By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy, and Matt Toresco, Chief Executive Officer, Archo Advocacy
Imagine a healthcare system where patients pay monthly premiums to maintain access to a plan. They pay co-pays before they see their physicians. They pay 100% of the cost of their visits and tests to meet a “deductible” before their insurance, which they pay to access, agrees to cover anything. Then they pay again at the pharmacy counter when they pick up medications. Over the course of a year, they end up spending more than $20,000 on healthcare costs. This scenario is the reality for many patients living in the United States, but it only gets worse.
Every step of the way, they meet resistance from the insurance company they pay to cover their healthcare costs. Prior authorization requirements. Drug formularies that exclude the medications their physicians prescribe. Denials of coverage for services contractually covered under their plans. A labyrinthine series of hoops and paperwork for which they are personally responsible, all to prove to the company that they pay that the care those insurers promised to cover should be covered.
Now, imagine living with a chronic disease and attempting to navigate all of these costs and hurdles while enduring the physical, mental, and emotional toll of just trying to survive, all while being told that this is the best healthcare system in the world and that they should feel lucky.
Those living in one of the 72 countries where leaders have refused to implement this “model” should consider themselves lucky (World Population Review, 2026).
In 2025, Americans who purchase health insurance from their respective marketplaces got the news that their health insurance premiums would be increasing by an average of 21.7% in 2026, while those who receive coverage through their employers saw increases ranging from 6% to 7% (Holahan, O’Brien, & Kennedy, 2025), not because those price increases were warranted, but because Congressional leaders failed to extend enhance premium tax credits they implemented at the height of the COVID-19 pandemic.
Those enhanced premium tax credits impacted roughly 22 million people—about 90% of those who enroll in insurance through the Affordable Care Act marketplaces (Iacurci, 2026)—a number that is both immense and yet just ~6% of the total U.S. population.
That’s correct:
A policy affecting just 6% of the U.S. population led to a nearly 22% increase in marketplace premiums.
According to recent polling by the Pew Research Center, 93% of respondents identified the cost of healthcare as their top economic concern (Figure 1).
Figure 1 – The Cost of Health Care, Good and Housing Are Top Economic Concerns for Americans
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| Photo Source: Van Green, Cerda, & Shepard, 2026 |
Meanwhile, health insurance companies, such as CVS Health, UnitedHealth, and Elevance have seen annual revenue growth ranging from 7.8% (CVS) to 12% (UnitedHealth and Elevance), all while implementing artificial intelligence (AI) tools not to improve the quality of care, but to ensure that their profits are maximized by denying care (Mello et al., 2026).
The truth about the American healthcare system is that it does not ensure the health of those stuck in it but rather ensures profits for insurance companies. Worse still, the Affordable Care Act (ACA)—so blithely named by Congress to suggest that it would make healthcare affordable for Americans—was designed in such a way that the system was made worse.
In 2023, researchers at KFF discovered that health insurance companies providing coverage under Medicare Advantage plans denied 3.2 million prior authorization claims—roughly 6.4% of all prior authorization requests—and that just 11.7% of those denials were appealed. Of those appeals, 81.7% were successfully appealed in the patients’ favor (Biniek et al., 2025).
Research conducted in 2025 by PlusInc found that, of 36.7% of respondents who had appealed their insurers’ decision to deny coverage of a service, medication, or medical device, 70% reported that they were ultimately able to get that denial partially or fully reversed in their favor (Macsata, et al., 2025).
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| Photo Source: PlusInc |
Despite this high success rate, health insurers don’t make the appeals process easy. Appeals often require multiple attempts, mounds of paperwork, and seemingly endless wrangling just to get a health insurance company to do what they promised.
So, what do American patients get for paying the equivalent of a minimum wage annual income—nearly twice as much as other comparable governments pay per patient?
When compared to eleven other comparable nations (Australia, Austria, Belgium, Canada, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom):
- The lowest life expectancy rates
- Exponentially higher maternal mortality (death) rates
- Exponentially higher hospitalization rates for congestive heart failure and diabetes
- Significantly lower percentages of residents who have a regular source of healthcare services
- Significantly lower physician-to-patient ratios (Telesford et al., 2025).
All of these outcomes indicate that our system isn’t working. Moreover, it hasn’t been working for a while. The data tell one story, but the lived experiences of American patients tell another.
The Number Nobody's Asking About
The West Health-Gallup survey published in November 2025 highlights 47% of Americans fear they can't afford healthcare. That's not a statistic. That's a system signaling collapse.
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| Photo Source: West Health-Gallup |
The survey shows family premiums hit $26,993 this year, with workers contributing $6,850 from their paychecks. Most employees don't realize they're paying this hidden tax because they only look at their take-home amount.
Healthcare costs are rising by 6% annually, while general inflation is at 2.7% and wage growth is at 4%. The math doesn't work. It can't work. It was never designed to work for patients.
What "High-Performing" Actually Means
The survey ranked states by healthcare performance. Even in the top-performing states, 15% of residents can't afford their medications. In the lowest-ranked states, that number hits 29%.
Here's what nobody's saying: insurance coverage and patient outcomes are fundamentally disconnected.
The current model limits physicians to 5-7 minutes per patient. They see 40+ patients daily just to keep revenue flowing. There's no time to understand complicated issues or surgical histories. Physician apathy isn't a character flaw. It's a business model that no physician wants to practice but has no time or pull to do otherwise!
The Baseline Budgeting Trap
Baseline budgeting uses the previous year's budget as the starting point for next year, without evaluating fraud, waste, or abuse. It is a trap!
Patients are never part of these internal budgeting processes. Nobody asks how families fared paying for healthcare last year. The system expects you to shoulder the load and keep paying higher premiums.
Pricing gets set without patient insight. Financial constraints don't factor into the equation. The survey shows 35% of Americans—91 million people—report they couldn't access quality healthcare if they needed it today. That's financial toxicity at scale.
The Vertical Integration Stranglehold
Three PBMs now control 80% of all prescriptions in America. They're vertically integrated with major insurers—CVS/Caremark with Aetna, Express Scripts with Cigna, OptumRx with UnitedHealthcare.
These companies own the PBMs, specialty pharmacies, retail pharmacies, surgery centers, and even provider practices. They make tens of billions in quarterly profit while premiums climb year after year.
There is too little competition. The insurance companies have amassed so much power and lobbying money that they get everything they want. That's not in the best interest of patients or clinicians.
The ACA Perfect Storm
The Trump Administration and Congressional Republicans let the ACA subsidies expire. Their lapse will result in premiums doubling for more than 20 million Americans. The average subsidy recipient can expect to see annual premium payments jump 114%—from $888 to $1,904.
But here's the question nobody's asking: Why are premiums so high in the first place, and why have they continued to rise when the risk pool expanded post-ACA implementation?
The ACA was sold as competition and cost reduction. Instead, it guaranteed customers to insurance companies…subsidized by taxpayers. Since its founding, costs have only increased to insane levels. Nothing has gotten cheaper, even though everyone must now have health insurance by law.
Based on pure economics and math alone, that should not be. This clearly points to crony capitalism, where winners are allowed to win as much as they want, at the expense of everyone else.
What Happens When Fear Becomes Reality
The survey shows that 55% of Americans cite long wait times as a reason they do not seek care. Another 27% mention work schedule conflicts. One-third skipped recommended medical procedures due to cost.
When financial barriers become reality for millions simultaneously, people skip appointments or delay care. This leads to worsening symptoms, disease progression, and medication non-compliance.
All leading to worse health outcomes, decreased presenteeism at work, and decreased productivity. This isn't a healthcare crisis. It's an economic crisis. Healthcare in its current form is just economics. The American healthcare system needs a reboot!
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.
References:
[1] Biniek, J. F., Sroczynski, N., Freed, M., & Neuman, T. (2025, January 28). Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. Washington, DC: KFF. https://www.kff.org/medicare/nearly-50-million-priorauthorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/
[2] Daniller, A. (2025, December 10). Most Americans say government has a responsibility to ensure health care coverage. Washington, DC: Pew Research Center: Reseach Topics: Politics & Policy: Political Issues: Health Policy. https://www.pewresearch.org/short-reads/2025/12/10/most-americans-say-government-has-a-responsibility-to-ensure-health-care-coverage/
[3] Gonya, D. (2017, January 10). From The Start, Obama Struggled With Fallout From A Kind Of Fake News. Washington, DC: National Public Radio: All Things Considered. https://www.npr.org/2017/01/10/509164679/from-the-start-obama-struggled-with-fallout-from-a-kind-of-fake-news
[4] Health Affairs Research Brief. (2022, October 06). The Role Of Administrative Waste In Excess US Health Spending. Health Affairs. https://www.healthaffairs.org/content/briefs/role-administrative-waste-excess-us-health-spending
[5] Holahan, J., O’Brien, C., & Kennedy, N. (2025, December 18). Understanding the Extraordinary Increase in ACA Premiums in 2026. Washington, DC: Urban Institute: Research: Publication. https://www.urban.org/research/publication/understanding-extraordinary-increase-aca-premiums-2026
[6] Iacurci, G. (2026, February 24). The ACA health coverage subsidy lapse hit 22 million people. Here are some of their stories. Englewood Cliffs, NJ: CNBC. https://www.cnbc.com/2026/02/24/aca-enhanced-subsidy-expiration-effects.html
[7] Macsata, B. M., Hopkins, M. J., Lathan, V. & Laws, J. (2025, November). Navigating Healthcare: Findings from Quantitative Patient Survey in the United States. Washington, DC: PlusInc. https://www.plusinc.org/s/2025_PLUSINC_Project_Prior_Auth_Workplan_112425-FINAL-NAVIGATING-HEALTHCARE-ne7x.pdf
[8] Mello, M. M., Trotsyuk, A. A., Mahamadou, A. J. D., & Char, D. (2026, January). The AI Arms Race In Health Insurance Utilization Review: Promises Of Efficiency And Risks Of Supercharged Flaws. Health Affairs, 45(1), 6-13. ttps://doi.org/10.1377/hlthaff.2025.00897
[9]Telesford, I., Wager, E., & Cox, C. (2025, October 06). How does the quality of the U.S. health system compare to other countries? Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/
[10] Toresco, M. (2026, March 12). The Number Nobody's Asking About. Archo Advocate Brief. https://archo-advocate-brief.beehiiv.com/p/the-number-nobody-s-asking-about
[11] Van Green, T., Cerda, A., & Shepard, S. (2026, February 04). A Year Into Trump’s Second Term, Americans’ Views of the Economy Remain Negative. Washington, DC: Pew Research Center: Research Topics: Economy & Work. https://www.pewresearch.org/politics/2026/02/04/a-year-into-trumps-second-term-americans-views-of-the-economy-remain-negative/
[12] World Population Review. (2026). Countries with Universal Healthcare 2026. Walnut, CA: World Population Review: Country Rankings. https://worldpopulationreview.com/country-rankings/countries-with-universal-healthcare