Imagine buying a car without knowing the price until six weeks after you drove it home. Imagine ordering dinner and receiving the bill only after the restaurant consulted your employer about what it was willing to cover.
That is not a hypothetical. That is American healthcare — a system in which the true cost of care is almost never visible at the moment it matters most, and in which patients routinely discover what they owe long after they had any chance to make a different choice.
In Gallup’s most recent survey, 17 percent of Americans said they were satisfied with the cost of healthcare — the lowest figure the polling organization has ever recorded. Not frustrated. Not skeptical. Seventeen percent satisfied.
At some point, a number like that stops being a data point and starts being an indictment.
I have spent my career as a healthcare executive, and I have watched this frustration play out in examination rooms, billing departments and boardrooms. Patients who want to be responsible consumers — who want to compare options, weigh costs and make informed decisions — are denied the basic tools to do so. They are not passengers who chose the back seat. They were put there by a system that was never designed to let them drive.
With satisfaction at record lows and costs still climbing, a new political consensus is forming around an old idea: give patients more control. President Donald Trump has made “returning healthcare dollars to patients” a signature theme. Policymakers on both sides of the aisle are talking about consumer-directed care with renewed energy.
The direction is right. After decades of reforms that promised transformation and delivered paperwork, skepticism is entirely warranted, and those pushing for change should welcome it. Good ideas hold up under scrutiny.
The core challenge is straightforward to state: build a healthcare system that works the way every other consumer market does — where people can see prices, compare quality and make decisions in their own interest. The answer is not a new government program or a sweeping regulatory overhaul. It starts with something more fundamental: treating patients as active participants in their care rather than passive recipients of a system built around everyone but them.
When patients have real purchasing power — when they can see prices, access quality data and bear meaningful responsibility for their choices — the entire incentive structure of health care begins to shift. Providers compete on value. Unnecessary procedures face scrutiny. And patients, finally acting as informed consumers rather than captive ones, spend more deliberately. This is not a theory. It is how markets work in virtually every part of the economy.
The evidence backs this up. The landmark RAND Health Insurance Experiment — still one of the most rigorous studies ever conducted on healthcare behavior — found that patients with a greater financial stake in their decisions spent significantly less on care with no measurable decline in health outcomes. Skin in the game produces smarter choices. The data has been there for decades. The will to act on it has not.
None of this requires dismantling the healthcare system. It requires something harder: the political will to put patients at its center. That means price transparency with real teeth, not disclosure requirements that produce documents no one reads. It means benefit designs that give patients genuine choices and genuine savings when they make them wisely. It means trusting Americans — as we trust them in every other consequential decision in their lives — to make good decisions when given good information.
The unexpected bill arriving weeks after surgery is not a glitch. The inscrutable explanation of benefits is not an accident. They are features of a system optimized for everyone except the patient. Changing that will require real political will, not just political interest. The goal isn’t complicated: a healthcare system under which patients finally have the same information, agency and leverage as everyone else at the table.
The Center for Medicare and Medicaid Innovation, the innovation arm of the nation’s health agency, is positioned to test patient-directed approaches that evaluate the effect of consumer engagement on access, affordability and patient experience. A well-designed CMMI demonstration could inform broader reforms across public programs and private markets.
A national pilot could focus on routine services such as primary care, diagnostic testing, outpatient procedures and prescription medications. With access to clear pricing and quality information, Medicare and Medicaid beneficiaries could choose among high-performing providers, fostering a more transparent and patient-centered healthcare marketplace.
David J. Shulkin served as the secretary of the Department of Veterans Affairs in the Trump administration and VA’s undersecretary of health in the Obama administration. He wrote this for InsideSources.com.
