Failure to Account for Real-World Complexities in Health Policy, JAMA Health Forum, Feb. 5, 2026, by Lanhee J. Chen, Erin Duffy, and Atul Grover
Congress could focus on incremental reforms to enhance the affordability of health care. Both parties have members who would instead like to return to bigger arguments about how to completely restructure the health system and reduce health care costs for all individuals in the US. Long-standing policies based on ideological, polarized positions are again being proposed as the fix for affordable health insurance. On the left, some progressives are arguing for national health insurance or single-payer, universal coverage. On the right, some conservatives are arguing that US health care can only be fixed by scrapping much of the federal government’s involvement in health care and letting a free market with a less prominent role for insurance solve continuing problems with affordability and access.
But the ideological purists on both sides are missing the point.
It would be useful to keep in mind 3 important realities of US health policy. First, the affordability question most patients and their families ask is “Can I afford health care?” For many, the answer is, “No.” Those who want major reforms to US health care often aim to reduce the aggregate cost of care to taxpayers through major changes such as creating a single insurer or eliminating most insurance from health care transactions. Although most US individuals are relatively satisfied with their own health care coverage, which is similar to other nations, individuals believe their own health care costs are the most urgent health care problem.
A second reality is the unique view of health care in the US. Individuals in the US disagree with the premise that health care is a pure social good that must be available to all. Advocates for more government intervention and support for health care hold up examples from other high-income countries (especially western European of Nordic countries); however, almost all of these nations have long established health care as a basic right; in fact, many countries (including Belgium, Finland, Germany, Iceland, Italy, Luxembourg, Spain, and Sweden) have enshrined the right to health care in their constitutions. The US Constitution does not include health care as an inalienable right. Academics can argue the merits of single-payer universal coverage proposals, but implementing such policy change in the US is unlikely.
Third, the US has a health care financing system that is more complex and varied than the nations and would be administratively, financially, and politically difficult to unwind. Revenue is distributed beyond many parts of the health care system, and both large publicly traded companies and private investors are heavily invested in its complexity. What scholars often refer to as excess costs in US health care spending accrue to both nonprofit and for-profit insurance companies and administrators, health facilities, health professionals, and prescription drug companies; all entities have a stake in the current financing and delivery system. Federal and state governments enjoy lower administrative costs, but also pay clinicians below commercial market rates. These lower rates can have an impact on the availability of clinicians, care accessibility, and the quality of care available – particularly in parts of the country where there are clinician shortages.
What do these realities mean for the current standoff in US health care policy? If policymakers approach the debate over health care affordability from the hard right or left, no remedy is likely to be found for those likely to lose their insurance coverage this year as a result. It is also unlikely that a solution to concerns about affordability will be found through a major national overhaul of health care financing and delivery in the next several election cycles.
Policymakers should consider a solution that includes elements drawn from what both Republicans and Democrats have asked for during this debate. Thus, help for those impacted by the expired [ACA] subsidies will not come through sweeping change but rather through incremental adjustments that continue to build on center-left or center-right approaches. Minimum, small-dollar premium contributions have been proposed by some Republicans as a mechanism to mitigate fraud, though with the potential to create administrative barriers for some individuals with low incomes.
Making health care costs more affordable for families and for the country is likely to occur only through careful, incremental changes in multiple aspects of the health financing and delivery system rather than ideologically driven sweeping change. In the short term, policymakers should focus on the realistic adjustments to existing policy that enable more individuals to access the care that they need.
The ongoing debate over US health reform, as with other issues, has gotten entangled in both political polarization and ideological extremism. Although partisans on both sides are unlikely to admit it, the best solutions to enhancing affordability and access lie in the middle – taking ome ideas from each side and balancing the trade-offs to maximize the benefits to patients. Policymakers ought to keep in mind that the understanding of health affordability among US individuals is based on their personal economics, that there is no right to health care in the US, and that sweeping change for the left or right is unlikely given the political situation the country is in today. Compromise and incremental adjustments feel unsatisfying, but they are the realistic path to addressing the health system affordability challenge in the US.
Priced Out: The economic and ethical costs of American Health Care, Princeton University Press, 2019, by Uwe E. Reinhardt
This book seeks to shed light on important and often bizarre and curious facts and realities about the many facets of our mysterious and expensive health care system.
Unfortunately, we are too shy in this country to debate forthrightly the ethical precepts we would like to see imposed on our health care system. It can fairly be said that this shyness is particularly evident on the right of the ideological spectrum – among Americans who would prefer to see health care rationed at least to some extent by price and ability to pay, that is, by income class.
In 1997, I published in the Journal of the American Medical Association:
“As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or being cured from a given illness as does the child of a rich American family?”
Remarkably, but not surprisingly, all five physicians who wrote letters to JAMA on my article failed to answer my simple question. Instead, they furiously went ad hominem, writing me off as a “socialist propagandist” – merely for raising a question that every thoughtful person should be able to answer.
From the Foreword by Nobel Laureate Paul Krugman:
“As Uwe says, the crucial question is one that he stated in a Journal of the American Medical Association article after the failure of the 1993 Clinton health plan: Should the child of a poor American family have the same chance of receiving adequate prevention and treatment as the child of a rich family?”
From the Forward by Senate Majority Leader William H. Frist, MD:
“But throughout his life you could sense his dismay, and he comes back to it again and again throughout this work. How could a nation so wonderful and so powerful and so full of resources not have consensus, or at least a majority view, as to a more rational social compact for those less fortunate?
“Was Uwe conservative or liberal, a Republican or a Democrat? I could never figure it out. For a while after I left the Senate, people would have us speak at conventions as a contrast, me (the former Republican Majority Leader) representing the “right” and Uwe (the German Canadian Ivy League professor) representing the “left.” That didn’t last long. Halfway through the debate, he would be outarguing me from the right with market-based principles and choice, leaving me holding the center-left position demanding universal access – just the opposite of where we started the debate!
“He says the proposals of Democrats for the most part are most consistent with the values of health care as a “social good,” and those of Republicans are most consistent with health care treated as a private consumption good subjected to pricing and the ability to pay.
“What I can say for certain is that Uwe’s unwavering central organizing philosophy [was]: ‘Should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family.’”
From the Epilogue by Tsung-Mei Cheng, Uwe’s widow and, herself, a health policy analyst:
“The issue of universal coverage is not a matter of economics. Little more than 1 percent of GDP assigned to health could cover all. It is a matter of soul. — Uwe E. Reinhardt
“On universal health coverage. First, there can be no argument that Uwe passionately believed in universal health coverage (UHC), that is, health insurance that provides affordable and timely access to needed health care for all regardless of the individual’s ability to pay, as a moral imperative. Deeply troubling to Uwe since coming to America and studying health care was seeing so many hard-working and less fortunate Americans not getting their fair share in so rich a nation with so luxuriously endowed a health care system as the American system. Time and again, Uwe pronounced: What have we Americans become as a people to allow so much callousness and outright cruelty in a health system that is abundantly endowed with resources – in many instances excessively well endowed – and, as most Americans must know, is home to much human kindness and excellence?
“On a single-payer Medicare-for-All system for America. In 1989, Uwe recommended the single-payer system to Taiwan when Taiwan’s government was seeking to implement universal health insurance.
“Uwe wrote this as early as 2007 in an article for the Milken Institute Review: I don’t view the Canadian health care system as a model for the United States for at least two reasons. First, the highly egalitarian precepts in the Canadian approach do not seem compatible with Americans’ preference for letting money talk when it comes to health care – or, for that matter, education or the administration of justice. Second, single-payer government-run health systems are especially difficult to administer well in a political system so open to influence through campaign contributions. By the same token, though, I don’t buy the argument that government-run single payer systems are inherently less efficient than market-oriented health systems. In the end, each nation must decide which style of rationing – by the queue or by price and ability to pay – is most compatible with its culture. Mantras about the virtues of markets are no substitute for serious ethical conviction.”
Uwe Reinhardt’s Conclusion: A Novel (My Own) Reform Proposal: Give Rugged Individualists Their Freedom
I propose that by age twenty-six all Americans must choose either to a) join an insurance arrangement that forces on them community-rated premiums or, alternatively, b) take a chance on being uninsured or relying on a health insurance market with premiums based on the individual’s health status. If they choose the rugged individualist route, however, they could never later on join the social solidarity pool. That scheme would accommodate Libertarians who do not wish to be told by the government what to do about their health insurance.
To the objection that age twenty-six is too young an age to have to make such a monumental lifetime decision, I would respond that we ask young Americans entering the military service to make a far more serious choice, one that may risk their limb and life.
Comment:
By Don McCanne, M.D.
Today’s HJM has unusually long excerpts & commentary – to highlight several pivotal messages. 1) A position of political “compromise” for health care reform is in fact extreme – resulting in higher costs and poorer clinical performance. 2) Repetition of a simple symbolic message, like the rich/poor kid contrast, can help doubters realize what a health care system that serves all everyone is really about. 3) For those who nonetheless insist that the libertarian view must be accommodated, they will simply have to learn what the roar of the lion is all about!
We start with a JAMA blog by Lanhee Chen et al. explaining that the single payer model and the free market solution represent the two political extremes for health reform, and that advocates of either position are missing the point. The authors conclude that the optimal paths to enhancing affordability and access lie in the middle: blending ideas from each extreme and balancing trade-offs to maximize benefits to patients.
Not meaning to be unduly facetious, but isn’t that what we have been doing for over half a century, resulting in the most expensive yet among the poorest performing health care systems among wealthy nations? In fact, HJM in December addressed this matter when we used AI to describe the battle of two Nobel Laureates: Milton Friedman and free markets, which work only for those who have the resources vs. Kenneth Arrow and the need for universal public funding if we are to provide everyone with the health care that they need.
It’s interesting that the authors of the JAMA article chose Uwe Reinhardt’s ”Priced Out” as the first of three references. Reinhardt’s primary theme in his book and throughout his career as a health economics educator, was to pose the question to his students and to us, “Should the child of a poor American family have the same chance of receiving adequate prevention and treatment as the child of a rich family?”
Think about that. Obviously a single payer system that provides access for everyone to all necessary care regardless of ability to pay allows us to answer in the affirmative. In contrast, a system that requires financial resources that patients may lack forces us to say “no”. Though our current system offers some exceptions (e.g., Medicaid), high rates of cost barriers to care and resulting financial hardships (even bankruptcy) prove that free markets for health care in the US often fail the Reinhardt test. As Uwe says, they are also frequently lacking in soul.
After my years of studying Uwe’s work and speaking with him, I know that when he declines to take a position on the specifics of health care reform, in his heart he has only one position: health care for everyone.
We frequently counter those who insist that incremental reform should place us in the comfortable center, for it could never work if we believe that everyone should have affordable health care. That is what is interesting about Uwe’s unexpected conclusion in “Priced Out.” Others cite his conclusion as proof that Reinhardt is a moderate, preferring the middle road to reform. But if you really listen to the lessons that he has given us, how could he ever advocate for a system that divides us into a choice of community-rated premiums that many of us could never afford, or becoming a rugged individualist who excludes himsefl forever from joining the social solidarity pool?
Those who read this recommendation and think that this is a moderate position must be deaf. When these words by Uwe Reinhardt are exposed to an ethically functioning brain, you cannot possibly escape hearing the very loud roar of the lion in Uwe’s soul.
Uwe and I were born the same month. We both devoted our lives to studying and teaching on health care justice: he as a distinguished professor and me as a practicing physician involved in health care activism. Sadly, we have lost Uwe and his great talents. I have significant medical disorders, topped by heart failure, so I will likely also soon be leaving, but when I do, I pray that the entire nation will be able to hear my loud roar as I depart.
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