June 2026

When Coverage Isn’t the Same as Care

Written By Deane Waldman, MD, MBA

Having health insurance and getting care are two different things. You have a plan, but you can’t get an appointment. You have a doctor, but you wait months to see one. You do everything right and still end up with confusing bills, surprise costs, or a denial from someone you’ve never met.

That gap, between being covered and actually getting care, is one of the most misunderstood problems in American healthcare. If you’re insured but still can’t get what you need, what good is your insurance policy? And who is the system really working for, if it’s not you?

Part of the answer is the doctor shortage, and it’s getting worse. The Association of American Medical Colleges projects a shortage of up to 86,000 physicians by 2036. The nursing shortage is also adding strain, with 250,000 positions unfilled at this time. The strain is felt throughout the country, but especially in rural and lower-income communities. Fewer doctors mean longer waits and delayed diagnoses, even for the fully insured.

Why care is so hard to get even with insurance, why there are fewer doctors, and why healthcare is increasingly unaffordable are the questions my co-author Vance Ginn and I set out to answer in “Become an Empowered Patient.”

Part of the problem is that too many hands are on the steering wheel. Insurance rules, employer requirements, health plans, prior authorizations, federal mandates, network restrictions, and billing departments all play a role in what care you can get, when, and at what price. Americans are forced to accept decisions about their care that they had no part in making.

Access and affordability can’t be pulled apart. You might have coverage on paper, but if the only specialist is two hours away and booked through next spring, that coverage doesn’t do much for you today. If you mess up the pre-authorization forms or insurance denies your care, what then?

Money shapes everything. People delay appointments, skip tests, or leave a prescription at the counter because they’re scared of the bill. Even insured patients are doing math on premiums, deductibles, copays, and out-of-network charges, all of which cost more pretty much every year. Sometimes you don’t find out what you owe until long after the care is done.

Doctors feel it too. Most went into medicine to care for people and then find themselves buried in paperwork, approvals, and denials that keep them away from patients. All those hours complying with federal mandates, filling out forms, and working through or around excessive security requirements are hours doctors want to spend with patients, but can’t. Bureaucracy comes first. Patients are left to wait.

The core problem is disconnection. Patients are disconnected from doctors by third parties. Patients are also disconnected, by those same third parties, from their healthcare dollars. Always remember, healthcare dollars spent by third parties come from hard-working Americans. It’s not Washington’s money or an insurance company’s money. Those are YOUR dollars they are spending.

Because of disconnection, decisions about your care get made far from you or your doctor. Patients too often can’t decide their own care. They’re just along for the ride.

None of this means patients are powerless. The more you question accepted wisdom about healthcare, ask direct questions, and stay involved in your own treatment, the harder you are to sideline. It also doesn’t mean patients, especially the medically vulnerable, should be left to their own devices. Safety nets matter, and the people who depend on them need protecting. The real question is whether the system we have can provide timely, affordable care to the healthy majority while still protecting the medically vulnerable.

Sadly, the answer is no. Long waits, baffling bills, denied approvals, narrow access, rising costs and, worst of all, Americans dying while waiting in line for care, so-called death-by-queue, are all signs of a system that has drifted away from the reason to have a healthcare system at all: the health of We the People. They come first, or they should.

The problem isn’t lack of coverage. It isn’t inadequate spending, as we spend double what most other countries spend. The root cause of healthcare system failure is one word: disconnection, both of people from their money and patients from their doctors.

When you have identified the root cause of a patient’s sickness, the cure becomes clear. Since disconnection is the root cause, the cure is reconnection. The way to reconnect is called the Empower Patients Initiative and can be found in “Become an Empowered Patient” or “Sé un Paciente Empoderado.”