America does not have a single healthcare crisis. It has affordability, access, and safety crises. Washington has divided them by party, and each party is concentrating on only half of the problem.
Republicans focus on what healthcare costs taxpayers and on stopping fraud, waste, and abuse. That concern is legitimate. The Centers for Medicare and Medicaid Services (CMS) recently reported a record $41.9 billion in Medicare program-integrity savings in fiscal 2025. The 2025 reconciliation law also seeks large federal Medicaid savings through work requirements, more frequent eligibility reviews, and financing changes. The law’s Medicaid provisions were projected to reduce federal spending by roughly $887 billion over a decade, while increasing the number of uninsured Americans by 7.5 million in 2034. Major work requirements begin Jan. 1, 2027.
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Democrats focus on the other side: the people who may lose coverage, hospitals already struggling financially, emergency departments that are overcrowded, and nurses working under unsafe pressure. Those concerns are legitimate, too. KFF Health News reported in July that states were already cutting Medicaid budgets even before most federal reductions take effect. Coverage lost on paper can become delayed care, uncompensated hospital treatment, and still more pressure on emergency rooms.
But the national debate has become a split screen. Republicans talk about what government spends while paying limited attention to what happens to access and patient safety. Democrats talk about protecting coverage and access to care while giving too little attention to whether the healthcare capacity already being purchased is affordable. Each side sees a real emergency, but neither confronts the whole one.
The latest employer data show why this division is untenable. According to an Aug. 20 Reuters report on Aon’s new projection, U.S. employer healthcare costs are expected to increase 9.5% in 2027, pushing average plan costs above $19,000 per employee. It would be the fourth consecutive year of nearly double-digit increases. Employers cannot absorb that indefinitely, workers cannot endlessly accept higher deductibles and contributions, and government cannot solve the problem simply by moving costs from one payer to another.
There is a neglected third question: Before cutting access or demanding more money, are hospitals and clinics using the capacity we already finance as safely and productively as possible? Hospitals cannot schedule emergencies, but they do schedule elective operations and admissions. Many concentrate scheduled cases on particular weekdays, creating artificial peaks in demand for beds, nurses, operating rooms, intensive care units, and diagnostic services. Emergency patients then board for hours or days, urgent surgery is delayed, nurses face unstable workloads, and hospitals conclude that they need more staff or new buildings. Days later, some of the same capacity may be underused.
The remedy is called smoothing elective admissions: distributing scheduled demand more rationally while reserving appropriate capacity for unpredictable emergencies. It does not mean performing fewer operations or asking clinicians to work harder. It means stopping the system from manufacturing part of its own shortage. Harvey Fineberg (then President of the Institute of Medicine, currently the National Academy of Medicine) and I described the approach in “Smoothing the Way to High Quality, Safety, and Economy,” and I summarized the accumulated evidence and implementation experience in STAT this March.
The results show why this belongs in both parties’ agendas. Cincinnati Children’s reported a financial benefit exceeding $137 million annually while avoiding more than $100 million in capital expansion. At the Ottawa Hospital, redesigned surgical flow was associated in one year with approximately 40 lives saved, $9 million in financial benefit, and the elimination of more than 600 annual surgical cancellations attributed to bed shortages. These institutions did not choose between affordability and access. Better operations improved both.
The same principle applies to primary care. St. Thomas Community Health Center in New Orleans serves more than 22,000 patients annually, many of them uninsured or covered by Medicaid. After redesigning appointment scheduling and patient flow, the Center reported that about 80% of patients could receive same-day appointments and roughly 90% could be seen within two days. Satisfaction with access reached 97%, annual operating margin improved by approximately $1.5 million, and the number of commercially insured patients doubled over two years. An insurance card is essential, but it does not create an appointment. Operational reform can make coverage more meaningful while strengthening the safety net financially.
The Journal of American Medical Association estimates that nationwide application of these operations-management methods could reduce U.S. healthcare spending by 4%-5%, more than $200 billion annually.
AS A DOCTOR IN CONGRESS, I’M STOPPING DRUG MIDDLEMEN FROM DRAINING AMERICAN FAMILIES
Republicans should not assume that reducing federal spending has solved the problem if millions lose coverage while the delivery system continues wasting capacity. Democrats should not assume that protecting every existing healthcare dollar would solve the problem if employers, workers, and taxpayers keep paying more for an inefficient and avoidably stressed healthcare delivery system. Both parties could ask CMS to sponsor transparent demonstrations in hospitals and outpatient clinics, analyze scheduled and emergency demand using existing claims data, publish the results, and reward measurable improvements in access, safety, and cost. No party has to endorse this intervention in advance, as the obligation is to at least evaluate it.
At some point, silence is not neutrality. If Republicans decline to examine an approach that may reduce spending without sacrificing care, or Democrats decline to examine one that may expand access and stabilize staffing without simply demanding more money, that silence is itself a decision — a decision to ignore this opportunity.
Eugene Litvak is the president and CEO of the nonprofit Institute for Healthcare Optimization and an adjunct professor at the Harvard T.H. Chan School of Public Health.
