What I Would Change in Medicine

After decades in medicine, working primarily as a hospital-based physician, I've come to a sobering realization: Much of the suffering I witness in the hospital isn't just due to illness. It's due to the fractured structure of our health care system.

If I could change one thing in medicine, it would be to create true equity and functionality in access to care. We’ve made progress since the early 2000s – thanks to the Affordable Care Act, I see far fewer uninsured patients than I did earlier in my career. But what we have now is coverage in name only for many. I regularly treat patients who technically have insurance but can't get the follow-up care they need. I discharge them knowing they won’t be able to afford their prescriptions or see the specialists I’d refer them to – because I’m not allowed to make that referral in the first place.

These patients return to the hospital, not because they want to, but because the outpatient system failed them. Their plans are often managed in name only. They’ve been assigned to a network but have no actual connection to it. In Sacramento County alone, where one in three residents is on Medi-Cal, the transition from inpatient to outpatient care is broken.

It’s easy to blame patient noncompliance or overuse of emergency services, but that narrative misses the point. When networks are inadequate and care coordination is nonexistent, the hospital becomes the fallback. I've seen people drive for hours to get here – not through a formal transfer, but because they or their loved ones realized it was faster and more reliable to show up at our emergency department than to wait days for an appointment that might not exist.

The root causes are structural. Reimbursement rates for public insurance are low, so many physicians opt out of accepting Medi-Cal or similar plans. That leaves patients with limited preventive care, delayed diagnoses, and few options – until things become emergent. We pay the price not just in dollars, but in irreversible complications, lost productivity, and human suffering.

One case stands out in my mind. A young man who received a kidney transplant at the age of four – his mother was the donor – moved out of state in his twenties to start a new chapter in life. But in doing so, he lost insurance coverage. The transition to a new state plan wasn’t simple or fast. He couldn’t get his anti-rejection medications, and though the kidney might have eventually failed, the lack of continuity hastened its decline. He ended up back in California on dialysis. Why do we place such a heavy administrative burden on individuals with lifelong medical needs just because they relocate?

This isn’t only about access. Administrative complexity continues to drain the system. Prior authorizations, redundant paperwork, and shifting formularies impose an immense burden. Every January, some of my patients face a new round of prior auths or “step therapy” requirements, even for medications that have already proven effective. The pharmacy benefit may have changed, and suddenly patients are made to fail again before they can succeed. It’s maddening – and worse, it’s dangerous.

Physicians didn’t go into medicine to spend hours justifying every clinical decision to insurance plans. And yet, here we are: According to some estimates, more than 30% of our health care spending goes toward administration. That’s not improving outcomes. That’s not advancing science. That’s paperwork.

What can be done?

On a local level, we can start by holding plans accountable. Are your networks adequate? What support do you provide for high-need patients? Managed care should mean more than assigning a member to a system – they should actually be able to use it.

Policies like Proposition 35, supported by organizations such as SSVMS and CMA, are a promising step toward strengthening Medi-Cal and ensuring more consistent coverage. But ongoing uncertainty about federal matching funds, and a tendency toward austerity in public health programs, makes progress tenuous.

At the very least, we must push for greater transparency in insurance plan structures. Patients should know what their plan covers, and providers should be empowered to deliver care without navigating a maze of restrictions and delays.

And above all, we must remember that the system should serve patients – not the other way around. The burden of navigating insurance, appealing denials, or proving the need for life-sustaining medication shouldn't fall on those already struggling with their health.

I’ve been practicing long enough to remember paper charts and handwritten notes. While electronic health records have improved many aspects of care, they’ve also introduced new forms of friction. The good news is that advocacy – at the local, state, and national level – has led to some relief in documentation requirements. That’s a sign that change is possible.

Ultimately, we as a people need to recommit to the idea that health care is a public good. Not a privilege based on employer, ZIP code, or administrative literacy. Because in the absence of good health, all other efforts – education, work, family – are compromised.

We can’t fix everything overnight. But we can start by acknowledging that the system we have is too complex, too opaque, and too punishing for too many. And we can continue to use our voices – not only at the bedside, but at the ballot box, in the boardroom, and in every space where decisions about care are made.