5 ways our health care system has become utterly insane, Your Local Epidemiologist, Nov. 12, 2025, by Katelyn Jetelina & Hayden Rooke-Ley
To me (KJ), the debate in Washington is far too small. The real story isnāt just whether subsidies stay or go ā itās how completely insane our health care system has become, and whether there will be a serious effort to address underlying costs in the system.
I know juuusssttt enough to get in trouble, so I partnered with the incredible Hayden Rooke-Ley, who is a leading national policy expert in this area, to break down the five ways the entire system has gone off the rails.
1. Costs vs. wages: A 20-year disconnect.
Over the past two decades, the cost of employer-sponsored health insurance has skyrocketed. Premiums, deductibles, and out-of-pocket costs have all soared ā far faster than wages. More than half worry theyāll fall into debt any time they use the health care system.Ā More than 60% of those in medical debt have insurance.
2. We pay the most and get the least.
Outcomes: Despite record spending, Americans live shorter, sicker lives than peers. We underinvest in prevention, such as primary care and social supports like housing and nutrition.
Access: More than 100 million Americans live in a primary-care desert, while almost 60 million live in a pharmacy desert.
Clinician workforce: Health care workers are burning out or leaving the profession altogether.
3. Americans donāt āover consumeā health care. Prices and private bloat drive costs.
Americans donāt visit the doctor more, we donāt go to the hospital more, and we donāt stay in the hospital for longer. The real difference is price.
Our system is drowning in private-sector bloat and bureaucracy, more so than any other country. Roughly one in four dollars spent on health insurance goes to something other than care, like marketing, billing, profits or middlemen.
4. Corporate and financial firms have taken over care.
Perhaps the most underappreciated transformation of the past 40 years is the corporate consolidation and financialization of medicine.
Private-equity firms now own everything from nursing homes 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.
5. Existing approaches have failed ā and the latest proposals are more of the same.
The idea was to embrace more free market principles in health care.
- Private insurers compete for patients: managed competition, pharmacy benefit managers, etc.
- Over-reliance on economic incentives: pushing physicians into value-based care, and patients rationing through higher deductibles
- Commercialization ā converting public hospitals to for-profit chains
The current debate recycles the same logic: more private control, higher out-of-pocket costs, and less regulation of prices or profits. The latest idea is that deductibles need to be higher and patients donāt pay enough. ā¦ This approach has failed for 40 years. ā¦
Bottom line
The U.S. health care system is uniquely dysfunctional. A different approach is entirely possible ā if we have the will to boldly govern the health care system in the interests of patients, clinicians, and taxpayers. That means directly tackling prices, eliminating middlemen, and breaking up behemoths. It also means returning ownership of care delivery to clinicians and communities and pursuing a strategy that builds the workforce and capacity to meet Americaās needs.
Health care touches everyone, and we need a system that works for us, not one that makes us work for it.
Comment:
By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.
Epidemiologists are sophisticated in thinking about the prevalence and spread of disease. However, they donāt understand much about health system financing and function. So this essay is a terrific primer for them. Itās an insightful status check on the unhealthy state of our health system. Impression (a medical term): Imbalanced, with excess money and a care deficit ā especially for those short on money. High costs and poor performance make it obvious that we need a transformed approach. Treatment plan: Radical shift from money focus to medical care.
Itās clear what policies are needed ā providing access to care for all, while keeping the system affordable overall and for each of us. This will require major shifts in approach. Ownership should be shifted to improve access and affordability for everyone, instead of increasingly guiding profits to the wealthy while impairing access and affordability for those with lower incomes ā workers and especially the indigent.
The policies we need seem obvious, so it is consensus and collective action that is needed. We actually mainly share core values. We almost all agree that everyone should have the health care that they need. Likewise, that a financing system should be distributed to ensure that the system is affordable for everyone, even if this means that the very wealthy pay a larger amount (that they would never miss), in order to avoid extracting sums from lower income individuals that are needed to meet their most basic needs.
Step back and think about it. If we worked together, we could meet the goals of accessible, affordable health care for everyone without anyone suffering adverse consequences. We are not asking the wealthy to suffer the pains of poverty.
Hayden Rooke-Ley (this time with Katelyn Jetelina) explains how to get the health system to work in favor of everyone. Isnāt it time that we listened to them, to all of the other advocates for health care justice for all, and indeed to our clear collective values?
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