America’s Wrong Turn: US Health Care in the Neoliberal Era, by John E. McDonough, Johns Hopkins University Press, August 2026
This book tells the story of how American health and medical care systems blew off course, when and why it happened, and describes who they damaged or benefited and how we can repair the harm. The long-cherished American value and expectation of “patients first” is now “profits first” for investors, shareholders, and executives. In the broad sweep of political and economic changes in the United States wrought by the neoliberal revolution that was jump-started in the 1970s and 1980s, medical care was not a prime target. Because health and medical care are so vital and intertwined in our economy and society, these sectors could not escape the revolution’s impact. Indeed, my key assertion is that neoliberalism is the principal explanation for the modern deterioration of US health and medical care. After more than four decades, this long and complex story needs telling.
Neither Ronald Reagan nor Milton Friedman nor any other promoters of their cause articulated any definitive set of neoliberal commandments. I identify seven values and principles that exemplify the neoliberal worldview from the US perspective. My selections involve those with the greatest impact on US health and medical care.
- The core value of any society must be freedom, especially economic freedom, and for individuals rather than for groups.
- The primary obligation of government and political leaders everywhere is to shrink the public sector as much as possible by cutting taxes and repealing regulations, even at the cost of higher public debt.
- The responsibility of the for-profit corporation and its top executives is to maximize shareholder value, and nothing else.
- While corporate monopolies and oligopolies interfere with well-functioning free markets, government antitrust interventions are cures worse than the disease.
- When services funded by or provided by the government can’t be repealed or abolished, they should be privatized.
- Labor unions impede the functioning of free markets by injecting and locking in inefficiencies.
- Nothing is free in society because someone always pays, and nothing funded by public treasuries should be provided to anyone for free.
Milton Friedman insisted that economic freedom must trump efforts to achieve greater equality and equity, and that doing so would result in the elimination of inequality. This belief has stalled progress and been disproven repeatedly over the past 50 years.
Here is a loaded question. Which has had a worse impact on American health and medical care systems – private equity or corporate consolidation? Between the two, corporate concentration is worse, hands down. The extraordinary rate and scope of mergers, acquisitions and consolidations of our key health and medical care system corporations, both for-profit and not-for-profit, have left deep and enduring marks on Americans’ health and well-being, both positive and primarily negative.
Policy change, whether big, medium, or small, never proceeds in a straight line year to year. Ups and downs, retreats and advances, wins and losses – these are normal and predictable. Across American society, citizens and organizations are seeing the unsustainable realities of unfair special treatment for the wealthy and substandard and second-class care for everyone else.
Comment:
By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.
There are two prominent political poles in the United States: conservative and liberal, generally held respectively by Republicans and Democrats.
Since about 1980 there has been an amalgam: Neoliberalism. This is a fairly conservative view that society’s progress lies in promoting the free market – thriving private, for-profit enterprise will benefit everyone. The Republican party, and Democratic party leaders, endorse it. In contrast, many Democratic rank and file advocate “progressive” strategies: a larger role for government policies and action.
In health care, neoliberalism imagines that for-profit entities — insurers and providers — will lead to an efficient and effective health care system. It hasn’t worked out that way.
Prof. McDonough lays out how the neoliberal turn in health care, now about 50 years old, has failed. E.g., Profit preoccupation: The focus by for-profit health companies on shareholder value and profits competes with the health-care mission rather than being incidental to it. Thus, their actions increase profits at the expensive of health. Ineffective consumerism: The “skin in the game” neoliberal theory imagines the patient as empowered to make economically disciplined choices. But (as Ken Arrow showed long ago) health care isn’t a normal consumer market: patients lack information, bargaining power, and often any realistic ability to shop. The result is financial barriers to needed care and medical debt. Power imbalance: Government retreats from the oversight role envisioned in neoliberalism, while private power grows. Tax cuts, deregulation, privatization, and weakened antitrust means the government can’t rein in prices and corporate behavior. Instead, health systems and insurers consolidate, labor is weakened, and market actors massively gain power.
Overall, we arrive at the ultimate neoliberal paradox: an ideology ostensibly favoring competition instead produced extraordinarily powerful private institutions and stunningly high prices. McDonough notes that in 1980 U.S. health spending began pulling dramatically away from peer countries, reaching at least 50% more as a share of GDP.
This year, there has been a distinct tilt toward progressivism, most evident with recent wins in Democratic primaries by progressive candidates.
This shift has created a dilemma and an opportunity. We tend to conduct our elections primarily between the two traditional parties – Republican and Democrat. However, when there are distinct policy divides within the Democratic party, especially between progressives and neoliberals, there can be policy strife. Even though voter polls demonstrate strong support for Medicare for All, especially among Democrats, neoliberals in the party have blocked Democrats from advancing it legislatively.
As voter enthusiasm for progressive strategies rises, and drives voter turnout, we have an opportunity to redirect Democratic party efforts toward the majority view: Medicare for All. We must insist that candidates state their views, and commit to pursue the progressive changes that are needed. Neoliberalism must cede to progressiveness as the guiding light of health care, as it has in all other wealthy nations around the world.
In McDonough’s book, you will read how neoliberalism has harmed our health care system. Make the time if you can. Then you will understand better – and be able to explain to others – why it is imperative to elect candidates who will jettison our long misbegotten love affair with neoliberalism in favor of enacting Medicare for All. We the voters now demand it.
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