We are frequently told that our health care system is expensive. However, most of us, including physicians, have no notion about what the health care system really is, to judge whether or not we are getting our money’s worth.

There are four major structural models for a health care system:

• The Beveridge model (socialized medicine): Health care is provided and financed by the government through tax payments (e.g., United Kingdom’s NHS).
• The Bismarck model: Health care is financed jointly by employers and employees through payroll deductions into private insurance plans (e.g., Germany).
• The national health insurance model (the single-payer): Uses private-sector providers but payments come from a government-run insurance program that every citizen pays into (e.g., Canada).
• The hybrid model: Uses a mixture of all the above. Employer-sponsored insurance (the Bismarck model) covers those who are employed. A single-payer (the national health insurance model) covers those over 65 years of age and those below a certain income level. The Veterans Health Administration (the Beveridge model) covers veterans (e.g., the United States).

Most of us, including physicians, have no idea about how a health care system should perform. Six criteria are established by the World Health Organization (WHO). There must be:

1. Quality care: Enhances the overall well-being of the population.
2. Responsiveness: Meets expectations regarding dignity and patient-centered care.
3. Fair financing: Ensures protection from financial ruin due to medical costs.
4. Efficiency and equity: Maximizes the use of resources while reducing disparities in care based on race, income, or location.
5. Access to essential medicines.
6. Leadership and governance.

Hence all practice schemes, ranging from HMOs to concierge practices, and all financial schemes, ranging from socialized medicine to out-of-pocket expenses, are considered as conventional in a nation’s health care system. Despite having the world’s top hospitals, the WHO ranks the United States last among developed nations.

U.S. health care governance

Unlike most countries that have health ministries, governance of health care in the United States is by a combination of executive leaders, federal legislative bodies, and state authorities. There is no single person, but the following individuals and groups oversee the health care system’s core functions:

• The Cabinet: Robert F. Kennedy Jr. is the secretary of Health and Human Services (HHS). He oversees a $2 trillion budget and all major operating divisions focused on public health, food safety, and insurance.
• Financing and insurance: Dr. Mehmet Oz is the administrator for the Centers for Medicare & Medicaid Services (CMS). He manages programs that provide health coverage to more than 170 million Americans through Medicare, Medicaid, and the health insurance marketplace.
• Public health: Dr. Casey Means is the U.S. surgeon general. As the “Nation’s Doctor,” she leads the U.S. Public Health Service Commissioned Corps and advises the public on health risks and disease prevention.
• The Food and Drug Administration (FDA): Under Dr. Martin Makary, it regulates the safety and efficacy of medical products, drugs, and most of the nation’s food supply.
• The Centers for Disease Control and Prevention (CDC): With acting director James O’Neill, the deputy secretary of HHS, it provides leadership for the prevention and control of infectious and chronic diseases.
• Legislative: The Senate Finance and the House Energy and Commerce committees are responsible for enacting health care laws and setting the federal budget for health programs.
• Individual states: States are in charge of licensing health professionals (doctors, nurses, etc.), regulating many private health insurance plans, and tort reforms.

The role of medical malpractice

This is my understanding of the U.S. health care system. My focus is on medical malpractice. The WHO endeavors to move health care systems toward “high-reliability” safety systems by encouraging providers to report errors voluntarily without fear of legal retaliation. This is not possible in the United States.

In the U.S., medical malpractice is a subset of tort law where unelected and unappointed lawyers in the legal system, rather than health agencies, set and enforce the rules. It is primarily managed at the state level through civil courts, run by lawyers, rather than federal regulation. It is driven by private litigation, specifically plaintiff attorneys and defense attorneys. Regulations vary by state legislatures, which are often populated by attorneys, and include tort reforms.

Medical malpractice litigation, mostly controlled by attorneys, significantly influences how health care is financed and delivered. Consequently, most doctors carry medical malpractice insurance, the costs of which are rising due to “nuclear verdicts” exceeding $10 million, one as high as $229.6 million. These expenses are passed on to the health care system as higher service fees.

There is also defensive medicine solely to reduce legal exposure. Fear of litigation leads to extra testing or to the avoidance of high-risk procedures. This adds over $50 billion annually to U.S. health care costs.

High malpractice risks in certain states cause “physician flight,” where specialists like obstetricians or neurosurgeons relocate to states with more favorable tort laws or malpractice insurance rates, creating local shortages.

There are emerging medical malpractice risks. As artificial intelligence takes on increasing roles in health care, the health care system must grapple with fault when an algorithm leads to a complication. Also, as nurse practitioners and physician assistants take on more primary care responsibilities, they assume medical malpractice litigation risks and their insurance rates increase. These, too, are passed on to the health care system.

In all fairness, medical malpractice litigation serves as quality control. Many hospitals use medical malpractice data, as found in the National Practitioner Data Bank (NPDB), to improve communications and to implement patient safety protocols. Just because this is so does not mean that medical malpractice litigation should have no limitations. Nor should it serve the interests of a single interest group, notably attorneys.

Howard Smith is an obstetrics-gynecology physician.