Last year I watched a patient of mine, I will call him Raymond, navigate what should have been a straightforward referral to cardiology. He had insurance. Good insurance. The kind politicians point to when they say the system is working. It took 11 weeks, four phone calls, two prior authorizations, and one emergency department (ED) visit to get him seen. He was not uninsured. He was not poor. He was not caught in some coverage gap we forgot to legislate away. He was a man with a heart problem and insurance that theoretically covered its treatment, trapped in a system that has no coherent architecture for delivering care.
I have been a primary care physician for 28 years. I have watched us debate this system for every one of them. And I want to say something that may be uncomfortable for those of us who have devoted careers to fixing it: We have been arguing about the wrong thing.
The illusion of a functional health care system
The American health care debate lives almost entirely in two lanes: insurance coverage and price regulation. Who has it, who does not, what things cost, who is allowed to charge what. These are real problems. I am not dismissing them. But they are downstream of something we almost never discuss: the fundamental architecture of how care is actually delivered in this country. We do not have a health care system. We have a health care market: fragmented, incentive-misaligned, structurally incapable of doing what we keep demanding it do with insurance layered on top of it and regulation layered on top of that. We have been treating the complications of a structural disease rather than the disease itself.
Consider what a functioning delivery system would look like. It would know where its patients are. It would reach them before they become expensive. It would coordinate between primary care, specialty, behavioral health, and pharmacy without requiring the patient to serve as their own case manager. It would not lose a man with chest pain in an 11-week authorization queue. No amount of insurance expansion or price negotiation builds that system. We can cover every American tomorrow and still deliver care through the same dysfunctional architecture. We have spent 50 years and trillions of dollars proving this.
A structural solution for health care delivery
So what would fix it? The answer, I have come to believe, is embarrassingly structural and almost entirely absent from our policy conversation. The United States Public Health Service (USPHS) Commissioned Corps, a uniformed service most Americans have never heard of, already exists as a deployable medical workforce. It currently operates at roughly 6,000 officers. Expanded deliberately to 50,000 or beyond, deployed into the underserved geographies and care gaps where the market will never go, integrated with a national primary care backbone, it becomes the delivery architecture we have never had.
This is not a government takeover of medicine. Private practice continues. Insurance continues. What changes is that we stop pretending the market will build the infrastructure it has had 60 years to build and has declined to build. We build it ourselves, the way we built the interstate highway system, not to eliminate cars, but to give them somewhere coherent to go.
The true cost of the status quo
I have spent the last several years writing a book about this argument. In doing so, I have become convinced of something that would have seemed naive to me earlier in my career: The actual fix is cheaper than the status quo. Not marginally cheaper. Dramatically cheaper. Because a functional delivery system prevents the downstream spending that is currently bankrupting employers, families, and the federal government. The most expensive health care system on earth is also the cheapest to fix if we are willing to fix the right thing.
Raymond eventually saw his cardiologist. He is fine. But I keep thinking about the patients who are not fine, who got lost somewhere in the same queue, who became a statistic in a dataset that will fuel the next round of the same debate we have been having since 1965. We owe them a better argument.
Vance Alm is a family physician.
