What is the US healthcare system actually optimizing for?: Structural critics

Follow the money

The US healthcare system employs 22 million people. It’s the largest employer in most states. It generates $4.3 trillion in annual revenue, which means every year, $4.3 trillion flows to people and institutions that need next year to be at least as expensive as this year.

This isn’t a system with a problem. This is a system doing what it was built to do. It’s just that what it was built to do isn’t making people healthy.

The lobbying math

The pharmaceutical and health products industry spent $374 million on lobbying in 2022. Hospitals and health services spent another $127 million. Insurance carriers, $160 million. These are the people writing the policy memos, funding the campaigns, staffing the agencies. When the single-payer advocates ask why Congress won’t pass Medicare for All, the answer isn’t ideological. It’s financial. You’re asking elected officials to shrink a $4.3 trillion industry that funds their campaigns.

The market defenders talk about innovation. Fine. Sixty percent of pharma R&D spending goes to drugs that are minor variations of existing molecules — me-too drugs that extend patent exclusivity without improving outcomes. That’s not innovation. That’s rent-seeking with a lab coat.

The patient-choice advocates want transparency. We like transparency. But transparent prices in a monopoly market don’t produce competition. They produce transparent gouging.

Where we concede ground: It’s all corruption is too simple. Plenty of people in the system are trying to help.

What would change our mind: A major structural reform passing without being gutted by industry lobbying within five years.

Read the full synthesis: What is the US healthcare system actually optimizing for?