My suggestions, as a practicing physician, to fix critical problems with the USA healthcare system
Donald Harvey Marks, M.D., Ph.D.
Emeritus Fellow, American College of Physicians
Key points: to fix critical problems with the USA healthcare system
Require all USA residents to have health insurance coverage
Drop the Medicare age to 55 and expand Medicaid to all states
Require all healthcare providers including doctors, dentists, psychologists, chiropractors to accept all forms of health insurance, including Medicaid
Medicare Medicaid and all private health Care funds will have the right and ability to arbitrate and bargain their fees with providers
Expand the medical provider Network to include doctors, nurse practitioners, Physicians assistants, advanced trained RNs, and pharmacists
Reduce the number of persons who are not entitled to be in the USA but who are receiving uncompensated healthcare.
Abstract
The United States healthcare system faces a dual crisis of unsustainable spending and suboptimal outcomes. Despite spending nearly one-fifth of its GDP—approximately $4.8 trillion in 2023—on healthcare, the U.S. ranks last among ten high-income nations in health equity, access, and outcomes. I propose a cogent, six-point reform strategy designed to restore systemic health by mandating universal participation, lowering the age of federal coverage, expanding the provider network, and drastically reducing administrative complexity.
Introduction: The Scope of the Pathology
The U.S. health system is currently on the verge of collapse. While the nation excels in specialized areas such as cancer care and medical innovation, it performs poorly in critical indicators like life expectancy, infant and maternal mortality, and patient choice. U.S. residents currently die the youngest and live the sickest lives among their international peers. This systemic failure is driven by extreme administrative complexity, an imbalance between specialist and primary care, and a reimbursement model that prioritizes the volume of care over its value.
I Propose A Multi-Faceted Protocol for Recovery
1. Ensuring Universal Coverage and Fiscal Accountability
A critical barrier to systemic health is the existence of the "essentially uninsured"—those with coverage they cannot afford to use due to high deductibles and premiums. Reform must require all U.S. residents to have health insurance coverage. Furthermore, to alleviate the burden of uncompensated care on the system, there must be a drastic reduction in healthcare services provided to residents not entitled to be in the country, which currently strains the uninsured healthcare infrastructure.
2. Expanding Federal Safety Nets: Lowering the Medicare Age
To bridge the gap between employer-sponsored insurance and current Medicare eligibility, the Medicare eligibility age should be dropped to 55 years, and Medicaid expansion must be mandated in all states. Currently, it is estimated that about 25 million Americans remain uninsured, and many others face "medical mysteries" where they avoid care for fear of cost until their conditions become critical. Expanding these programs provides a baseline of stability for an aging and vulnerable population.
3. Tying Licensure to Social Responsibility
A major impediment to healthcare access is the fact that many physicians opt out of government programs; in 2018, only 72% of physicians accepted new Medicaid patients compared to 90% for Medicare. Because all U.S. physicians receive some form of public funding during their training, they have a social responsibility to repay this investment. Therefore, as I have written elsewhere, all healthcare providers, including doctors and dentists, should be required to accept all forms of insurance, including Medicaid and Medicare, as a condition of medical licensure. While critics argue this may violate professional autonomy, the alternative—denying access to the sick—is far more onerous and unethical.
4. Empowering Payers: Arbitrating and Negotiating Fees
The U.S. incurs over 40% of global drug expenditures despite having only 4.5% of the population. To restore financial sustainability, Medicare, Medicaid, and all private healthcare funds must have the right to arbitrate and bargain their fees with providers and pharmaceutical companies. This includes the implementation of cost-effectiveness analyses to guide pricing and the potential revocation of FDA approval for drugs that are priced so high as to be essentially unavailable to those in need.
5. Expanding and Integrating the Provider Network
Addressing the physician shortage requires expanding the medical provider network to include nurse practitioners (NPs), physician assistants (PAs), advanced-trained RNs and pharmacists. Shifting toward a Patient-Centered Medical Home model—utilizing multidisciplinary teams—can improve the management of chronic illnesses, which account for 80 cents of every healthcare dollar spent. Utilizing machine learning and remote patient monitoring (RPM) can further optimize these teams, reducing hospitalization risks by up to 38.3% through better medication adherence.
6. Eliminating Administrative Bloat
Administrative costs account for one-quarter to one-third of all U.S. healthcare spending, nearly double that of other multi-payer systems. To cure this "administrative mystery," the system must:
* Establish a centralized clearinghouse for bill submission, modeled after the banking industry’s automated clearinghouse (ACH), to standardize claims.
* Simplify and automate prior authorization, which currently costs providers roughly $12 per claim in staff time.
* Harmonize quality reporting to ensure metrics are meaningful and not duplicative across different payers.
Conclusion: The Path to Sustainability
Restoring the U.S. healthcare system requires moving beyond incremental "band-aids" toward systematic reform. By aligning incentives toward quality, mandating provider participation in public programs, and leveraging the full scope of the medical workforce, we can reduce the $500 billion annually lost to administrative waste and ensure that healthcare is treated as a fundamental pilar of a stable functioning society rather than an opaque market commodity.
References
Adler, N. E. et al. (2016). Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care. National Academy of Medicine.
Balkrishnan, R. (2024). How to Save the US Health Care System From a Complete Collapse. The American Journal of Managed Care https://www.ajmc.com).
Blumberg, L. J., & Holahan, J. (2019). The Pros and Cons of Single-Payer Health Plans. Urban Institute.
Commonwealth Fund. (2024). Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System.
Cutler, D. M. (2020). Reducing Administrative Costs in U.S. Health Care. The Hamilton Project, Policy Proposal 2020-09.
Marks, D. H. (2024). Should All Medical Doctors Be Required to Accept Medicare and Medicaid as a Condition of Licensure?
Marks, D. H. (2023). Reducing the Influence of Politics in Healthcare.
Marks, D.H. Top Medical Journals including JAMA and NEJM Challenged by Department Of Justice. My personal experience with writing peer-reviewed medical studies
UnitedHealth Group / Avalere Health. (2025). Hospital Consolidation Continues, Contributing to Higher Prices and Spending.
Zhang, Y., & Chen, Y. The Role of Machine Learning in Reducing Healthcare Costs: The Impact of Medication Adherence and Preventive Care on Hospitalization Expenses. Columbia University / Georgia Institute of Technology.
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