What's Actually Broken in U.S. Healthcare Right Now — And What Physicians Would Change First
Commentary by Dr. Michelle Cooke, Family Medicine
Ask most Americans what's wrong with the U.S. healthcare system and you'll get a familiar list: costs are too high, access is too limited, and the experience of navigating care is needlessly exhausting. But according to Dr. Michelle Cooke, a family medicine physician practicing under the direct primary care model, the root of these problems is more structural — and more solvable — than most policy debates acknowledge.
"The most broken part of our healthcare system is the overreliance on insurance to pay for primary care," Dr. Cooke said. "Insurance was never designed to cover everyday healthcare needs — it was meant to protect against catastrophic events. Yet today, we've built a system where even the most basic care is filtered through insurance." The consequences of that misalignment, she argues, ripple through every corner of the system. Physicians spend mounting hours navigating prior authorizations and billing codes rather than treating patients. Administrative overhead inflates costs. And the foundational doctor-patient relationship — long considered the bedrock of effective medicine — erodes under the weight of bureaucratic friction.
Dr. Cooke's proposed remedy is as direct as her practice model: remove insurance from routine primary care altogether. "At the same time, we should expand access to and flexibility of Health Savings Accounts and Flexible Spending Accounts," she said. "These tools empower patients to take control of their healthcare dollars, reduce friction in accessing care, and support models like direct primary care." In the direct primary care arrangement, patients pay their physician a flat monthly fee in exchange for unlimited access to primary care services, bypassing insurers for routine and preventive needs entirely. Proponents argue the model reduces overhead, eliminates the incentive to over-bill, and restores the kind of longitudinal, relationship-based care that produces better long-term outcomes.
Critics of market-oriented healthcare reforms often raise the concern that deregulating payment structures could leave vulnerable populations behind. Dr. Cooke, however, draws a careful distinction between the mechanisms of payment and the goal of universal access. "Many people assume that universal healthcare requires universal insurance — but those are not the same thing," she said. "Insurance is simply a payment tool, and it's best suited for large, unpredictable medical expenses. Primary care, however, is predictable, ongoing, and relationship-based — it doesn't function well when forced into an insurance model." The argument reframes a politically charged debate: rather than treating insurance expansion as synonymous with healthcare access, it invites policymakers to consider whether the payment infrastructure itself may be contributing to the access problem.
Physician burnout, a crisis that has accelerated sharply since the COVID-19 pandemic, figures prominently in Dr. Cooke's analysis. The American Medical Association and other professional bodies have documented record levels of exhaustion and career attrition among physicians, with administrative burden consistently cited as a leading driver. By simplifying payment structures and removing intermediaries from routine care, Dr. Cooke contends, the system could address burnout and patient outcomes simultaneously. "By simplifying payment and removing administrative burden, we can improve outcomes for patients while reducing burnout for physicians," she said — framing the two objectives not as competing priorities, but as naturally aligned ones.
Whether reforms of this scale gain traction in a polarized legislative environment remains uncertain. But Dr. Cooke's perspective reflects a growing chorus of primary care physicians who argue that meaningful change begins not with expanding the existing insurance apparatus, but with questioning its role in primary care entirely. "If we can begin to untether primary care from insurance," she said, "we'll see stronger patient-physician relationships, better health outcomes, and a more sustainable system overall." For a healthcare debate often dominated by coverage statistics and premium benchmarks, it is a reminder that the structure of how care is paid for shapes, in profound ways, the quality of care itself.