Opinion | More administrators, fewer doctors

In 2024, the US health care sector employed nearly 18 million people. Politicians from both parties celebrate these numbers routinely. Health care is an economic engine, they say. A pillar of the middle class. A source of good jobs.

It is only half true: Health care does employ a lot of people. But that is nothing to celebrate.

Look at where the jobs are. While the number of physicians in the United States has doubled in the past five decades, the number of administrators has grown by more than 600 percent in that same time period. Billing departments, prior authorization teams, coding specialists, denial management units — these are among the fastest-growing features of American medicine. Other wealthy countries employ more doctors and nurses and far fewer administrators. The jobs the United States should be adding are clinical. The ones that have been added are too often administrative.

When Americans celebrate health care job growth without asking what those jobs actually do, we are measuring the wrong thing. This series has tried to focus attention on the right one: whether health care is becoming more affordable for the American people without sacrificing the medical excellence that saves lives.

There is no doubt that the American health care system is extraordinary at what it does best. When it comes to medical innovation — new cancer therapies, cardiac surgery, rare disease treatment — the United States leads the world. For the very sickest patients, with the most complex conditions, there is arguably no better place on earth to be treated.

That achievement is real. What drives it is the National Institutes of Health, academic medical centers, physician and scientist talent, and decades of public and private investment in basic and applied research. But the billing apparatus, prior authorization bureaucracy, market consolidation, and opaque pricing impose a tax on that achievement rather than enabling it. Affordability is not austerity. Affordability in health care comes from removing the waste that keeps patients from getting the care they need.

Look across the eight solutions in this series and you will notice something. Some rely primarily on markets: aggressive antitrust enforcement, expanding ambulatory surgery centers, value-based payments, and allowing nurse practitioners and pharmacists to practice at the top of their training. Some require government action: enforceable price limits, drug negotiation authority, standardized insurance rules, and administrative simplification. These do not map cleanly onto a party platform. That is intentional — and it is the point.

The political right’s instinct is that markets fix everything. But many health care markets are, in practice, government-protected monopolies. You cannot have a market solution where there is no market.

The left’s instinct is that the government should set the terms. But where real competition exists, it does lower costs and expand access. Neither instinct, applied rigidly, gets to affordability. Both, applied selectively and practically, will.

The only question worth asking about any reform proposal is simple: Does it make care more affordable for more Americans without sacrificing quality? If yes, pursue it. If not, set it aside.

So why does this matter right now, more than it did 10 years ago?

Two forces are bearing down simultaneously. The first is demographic. The number of Americans age 65 and older has already passed 60 million and is projected to approach 80 million by 2040. More older Americans means more chronic disease management, hospitalizations, and long-term care.

The second force is therapeutic. A new generation of cell and gene therapies is arriving — treatments that can cure previously untreatable diseases with a single dose, put certain cancers into lasting remission, and transform the lives of patients who once had few options. These are genuine breakthroughs. They are also often priced at $2 million or more per treatment.

Aging will increase demand. Breakthrough therapies will increase what medicine can do. Both are signs of progress. But progress becomes unaffordable if layered on top of waste.

If the nation arrives at that moment still carrying the existing inefficiency — administrative bloat, inflated prices, protected monopolies, incentives that reward volume over value — the system will not bend. It will break. Act now, while reform can still be thoughtful, or face a reckoning that is crisis-driven, blunt, and almost certainly worse.

The standard response to this kind of argument is patience. There is always another election. There is always a more politically favorable moment just ahead. And so the decision gets deferred — not because anyone concluded the problem wasn’t real, but because the immediate cost of acting always seems to exceed the immediate cost of waiting.

Yet, every year without antitrust enforcement is another year of consolidation that becomes harder to unwind. Every year without price reform is another year of contracts locked in at elevated rates. Every year without administrative simplification is another year in which more people are hired to navigate a system that should be simpler. The constituency for the status quo grows as more livelihoods come to depend on it. Delay compounds the problem and the consequences are concrete.

Rising costs price employers and workers out of insurance, swelling the ranks of the uninsured regardless of what laws dictate. For people who have insurance, premiums and out-of-pocket costs consuming household budgets grow, representing income not saved, not invested, not spent on a decent life — America getting poorer, household by household. On the government side, health care spending crowds out the public investment that actually produces long-term prosperity: a state spending 35 cents of every dollar on Medicaid spends fewer cents on universities and public infrastructure. The country that cannot control its health care costs is defunding its own future.

None of this requires waiting for Washington. States have more power over health care costs than is commonly understood. Governors do not need permission from Congress to repeal certificate-of-need laws, modernize scope-of-practice rules, enforce price transparency, or create affordability boards with teeth. Insurance market rules, Medicaid payment policy, scope-of-practice laws, and the oversight of hospital markets are all substantially state decisions. Indiana has shown what is possible by enacting price caps on hospital systems tied to Medicare rates, and other states should follow its lead.

Federal action remains necessary — on drug pricing, Medicare payment reform, and antitrust law. States cannot go it alone, but waiting for Washington to move first is a costly and unnecessary choice.

The interests that benefit from the status quo are organized and well-funded. The people who would benefit from reform are diffuse — spread across every ZIP code, every income level, every political affiliation. That asymmetry has sustained an unnecessarily expensive system for decades.

But the costs have grown too large to be quietly absorbed. Families feel them. Employers feel them. Governors feel them. The federal budget reflects them.

The question was never whether policy makers knew what to do. This series has hopefully put that argument to bed. The question — the only one that remains — is whether policy makers are finally willing to act.