Unequal Access to Orthopaedic Care Fuels Push for Healthcare Reform

Access to healthcare in the United States has long been a contentious and polarizing issue. Reports consistently frame the U.S. healthcare system as underperforming relative to its staggering costs. In 2024, the Commonwealth Fund—a nonprofit dedicated to improving healthcare access, quality, and efficiency—ranked the United States last among 10 peer healthcare systems, including countries such as Canada, the United Kingdom, and Germany. This ranking was particularly damning in the “access” category, where the United States fared the worst. Similarly, the Legatum Prosperity Index, a London-based think tank that evaluates national prosperity across multiple “pillars,” placed the United States 69th out of 110 countries in the health category, which measures outcomes, access to care, and availability of services.

Although perspectives on these reports vary, they highlight a fundamental flaw: The United States’ exorbitantly expensive healthcare system remains inaccessible to many. The term “access to care” has become a catch-all phrase, encompassing a multitude of barriers that restrict entry into the system. Understanding these barriers is key to any meaningful reform, particularly in specialized fields such as orthopaedic surgery, where access is even more limited due to a range of systemic and logistical challenges.

Two types of access: theoretical versus practical
A useful framework for understanding healthcare access divides it into two categories: theoretical (network) access and practical (personalized) access.

Theoretical access refers to a patient’s ability to enter the healthcare system, akin to gaining entry into a building before accessing an individual apartment. It encompasses factors such as insurance coverage, proximity to healthcare facilities, and the range of services offered by a given institution. This stage is often the first—and most formidable—barrier to care.

One of the most significant obstacles in theoretical access is the lack of insurance. Studies have shown that uninsured individuals are far more likely to forgo necessary medical care. A 2023 report found that nearly 47 percent of uninsured adults did not seek medical attention in the past year, compared to just 15 percent of those with commercial or public coverage.

Similarly, underinsurance—when insurance coverage is insufficient due to high costs or limited benefits—also restricts access. A 2022 Commonwealth Fund survey reported that 43 percent of working adults were underinsured, with premium costs being the main deterrent to better coverage.

This inverse relationship between underinsurance and access has been well documented in orthopaedic surgery. Patients often face prohibitive out-of-pocket costs, leading to delays in treatment and, consequently, worse clinical outcomes. The challenge is not just about having coverage—it is about having meaningful, usable coverage.

Practical access, on the other hand, refers to the ability to find and utilize specific healthcare services. If theoretical access is akin to entering a building, practical access is successfully navigating through hallways to reach the right apartment. This includes securing timely appointments, obtaining necessary referrals, and completing treatments such as surgeries or rehabilitative therapies.

One of the most pressing issues in practical access is the difficulty of scheduling appointments with specialists. Patients frequently report being bounced between providers before finally reaching the appropriate subspecialist. Even when an appointment is secured, wait times can stretch for weeks or even months. The longer patients wait, the more likely they are to seek care elsewhere, exacerbating no-shows as well as cancellations of office and surgical appointments.

A 2024 report from ECG Consultants analyzed wait times for new patients across metro areas and medical specialties. For orthopaedic surgery, the average wait time was 20 days, ranging from as little as 2 days to as long as 90 days. Even in cities with high densities of orthopaedic surgeons—Boston, Los Angeles, Atlanta, Philadelphia, and Seattle—appointment delays were significant. This underscores that supply alone does not guarantee access; inefficiencies in scheduling, pre-approvals, and administrative hurdles all contribute to bottlenecks in care delivery.

The cost of delay: when waiting becomes detrimental
Delays in orthopaedic care can have dire consequences. Many musculoskeletal conditions progress over time, leading to worse symptoms, increased disability, and higher treatment costs. The longer a patient waits for intervention, the more complex—and costly—the required procedure becomes. Delayed access to surgery may turn a simple procedure into one that is more complex, which may raise the cost of care and may diminish the results or outcomes. Beyond the financial burden, prolonged suffering negatively impacts patients’ quality of life, such as interfering with their ability to work or attend school.

Healthcare systems have attempted to mitigate delays, but often in counterproductive ways. One common “solution”—borrowed from the airline industry—is overbooking. This practice acknowledges systemic inefficiencies and assumes a certain percentage of no-shows. Although it maximizes provider utilization, it also leads to unpredictable rescheduling, exacerbating frustration for both patients and physicians. Instead of addressing fundamental access issues, many healthcare institutions merely adjust schedules to compensate for inefficiencies. In doing so, they inadvertently validate the inefficiency of the system, often promoting or amplifying, rather than fixing, its underlying problems.

The path forward: rethinking healthcare delivery
Patients and providers alike are frustrated by these systemic delays, but both are bound by external constraints. Many patients forgo coverage due to cost, and many providers structure their schedules to maximize efficiency within a broken system. Addressing these inefficiencies requires an honest appraisal of healthcare delivery and a willingness to consider alternative compensation models that prioritize patient care over volume-based revenue.

Reforming orthopaedic care accessibility will require more than just increasing the number of surgeons. It will necessitate streamlining administrative processes; reducing unnecessary pre-authorization barriers; and creating incentives for timely, high-quality care. Until then, both patients and physicians remain trapped in a system that prioritizes bureaucracy over accessibility—one in which merely opening the door to care remains a formidable challenge.

David S. Geller, MD, MBA, FAAOS, is a professor of orthopaedic surgery and pediatrics and the vice chair of strategy and innovation for the Department of Orthopedic Surgery at Montefiore Einstein in New York. He also serves as codirector of Montefiore’s Orthopedic Oncology Division, and he is the associate director of the Musculoskeletal Oncology Laboratory.

References

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