The American transportation system is much like the American healthcare system: inefficient, expensive, and dangerous. Everyone wants to fix it, but conventional wisdom often leads to solutions that make things worse. Building more roads destroys neighborhoods and paradoxically creates more traffic congestion. Similarly, unleashing market forces in healthcare leads to higher costs, consolidation, and neglect of our poor and rural communities.
If you live in one of South Carolina’s major metropolitan areas, you know how bad traffic can be. My son commutes between his offices in Greenville and Spartanburg, which are about 40 miles apart. Although most of the route is on Interstate 85, a one-way trip can take up to 90 minutes, with an average speed of just 27 mph.
Our car-centric transportation system has left us with urban sprawl and a legacy of climate change because we prioritized the wrong goals many decades ago. Instead of focusing on walkable communities and efficient public transportation, we squandered billions on highway infrastructure, under the illusion that the freedom provided by personal vehicle ownership was essential to the American Dream.
Automobile transportation is both time-consuming and expensive. According to the American Automobile Association, the average annual cost of owning and operating an automobile is over $11,000. Traveling by car is also dangerous. Safety interventions such as seat belts, airbags, antilock brakes, and stricter DWI laws have led to a steady decline in driving fatalities. However, over the past 10 years, this decline has stalled. In 2023 (the last year of data available at the Department of Transportation website), over 40,000 Americans died in traffic collisions while millions more suffered non-fatal injuries.
Cities across the United States are struggling to solve their transportation woes. These solutions usually involve expanding the “market” by building more roads and adding more lanes. Unfortunately, this strategy only worsens traffic due to a phenomenon economists call “induced demand,” in which an increased supply leads to greater consumption. The new lanes fill up as soon as the pavement dries.
This healthcare-transportation analogy was inspired by recent calls for "free market" reforms as an alternative to extending enhanced premium tax credits for people who get their insurance through the Affordable Care Act (ACA). According to the Kaiser Family Foundation, failing to extend these subsidies will more than double the annual out-of-pocket premium payments for ACA enrollees. Many middle-income enrollees may lose all financial assistance in purchasing health insurance.
Instead of agreeing to extend the premium tax credits, the administration and many members of Congress have proposed harnessing the free market by sending checks directly to patients to pay for healthcare services. Senator Bill Cassidy, the chair of the Senate Health, Education, Labor, and Pensions Committee, has publicly compared healthcare services to purchasing shampoo:
“By giving the patient the money herself, though, she becomes a wiser consumer. And just think about it. If she goes and gets two types of shampoo and one's a dollar cheaper, she'll get the cheaper one, and the other one lowers their price."
Senator Cassidy, who is a gastroenterologist, ought to know better. Then again, he was the critical vote to put an antivaxx activist in charge of the Department of Health and Human Services.
The irony of the ongoing discussion about market-based reform is that market failure is the fundamental flaw in our healthcare system. The U.S. is unique among developed nations because its healthcare system relies heavily on market principles. From pharmaceutical development to insurance claims processing, the pursuit of profit dominates every aspect of American healthcare. Even our sixty-year experiment with social insurance, the Medicare program, has fallen victim to the chaos of market forces. More than half of all Medicare beneficiaries are now enrolled in profit-driven Medicare Advantage plans, which are projected to cost over $600 billion more than traditional Medicare over the next eight years, without demonstrable improvements in quality.
Senator Cassidy, who is a gastroenterologist, ought to know better. Then again, he was the critical vote to put an antivaxx activist in charge of the Department of Health and Human Services.
The irony of the ongoing discussion about market-based reform is that market failure is the fundamental flaw in our healthcare system. The U.S. is unique among developed nations because its healthcare system relies heavily on market principles. From pharmaceutical development to insurance claims processing, the pursuit of profit dominates every aspect of American healthcare. Even our sixty-year experiment with social insurance, the Medicare program, has fallen victim to the chaos of market forces. More than half of all Medicare beneficiaries are now enrolled in profit-driven Medicare Advantage plans, which are projected to cost over $600 billion more than traditional Medicare over the next eight years, without demonstrable improvements in quality.
Our car-centric transportation system has left us with urban sprawl and a legacy of climate change because we prioritized the wrong goals many decades ago. Instead of focusing on walkable communities and efficient public transportation, we squandered billions on highway infrastructure, under the illusion that the freedom provided by personal vehicle ownership was essential to the American Dream.
Likewise, our market-based healthcare system has left us with a legacy of runaway costs, shameful disparities, and crushing medical debt. According to the U.S. Census Bureau, nearly 12% of South Carolinians have medical debt in any given year. People with chronic diseases and those who live in rural areas are more likely to have medical debt. Although the Affordable Care Act has increased access to health insurance, the rising out-of-pocket costs associated with high-deductible health plans are a significant contributor to medical debt. Furthermore, over 500,000 residents of South Carolina remain uninsured, with 94,000 of them ineligible for Medicaid due to the state's ongoing refusal to accept funding for expansion.
Years ago, our Academy planted the seeds of healthcare reform. In 2007, the AAFP joined 10 other national medical organizations in endorsing The Principles for Reform of the U.S. Health Care System. This document, with its eleven calls to action, is a guide for creating a healthcare system based on cooperation rather than competition—a system that promotes public health, provides adequate funding for essential health services, and ensures quality, affordability, and access for all.
Envision a future where affordable healthcare is recognized as a right rather than a privilege. In this future, quality medical care is accessible to everyone, regardless of their zip code or income level. The healthcare system focuses on disease prevention and is structured around physician-led primary care teams. Like walkable communities and effective public transportation, this vision prioritizes public well-being rather than being driven by market forces and corporate profits.
Fixing healthcare is a significant challenge, and achieving successful reform relies on setting up the right priorities. We should move away from outdated ideas about free-market reform and deregulation and instead focus on quality, affordability, and universal access. By learning from the mistakes in our transportation system, we can create a healthier and more equitable future.
Years ago, our Academy planted the seeds of healthcare reform. In 2007, the AAFP joined 10 other national medical organizations in endorsing The Principles for Reform of the U.S. Health Care System. This document, with its eleven calls to action, is a guide for creating a healthcare system based on cooperation rather than competition—a system that promotes public health, provides adequate funding for essential health services, and ensures quality, affordability, and access for all.
Envision a future where affordable healthcare is recognized as a right rather than a privilege. In this future, quality medical care is accessible to everyone, regardless of their zip code or income level. The healthcare system focuses on disease prevention and is structured around physician-led primary care teams. Like walkable communities and effective public transportation, this vision prioritizes public well-being rather than being driven by market forces and corporate profits.
Fixing healthcare is a significant challenge, and achieving successful reform relies on setting up the right priorities. We should move away from outdated ideas about free-market reform and deregulation and instead focus on quality, affordability, and universal access. By learning from the mistakes in our transportation system, we can create a healthier and more equitable future.