Navigating Health Care.

It’s Complicated.

If you’ve had to find a primary-care provider or pay a medical bill lately, you know that accessing and paying for health care can be very difficult. But why? What are the biggest problems? And how can we get the care we need in such a system?

By Patrick Luce ’99

When the CEO of one of the largest health insurance companies in the United States was gunned down on a midtown Manhattan sidewalk in December, the public reacted with anger and exasperation, not a surprising response to such a brazen attack.

What was surprising was the target of that public ire.

In this case, the vitriol normally reserved for the perpetrator was largely directed at the victim, UnitedHealthcare CEO Brian Thompson, and all he represented: the most expensive health-care system in the world—a for-profit system that is complicated and inaccessible to many; a system that, ultimately, leaves many behind.

The universal right to health care is ingrained in many industrialized nations, but that is not the case in the U.S. More than 70 percent of U.S. adults feel the health-care system fails to meet their needs, according to a 2023 Harris Poll conducted with the American Academy of Physician Associates. The poll found 54 percent of Americans think the health-care system is going in the wrong direction, more than 25 percent feel it is completely broken, and 26 percent grade the system with a D or F, while just 10 percent give it an A. Those from traditionally underserved communities have a worse view. U.S. News & World Report’s State of Equity in America conference found that 75 percent of Black Americans believe their race negatively affects the care they receive.

More than a quarter of people polled cited cost and poor access to care and insurance as the key problems in the U.S. system. Even those with insurance say it’s difficult to get treatment, largely due to a shortage of primary-care providers. One-third say the health-care system does not meet their needs because it takes too long to get an appointment.

These problems add up to a worldwide ranking that is dead last among the top 10 wealthiest nations, according to a survey by the Commonwealth Fund, an international organization that promotes equitable health-care systems. Of the five categories measured in the survey, the U.S. ranks last in access to care and health outcomes, and ninth in equity and administrative efficiency. The American system performed well in just one category—care process—ranking second, largely due to its emphasis on preventative services like mammograms and vaccinations.

“Especially concerning is the U.S. record on health outcomes, particularly in relation to how much the U.S. spends on health care,” the organization’s report reads. “The ability to keep people healthy is a critical indicator of a nation’s capacity to achieve equitable growth. In fulfilling this fundamental obligation, the U.S. continues to fail.”

The problems of cost and access were recurring themes when we asked URI alumni working in the health-care industry to provide their perspectives on the system. We asked practitioners—including doctors, nurses, and pharmacists—as well as administrators, to share their impressions of the U.S. health-care system and offer advice for patients and caregivers.

Akos Antwi ’14 Psychiatric Nurse Practitioner, Revive Therapeutic Services

Navigating the health-care system, even as a professional, can be intimidating. My clinical understanding has helped me advocate for clients and loved ones, ensuring they receive quality care. I’ve also seen firsthand how challenging it is when you lack that knowledge. There is a need for clear, transparent systems that empower patients.

Kerri Friel ’98, M.A. ’05 Professor of Dental Health Programs, Community College of Rhode Island

Dental care is a vital component of overall health, yet it is often undervalued in broader health-care discussions. One of the most significant barriers in dentistry, as well as other health-care professions, is the critical workforce shortage. Access to dental care is further limited by the high cost of services and the lack of insurance coverage.

Sarah McGinley, M.S. ’18 Nurse Practitioner and Owner, Weatherly Direct Primary Care

The lack of access for patients to their provider is problematic. The direct primary-care model of my practice allows me to have a smaller patient panel and, therefore, offer more personalized, thoughtful care. I focus on good communication and do my best to answer questions or concerns as they arise.

Mazen Taman, Pharm.D. ’23 Medical Student, Brown University Warren Alpert Medical School

The U.S. health-care system offers some of the most advanced medical technologies and expertise globally, but it is marred by significant disparities. Navigating this system can be daunting, particularly for those who lack resources or health literacy. Clear communication and empathy are the principles that now guide my medical training. Things work better when health-care professionals are patient-centric—aligning goals and meeting people where they are.

Shahnee Lagor ’04, ’15 Healthy Aging Nurse Coordinator, Robert Rock East Providence Senior Center/ Miriam Hospital VAT RN

If we educate people early and provide thorough care at all stages of life, we can drastically reduce illness, obesity, and disability, improving Americans’ quality of life. Furthermore, health coverage must be more available and affordable. The insurance companies have too much control over who receives what. It’s time we put lives over profits and create a health-care system that supports health and wellness from birth until death.

Julianne DeAngelis, ’93, M.S. ’97Program Manager, R.I.-based cardiac, pulmonary, and vascular rehab center

Three words: It’s too complicated. The layers both patients and providers have to work through are the biggest barriers to care.

Silifat Yussuff-Mustapha ’97Vice President of Nursing and Clinical Services, Unity Health Care, Washington, D.C.

This broken system demands radical change. The challenges go beyond inefficiencies. Chronic diseases are rampant, disproportionately affecting low-income and marginalized communities. Health disparities are not just numbers; they represent daily tragedies that reveal a moral and economic crisis. A radical transformation is essential, prioritizing evidence-based public health strategies and policies that tackle root causes rather than symptoms. Achieving universal access to affordable, high-quality care must become a reality, not just an aspiration.

Yohasma Marzan ’16Nurse Project Coordinator, Brown University Health Community Health Institute

Be persistent. It can be easy to get discouraged when facing barriers, but there are often resources available if you know where to look. As a nurse, I try to help patients by pointing them to community resources and assistance programs that might help.

John Stoukides ’85, Hon. ’05 Chair, Department of Medicine, Roger Williams Medical Center

We provide excellent care in the U.S., but not necessarily in the most cost-effective manner due to multiple nonclinical factors—legal/tort lawsuits, endless medical “information” on the internet, relentless medical advertising, a pharmaceutical industry that is turning out great therapies but also great profits, and insurance companies that are trying their best to control costs but frequently limiting necessary care. A single-payer system would be great, but it would never happen in this country.

Eugenio Fernandez Jr. M.B.A. ’13, Pharm.D. ’13 Founder, Asthenis Public Health Hub

Some of the biggest barriers are accessibility to primary care and the underutilization of pharmacists who work outside of chain pharmacies. The laws that limit pharmacists are outdated. We must educate lawmakers and encourage them to modernize health care by allowing pharmacists to provide care, including testing for things like strep throat; prescribing medications, like antibiotics, for simple illnesses; and administering vaccinations. This would improve access for underserved populations and alleviate some of the burden on primary-care providers.

Pamela Lauria ’92, M.S. ’97 Primary-Care Nurse Practitioner, Brown University Health; R.I. State Senator, District 32

We have a critical shortage of primary-care providers, leaving those left with more and more patients who need care. For decades, we have prioritized medical procedures rather than preventing the need for them. One big positive I have seen over time is that patients are more informed and active participants in their health care. My goal is for affordable, accessible, and equitable care. We need to slowly move toward a universal health coverage, similar to Medicare.

Eric Tirrell ’13Clinical and Research Manager, Butler Hospital Center for Neuromodulation-Interventional Psychiatry

The United States has some of the most advanced technologies and world-renowned experts in their respective fields. However, Americans find navigating the health-care system challenging, costly, time-consuming, and complicated. When access to care is not a barrier, you can receive the best treatment possible. However, a lack of understanding about the complexities of insurance coverage, deductibles, and billing can result in high out-of-pocket costs. This can add financial stress to the medical conditions patients are seeking to treat.

The problems with U.S. health care are many, and there is no simple solution, says URI College of Nursing professor Betty Rambur, an expert on health-care cost and policy and author of Health Care Finance, Economics, and Policy for Nurses: A Foundational Guide. But among the myriad problems, two themes stand out: money and access.

“It’s too expensive,” Rambur says. “Cost is well documented as Americans’ greatest concern with the U.S. system. We have the most expensive system in the world, yet we have real problems with quality. Structural racism is built into the system, and we have an enormous income divide.”

Many point specifically at health insurance companies as the culprit when it comes to cost. Providers struggle to be reimbursed at a level that covers costs and allows them to make a living. Mental-health, maternity, pediatric, and primary-care providers are not well reimbursed by insurance or government payers like Medicaid, Rambur says. “And currently, only 5% of our total national health-care expenditure of $4.9 trillion is directed toward primary care, while high-performing nations have a robust focus on primary care.”

Pharmacists—especially at the dwindling number of smaller, independent pharmacies—are often forced to operate at a loss, largely because of third-party middlemen known as pharmacy benefit managers, or PBMs, which maintain a stranglehold over pricing structures and reimbursement. PBMs frequently fail to pay what it costs pharmacies to acquire drugs, forcing them to take a loss to fill prescriptions they can’t refuse, according to Matt Olivier, Pharm.D. ’06, who owns and operates Matt’s Local Pharmacy in Middletown, R.I.

“A lot of independents are closing because we can’t dispense medication without losing money. We can’t get medications for what they’re willing to reimburse,” Olivier says. “They’re essentially forcing us out of business.”

But reimbursement practices are only part of the problem in the complex, fee-for-service health-care system, Rambur says, noting that the first health insurance company, Blue Cross Blue Shield, was intended only to reimburse hospitals and doctors for illness care, not to be a health-care plan, coordinate services, support wellness, or contain costs.

“There is an intrinsic challenge with an insurance model, because insurance is supposed to be for rare events—floods, fires, etc.—and we share the financial risk with others,” Rambur says. “But we will all get sick; we will all need health care. People get upset with insurance companies, but the cost of insurance is largely a reflection of the cost of care, and our prices are higher than anyplace else in the world. It is difficult to assess the real value of health care.”

“People get upset with insurance companies, but the cost of insurance is largely a reflection of the cost of care, and our prices are higher than anyplace else in the world.”

­—Betty Rambur Professor, URI College of Nursing

Patients must rely on providers to advise them on what treatments they need. Even with their patients’ best interests at heart—and possibly because they have their patients’ best interests at heart—providers often fall victim to what Rambur calls the “Gucci effect” of overtreatment and over-screening. Rambur points to prostate exams, which the American Medical Association recommends for men starting at age 45. Many wealthy countries do not do routine prostate screenings, unless there’s a particular reason to do so. Not doing a preventative screening might seem antithetical to quality care, but, she says, the prevalence of these screenings contributes to the low value of care Americans receive.

“Over-screening leads to overdiagnosis, which leads to overtreatment,” Rambur says. “Prostate screening, for example, has been found to lead to overtreatment, and the treatment often has horrible outcomes—like incontinence and impotence resulting from surgery. Some people might really need the surgery, but for others, the question should be, ‘Would you die with it, not of it?’”

Furthermore, the fee-for-service system, in which providers charge separately for each procedure, is ripe for fraud and abuse. “We do screenings on things for which there’s a lot of downstream revenue. We don’t do screenings on things where there isn’t,” Rambur says. “I would challenge my colleagues to consider the value of what we’re contributing. What’s the cost, and what’s the outcome? Is there a way to do this better?

“When we look at health care, we need to think about value, which is determined by the cost and quality of care—and by outcomes. But there’s a lot of money in the illness industry. A lot of money,” Rambur says. “People are starting to understand that we do not have the best health-care system in the world. The data has been very clear about that for a long time.”

Short of a complete overhaul, there are things that could improve the system, Rambur says. More in-home care could reduce hospital costs, while also making patients more comfortable. Better reliance on nurse practitioners can expand the roster of primary-care providers, increasing access and potentially lowering costs.

The federal government could help by offering a public option, like the one proposed by Republican President Richard Nixon in 1971 or the more recent Medicare for All options, Rambur says. “Regardless of how health care is financed, we must stop paying for low-value care. It causes financial harm to individuals, businesses, and taxpayers, and often physical and emotional harm to patients and families.” She adds that the government could follow other countries’ leads and regulate health-care prices, but that could face legal challenges in a free-market economy. There are no simple solutions.

So, faced with these obstacles, and few concrete solutions, how can consumers find the care they need? Rambur says: Be your own advocate. Don’t take what your provider or insurance company tells you on face value; insist that they involve you in your own health care, and make your voice heard.

“It’s important that people start questioning the recommendations,” Rambur says. “There’s a piece in the Affordable Care Act called shared decision-making. If you’re my provider, you and I—together—think about my values, and what’s important to me. So much of the health-care system has revolved around the system, not the patients. That has to change.”

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