The Insurance Crisis and a Return to Direct Care: Why Now Is the Time for Something Different
*This post is part 1 of a 3-part series. Part 2 coming soon!
A few years from now, we may find ourselves looking back at this moment and appreciating that collectively, we are in a much better place.
As I write this piece (early November, 2025), however, our healthcare situation in the United States is looking rather dire, for a variety of reasons. One of the chief contributors to this grim outlook is the cost of care - and in particular, the cost faced by regular, every day people - to get the care they need.
The Current State of Health Insurance: A System in Crisis
The Rising Cost Burden
Consider this: thus far in 2025, family premiums paid by folks on an employer-based plan (a health insurance plan provided as a benefit for the work they do for their employer) have gone up by an average of 6%. In contrast, workers' earnings have only increased by an average of 4%, and inflation has gone up by around 2.7%. So the increases in premiums for the best plans out there are outpacing wage growth and inflation. And that's just taking premiums into consideration; that doesn't even cover deductibles and unexpected out-of-pocket costs, like instances of non-coverage.
This continues an overall trend that we have been seeing for a number of years; healthcare is just straight-up getting more expensive, and we can (and should) recognize that a lot of aspects of our system play into that: unclear billing practices and sky-high rates for testing, imaging, and care provided by large hospital and healthcare systems; increased involvement of middle management in healthcare spaces and the salaries that those folks get paid; the profit margins taken by health insurance carriers; the lack of direct negotiation on drug prices by the federal government; and more.
Things get more complicated, though, when we zoom out a bit more. Because there are tens of millions of Americans on Medicaid and Medicare, and the funding for those plans is an ever-more open question. Those programs, while very popular, have been slowly but steadily defunded and weakened by political interest endeavors that serve the extremely wealthy - a small minority of people who often don't want to pay modestly more in taxes so that more of their human neighbors have access to the most basic, foundational care.
There are also tens of millions of Americans on federally-subsidized healthcare plans in the ACA (sometimes referred to as "Obamacare") marketplace, who do not get health insurance from their employer or who are self-employed, and who don't qualify for Medicaid or Medicare. And the subsidies for many of those plans may not be renewed under the current governmental regime.
What that means for people who get healthcare coverage through the ACA marketplace is that, in at least some states, their premiums will be going up by 75% or more. For a couple aged 55-64 in Nevada, for example, this could increase the out-of-pocket cost of health insurance from $13,700 per year to $23,700 per year - and again, that only takes premiums into account.
And then there's the problem of underinsurance - having coverage on paper, but not being able to use it for the things you need. That's also becoming more and more common.
The short version is this: things are getting out of hand. And there is an essential paradox here, as people find themselves waiting for a month to see their established primary care provider (and sometimes much longer), and even longer than that to see a specialist. The quality of care is going down across our country. And that's not because physicians and providers don't care; they do care, and very deeply. But they are also burnt-out and fatigued seeing more patients per day and doing more unpaid back-end work as time goes on.
The result is that very few of us living every day lives are happy - not as patients, and not as healthcare providers. In fact, very many of us are outright struggling. I see this myself multiple times per week.
What this moment calls for, in my view, is for us to move in a different direction - to consider and shift toward a different model. It appears our elected officials - particularly at the federal level - are not prepared to ensure we get our needs met. And large-scale industry will always prioritize profit over people when given the chance, especially when the company is publicly traded.
What You're Actually Getting (or Not Getting) Through Insurance
Out-of-pocket maximums are already devastating family budgets, and as we've reviewed so far, things are poised to get worse.
In the United States, we spend almost twice as much per person on healthcare with worse health outcomes than other similarly wealthy nations. Just consider life expectancy - ours is 4.1 years lower than countries with the same level of technological development.
And it's not as though the value we're getting in return is improving, either. For a long time already, extremely short appointments (15-20 minutes) have been the standard, and for primary care visits in particular, they appear to be shortening. They are now down to an average of 7-18 minutes, with more inappropriate prescribing (and likely other key errors) taking place as a result.
One could (and should) point to a number of factors that might be at play here: poor-to-no regulation of our food supply; the over-polluting and lack of safety in our living environments; the extreme upward transfer of wealth over the last several decades, leaving many Americans under-resourced; and more. And then, of course, there's the fact that we handle health coverage differently than all other industrial nations - and not in a way that works.
The Hidden Costs Beyond Premiums
Based on each person's plan, in addition to short appointments and long waits to see their providers, they may (and do) find themselves with restricted provider networks. Limiting options also means limiting availability. Preventive care benefits are frequently highly limited or not adequately incentivized. And all of that drives more people to over-rely on emergency rooms, where expenses run even higher than elsewhere. People are forced to fight for coverage of care that they need, often meaning many hours navigating phone trees and fighting bureaucracy. That can force people to take time off of work, losing out on wages in the vain hope of having fewer medical expenses to pay. (And handling that is stressful, to boot.) Prior authorization barriers routinely greatly delay or deny care to people who really need it.
This is a bona fide crisis.
Who's Being Left Behind by the Insurance Model?
The answer to this question, realistically, is: anyone and everyone who isn't exorbitantly wealthy. And considering that 60% of the world's billionaires inherited their wealth rather than earning it, you can clearly see what the prospects of becoming profoundly wealthy are for just about all of us.
But let's break down a few examples of people who are being left behind, anyway.
The Healthy and Health-Conscious
These are folks who infrequently use conventional medical services - either because they don't need them or they don't trust them. These may be folks seeking care approaches that treat the root causes of medical concerns. They may invest in health foods and exercise routinely. They might meditate regularly and get plenty of positive social interaction.
In the current insurance marketplace, these people are highly likely to be penalized for being healthy - paying ever more for health coverage that they don't practically need, just in case something catastrophic happens.
Those with Chronic Conditions
These are our friends, family members, and neighbors with conditions they never asked for. Type 2 diabetes; autoimmune disease; digestive conditions; major depressive disorder; and many more.
People with chronic conditions have been better protected under the ACA in recent years than they were before. And the ACA is very far from perfect, but protections for people with chronic conditions are essential to ensure that they can get the care that they need.
However, the current administration's new ACA marketplace rules mean those protections are slowly evaporating, and that means that those folks stand to take an even harsher hit than those without chronic conditions. On top of that, individuals with chronic conditions cannot afford to roll the dice and go without health insurance the way that others sometimes can get away with.
It's not as though having chronic conditions is a cakewalk right now either, though. It is exceptionally common for essential diagnostic tests, medicines, and treatments to be under-covered, or not covered at all. Care is frequently highly fragmented, across an ever-increasing number of specialists. And coordination between specialists is challenging, because providers are so strapped for time and worked threadbare.
The Self-Employed and Small Business Owners
These folks get screwed in a different way: not having access to employer-based coverage, and not having the size or power needed to negotiate for fair terms on health insurance themselves.
This tends to leave them with extremely limited options for plans they can afford on various marketplaces. And in turn, this means doing the difficult dance of balancing business investment and livable income with healthcare costs; in effect, the same bucket many Americans are already in, but in some ways, an even deeper one.
So, we've pretty clearly established that this system is busted and needs help. What, then, do we do about it? More on that in Part 2! (Coming soon!)
And as always, Dr. Matt is available to discuss the ins-and-outs for you! If you are curious about your constitution & health (or health of a loved one), you can book a cost-free, 15min Consultation, and we’ll discuss!
Professional disclaimer: please do not initiate any herbal or other medicinal interventions without the guidance of a knowledgeable provider.
Dr. Matt Van Auken, MD, MPH
Dr. Matt is an Ayurveda-trained, triple board-certified physician.
