and improving outcomes in its service area. Otherwise, it pays taxes like everyone else.¹⁹
Then there is the workforce.
America does not have a doctor shortage so much as a maldistribution crisis wrapped in educational debt.²⁰ We train clinicians at enormous cost, then funnel them into subspecialties and urban centers because that is where survival is financially possible.²¹
Fixing this is not complicated. It requires tuition-free medical and nursing education tied to service commitments, expanded scope-of-practice for non-physician clinicians, and immigration policies that welcome trained health workers rather than wasting their skills.²²
Other countries treat health workforce planning as infrastructure. We treat it as an accident. That alone explains much of the gap.²³
Technology, meanwhile, needs to be demoted from savior to tool.
Electronic records should talk to each other. Data should follow patients. AI should reduce clerical burden, not generate new billing games. The measure of success is not innovation theater but minutes returned to care.²⁴
And yes, this all costs money—just less than what we already spend badly.²⁵
The political mistake reformers make is arguing that better health care requires higher spending. The truth is harsher and more persuasive: we are already paying for a Rolls-Royce system and driving it into a ditch.²⁶ The task is to reallocate, not explode the budget.
The sequencing matters. Coverage expansion first. Cost controls embedded early. Workforce reform alongside reimbursement change. Drug pricing in parallel. Antitrust throughout.²⁷ Do this in pieces, transparently, with pilots and metrics, and the panic subsides.
What cannot happen—what has failed every time—is half-reform. Tweaks that preserve the extraction model while promising relief later.²⁸ That path leads exactly where we are now.
The moral argument, finally, is not abstract.
A system that ties survival to employment, geography, and luck is not merely inefficient. It is corrosive. It teaches people to delay care, to hide illness, to fear time. It turns health into a private gamble and then acts surprised when the house wins.²⁹
Best-in-world health care after 2028 is not a fantasy. It is a decision. Other countries made it decades ago. We have simply been negotiating with the wrong stakeholders.³⁰
If the next administration wants a legacy that actually lasts, it will stop asking whether America can afford universal, affordable care—and start asking why we tolerate anything less.³¹
Biibliography
1. Institute of Medicine. Hidden Costs, Value Lost: Uninsurance in America. National Academies Press, 2003. Foundational analysis of how delayed care and insurance gaps create cascading health and financial harm.
2. Kaiser Family Foundation. “Americans’ Challenges with Health Care Costs.” KFF, 2023. Survey data documenting widespread care deferral due to cost and insurance instability.