No one in their right mind would support the thesis that the American healthcare system, as it exists currently, is not in need of immediate and tremendous repair. The disagreement, as it is with so many issues, comes not from a contention over the issue itself but rather what can or should be done to correct the situation. The political right says that we need to put more power in the hands of patients and doctors while simultaneously pushing for decreased public funding and continued deregulation to appease the heads of major hospital, insurance and pharmaceutical companies. The political left wants to see more government investment in this sector with the possible outcome being the eventual creation of a single-payor healthcare system like those in Canada and Western Europe. While these competing interests fight and shout each other down, the rest of us continue to wade through the muck and mire of a confusing and hopelessly disjointed medical hellscape.

The rest of us continue to see insurance premiums and deductibles rise alongside the price of prescriptions and office visits. We’ve seen hospitals close and wait-times creep up as the medical industry follows the same track of consolidation that we’ve witnessed in food, media, tech and transportation. The core problem, the one that we have grown so accustomed to dealing with, is that healthcare, whether rightly or wrongly, is a business and must generate revenue if not profits. Every entity, from the drug wholesalers to the medical device manufacturers add their own margin to the cost of a pill, a machine, a procedure or a surgery. With little to no transparency or regulation to keep pricing reasonable and predictable, consumers are constantly blindsided by hospital bills, prescription copays and constant changes to formularies and provider networks. There is scant consistency from month to month and virtually none from year to year. Yes, insurance plans almost always have coverage material available online or on paper, but this knowledge and familiarity with the healthcare apparatus does little to nothing when it come to foreseeing the future.

That, we have long been told, is the purpose of health insurance; it’s the buffer between us and the unpredictable nature of health expense. Insurance is, at its heart, an exercise in speculation. During a narrow window of time each year one must select from among a host of coverage options while keeping in mind that there is absolutely no way to know or even be reasonable certain that your plan will meet your needs for the next 12 months. Will I be able to make it through another year on a high deductible/low premium plan in my current lifestyle of sloth and gluttony? Will my primo coverage choice simply suck thousands of dollars out of my paycheck and offer nothing but the hollow sense of satisfaction that if something happens I’ll be well covered. It is a gamble, a gamble that nearly always ends up costing the player more than expected, either because we overestimate our health or underestimate our needs. Hindsight, being 50/50, will always show us that we could have or should have done things differently, but the marketplace has zero sympathy for people who, through no fault of their own, bet their chips on the wrong hand.

But cost is only one of the most talked about problems. There is also the matter of America’s healthcare facilities and staff being forced to treat so much more than the medical problems of a deeply damaged social network. They must be therapists, investigators, psychologists, social workers, cops and counselors. Because they work within a business, they must also be salespeople, marketers, lawyers, networkers and brand consultants. Because the broader social apparatus has failed on so many other fronts, there are too few places for America’s homeless, addicted, victimized and psychotic to seek help. So they come to the hospital, one of the few places open at all times where their complaints, whether real or imagined, are legally required I be heard. Much of the time their respite is brief and always temporary as hospitals are not shelters. They are not psychiatric institutions. They’re not nursing homes or rehab facilities, orphanages or employment agencies. Hospitals are, ostensibly, places where emergent medical conditions can be triaged and more complex health problems treated. Of course this responsibility remains, but their ability to meet those obligations is often compromised due to the non-medical demands pressed upon them by a broken social welfare system.

At the end of the day, healthcare reform, or rather the potential for its realization, hinges upon this country’s willingness to radically transform, not simply the mechanisms of care, but its citizens’ understanding and expectations of what healthcare should be. This is not an easy project. It is not something that can be accomplished in a single law or an administration. It cannot be accomplished in a decade r even in a single generation. This change in attitudes and ideas will require many years of reconditioning and the acceptance of some uncomfortable realities, but will, I truly believe, lead to a more efficient, effective and, above all, equitable healthcare delivery environment.