The US spends approximately $4.5 trillion annually on healthcare — $13,493 per person, roughly double the average of other developed nations. Despite this spending, the US ranks last among 11 high-income countries in healthcare outcomes (Commonwealth Fund, 2021). Higher spending + worse outcomes = a system optimized for something other than health.

The Chargemaster: every hospital maintains a "chargemaster" — a list of prices for every service and supply. These prices are: internally generated (no market forces), wildly variable (the same procedure can cost 10x more at one hospital than another), and almost never the price anyone actually pays (insurance negotiates discounts). The chargemaster exists as an inflated starting point for negotiation. Uninsured patients are billed chargemaster rates — the highest prices in the system — paid by those least able to afford them.

Insurance intermediation: the US is the only developed country where health insurance is primarily tied to employment. This: limits job mobility (people stay in jobs for insurance — "job lock"), creates administrative complexity (billing departments, prior authorizations, claims processing consume 15-30% of healthcare spending), and produces millions of uninsured/underinsured when employment changes.

Pharmaceutical pricing: the US is the only developed country that doesn't negotiate drug prices nationally. Medicare was explicitly prohibited from negotiating drug prices until the 2022 Inflation Reduction Act (which allows negotiation on only 10 drugs initially). The pharmaceutical industry spent $373 million on lobbying in 2022 — more than any other industry — to maintain this pricing structure.