Americans spend more per person on healthcare than any country on earth, roughly $13,400 a year, nearly double the average of our economic peers. For that money we get a life expectancy of 79 years. The peer-country average is 82.7. We are paying first-class fare and riding in the cargo hold, and we’ve been doing it so long we’ve stopped noticing the ticket price.
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Right now, more than twenty million Americans on the ACA marketplace are opening renewal notices and watching their premium payments more than double. The average subsidized enrollee went from paying $888 a year to $1,904, a 114% jump, once the enhanced tax credits expired at the start of this year. Insurers are proposing some of the largest rate increases since 2018. Some people are dropping coverage entirely. Some are keeping it for a kid and going without it themselves.
This is the version of healthcare reform Washington actually delivered. Meanwhile, the reconciliation bill passed last year is now rolling into states as work requirements, more frequent eligibility checks, and new immigrant eligibility restrictions on Medicaid, changes projected to push millions more people off coverage over the next several years. Two major healthcare stories, same year, and neither one touches the actual machine. One changes how much of the bill you pay. The other changes who’s allowed to get the bill in the first place. Both leave the thing that makes the bill so expensive completely alone.
The Number That Should Actually Bother You
. Americans spend more per person on healthcare than any country on earth, roughly $13,400 a year, nearly double the average of our economic peers. For that money we get a life expectancy of 79 years. The peer-country average is 82.7. We are paying first-class fare and riding in the cargo hold, and this year we just watched the fare go up again while nobody touched the plane.
Give the System Its Due First
Before the takedown, the fair version, because a takedown without one is just tribalism with better vocabulary.
America’s model isn’t stupid. Employer-sponsored health insurance exists because of wage controls during World War II, when businesses couldn’t compete for workers on salary, so they competed on benefits instead. It became permanent because the tax code rewarded it. Federalism means fifty state-level experiments instead of one national mandate, which is slower and messier, but it’s also why San Francisco and rural Wyoming fit inside the same passport. A country of 340 million spanning six time zones is not Finland, population 5.6 million, and pretending that comparison is 1-to-1 is its own kind of dishonesty.
And on the metrics America actually optimized for, it wins. The U.S. still produces more Nobel laureates, more unicorn startups, and more top-20 research universities than the rest of the world combined. Venture capital flows here because the system rewards risk in a way most regulated economies don’t.
The problem isn’t that America chose a different model. The problem is what that model does to the people who aren’t at the top of it, and how consistently both parties decline to fix the parts that are fixable.
That’s the Peterson-KFF Health System Tracker, and it’s the kind of gap that should be the most argued-about fact in American politics. Instead it barely makes the news, because it doesn’t fit a 30-second outrage cycle. There’s no villain to point a camera at. Just a system whose incentives evolved, over decades, to reliably produce exactly this outcome, premium spike after eligibility rule after premium spike, forever.
Healthcare, education, and campaign finance look like three separate debates. They aren’t. Each one rewards the same thing: routing a public necessity through a private incentive structure, then letting whoever profits from that arrangement help write the rules that govern it. Once you see that pattern, the rest of this piece is just proof.
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Give the System Its Due First
Before the takedown, the fair version, because a takedown without one is just tribalism with better vocabulary.
America’s model isn’t stupid. Employer-sponsored health insurance exists because of wage controls during World War II, when businesses couldn’t compete for workers on salary, so they competed on benefits instead. It became permanent because the tax code rewarded it. Federalism means fifty state-level experiments instead of one national mandate, which is slower and messier, but it’s also why San Francisco and rural Wyoming fit inside the same passport. A country of 340 million spanning six time zones is not Finland, population 5.6 million, and pretending that comparison is 1-to-1 is its own kind of dishonesty.
And on the metrics America actually optimized for, it wins. The U.S. still produces more Nobel laureates, more unicorn startups, and more top-20 research universities than the rest of the world combined. Venture capital flows here because the system rewards risk in a way most regulated economies don’t.
The problem isn’t that America chose a different model. The problem is what that model does to the people who aren’t at the top of it, and how consistently both parties decline to fix the parts that are fixable.
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The Kids Are Fine. The System Around Them Isn’t.
For years, American 15-year-olds have been described as ranking near the bottom of the developed world on the PISA international exam. That’s not what the data says. In the 2022 results, the U.S. ranked 6th in reading and 10th in science out of 81 education systems, comfortably above the OECD average in both. Math is the actual weak spot: 26th place, below average, the lowest U.S. math score PISA has ever recorded.
So the honest headline isn’t “American kids are falling behind the world.” It’s “American math instruction has a specific, isolated problem, buried inside a national mediocrity story that isn’t true for reading or science.” Less satisfying to say on a podcast. More useful if you’re actually trying to fix it.
The more interesting number is the 102-point gap in PISA math scores between American students in the top and bottom socioeconomic quartiles, one of the widest such gaps among wealthy nations. That’s the mechanism. Most U.S. public schools are still substantially funded through local property taxes, so the quality of a kid’s education is tied to the real estate values of the neighborhood they happened to be born into. Finland doesn’t fund schools that way, and it isn’t magic teaching that closes the gap, it’s that Finnish teachers log around 600 instructional hours a year versus roughly 1,080 for the average American teacher, with the difference going to prep and support. The funding model just doesn’t sort children by zip code before the first bell.
Then there’s the price tag America attaches to climbing its own mythology. The average American graduate leaves college with tens of thousands of dollars in debt. Germany’s public universities are tuition-free for citizens and international students alike. Slovenia treats higher education as a right, not a reward. Neither country is secretly richer than the United States. They decided debt shouldn’t be the entry fee for opportunity, and funded that decision on purpose.
The Real Export Nobody Talks About
Healthcare costs, specifically, aren’t primarily a lobbying story. They’re a fee-for-service story: providers get paid per procedure rather than per healthy patient, which rewards volume over outcomes. They’re a consolidation story, a patent story, and a certificate-of-need story, since many states let existing hospitals veto new competitors. They’re an administrative story too. American insurers and providers spend far more on billing and paperwork than single-payer systems do. None of that requires a single lobbyist in a single room.
You can watch that machine run in real time this year. More than twenty million ACA enrollees are absorbing premiums that more than doubled once the enhanced subsidies lapsed. A separate reconciliation bill is layering new work requirements and more frequent eligibility checks onto Medicaid, with projections of millions more losing coverage over the next several years. Both are real, consequential policy fights, and both are entirely arguments about who pays and who qualifies. Neither one is an argument about fee-for-service, consolidation, the patent system, or certificate-of-need laws, which are the actual load-bearing walls of the cost problem. You can spend an entire election cycle re-litigating who gets the bill without ever asking why the bill is so large.
What lobbying does is protect those mechanisms from reform once they exist. Federal lobbying spending hit a record $5.08 billion in 2025, per OpenSecrets, up from $4.4 billion the year before, itself a record. Healthcare, defense, and finance dominate the spending, and it has climbed every year since 2016, through Trump’s first term, through Biden, into Trump’s second, regardless of who campaigned on draining the swamp. Lobbying isn’t the engine. It’s the accelerant, and increasingly the insurance policy, keeping the engine from ever getting redesigned.
That insurance policy works because of structure, not conspiracy. American elections are expensive, campaign money is unlimited in most ways that matter, and reelection depends on donor relationships that outlast any single administration. Most developed democracies regulate campaign finance far more tightly than the United States does. That’s not a coincidence. When your reelection depends on the industries you’re supposed to regulate, you get the regulatory outcomes those industries prefer, whether the person in office is a Democrat or a Republican. Neither party has passed serious campaign finance reform in decades, because the system that exists is the one that got them elected.
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Mechanism, Not Mascots
Line it up and a single pattern emerges. America doesn’t provide healthcare, education, or campaign integrity as a public good administered by the state. It provides them as products, distributed through employers or the market, funded through a tax code never redesigned for the world it now operates in. That model concentrates decision-making power with whoever pays for the product, which is increasingly not the person using it.
It doesn’t have to work this way. Iceland didn’t luck into topping the World Economic Forum’s gender equality index for sixteen consecutive years. It passed mandatory equal parental leave and legally required pay-gap reporting, and funded both. That’s the difference between an institution built to produce an outcome and one built to protect an incumbency.
Both major American parties have held the White House, House, and Senate simultaneously within the last two decades. Neither used that window to touch campaign finance, healthcare’s underlying cost structure, or school funding formulas in any structural way. They touched the edges, passing the bills that were fundable rather than the ones that were necessary. This year’s healthcare fight followed the same pattern almost exactly. A major reconciliation bill was the kind of vehicle that could have touched fee-for-service payment, hospital consolidation, or patent exclusivity. It was used instead to add work requirements and tighten eligibility, the fundable fix, not the necessary one. That’s what a captured incentive structure looks like from the inside: everyone agrees something is broken, and nobody with the power to fix it has a personal reason to.
The Uncomfortable Part
This usually ends with a call to arms about corrupt politicians and greedy lobbyists, as if the problem is entirely upstream of you. It isn’t.
You didn’t need Peterson-KFF to tell you healthcare got more expensive this year. You have a renewal notice in your inbox that already told you. But you know the lobbying numbers exist too. You’ve heard the healthcare stats before, probably from three different podcasts. None of this is secret. The Peterson-KFF data is public. OpenSecrets publishes lobbying totals every quarter, free, searchable by client and by bill. The PISA breakdowns are on the OECD’s own website. This is information you had access to and didn’t go looking for, because a five-minute outrage clip about a politician’s gaffe is easier to consume than a report about property-tax-funded school inequity, and the algorithm knows it.
Politicians change the subject because changing the subject works.
It works because most of us take the bait, every time, choosing the manufactured controversy over the structural one, the mascot over the mechanism. If you want a system that funds outcomes instead of optics, that starts with refusing to reward the people who keep handing you the easy, satisfying, useless version of the story. Nobody’s going to build that discipline for you. That’s the uncomfortable part.
