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Steve Tierney, Senior Medical Director at Southcentral Foundation, has played a central role in advancing the organization’s award-winning Nuka System of Care. Joining the foundation in 1995 as a primary care physician, Dr. Tierney helped lead the transformation toward a relationship-based, customerowned healthcare model serving Alaska Native and American Indian communities. Trained as both a family physician and acupuncturist, he earned his medical degree from the Uniformed Services University in Bethesda, Maryland. Dr. Tierney is widely recognized for his expertise in quality improvement, healthcare transformation, data integration, and integrated primary care, and frequently speaks at national and international healthcare forums.
When Basic Care Becomes Complicated, Costs Explode
Ask anyone about healthcare in the United States—patients, doctors, nurses, even politicians—and you’ll hear the same thing: frustration, anger, and disbelief. Costs keep climbing, quality lags behind other nations, and every year the situation seems worse, not better. But here’s the truth almost no one talks about: healthcare itself isn’t the problem. Insurance is.
For the money we spend, the value delivered to the American health consumer is shockingly poor. Unforgivable, even. In a country that prides itself on technological innovation, simple tasks—refilling a prescription, scheduling a lab test, transferring medical records—are maddeningly complex. Communication with provider offices is often a nightmare. And rapid, easy access? Forget it.
We hear constantly that chronic conditions like diabetes and hypertension drive up costs. But why do they cost so much? The answer is simple: we’ve made basic care hard. Checking labs, refilling medications, and staying in touch with providers should be effortless. Instead, it’s a bureaucratic obstacle course.
Here’s the kicker: when people with chronic conditions can afford their medications, get timely refills, and complete routine monitoring, they stay healthy. Hospitalizations plummet. Costs drop dramatically. But when the system makes these basics difficult, a small percentage of patients spiral out of control—and they account for nearly 80% of the costs. It’s not the diseases themselves. It’s the broken process.
Shifting Healthcare Power Back to Patients
So who controls that process? The payers. Insurance companies dictate the rules, and we keep handing them our money—through premiums, employer contributions, and government programs—expecting them to fix the mess they created. Why would they? For them, it’s not broken at all. It’s wildly profitable.
Consider this: in one home health program, 60% of staff time was spent filling out insurance paperwork—just to convince payers to fund care they promised to cover. Only 40% of time went to actual patient care. We solved it by cutting out the middleman: we stopped billing and directly employed the team. Hospitalizations dropped. ER visits declined. That’s what real value looks like.
Imagine a different approach. What if, during employee onboarding, you could choose: traditional insurance or an annual contribution to your own health savings account (HSA) for direct payment of nonacute care? What if clinics asked, “Will you use insurance or direct pay with your HSA?” Suddenly, the power shifts—from payers to people.
The Future of Healthcare
Here’s the truth: ambulatory care is cheap—until you add the insurance paperwork. If HSAs rolled over year to year, people could save for future needs. Employers could redirect dollars away from legacy payers and into the hands of consumers. Insurance companies would finally feel the pressure to change—or lose market share.
We don’t need “Medicare for All.” We need Healthcare for All—not insurance for all. Until we stop feeding the insurance machine, nothing will change. The system isn’t broken for payers. It’s broken for everyone else.
The solution isn’t complicated. Setting up HSAs is easy. Changing onboarding and check-in processes is easy. What’s hard is breaking our dependence on a product no one likes. But consumer dollars have power. It’s time to use it.
Healthcare isn’t broken. Insurance is. Let’s stop paying for failure—and start funding value.
