Let\u2019s dig in.<\/p>\n
Over the past two decades, the cost of employer-sponsored health insurance\u2014how the vast majority of privately insured Americans obtain their health care\u2014has skyrocketed. Premiums, deductibles, and out-of-pocket costs have all soared\u2014far faster than wages.<\/p>\n
This widening gap means workers earn less, even when their salaries rise on paper. Every dollar going to premiums is a dollar not going to rent, groceries, or childcare.<\/p>\n
And the human toll is clear. One in three<\/a> Americans has medical debt, and more than half worry they\u2019ll fall into debt any time they use the health care system. That fear changes behavior: people delay appointments, skip medications, or avoid care altogether.<\/p>\n Medical debt is now the most common form of debt in collections ahead of credit cards, utilities, or personal loans. Nearly 60% of those in medical debt have insurance.<\/p>\n The United States spends far more on health care than any other wealthy country yet achieves worse outcomes, less access, and a more demoralized workforce.<\/p>\n Outcomes: Despite record spending, Americans live shorter, sicker lives than peers in Europe, Canada, or Japan. Infant mortality, maternal mortality, and chronic disease rates all rank near the worst among high-income nations. A key reason is that we pour money into specialty medical services while underinvesting in prevention, such as primary care and social supports like housing and nutrition.<\/p>\n Access: Critics often argue that \u201cat least we don\u2019t have long wait times like other countries.\u201d However, increasingly the opposite is true (and this is never a fair comparison, as we spend twice as much as they do). More than 100 million Americans<\/a> live in a primary-care desert, while almost 60 million live in a pharmacy desert. Services to treat mental health are notoriously lacking, and Medicare does not even cover long-term care.<\/p>\n Clinician workforce: Health care workers are burning out or leaving the profession altogether. Home health care aides are paid extremely low wages<\/a> for heroic work. As corporations attempt to convert salaried positions into gig work, some nurses are compelled to bid against one another<\/a> for shifts. Many physicians report moral injury working in systems that prioritize billing over care, eroding autonomy and morale.<\/p>\n There\u2019s a common myth, especially amongst policymakers, that we spend too much on health care because we consume too much of it. A similar narrative has taken hold about doctors: because they get paid for each service, they provide too much care. Certainly, there is low-value care in the U.S. health care system. And as profit-seeking corporate actors own more and more of the system, they\u2019re finding ways to bill for more\u2014and more expensive\u2014services.<\/p>\n But Americans don\u2019t<\/a> <\/a>visit the doctor more, we don\u2019t go to the hospital more, and we don\u2019t stay in the hospital for longer. We even get significantly fewer of many of the most popular procedures\u2014like coronary angioplasties, knee replacements, hip replacements, and gall bladder and prostate removals. The real difference is price<\/a>. Take a look at this graph, as one example for hip replacements: <\/p>\n A colonoscopy or MRI can cost 10 times more at one hospital than another across town, depending on which insurer you have. These differences have little to do with quality or cost of care. They\u2019re the result of opaque negotiations between insurers, hospitals, and pharmacy benefit managers, and other middlemen in the system. We\u2019ve created a system where no one knows what anything costs: not the doctor, not the patient, sometimes not even the insurer. The surprise bill arrives weeks later.<\/p>\n On top of high prices, our system is drowning in private-sector bloat and bureaucracy. More so than any other country<\/a>. Every insurer has its own prices (and endless price negotiations with providers), billing processes, prior authorization rules, and reporting requirements. The result is staggering inefficiency: roughly one in four dollars spent on health insurance goes to something other than care, like marketing, billing, profits, or middlemen.<\/p>\n Doctors spend nearly half their time on paperwork. Patients spend hours on hold, fighting over denied claims. And all of it is baked into costs.<\/p>\n Perhaps the most underappreciated transformation of the past 40 years is the corporate consolidation and financialization of medicine. Care delivery\u2014once local and community-based\u2014is now dominated by corporations.<\/p>\n Vertical consolidation is now a defining feature<\/a> of American health care. UnitedHealth Group isn\u2019t just the largest insurer; it\u2019s also the largest employer of physicians and the largest operator of home health and hospice agencies. CVS Health, the largest pharmacy chain, also owns the biggest pharmacy benefit managers\u2014and now giant insurer, Aetna. McKesson, a pharmaceutical distributor, now operates<\/a> the nation\u2019s largest chain of oncology practices and is rapidly expanding into other specialties. These combinations raise all the conflicts of interest you\u2019d expect\u2014higher prices, business steered away from independent providers and pharmacies, gaming regulations, and more.<\/p>\n Hospitals have been on a similar trajectory. No longer charitable facilities, they\u2019ve been buying up physician practices, starting insurance plans, and operating financial investment firms. Public hospitals have declined sharply, while giant for-profit systems, such as HCA Healthcare and CommonSpirit, have expanded<\/a> nationwide. In half of U.S. metro areas, just one or two systems dominate<\/a> the market.<\/p>\n Then there\u2019s private equity (PE). From 2000 to 2020, PE\u2019s footprint in health care exploded<\/a> 25-fold\u2014from $5 billion to more than $100 billion a year in deals, totaling over $1 trillion.<\/p>\n Private-equity firms now own everything from nursing homes<\/a> and hospices, to emergency departments and physician practices. Their model is simple: buy up fragmented practices, cut labor costs, raise prices, and resell for profit. Evidence shows quality declines, and in some cases, mortality rises, after PE takeovers.<\/p>\n None of this happened by coincidence. Our current governing approach began in the 1980s, when a bipartisan consensus emerged around how to address accelerating costs in the system. The idea was to embrace more free market principles in health care, resulting in three significant shifts in how we approached policy:<\/p>\n Private insurers compete for patients (called managed competition), which was hypothesized to lower costs and improve quality. In reality, the government pays hundreds of billions to the nation\u2019s largest insurance companies, which now operate most of Medicaid and Medicare, and all of the ACA exchanges. The same happened with prescription drugs: instead of Medicare negotiating prices directly with pharmaceuticals, it\u2019s now the job of pharmacy benefit managers (PBMs), costing Americans more.<\/p>\n Overreliance on economic incentives\u2014the notion that physicians and patients won\u2019t do the right thing unless they have more \u201cskin in the game.\u201d Democrats embraced this ideology<\/a> by pushing physicians into \u201cvalue-based care,\u201d a rebranding of HMO-style managed care, and a close cousin of privatized Medicare<\/a>. On the patient side, Republicans insisted that they actually needed higher deductibles, so they would ration their care more wisely. But, again, Americans don\u2019t \u201cuse\u201d too much health care. Plus, a patient can\u2019t \u201cshop\u201d for emergency surgery or chemotherapy.<\/p>\n Commercialization: The U.S. began converting<\/a> public hospitals to for-profit chains, and abandoned care delivery models with commitments to voluntarism (i.e., actual non-profits) and professional ethics (i.e., clinician-owned medical clinics).<\/p>\n The current debate <\/a>recycles the same logic: more private control, higher out-of-pocket costs, and less regulation of prices or profits. The latest idea<\/a> is that deductibles need to be higher and patients don\u2019t pay enough.<\/p>\n This approach has failed for 40 years. It will continue to fail because it doesn\u2019t address the true crisis of U.S. health care: high costs from high prices (especially for new technology); consolidation and extraction at every level; and lackluster and misallocated capacity.<\/p>\n The U.S. health care system is uniquely dysfunctional. A different approach is entirely possible\u2014if we have the will to boldly govern the health care system in the interests of patients, clinicians, and taxpayers. That means directly tackling<\/a> prices, eliminating middlemen, and breaking up<\/a> behemoths. It also means returning ownership of care delivery to clinicians and communities<\/a> and pursuing a strategy that builds the<\/a> workforce and capacity to meet Americans\u2019 needs.<\/p>\n Health touches everyone, and we need a system that works for us, not one that makes us work for it.<\/p>\n Love, YLE and HR-L<\/p>\n Hayden Rooke-Ley<\/a>, JD, is a Senior Fellow at the Brown University School of Public Health. His scholarship focuses on corporate consolidation in health care, Medicare and Medicaid financing, and labor and workforce issues in the health sector. He has published in leading journals, including the New England Journal of Medicine and Journal of the American Medical Association (JAMA), and he advises state and federal policymakers, enforcement agencies, and other health care stakeholders. He is a licensed attorney in Oregon and earned his JD from Stanford Law. His work can be found on X<\/a> and LinkedIn<\/a>.<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/il\/wp-content\/uploads\/2025\/11\/https:\/\/substack-post-media.s3.amazonaws.com\/public\/images\/fcce7f13-446a-4e26-a51a-4b84a33bd7c9_1958.jpeg\")
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