The American Health Care Paradox

Why the world’s most expensive medical system struggles to deliver better health—and why Americans remain reluctant to replace it

An examination of American health care, international comparisons, pharmaceutical middlemen, the economics of prescription drugs, the diversity of the medical profession, and the political forces that keep the system intact.

There is something extraordinary, and perhaps uniquely American, about the country’s health care system. The United States spends more money on medical care than any other nation on earth. It has some of the world’s finest hospitals, leading medical research institutions, pharmaceutical laboratories, surgeons, and diagnostic technologies. It attracts physicians and scientists from around the world.

And yet, when Americans compare the results of their health care system with those of other wealthy democracies, an uncomfortable picture emerges: They pay substantially more, frequently receive less predictable access to care, and do not necessarily live longer or healthier lives.

This is not simply an argument about whether government or private enterprise should run hospitals. Nor is it an argument that every country with publicly financed medicine has solved the problem. Canada, Britain, France, Germany, Sweden, and Australia have different systems, different strengths, and different shortcomings.

But their collective experience raises an important question: Why does the United States spend so much more to achieve results that are, in several important respects, no better—and sometimes considerably worse?

The answer involves more than insurance companies. It involves the peculiar economics of American medicine, a fragmented system of payment and administration, pharmaceutical pricing, physician shortages, political ideology, and a deeply ingrained American belief that private competition is inherently superior to government administration.

The evidence suggests that this belief deserves considerably more scrutiny.

1. The price of American medicine: An extraordinary international outlier

The most revealing way to begin is with the numbers.

According to the OECD’s Health at a Glance 2025, the United States spent approximately $14,885 per person on health care in 2024, adjusted for purchasing-power differences. The OECD average was approximately $5,967.

In other words, America spent roughly two and a half times the average of the developed countries belonging to that organization.

The United States devoted 17.2 percent of its gross domestic product to health care. The OECD average was 9.3 percent.OECD+2

The comparison with other wealthy democracies is particularly revealing.

Country	Health spending per person, 2024 (approx. USD PPP)
United States	$14,885
Switzerland	$9,963
Norway	$9,393
Germany	$9,365
Netherlands	$8,436
Sweden	$7,871
Australia	$7,469
France	$7,367
Canada	$7,301
United Kingdom	$6,747
OECD average	$5,967

Source: OECD, Health at a Glance 2025. Figures are rounded and reflect 2024 estimates or nearest available year. PPP means purchasing-power parity.

These are not comparisons between America and impoverished countries with rudimentary medical facilities. These are wealthy industrialized nations with sophisticated hospitals, advanced medical research, modern surgical facilities, and highly trained medical professionals.

Some operate national health services. Others rely on compulsory insurance arrangements, nonprofit insurers, regulated private insurers, or combinations of public and private financing.

The distinction matters. Calling all of them countries with “socialized medicine” is misleading. In Britain, for example, the government operates much of the hospital system. In Germany, physicians and hospitals are frequently independent, while insurance is organized through regulated nonprofit and other sickness funds. France combines public financing with a substantial private medical sector.

The common feature is not government ownership of every hospital. It is a much greater degree of collective financing, regulation, and purchasing power.

America’s higher spending is not explained by Americans simply receiving more medical treatment. The United States actually has fewer practicing physicians per capita than the OECD average: 2.7 per 1,000 people, compared with 3.9. It also has fewer hospital beds per capita.

The American system is expensive partly because the prices charged for medical services, hospital care, pharmaceuticals, and administration are extraordinarily high.OECD+1

That is an important distinction. America does not necessarily consume two and a half times as much health care. It pays considerably more for much of what it consumes.

2. What do Americans get for all that money?

The most important question is not how much a country spends, but what its citizens get in return.

The Commonwealth Fund’s 2024 report, Mirror, Mirror: A Portrait of the Failing U.S. Health System, compared ten wealthy countries across 70 measures of performance. It examined access to care, quality of care, administrative efficiency, equity, and health outcomes.

The United States finished last overall.

Australia, the Netherlands, and the United Kingdom occupied the top three positions. The United States also ranked last in health outcomes, equity, and access to care.Commonwealth Fund+2

Consider some of the underlying indicators:

• Life expectancy: Americans have a shorter life expectancy than residents of comparable wealthy countries.
• Preventable deaths: The United States performs poorly in deaths that could have been avoided through effective preventive care.
• Treatable deaths: Americans are more likely to die from conditions that effective medical treatment should be able to address.
• Affordability: Americans are more likely to postpone or avoid medical treatment because of cost.
• Equity: Lower-income Americans face substantially greater barriers to receiving appropriate care.

There are important qualifications. Life expectancy is influenced by more than medical care. Poverty, violence, obesity, drug-related deaths, transportation, housing, diet, and other social conditions all contribute. A health system cannot be held solely responsible for every difference in national health.

Nevertheless, when a country spends so much more on medical care and performs so poorly on several measures directly related to medical access and outcomes, it is difficult to argue that its system is delivering exceptional value.

America has extraordinary medical institutions. Its problem is that access to those institutions is unevenly distributed and extraordinarily expensive.

3. Waiting for a doctor: Is socialized medicine really slower?

One of the most frequently repeated arguments against government-financed health care is that patients must wait months to see a physician.

There is truth to this concern, particularly in Canada and Britain. But the international evidence is considerably more complicated than the political rhetoric suggests.

The OECD’s 2025 Health at a Glance report examined waiting times in ten countries. It found:

• Nearly one in five respondents waited more than a week to see a general practitioner or nurse.
• More than half waited at least two days.
• For specialist appointments, just over half waited one month or longer.
• In Canada and the United Kingdom, more than 10 percent of respondents reported waiting over a year to see a specialist.

OECD+1

Canada is a particularly instructive example. Statistics Canada reported that among Canadians who received an initial specialist consultation in 2024, 35 percent waited less than one month, 30 percent waited between one and three months, and 36 percent waited three months or longer.Statistics Canada

The United States, however, has its own waiting-time problems.

The American experience is complicated by the fact that having insurance, having a physician who accepts that insurance, and being able to afford the associated costs are three different things.

A patient with excellent employer-sponsored insurance and access to a well-staffed metropolitan hospital may obtain an appointment relatively quickly. Someone without insurance, living in a rural community, or dependent on a physician who does not accept their coverage may encounter a very different reality.

An older Commonwealth Fund survey found that only 6 percent of Americans who needed a specialist reported waiting two months or longer, compared with 30 percent of Canadians. That is a meaningful American advantage, although the data are from 2016 and should not be mistaken for a current measurement. Commonwealth Fund

The lesson is not that one system always delivers faster care. It is that countries make different trade-offs.

Issue	United States	Canada	United Kingdom
Primary care access	Highly variable	Can involve delays	Can involve delays
Specialist access	Often quicker for well-insured patients	Frequently longer waits	Frequently longer waits
Financial barriers	Significant	Much lower for covered hospital and physician services	Much lower for NHS-covered services
Universal basic coverage	No	Yes	Yes
Private medical services	Extensive	Available within regulatory limits	Extensive

The table is necessarily simplified. Each country has regional differences, private options, and exceptions.

The United States has an advantage in some forms of rapid access, particularly for people with generous insurance and the financial resources to use it. Canada and Britain have more serious problems with certain specialist and elective-surgery queues.

But there is a fundamental distinction between waiting for an appointment and being unable to afford one.

A person waiting three months for a publicly financed specialist appointment has a problem. A person who cannot obtain an appointment because the treatment is financially out of reach has another problem, and it is not necessarily a lesser one.

The American system tends to make access dependent on the patient’s insurance and financial circumstances. Other systems tend to ration some services through waiting lists and available capacity.

Neither approach is perfect. The real policy challenge is to combine affordability with adequate medical capacity.

4. Who are America’s physicians? The racial and ethnic composition of the profession

The American medical profession is highly educated, internationally recruited, and increasingly diverse. But its racial and ethnic composition still does not reflect the population it serves.

The Association of American Medical Colleges’ 2026 physician workforce report provides the latest national breakdown, based on active physicians in 2025.

Physician workforce by race and ethnicity, 2025

Race or ethnicity	Share of physicians
White	55.8%
Asian	20.2%
Hispanic, Latino, or Spanish origin	6.8%
Black or African American	5.4%
Multiracial, non-Hispanic	1.7%
Other	1.3%
American Indian or Alaska Native	0.3%
Native Hawaiian or Other Pacific Islander	0.1%
Unknown	8.5%

AAMC+1

These figures deserve some explanation. Hispanic or Latino origin can overlap with racial identification in some demographic systems. The AAMC’s categories also include people who identify with more than one racial group. Consequently, these figures should be understood within the organization’s reporting methodology rather than as a perfect accounting of every physician’s identity.

The disparities are striking.

Hispanic Americans represent approximately one-fifth of the national population but only about 7 percent of physicians. Black Americans represent a substantially larger share of the population than their 5.4 percent representation in medicine.

Asian Americans, conversely, are considerably more represented among physicians than their share of the general population.

A 2023 KFF analysis found that the underrepresentation of Hispanic physicians was particularly pronounced in California, Texas, and New Mexico. In New Mexico, for example, Hispanic residents constituted nearly half the population but only 17 percent of physicians. In California, the respective figures were approximately 40 percent and 7 percent.KFF+1

Why does this matter?

It is not simply a question of representation for its own sake. Research has associated physician-patient racial and cultural concordance with improvements in certain aspects of communication, trust, and patient experience. Language differences can also affect the quality of medical consultations.

A physician who understands a patient’s cultural background may be better positioned to recognize certain concerns, communicate effectively, and establish trust.

There are also geographic disparities. Poorer rural communities and underserved urban neighborhoods frequently struggle to attract and retain physicians, regardless of the physician’s ethnicity.

The physician pipeline is expensive and lengthy. Medical school, residency, and specialty training require many years, and the financial burden of becoming a physician can discourage talented students from lower-income families.

A country that spends nearly $15,000 per person on health care should be asking why it has fewer physicians per capita than the OECD average and why so many communities remain underserved.

That is a workforce-planning problem, not merely an insurance problem.

5. The pharmaceutical middlemen: What exactly are pharmacy benefit managers?

One of the more bewildering features of American medicine is the number of businesses that stand between the manufacturer of a prescription drug and the patient who needs it.

The most important of these intermediaries are known as pharmacy benefit managers, or PBMs.

A PBM is essentially a purchasing and claims-management organization hired by an insurance company, employer, or other health plan to administer prescription drug benefits.

Its responsibilities can include:

1. Negotiating prices and rebates with pharmaceutical manufacturers.
2. Establishing which drugs are covered by insurance.
3. Developing prescription drug formularies.
4. Processing pharmacy claims.
5. Negotiating reimbursement arrangements with pharmacies.
6. Managing specialty-drug distribution and mail-order services.

In theory, the PBM is a purchasing agent working on behalf of the health plan and its members.

The theory makes sense. A large organization negotiating drug prices for millions of people should have more bargaining power than an individual patient or small employer.

The difficulty is that the PBM business has become extraordinarily concentrated.

The Federal Trade Commission reported in July 2024 that the six largest PBMs managed more than 90 percent of prescriptions in the United States. The three largest controlled nearly 80 percent.

Even more troubling, the largest PBMs are connected through corporate ownership to major insurance companies and pharmacy operations.Federal Trade Commission+1

This creates potential conflicts of interest.

Imagine a company that owns an insurance operation, a pharmacy benefit manager, and a mail-order pharmacy. It may have financial incentives to direct customers toward its own affiliated businesses.

It may also negotiate rebates from drug manufacturers that are not necessarily passed along to patients at the pharmacy counter.

The rebate problem

Suppose a pharmaceutical manufacturer establishes a relatively high list price for a medication. It then offers a substantial rebate to a PBM in exchange for favorable placement on the PBM’s formulary.

The PBM may receive a financial benefit from that arrangement. But the patient whose insurance requires a copayment calculated from the drug’s list price may not receive the corresponding savings.

The manufacturer, PBM, insurance company, and patient can therefore have very different financial interests.

A lower-priced alternative might even be less attractive to an intermediary if the existing arrangement produces more favorable rebates.

The FTC has also raised concerns about PBM reimbursement practices, the treatment of independent pharmacies, and arrangements that may discourage lower-cost competitors.

Its findings are significant, although they should be understood as findings from an interim staff report rather than a final judicial determination that every criticized practice is unlawful.Federal Trade Commission+2

Do we actually need PBMs?

We need the functions they perform. We do not necessarily need the current corporate structure.

Some organization must negotiate pharmaceutical purchases, process claims, maintain drug formularies, and manage pharmacy payments.

But those functions could be performed by a government purchasing agency, an insurance company, a nonprofit administrator, or a competitively regulated service provider.

The question is whether the present arrangement produces enough value to justify its costs and complexity.

If the intermediary saves an employer or insurance plan money but does not pass the savings to the patient, the system deserves scrutiny.

If it creates financial incentives that favor its own affiliated businesses over independent pharmacies, the problem becomes even more serious.

There is nothing inherently wrong with a middleman performing a useful administrative service. There is something wrong when the middleman becomes so powerful and opaque that the public cannot determine who benefits from the transactions.

6. Pharmaceutical discount programs: Why can the same medication have dramatically different prices?

The existence of pharmaceutical discount programs raises an interesting question about American drug pricing.

How can a medication cost one patient $150 through insurance but another patient obtain it for considerably less through a discount arrangement?

Does the cheaper medication come from a different manufacturing lot? Is it an inferior product? Is the manufacturer simply charging some customers more than others?

The answer requires distinguishing the physical product from its financial arrangements.

A prescription medication has a manufacturer, a production cost, a distribution chain, and a regulated selling price. But the amount ultimately paid can depend on the purchasing arrangement.

The list price, the pharmacy’s acquisition cost, the insurance company’s negotiated price, manufacturer rebates, pharmacy reimbursement, and the patient’s out-of-pocket payment are not necessarily the same number.

That distinction is essential.

A different price does not, by itself, mean a different manufacturing lot.

The economics of a discount program generally concern who is paying, which contractual arrangement applies, and which parties are absorbing or foregoing revenue. Price differences do not establish that one patient is receiving a different-quality manufacturing batch.

The pharmaceutical industry also distinguishes between brand-name drugs and generic medicines. Generic medicines have their own FDA approval requirements and manufacturing standards. But the question of whether a particular product is the same as another product is a regulatory and pharmaceutical matter, not something that can be determined from its retail price alone.

There is a broader economic question here.

If a manufacturer can profitably sell a product at a substantially lower price under one arrangement, what does that tell us about the original price?

It does not automatically prove that the original price was fraudulent. Research and development, clinical trials, patents, marketing, distribution, and the cost of developing unsuccessful drugs all contribute to pharmaceutical economics.

But it does demonstrate that the relationship between production cost and retail price is not straightforward.

The American pharmaceutical market is particularly vulnerable to this opacity because so many different parties negotiate separate prices and rebates.

The result is a market in which the patient often has the least information and the least bargaining power.

7. Are Americans being overcharged for prescription drugs?

This is perhaps the most uncomfortable question in the pharmaceutical business.

If a manufacturer can sell a medication at a discounted price and still make money, why should another customer pay substantially more through an insurance arrangement?

There are several possible explanations:

• The manufacturer may be offering a discount to attract customers or compete with another product.
• The manufacturer may be accepting a lower margin to increase sales volume.
• An intermediary may be retaining part of the difference between the negotiated price and the amount charged to the patient or insurer.
• An insurance arrangement may involve rebates and contractual terms that are not reflected in the patient’s pharmacy receipt.
• A drug may have substantial research and development costs that the manufacturer seeks to recover through its pricing strategy.

But there is a fundamental problem with this system: Consumers generally cannot see the actual economics of the transaction.

A patient may pay a high copayment without knowing that the insurer, PBM, or manufacturer has negotiated a substantially different price.

That is not necessarily evidence of fraud, but it is evidence of a market that does not function like the competitive marketplace Americans are accustomed to imagining.

In an ordinary retail transaction, a consumer can compare prices and decide whether the product is worth buying. In pharmaceutical purchasing, the person receiving the product may have little influence over the negotiated price and may not even know what the other parties are paying.

The fundamental question is whether the price reflects the value of the medication, the cost of developing it, or the negotiating power of the various businesses involved.

Often, it reflects some combination of all three.

The United States has begun addressing this problem through Medicare drug-price negotiations and other pharmaceutical pricing reforms. These measures challenge the long-standing assumption that pharmaceutical manufacturers should have almost unlimited discretion in setting prices.

The larger lesson is that competition alone does not necessarily produce reasonable prices when consumers lack information, alternatives are limited, and intermediaries control access to the market.

8. Do Americans actually like their health care system?

This is where the political discussion becomes especially interesting.

The answer depends on whether Americans are evaluating their personal medical experiences or the health care system as a whole.

Many Americans like their doctors. They appreciate their local hospitals. They value access to advanced treatments and the ability to choose specialists. People with excellent employer-sponsored insurance may have relatively few complaints about the system.

But their opinion changes when they are asked about the national system and its cost.

A November 2025 Gallup survey found that only 16 percent of Americans were satisfied with the overall cost of health care in the United States. Eighty-two percent were dissatisfied.

Yet 57 percent expressed satisfaction with their own health care costs.

There is an even more revealing difference in attitudes toward coverage: 65 percent rated their own health insurance coverage as excellent or good, while only 24 percent rated health coverage nationally that favorably.Gallup.com+1

This is an important political distinction.

Americans frequently believe that their own arrangements are working reasonably well, even when they recognize that the national system is deeply troubled.

It is the difference between personal experience and collective experience.

Someone with a good job, comprehensive insurance, a trusted physician, and a manageable deductible may reasonably wonder why the entire system should be changed.

That person may also be reluctant to support a government program that could alter existing coverage.

The problem is that the American system does not work equally well for everyone.

A person who loses employment may lose health insurance. Someone with a chronic illness may encounter enormous expenses. A family may have insurance but discover that a particular hospital or physician is outside its network.

A medical emergency can become a financial crisis.

The American public therefore has a somewhat contradictory relationship with health care: It likes the medical professionals and institutions it knows, dislikes the costs and uncertainty, and remains divided over who should be responsible for fixing the system.

9. Is the federal government actually more efficient than private enterprise?

This is a particularly interesting question because it challenges one of the fundamental assumptions of American economic and political life.

Americans have been taught that private enterprise is generally more efficient than government.

There is considerable truth to the argument. Competitive businesses have incentives to reduce costs, innovate, improve customer service, and eliminate unnecessary operations.

But those incentives do not operate equally well in every industry.

Health care is not an ordinary consumer marketplace.

Patients frequently cannot determine what medical services they need, cannot shop around during an emergency, and often cannot evaluate the quality of treatment before receiving it. Their decisions are heavily influenced by physicians, insurers, hospitals, and pharmaceutical companies.

Furthermore, the person receiving medical care is often not the person paying for it.

This creates an unusual marketplace in which the buyer, seller, provider, and payer may all be different entities.

The administrative consequences are substantial.

Consider the paperwork required when an American physician treats a patient.

The physician’s office may need to determine:

• Whether the patient has active insurance.
• Whether the physician is in the insurance network.
• Whether the proposed procedure is covered.
• Whether prior authorization is required.
• What deductible applies.
• What copayment or coinsurance is owed.
• Whether the insurer will approve the claim.
• Whether the insurer will subsequently deny payment.

Different insurers have different rules. Different plans have different requirements. The same procedure can generate different administrative processes depending on the patient’s coverage.

This is not necessarily efficient competition. It is often expensive duplication.

The international evidence is particularly revealing.

The Commonwealth Fund’s 2024 study ranked Australia and the United Kingdom at the top for administrative efficiency.

In Australia, electronic claims processing allows rapid payments through public and private insurance arrangements.

In Britain, the National Health Service does not require physicians to bill individual patients or submit a separate conventional insurance claim for every service. Providers are compensated through the NHS’s administrative arrangements.

The United States ranked last in administrative efficiency.

The report specifically identified the enormous administrative burden associated with thousands of health plans, each maintaining its own coverage rules, payment requirements, and reporting procedures.Commonwealth Fund+1

A separate study published in Health Affairs examined billing and insurance-related administrative costs across several countries.

It found that the administrative cost associated with processing an inpatient surgical bill ranged from approximately $6 in Canada to $215 in the United States, after adjusting for purchasing-power differences.Health Affairs

That is a remarkable difference.

It suggests that the American health care system spends enormous amounts of money simply determining who owes whom.

But is government inherently more efficient?

Not necessarily.

Government agencies can be bureaucratic, slow to adopt new technologies, vulnerable to political interference, and reluctant to eliminate ineffective programs.

A poorly designed government health system can be every bit as frustrating as a poorly designed private one.

Nor should Medicare’s administrative costs be compared casually with the administrative costs of a commercial insurer. The programs have different populations, benefits, accounting definitions, and responsibilities.

The stronger argument is not that government always performs better.

It is that certain administrative functions are inherently more efficient when performed through standardized, centralized systems rather than thousands of competing arrangements.

A single electronic payment framework, standardized medical billing, common reporting requirements, and transparent purchasing arrangements can eliminate considerable duplication.

That does not require government to own every hospital or employ every physician.

It requires government to establish a simpler operating framework.

There is a difference between government managing medical treatment and government organizing the financial infrastructure through which medical treatment is paid for.

The distinction is frequently lost in American political debate.

10. Why are Americans so reluctant to change?

If the evidence is so compelling, why hasn’t the United States adopted a universal health care system?

The answer is political, economic, cultural, and historical.

There are several reasons.

First: Americans fear losing what they already have.

The United States has approximately 160 million people covered through employer-sponsored health insurance, according to recent Census and health coverage estimates.

For many of these people, their employer’s health insurance is an important part of their compensation.

They may not love their insurance company, but they know how their existing arrangement works.

The prospect of replacing it with a new government program creates uncertainty.

Politicians understand this fear. The phrase “government takeover of health care” has considerable political power, even when a proposed reform would retain private hospitals, physicians, and insurance options.

Second: The health care industry has enormous economic and political influence.

American medicine is not simply a collection of doctors and hospitals.

It is a vast economic ecosystem involving:

• Private health insurance companies.
• Pharmaceutical manufacturers.
• Pharmacy benefit managers.
• Hospital corporations.
• Medical device manufacturers.
• Medical laboratories.
• Pharmaceutical distributors.
• Billing and claims-processing companies.
• Specialized health care consulting firms.

Each has an economic interest in the existing arrangements.

A fundamental restructuring would change how money flows through this ecosystem.

Some companies would lose revenue. Others would gain. Some administrative functions would become unnecessary.

It is hardly surprising that organizations with substantial financial interests in the existing system participate actively in political debates over reform.

Third: Americans have a deeply rooted suspicion of centralized government.

The United States developed a political culture that places considerable emphasis on individual choice, private ownership, and limited federal authority.

Universal health care is therefore frequently presented as a question of political philosophy rather than administrative design.

For some Americans, government-financed health care represents an unacceptable expansion of federal power.

For others, the ability to obtain medical treatment without fear of financial ruin represents a basic obligation of a modern industrial society.

These are fundamentally different views of the relationship between citizens and government.

Fourth: Americans confuse universal coverage with government ownership.

This is perhaps the most important misunderstanding.

Universal health care does not necessarily mean that the government owns hospitals, employs physicians, or makes every medical decision.

Germany, France, the Netherlands, and Switzerland demonstrate that universal coverage can coexist with substantial private-sector participation.

The government can establish coverage requirements, regulate insurers, negotiate prices, and ensure that everyone has access to essential services without taking over the entire medical profession.

The question is not necessarily whether medicine should be private or public.

It is how much responsibility the public should collectively assume for financing and organizing it.

Fifth: The existing system has powerful beneficiaries.

This is perhaps the most difficult political obstacle.

Millions of Americans work in health insurance administration, medical billing, claims processing, and other parts of the system.

Some of these jobs are necessary. Others exist primarily because the system is fragmented.

A simpler system could eliminate substantial administrative expense, but it would also disrupt businesses and employment.

Any serious reform must address this transition rather than pretending that institutional restructuring comes without consequences.

11. What might a better American health care system look like?

The debate is frequently framed as a choice between preserving the existing system and adopting a single-payer model similar to Canada’s.

But there are other possibilities.

The United States could examine the experiences of several countries and construct a system that combines their most successful features.

A reasonable framework might include:

Universal basic coverage. Every American would have access to essential medical services regardless of employment, income, or preexisting medical conditions.

A standardized payment system. Hospitals and physicians would operate under simpler billing and reimbursement requirements.

Private medical practices and hospitals. Physicians would retain professional independence, and private hospitals could continue operating.

Stronger pharmaceutical purchasing arrangements. The federal government or a designated nonprofit purchasing organization could negotiate prices on behalf of a much larger population.

Greater transparency. Patients and employers would have access to understandable information about medical costs, insurance payments, and pharmaceutical pricing.

Expanded primary care. More resources would be directed toward preventive medicine, family physicians, and early diagnosis rather than relying disproportionately on expensive hospital treatment.

A more rational physician workforce strategy. Medical education, residency programs, and incentives for rural practice would be coordinated with the country’s actual needs.

None of these ideas requires abandoning American medical innovation or dismantling the country’s leading research institutions.

Indeed, one could argue that a system that spends less on administration and unnecessary financial transactions would have more resources available for research, medical education, and patient care.

The objective should not be to eliminate private enterprise.

It should be to make private enterprise serve a more coherent public purpose.

12. The larger question: What is health care supposed to accomplish?

There is a philosophical question underneath all these statistics.

Is health care a consumer product, like an automobile or a television, that individuals should purchase according to their financial means?

Or is it an essential public service, like education, public safety, or basic infrastructure, that a prosperous society should make available to everyone?

Americans have never completely resolved this question.

They have built a system that attempts to accommodate both philosophies.

Private insurance, employer-sponsored coverage, Medicare, Medicaid, veterans’ health programs, and government subsidies coexist in a complicated arrangement that has evolved through decades of political compromises.

The result is a system that can provide extraordinary care to some people while imposing considerable financial and administrative burdens on others.

The international comparisons are difficult to dismiss.

The United States spends approximately $14,885 per person annually on health care. The OECD average is approximately $5,967. The United States has fewer physicians per capita than the OECD average. It performs poorly on several measures of health outcomes, affordability, and equity. And its administrative system is among the least efficient of the wealthy countries studied by the Commonwealth Fund.

This does not mean that every publicly financed health system is superior. Canada’s waiting lists are real. Britain’s National Health Service faces serious staffing and capacity problems. Germany and France have their own financial and demographic challenges.

But these countries demonstrate that universal coverage does not require the destruction of advanced medical care or the abandonment of private medical practice.

The American challenge is to determine which parts of its health care system actually produce value and which parts exist primarily to manage the financial complexity created by the system itself.

The pharmaceutical middlemen are one example. The enormous insurance-billing apparatus is another. The proliferation of separate payment arrangements is a third.

These are not inevitable characteristics of modern medicine. They are the consequences of institutional choices.

Perhaps the most revealing statistic is not the amount America spends, but the proportion of its population that remains dissatisfied with the national system despite that spending.

Only 16 percent of Americans told Gallup in 2025 that they were satisfied with the overall cost of American health care.

A country that spends more than twice the OECD average per person should be able to do better.

The question is whether Americans are willing to reconsider the assumptions that created the system they have.

The United States has demonstrated an extraordinary capacity to organize complicated national enterprises when it decides that doing so is necessary. It built the interstate highway system, landed astronauts on the moon, developed the internet through public research investment, and created Medicare and Social Security.

There is no compelling reason that organizing an affordable, accessible health care system should be beyond its capabilities.

The real obstacle may not be a shortage of money, medical knowledge, administrative expertise, or technological sophistication.

It may be that the country has become so accustomed to the existing arrangement—and so politically divided over alternatives—that it has difficulty imagining something better.

And that, perhaps, is the greatest paradox of American health care: A nation capable of producing some of the finest medicine in the world has yet to agree on how to make that medicine reliably accessible to its own people.

Selected sources and further reading

These are the principal research sources underlying the article.

1. OECD – United States: Health at a Glance 2025. International spending, workforce, and health-system comparisons.
2. OECD – Health Expenditure Per Capita. Detailed international spending comparisons.
3. Commonwealth Fund – Mirror, Mirror 2024. Ten-country comparison of health care performance.
4. OECD – Waiting Times, Health at a Glance 2025. International appointment and treatment waiting times.
5. AAMC – U.S. Physician Workforce Data Dashboard, 2026. Physician demographics and workforce composition.
6. Federal Trade Commission – Pharmacy Benefit Managers, 2024. Concentration, rebates, pharmacy relationships, and pharmaceutical middlemen.
7. Health Affairs – Billing and Insurance-Related Administrative Costs. Cross-national administrative cost analysis.
8. Gallup – Americans’ Satisfaction With Health Care Costs, 2025. Public attitudes toward health care costs and coverage.