Building a Better Healthcare System to Make a Healthier America

Co-authored by Sandro Galea, M.D., and Nason Maani, Ph.D.

When considering how we might improve healthcare, an industry that accounts for more than 17% of the country’s GDP, it might be worth recognizing that there is much about healthcare that is not working well. There is a vast literature about how we might improve healthcare delivery in the U.S. and recent writing about how we might cut healthcare costs — a central priority for creating a better healthcare system. It is no secret that U.S. healthcare — while world-leading in its ability to train physicians, lead biomedical research, and offer cutting-edge diagnoses and treatments — suffers from ballooning costs, fragmentation, and challenges with access and affordability for a large proportion of the population. Efforts to address such fundamental failings are complicated by vested interests of private insurance companies, private healthcare, and pharmaceutical companies, which wield disproportionate influence over policy, as compared to their influence in peer countries, and which continue to extract uniquely high profit margins from the U.S.

In the 2023-2024 election cycle alone, it is estimated that the pharmaceutical/health products industry spent $384,507,360 on lobbying. An Axios report based on an analysis of company financial filings by Public Citizen noted that in 2021, Americans were paying more for 20 blockbuster drugs than the rest of the world combined.

Payments in the form of inpatient or outpatient care average around $7,500 per person in the U.S., as compared to just under $3,000 on average among peer countries. This cost places burdens on American citizens of a nature and scale so unique and challenging that they are almost hard to describe to those in peer countries. As Berwick and colleagues note in a recent commentary, around half of all families struggle to afford healthcare, a third have to choose between food and healthcare, and 25 million Americans remain uninsured. In the self-proclaimed land of opportunity, medical debt is the largest contributor to individual bankruptcy.

There is, in other words, a fundamental problem of power asymmetry, cost-effectiveness, and fitness for purpose in the U.S. healthcare industry. Any administration seeking to improve efficiency should look to U.S. healthcare as an example of a uniquely expensive yet underperforming area, dominated by powerful vested interests, and underserving a large swath of the population.

Drug pricing, another uniquely prevalent U.S. policy problem, is driven to a large degree by government-protected market exclusivity and business and legal strategies to oppose effective improvements in affordability, such as biosimilars or generic medications, compounded by a lack of bargaining power by payers. The U.S. experiences uniquely steep increases in the price of many medicines (not just novel or uniquely effective ones), with costs on average doubling for branded medication from 2010-2016.

While individual policy proposals have sought to address different elements of this affordability matrix (and it appears some may be unwound by the new administration), upstream of these lies a fundamental and uniquely skewed power imbalance between commercial elements of the health system and the U.S. public. Transparency is sorely lacking across the complex chain between U.S. drug manufacturers and patients’ drug pricing decisions and negotiations, which includes wholesalers, prescribers, retailers, insurers, and pharmacy benefit managers. A key priority for any administration seeking to make American health better again would be to use its mandate to fundamentally shift this power asymmetry in ways that better reflect drug approval, conflict of interest management, transparency, and pricing negotiations in high-income countries, which enjoy far lower costs, greater transparency, and lower inequalities in access in their dealings with the same set of products and companies.

Population health can be regarded as a cornerstone of a vibrant and robust economy, and high levels of preventable ill-health as a form of taxation from which no party benefits. Economic modeling indicates that when considering rising treatment costs, and the cost to economic productivity from preventable illness, the economic burden of NCDs in the U.S. in 2015-2050 alone will reach over 90 trillion USD, 265,000 USD per capita, or an annual tax rate of around 10.8% on aggregate income. These costs are particularly high because of the high levels of preventable ill-health in younger Americans. In 2021, obesity rates in the U.S. were over 40% in 39 U.S. states, and over 45% in 14 among adults, including 41.8% of females and 33.9% of males under the age of 25.

However, beyond the potential direct and indirect economic costs, improving health at all ages helps increase freedom to choose how to live, to take risks in other aspects of life, to extend the window for one to enjoy the fruit of one’s labor as a result, and to see the next generation flourish. We suggest therefore that it is possible to reframe U.S. health as a cornerstone of wider U.S. economic security, well-being, freedom, and prosperity, aligning well with the goals of the new administration, indeed, of any administration, looking to make the country better. The goal of better health is too important to be either politicized in the current moment or ignored amidst the pace of proposed reforms in non-healthcare arenas of government action. It is fair to say that America should be healthier again and that transparency, a rebalancing of interests toward the American people, and a reframing of health as a cornerstone of future prosperity and freedom should form key parts of that goal.

Nason Maani, Ph.D. is a lecturer at the University of Edinburgh.

This also appears on Substack.