Why the US Healthcare System Is So Expensive — And What We Can Actually Do About It
By Dr Cois, Emergency Physician
She came in on the bus.
An 84-year-old woman. No family in town. No car. She sat in my waiting room for four and a half hours on a Monday afternoon while we completed her workup. Her blood pressure was 222 over 104. She had a headache.
For the past twenty years, she had seen the same primary care physician. Meticulous with her medications, her follow-up appointments, everything. And she had been well. Her blood pressure was managed. No acute presentations for years.
Then, at the start of January 2025, her insurer informed her they would no longer cover her long-standing physician. Her doctor hadn't retired. Hadn't gone out of business. The insurance company had simply decided to stop paying for her to see him.
The earliest appointment she could find with a new covered provider was June. Five months away. She lives on approximately $60 per day. Paying out of pocket was not an option. So her antihypertensives lapsed. And her blood pressure climbed.
An ounce of prevention is worth a pound of cure. But only if you can actually access the ounce.
We did the right workup — a full hypertensive emergency evaluation including blood tests and a CT scan of her head. Everything came back unremarkable. We treated her blood pressure, got it into a safer range, and discharged her with enough medication to bridge her until June.
That hospital encounter cost the healthcare system orders of magnitude more than a single outpatient prescription refill would have. And it cost her an afternoon of her life, sitting alone in a fluorescent-lit waiting room, having done nothing wrong.
This is what I see in the Emergency Department. Not as an occasional exception. As a pattern.
And today, I want to talk about why — and what serious proposals exist to actually fix it.
The Numbers Don't Lie
The United States spends more on healthcare than any other nation on earth — approximately $13,500 per person per year. That is roughly twice what peer nations like Germany, Canada, France, and Australia spend per capita.
For that extraordinary investment, Americans do not receive commensurate outcomes. The Commonwealth Fund's comparative healthcare benchmarking consistently ranks the US last or near-last among wealthy nations on life expectancy, infant mortality, preventable death rates, and equity of access.
To be clear about the nuance: the US system does some things brilliantly. For those with excellent insurance who need highly specialised care, the depth of expertise and technology is genuinely world-class. The problem is not what the system does for the well-insured and acutely ill. The problem is what it does — or fails to do — for everyone else.
Why Does It Cost So Much?
The reasons are structural, interlocking, and decades in the making.
Fragmentation and administrative overhead. The US healthcare system is not a system — it is a patchwork of private insurance plans, Medicare, Medicaid, the Veterans' Affairs system, the Indian Health Service, and CHIP, all funded differently, governed differently, operating differently by state. Electronic health records frequently don't communicate across systems or state lines, leading to duplicated testing and broken continuity of care. Administrative costs consume approximately 34% of total US healthcare expenditure. In Canada, with a single-payer system, that figure is around 12%.
Prices are simply higher. Americans do not use dramatically more healthcare than people in comparable nations. They pay dramatically more for each unit of it. An MRI that costs $300 in Japan or Germany can cost $3,000 in the US. Prescription drugs are the most expensive in the world. Without a unified negotiating entity, prices are set by what the market will bear — and when someone is sick and needs treatment, the market bears a great deal.
Fee-for-service incentives. The dominant payment model rewards volume — more tests, more procedures, more visits. It does not automatically reward prevention, coordination, or the kind of careful longitudinal care that keeps people out of the Emergency Department.
The downstream cost of the uninsured. When people cannot access or afford preventive care, they delay. Delayed care becomes crisis care. Crisis care is delivered in Emergency Departments. Emergency care is the most expensive care that exists. Research confirms that frequent ED users are less likely to have regular outpatient follow-up and more likely to miss preventive screenings.¹ We are spending enormous sums treating the consequences of not preventing disease, while chronically underinvesting in the infrastructure that prevents it.
Monopolisation. Far from a functioning free market, the US healthcare industry has consolidated dramatically. Four pharmacy benefit managers now control approximately two-thirds of the entire prescription drug benefit market.² That is not competition. That is an oligopoly — and it produces the pricing outcomes you would expect from one.
Three Proposals — One Spectrum
There are three serious reform frameworks currently in public debate. They sit at different points on a spectrum and reflect genuinely different philosophies about how to fix what is broken.
Medicare for All
The most ambitious proposal: a single, government-administered health insurance programme covering all Americans, eliminating premiums, deductibles, and co-pays at the point of care. A landmark analysis published in The Lancet estimated that this model would generate approximately 13% savings in national healthcare expenditure — over $450 billion annually — and save more than 68,000 lives per year compared to the current system.³
The mechanism is clear: one payer means one billing system. Administrative overhead collapses. The government becomes the single negotiating entity for drug prices and provider fees. Everyone is covered. The fragmentation disappears.
The trade-offs are real. Significant new taxes would be required during transition. The displacement of the employer-sponsored insurance system is logistically complex. And political feasibility has been the persistent barrier — this model has strong public and physician support but has not come close to legislative passage despite years of advocacy. H.R.3069, the current Medicare for All Act, was introduced in the 119th Congress in 2025 and remains in committee.⁴
The Great Healthcare Plan (Market-Oriented Approach)
The Trump White House released a one-page framework in January 2026 outlining a market-based philosophy: deregulate, expand consumer choice, promote price transparency, and allow competition to drive costs down. The Kaiser Family Foundation's independent analysis of this plan flagged significant open questions — particularly around protections for people with pre-existing conditions and the implications for coverage levels.⁵
Some elements have genuine merit: price transparency is a real need, and administrative deregulation could reduce some friction. But the fundamental challenge is structural. Healthcare is not a standard market. You do not comparison-shop for emergency appendectomies. You do not negotiate the terms of your stroke treatment. The conditions that make market competition work — informed consumers, the ability to walk away, symmetrical information — are systematically absent in acute medical care.
And the empirical record is clear: the US has had the most market-oriented healthcare system among wealthy nations for decades. The result is the highest costs and outcomes that rank last among peers. The experiment has been run.
The EMBRACE Plan
EMBRACE — Expanding Medical and Behavioral Resources with Access to Care for Everyone — was proposed in a paper published in Annals of Internal Medicine by Lancaster, O'Connell, Katz, Manson, and colleagues.⁶ This is the framework I find most compelling, and I want to explain why.
EMBRACE proposes a tiered universal coverage model. Tier 1 is publicly funded, lifetime basic coverage for the entire population — covering all care that is life-saving, life-sustaining, or preventive, based on the best available evidence. Tier 2 is optional private insurance covering quality-of-life and functional therapies beyond the essential core.
The system would be overseen by a quasi-governmental, largely independent board — modelled on the Federal Reserve — composed of physicians and key stakeholders, funded by Congress through interval appropriations but insulated from short-term political pressures.
This matters enormously. One of the deepest structural problems in US healthcare is political capture — the system is shaped by the lobbying power of insurance companies, pharmaceutical manufacturers, and hospital systems. An independent board that makes evidence-based coverage and reimbursement decisions without being overturned by every election cycle is not a small thing. It is a governance innovation.
EMBRACE achieves the same fundamental goal as Medicare for All — universal coverage through a single-payer system — while building on existing structures rather than dismantling them overnight. The history of Medicare for All is a history of legislation that reaches committee and goes no further. EMBRACE provides a pathway that is realistic.
The only true innovation in US healthcare that should matter to us right now is the innovation that makes healthcare accessible and affordable. Everything else is a Tier 2 upgrade in a system that hasn't fixed Tier 1.
Why This Is a Tier 1 Issue
On this show, we use a Two-Tier Blueprint for long-term health. Tier 1 is the foundation: diet, exercise, sleep, stress management, and having a primary care provider. Tier 2 is the upgrade pack: supplements, saunas, wearables.
Pillar 5 of Tier 1 is having a primary care provider. And the US healthcare system is actively undermining it. When insurance networks shift and people are forced to re-establish care from scratch — or when cost makes that impossible — the preventive infrastructure collapses.
Even patients who are disciplined about diet, exercise, sleep, and stress still need blood pressure screening, cancer screening, vaccinations, and someone to prescribe medications when genetics creates a need that lifestyle alone can't fully address. A functioning primary care system is how all of that happens — consistently, longitudinally, and equitably.
No amount of post-acute intervention undoes what accessible, consistent primary care prevents.
How Should This Modify Your Practice?
This is not an abstract policy debate. Here is what I want you to do with it.
• If you have a primary care provider, call them this week. Book your annual visit. Get your blood pressure, your basic screening labs, your vaccinations up to date. These are the ounce of prevention.
• If you don't have a primary care provider, book one today — even if the first available appointment is months away. The appointment in June matters. Don't wait for the bus ride to the Emergency Department.
• If you receive a medical bill, call your insurer and the hospital and ask for an itemised breakdown. Challenge charges you don't understand. Before elective procedures, ask for a cost estimate upfront. Federal law now requires hospitals to publish their prices — use that.
• Get politically informed. Research where candidates stand on healthcare access and reform. This is not about party affiliation — it is about whether the people you elect understand that the current system is producing preventable suffering at scale, and are committed to changing it.
Extend Yourself
This episode of Overheard in the Emergency Room goes deeper into all of this — including a detailed walkthrough of the three reform proposals, evidence-based mythbusting on the most common arguments against reform, and a full breakdown of how fragmentation and monopolisation drive costs.
You can listen on Spotify, watch on YouTube, and find full episode notes and references at drcois.com.
Dr Cois
Emergency Physician. Creator of Overheard in the Emergency Room. Founder of DrCois.com — evidence-based medicine for everyday people. Fewer bad days. More good decades.
References
1. Peppe EM, Mays JW, Chang HC. Characteristics of Frequent Emergency Department Users.
2. Guardado JR. Competition in PBM Markets and Vertical Integration of Insurers with PBMs. AMA; 2025.
3. Galvani AP, et al. Improving the prognosis of health care in the USA. The Lancet. 2020;395(10223):524-533.
4. H.R.3069 — Medicare for All Act, 119th Congress (2025-2026).
5. KFF. The 'Great Healthcare Plan' Leaves Open Questions for People with Pre-existing Conditions. 2026.
6. Lancaster GI, et al. The EMBRACE Health Plan. Ann Intern Med. 2009;150(7):490-492.
