Updated May 12, 2024 - Health

U.S. health care is increasingly like a casino

Illustration of a red cross design on playing cards.

Illustration: Lindsey Bailey/Axios

For the decade-ish that I've been reporting on health care, insurance coverage has dominated conversations about who has access to care. But in the post-pandemic era, it's become clear that having insurance is only the first step toward receiving quality care.

Why it matters: Where Americans live, their health status and a range of socioeconomic factors increasingly determine their experience with the health care system, and in many cases that experience appears to be getting worse.

  • Affordability, while critical, isn't synonymous with access. Long wait times for doctor appointments, crowded emergency departments, complicated insurance requirements and a dearth of local providers are all making things tougher on patients.
  • For many people, whether they can get the care they need when they need it seems to come down to the luck of the draw.

State of play: Provider shortages and a post-pandemic surge in demand for care have played a large role in today's squeeze.

  • That's being felt all along the care continuum, whether you're trying to schedule an annual physical or waiting in the ER.
  • "All the noise that we're hearing is a signal. This is real," said Joe Betancourt, president of the Commonwealth Fund. "There's no doubt that in my career ... I've seen access challenges evolving."

Zoom in: Primary care especially is in short supply, which is particularly alarming given its role in keeping people healthy and from needing more specialized care down the road.

  • The number of primary care doctors isn't keeping up with population increases, partly because it's hard to convince medical students graduating with mountains of debt to resist the draw of more lucrative specialties.
  • Factors like administrative burden and burnout have meanwhile "led to what's a pretty daunting exodus in primary care and a significant decrease in people going into primary care," said Betancourt, who is a primary care doctor himself.
  • Specialists are also being stretched thin, he added.
  • Staffing shortages — particularly among primary care physicians — are projected to only get worse, according to the Association of American Medical Colleges.

Between the lines: Who has bad luck when it comes to getting care can be predictable — or at times it isn't really luck at all.

  • "The Silicon Valley where I live is a lesson in how money talks," said KFF president and CEO Drew Altman.
  • "Primary care docs and specialists have been lured by generous tech company benefits into concierge practices that have long waiting lists ... leaving little left over for working and low-income people — most people — even if they can afford it."

What we're watching: Experts chalk up the recent surge in demand to people catching up on care they put off during the pandemic.

  • If and when that subsides, it would likely alleviate at least some of the challenges with getting appointments.
  • New technology could help with some more systemic issues, like administrative burden. And expanding the scope of practice for non-physician providers, like physician assistants and nurse practitioners, could also increase the system's capacity.
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