The murder of UnitedHealthcare CEO Brian Thompson triggered a disturbing avalanche of complaints about health insurers systems for prior review for many services and claims reimbursement.

UHC is a large insurer and has been criticized for its high denial rates. A Senate Committee concluded UHC, Humana and CVS, which owns Atena, were denying coverage for nursing care for patients recovering from falls and strokes to boost profits. And is now under the Justice Department investigation for abusing Medicare Advantage Accounts for inappropriate diagnose claims.

Generally, dealing with health insurance companies, even when issues are resolved favorably, is too often unnecessarily time consuming, tedious and exasperating.

Doctors complain negotiating with insurance companies to secure approvals is only getting worse. Many have sold their practices to private companies and become employees in part to avoid those hassles.

Critics were quick to jump on the Thompson tragedy as an indictment of Obamacare. A recent Gallup survey indicates only 44% of Americans rate our healthcare system as good or excellent, down from 62% just prior to the 2010 passage of the Affordable Care Act.

What’s overlooked is why we have this system and the radical changes necessary to reform it.

The ACA was intended to ensure quality coverage for virtually all Americans—either through mandated employer-sponsored plans or private insurance purchased with income-tested subsidies—and to bring healthcare costs under control.

The poor and elderly have Medicaid and Medicare.

This cut the share of Americans without coverage in half to about 8%. But on costs and quality it’s a mixed bag.

Prior to the ACA, healthcare spending as a share of GDP was rising but since its inception, that has held steady at about 17%, even with a 10% increase in the insured population. But that share of GDP is 40% to 63% greater than in other industrialized nations like Germany, the Netherlands and UK.

On quality of medical service delivery, our system compares quite well but on accessibility—that’s where barriers imposed by insurers’ approval processes come into play—and outcomes—as measured by avoidable deaths and life expectancy—we rank near the bottom.

Competition alone can’t fix these problems, because we don’t let prices ration healthcare. We view it as an entitlement like elementary and secondary education, not a commodity like designer shoes. But the system can’t permit everyone to have all the care they like.

Rationing is inevitable—for example, by limiting access to certain drugs.

With 42% of the population obese and at $1350 a month, letting everyone who wants Wegovy have it has become a highly charged issue about what scope of care that should be guaranteed.

It became apparent in the public debate leading up to the passage of the ACA that many Americans that had insurance did not want to give it up in favor of a public, single-payer system like the British National Health Service. And they didn’t want government bureaucrats making decisions about treatments.

What emerged was a complicated system like some in Europe, but with terribly important omissions.

Mandatory systems of non-profit funds and private companies are funded by a payroll tax in Germany and by employer and employee premiums adjusted according to incomes in the Netherlands.

Prices are regulated and the treatments covered are fairly well-defined. Essentially, the government orchestrates the rationing through those requirements.

Here, insurers compete on premiums charged, required co-pays, range of services covered, scope of in-network work physicians and facilities and how tough they are in applying the rules.

An insurer can be tough with high denial rates and by making approvals processes so time-consuming that patients give up—that’s our nasty system of private rationing.

With the ACA, insurers’ administrative costs as a share of premiums are capped and profits are a slim 2.4% of premiums—even reducing those to zero wouldn’t improve conditions much.

To grow and create shareholder value insurers have become part of vertically integrated companies controlling the entire supply chain from drug stores to pharmacy benefit managers, physician practices and hospitals. They can shift costs around and game government efforts to control what they charge and regulate the quality of access.

The only real answers to high costs, bureaucratic hassles and arbitrary treatment and claim denials are to have the government regulate prices and arbitrate exactly what people are offered.

It’s been so long since we have had anything resembling free markets, the best solution may be to impose on providers, hospitals and facilities competition with their German counterparts by setting our prices and scope of coverage equal to theirs.

That would impose wrenching adjustments on the business practices and fees charged by doctors, hospital bureaucracies and drug companies. But the present system pays providers more for delivering a lower quality of care than in Europe—that’s what we’d expect from monopoly abuse.

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Peter Morici is an economist and emeritus business professor at the University of Maryland, and a national columnist.