It's not a caricature, it's real.

For several years, West Health has been publishing a report in collaboration with Gallup to assess the affordability and value of healthcare in the United States. The most recent report shows that the situation has steadily worsened, with now 45% of Americans reporting an inability to pay, or at the least a heavy strain in paying for their healthcare expenses. Of the 45%, 8% are desperate, meaning that close to 1 in 10 Americans are at the end of their financial rope and simply cannot pay for their share of medical and pharmacy expenses. And to add insult to injury 94% of Americans believe they are getting inconsistent or poor value. Plainly said, it's expensive and it ain't good.

Twelve years ago, I self-published a booklet -- more like a manifesto than a book -- called The Incentive Cure, in which the illustration below was featured in the first chapter. The message was simple: health care costs are ballooning and crushing Americans. The secondary message was that the United States were falling behind most other countries in the effectiveness and affordability of its health system.

The West Health report, unfortunately, confirms that the weight of the system on Americans is heavier than it has ever been, and the value is lower than it has ever been. So what can be done? The recipe isn't complicated, but its execution is. And it may be impossible for the incumbents because they are part of the problem and benefit from the status quo.

Let's consider member cost-sharing. The most recent annual report published by the KFF shows how much cost-sharing has increased over the past decades, and shifted from premium contribution to out-of-pocket costs when accessing care. Companies that regularly work with physician practices and hospitals estimate that the current level of uncollectible receivables -- patient cost share -- is at least 3% of total plan costs. That doesn't seem like much, but given that plan members' collective share of total plan costs is, on average, 15%, one fifth of that amount ends up in bad debt. Consider the number of individuals affected by the inability to pay. It's incredibly significant. And consider how they must feel emotionally. Consider how they would likely consider changing physicians and continuity of care because they can't go back to the place where they owe money. Consider how they may simply not get the care they need.

What most employers don't realize is that the unaffordable cost-shares aren't for silly out-of-network choices, but rather for everyday cancer care, maternity care, mental and behavioral health care. Having a baby in the United States, for most individuals covered under a group health plan, results in a multi-thousand dollar out-of-pocket bill.

It's important to note here that the fact higher cost-sharing results in the self-reduction of needed care should not come as a surprise to anyone. Forty years ago (yes, 40) RAND conducted a large scale study that conclusively showed that higher cost-sharing resulted in lower use of health care, irrespective of the value of that care. Said plainly, good care, bad care, and neutral care all go down as cost sharing goes up. What the RAND study didn't show, nor could it anticipate, is that ever-increasing cost sharing would result in significant financial harm. But that's what's happening now.

There are few options to right what clearly seems to be a wrong, other than to reduce cost-sharing and increase the plan's portion of plan costs for all care -- good, bad, indifferent. The solution, therefore, seems to be to take a new approach to cost-sharing.

One such option was recommended by David Anderson, Mark Fendrick and Michal Horny in a JAMA Internal Medicine paper. While the approach creates better equity and reduces the potential for financial harm, it doesn't eliminate it. A complementary policy would be for employers and providers to create a small pool of funds that could cover uncollectable cost-sharing. This is the type of innovation that we're implementing at XO Health Inc. and that plan members will benefit from. Yes it's hard, much harder than the status quo, but that's what we're willing to do to help Americans and their employers: operationalize scalable and effective solutions, however hard it may be.