“It’s not the patient who overuses the system,” Feldman added, tightening the cap on her thermos, “it’s the system that overcharges the patient.”
In the American system, every actor in the chain—insurers, hospitals, device makers, drug companies—sets prices behind closed doors, each guarding its margin. No other developed nation allows that opacity on a national scale. Even now, when Medicare has finally gained limited power to negotiate drug prices, the rule applies to only ten medicines and excludes private insurance altogether. The rest are priced like luxury goods, determined not by cost but by leverage.
Each form, each code, each denial adds a little more distance between the patient and the care they actually need.
Martin’s cousin Leah, who runs operations at a Toronto hospital, laughed when he described the U.S. billing labyrinth. She oversees her entire finance department in a room smaller than an American waiting area. “We send one invoice to one payer,” she said. “If there’s a problem, we fix it that day.” Then she paused, thinking of his mountain of paperwork. “You don’t need a Ph.D. to see the inefficiency,” she said, “you need a calculator and a conscience.”
Administrative waste has become the quiet hemorrhage of American health care. Analysts estimate that roughly $265 billion a year—about eight percent of all spending—vanishes into billing and insurance paperwork. U.S. hospitals now employ more clerical staff than nurses. The American Medical Association reports that physicians spend two hours on documentation for every hour of patient care.
Martin imagined those hours as he drove past the medical complex on his way home: windowless offices stacked above one another, fluorescent lights humming, printers exhaling the smell of toner and paper. That antiseptic odor from the exam room followed him into the parking lot.
In countries where paperwork doesn’t dominate, the hum sounds different. Germany’s sickness funds, France’s national plan, the Netherlands’ regulated private insurers—all operate on a simple premise: health care as a public utility first, a business second. The details vary, but the outcomes converge. Citizens in those countries live longer, see doctors more often, and spend half as much. The United States devotes nearly eighteen percent of its economy to health care; most peers spend around ten.
When told this comparison, Feldman sighed. “Other nations don’t spend less because they ration more,” she said, “they spend less because they plan better.”
Planning, in that sense, doesn’t mean central control; it means coordination—of prices, of data, of incentives.
America has chosen competitive chaos instead: employer insurance for workers, Medicare for the elderly, Medicaid for the poor, Veterans Health for some, ACA marketplaces for others. Each program has its own rules, its own forms, its own lobbyists. Millions fall through the cracks.
Coordination isn’t a utopian idea; it’s a proven one.
History offers proof that coordination works. When Lyndon Johnson signed Medicare into law in 1965, hospital administrators warned it would bankrupt the nation. Half a century later, Medicare’s per-person cost growth is lower than that of private insurance. Canada’s single-payer system faced similar panic in the 1970s but stabilized within a decade, now covering everyone for roughly half the U.S. price.