been shaping patient behavior for years.


American health care stays trapped in this pattern because people adapt to it quietly. They learn when to stop asking questions, when to delay care, and when to absorb costs rather than fight them. As long as the system rewards exhaustion and compliance, it doesn’t need to change. It only needs patients to keep adjusting their lives around it.


references.


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