At the Breaking Point: Hopes for Health Care Reform in 2026
A physician colleague recently told me that increasingly she is seeing patients turning 65 years old seeking care for the first time in their adult life as they qualify for Medicare. These people have gone without care for decades and present with chronic conditions such as diabetes, heart disease and kidney disease. The opportunity for prevention or mitigation has passed. Health care coverage matters.
Our health care system is at the breaking point. We need real solutions.
Solutions need to be multi-faceted, addressing many areas
Consider the following:
➡️ The rate of physicians leaving clinical practice has been increasing steadily since before the COVID-19 pandemic - now 4.9%/yr leave practice
➡️ Medical students choosing primary care is declining.
➡️ 27-30% of US adults have no usual source of care
➡️ A 2025 survey showed that 41% of adults have medical debt
➡️ Almost 2/3 of personal bankruptcies are due to medical debt
➡️ While the risk of medical debt is much higher for the uninsured, those with insurance constitute the largest number of people with debt (many are "underinsured" e.g., high deductible plans)
➡️ 5% of the population accounts for over 50% of the nation's health care expenditures.
➡️ 30% of the US health care expenditures is due to administration, far higher than any other country
This data demonstrates that our health care system is not working for many of us, physicians and patients alike, but especially for those without health care coverage.
Current Proposed Solutions Won't Make a Dent
Health Savings Accounts (HSAs) have been proposed as a solution by the current administration and others. However, HSAs benefit those 52% who get their coverage from their employers or those with the financial means to put away money, and since most people in this country live paycheck to paycheck, is therefore not a solution. Further, giving people $1,500 to put into an HSA as has been proposed is also not a solution. One encounter or episode of care - e.g., ED visit due to a car crash or fall, a cancer diagnosis or a knee replacement - will not be covered by this relatively small amount of money.
Price transparency is a start, but not a full solution. Most health care services are not price sensitive (in economics its called "inelastic"). People do not shop for the lowest price cardiac surgeon or lowest price cancer care. Moreover, how do you "shop" if you have an emergency? Additionally, even if people could "shop", studies have shown that people equate higher health care prices with higher quality. There are other ways to address out of control prices and the variation across regions.
And it's only going to get worse. As millions will be forced to go without health care coverage due to the enhanced subsidies expiring and the damaging cuts due to the "Big Beautiful Bill", the system will collapse further. Uninsured adults are much more likely to delay or go without necessary care due to cost compared with insured adults. This means higher mortality, further erosion to lifespan, and adults who cannot work due to illness or injury.
Policy Solutions to Implement Now
Insurance is how the US has provided health care to the population. It is not a perfect fit for provision of health care services like it is for cars or homes and is likely why it is highly regulated and so complex. Making big changes all at once though is not a viable solution. Determining the bigger solutions will take time and, like the ACA, will require "sausage making".
The big questions are a matter of principles and values - do we as a people believe people have a right to care? A right to health? Do we see an economic and national security need for a healthy and productive population?
But for now Congress can do the following:
☑️ Lower Medicare eligibility to age 50
☑️ Expand Medicaid in ALL states and expand programs that strengthen rural health institutions
☑️ Augment and strengthen the ACA marketplaces and continue enhanced subsidies until more permanent solutions are implemented
☑️ Ensure coverage of all pregnant women, children, teens, and young adults through Medicaid and expansion of eligibility of the CHIP program. Prevention should start in childhood
☑️ Strengthen primary care by establishing innovative models of care, providing federally subsidized support for technology and infrastructure for primary care practices and expand loan repayment programs and GME slots for primary care providers.
☑️ Whole of government and industry commitment to addressing social drivers of health including unhealthy processed and cheap food, housing, education. Salt and sugar in food products should be more tightly regulated, especially food marketed to children.
☑️ Expand global payments and episodes of care models; focus on the highest cost types of care
☑️ Reduce administrative waste once and for all - simplify billing and coding, standardize and regulate prior authorization practices, incentivize digital solutions for administrative functions
☑️ Establish site neutral payments
☑️ Impose caps on hospital annual price growth, cap non-profit hospital executive compensation
☑️ Change regulations to allow for quicker move to generic drugs and eliminate (or increase regulation) of pharmacy benefit managers (PBMs)
Conclusion
In the current environment, large changes are not likely to happen. No matter your political bent, we can all agree that our system is broken, health care expenditures are just too high and physicians are exhausted. It will get worse as the current administration is dismantling our public health infrastructure, allowing charlatans to make non-evidence-based vaccine policy and are defunding our once esteemed medical research ecosystem. The hope is that 2026 will bring in new members of Congress that want to protect people and pass solutions that will make our health care system better and work for the people who vote for them.