The U.S. health care system leaves much to be desired.

It is convoluted, fragmented, complex and confusing. Experts have also raised concerns about quality, and disparities are rampant. And, of course, it is excessively costly – far more so than in any other developed nation. Given these failings, it is not surprising that Americans are unhappy with their health care system.

As the public reaction to the killing of UnitedHealthcare CEO Brian Thompson has made clear, however, many Americans are perhaps most unhappy with their health insurers. Indeed, just 31% of Americans have a favorable view of the health insurance industry, according to a 2024 survey.

Yet, given the recent tragic events, as a health policy scholar, I think it would be prudent to take a step back and reflect on the broader health care system and how the U.S. got to this point.

Many sources of health care frustration

Few with any personal experience or professional expertise would describe U.S. health care as the gold standard of health care systems.

For a number of historical and political reasons, it is barely a “system” but rather a complex patchwork with countless different approaches to covering the costs of health care that include splitting the costs between individuals, employers and governments.

Governments also extensively regulate health and health care and, although in a diminished role today, serve as the providers of care through state and county hospitals as well as the Veterans Health Administration.

The result is a regulatory amalgam made up of countless entities. The Affordable Care Act reforms only added additional layers of laws and regulations to an already complex framework.

Yet, even beyond this general structure, Americans face many challenges. Indeed, no other health care system in the world is pricier. This involves costs for medical services but also extremely high administrative costs. Pharmaceuticals are just one example of the excessive financial burden carried by Americans.

For many Americans, these costs are too high, with an estimated 530,000 medical bankruptcies annually.

And despite that high price, concerns persist about quality and access.

In addition, the system tends to be highly inequitable and subject to countless disparities that make it harder for many poorer, rural and nonwhite Americans to access care.

The role of insurers

In the United States, insurers play a crucial role in connecting – and at times disconnecting – patients with the care they require.

They are also at the forefront of many of the starkest frustrations that Americans experience – even the ones they are not directly responsible for. While medical providers and pharmaceutical companies charge the world’s highest prices, it is generally up to insurers to tell patients how much they still have to pay or that their care won’t be covered. Insurers are also the ones who determine whether a drug is not covered or a doctor is “out of network,” meaning patients can’t get the specific treatment or care they desire.

To be sure, insurers are not just the messenger – they also add to many of the frustrations patients experience every day. For example, a patient may have to travel very far or wait a long time for an appointment if their provider network is too narrow or simply does not have enough providers. Moreover, the directories and searches that insurers use to show what providers are “in network” may be inaccurate, as they rarely get updated.

For many individuals, this can mean delayed or forgone care, which has major implications for their health and finances. For some, it can even lead to preventable deaths.

Some of the practices insurers are most infamous for, such as rescinding coverage over minor clerical issues and refusing to cover preexisting conditions, ended under the ACA. But some of these issues could return if the incoming Trump administration seeks to undo some of the ACA’s protections.

Even today, so called short-term, limited-duration health plans promise good coverage for lower premiums, but even basic items may not be covered. Many plans, for example, do not cover prescription drugs or even hospital emergency rooms.

Blame the system, not just the insurers

Why do insurers act the way they do? For many, the answer may seem simple: to make money. This, of course, rings true – insurers in the U.S. rake in billions of dollar. However, while they tend to be profitable, their margins generally range only from 3% to 5%.

But the story is more complicated than that. With government power limited, insurers are perhaps the only force in the U.S. health care industry trying to rein in rising costs in a health care system where everyone seeks to maximize their profits.

That means insurers take on the role of bad cop, doing things such as limiting access to certain care or doctors. But there are several prudent reasons for doing so; for instance, it’s in the public’s best interest when insurers do not cover drugs that have been shown ineffective or of low quality. And ultimately this does keep premiums lower than they would otherwise be. Of course, insurers and their CEOs profit handsomely in the process. And at times, their methods are ethically and legally questionable.

Ultimately, many if not most of the frustrations Americans experience with health care have their origins in a poorly designed system that is highly inefficient and offers countless opportunities for profit. Yet insurers are only one – perhaps the most visible – part of that broken system.