5 Ways our Health Care System has become Utterly Insane
By Katelyn Jetelina and Hayden Rooke-Ley
November 12, 2025
We could be on the verge of ending the longest government shutdown in U.S. history—though nothing is guaranteed.
While Congress debates whether to extend subsidies for the Affordable Care Act (ACA) coverage, Americans with all types of insurance are bracing for higher premiums, narrower networks, and more impossible choices.
So, to me, the debate in Washington is far too small. The real story isn’t just whether subsidies stay or go—it’s 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 juuussstttt 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.
Let’s dig in.
1. Costs vs. wages: A 20-year disconnect.
Over the past two decades, the cost of employer-sponsored health insurance—how the vast majority of privately insured Americans obtain their health care—has skyrocketed. Premiums, deductibles, and out-of-pocket costs have all soared—far faster than wages.
This widening gap means workers earn less, even when their salaries rise on paper. Every dollar going to premiums is a dollar not going to rent, groceries, or childcare.
And the human toll is clear. One in three Americans has medical debt, and more than half worry they’ll fall into debt any time they use the health care system. That fear changes behavior: people delay appointments, skip medications, or avoid care altogether.
Medical debt is now the most common form of debt in collections ahead of credit cards, utilities, or personal loans. Nearly 60% of those in medical debt have insurance.
2. We pay the most and get the least.
The United States spends far more on health care than any other wealthy country yet achieves worse outcomes, less access, and a more demoralized workforce.
Outcomes: Despite record spending, Americans live shorter, sicker lives than peers in Europe, Canada, or Japan. Infant mortality, maternal mortality, and chronic disease rates all rank near the worst among high-income nations. A key reason is that we pour money into specialty medical services while underinvesting in prevention, such as primary care and social supports like housing and nutrition.
Access: Critics often argue that “at least we don’t have long wait times like other countries.” However, increasingly the opposite is true (and this is never a fair comparison, as we spend twice as much as they do). More than 100 million Americans live in a primary-care desert, while almost 60 million live in a pharmacy desert. Services to treat mental health are notoriously lacking, and Medicare does not even cover long-term care.
Clinician workforce: Health care workers are burning out or leaving the profession altogether. Home health care aides are paid extremely low wages for heroic work. As corporations attempt to convert salaried positions into gig work, some nurses are compelled to bid against one another for shifts. Many physicians report moral injury working in systems that prioritize billing over care, eroding autonomy and morale.
3. Americans don’t “overconsume” health care. Prices and private bloat drive costs.
There’s a common myth, especially amongst policymakers, that we spend too much on health care because we consume too much of it. A similar narrative has taken hold about doctors: because they get paid for each service, they provide too much care. Certainly, there is low-value care in the U.S. health care system. And as profit-seeking corporate actors own more and more of the system, they’re finding ways to bill for more—and more expensive—services.
But Americans don’t visit the doctor more, we don’t go to the hospital more, and we don’t stay in the hospital for longer. We even get significantly fewer of many of the most popular procedures—like coronary angioplasties, knee replacements, hip replacements, and gall bladder and prostate removals. The real difference is price. Take a look at this graph, as one example for hip replacements:
A colonoscopy or MRI can cost 10 times more at one hospital than another across town, depending on which insurer you have. These differences have little to do with quality or cost of care. They’re the result of opaque negotiations between insurers, hospitals, and pharmacy benefit managers, and other middlemen in the system. We’ve created a system where no one knows what anything costs: not the doctor, not the patient, sometimes not even the insurer. The surprise bill arrives weeks later.
On top of high prices, our system is drowning in private-sector bloat and bureaucracy. More so than any other country. Every insurer has its own prices (and endless price negotiations with providers), billing processes, prior authorization rules, and reporting requirements. The result is staggering inefficiency: roughly one in four dollars spent on health insurance goes to something other than care, like marketing, billing, profits, or middlemen.
Doctors spend nearly half their time on paperwork. Patients spend hours on hold, fighting over denied claims. And all of it is baked into costs.
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. Care delivery—once local and community-based—is now dominated by corporations.
Vertical consolidation is now a defining feature of American health care. UnitedHealth Group isn’t just the largest insurer; it’s also the largest…