Healthcare costs are not rising because of bad luck. They rise because of misaligned incentives, a system built around treating illness rather than preventing it, and a collective reluctance to have honest conversations about the economics involved. There is no single solution. That is why this conversation has to stay open.
U.S. healthcare spending has grown from $74 billion in 1970 to $5.3 trillion in 2024. That is not a crisis that snuck up on us. It is the entirely predictable result of a system structured to generate revenue from illness, not to prevent it.
At current growth rates, costs double roughly every nine years. The question is not whether this is sustainable — it clearly is not. The question is whether we are willing to be honest about why it keeps happening.
Healthcare spending in America is not distributed evenly. A small fraction of the population — people managing chronic, complex, often preventable conditions — accounts for the vast majority of total cost. The top 1% account for nearly 22% of all costs. The top 5% account for half.
This concentration is not random. The conditions driving it — heart disease, diabetes, obesity, hypertension — are, in a significant proportion of cases, preventable. That is the most important sentence on this page.
This is not an argument against modern medicine. When someone needs a bypass surgery, they should get one — and they should get the best one available. The system's capacity to intervene in acute crisis is genuinely extraordinary.
The argument is that we have built an entire economic architecture around that intervention moment — and almost nothing around the decade of opportunity that precedes it. A patient with high blood pressure, early metabolic disease, a family history of cardiac events — the system sees that person as a future revenue event. It should see them as a prevention opportunity.
Prevention is not passive. It requires active clinical engagement, early diagnostic intelligence, and a willingness to have difficult conversations with patients about lifestyle, risk, and trajectory. It requires providers who are incentivised to keep people well, not to treat them when they deteriorate.
Most catastrophic health events are preceded by years of detectable risk. Early diagnosis changes trajectories — and costs.
The further upstream an intervention, the less dramatic and less expensive it needs to be. Catching hypertension is far cheaper than treating heart failure.
Some people will need complex, expensive care. They should receive the best available — not care rationed by what their zip code or insurance tier allows.
One of the most uncomfortable truths in American healthcare is that the financial incentives of providers are not aligned with patient outcomes. They are aligned with procedure volume.
A cardiologist who owns an ambulatory surgery centre has a measurably different referral pattern than one who does not. This is not a conspiracy. It is human nature responding rationally to financial structure. When ownership creates economic benefit from procedures, procedures increase — regardless of whether they are the best clinical choice.
This is the insight at the heart of J. Timothy Bricker's research at Texas Children's Hospital, and it extends far beyond cardiology. Across specialties, ownership of downstream resources reliably shifts clinical decision-making in directions that benefit the owner.
The solution is not to demonise individual providers. It is to restructure the incentives — to make the financially rational choice and the clinically optimal choice the same choice.
Studies consistently show that physicians who have ownership stakes in ambulatory surgery centres refer patients to those facilities at significantly higher rates than non-owner colleagues — independent of clinical indication.
The effect is subconscious as much as deliberate. Ownership creates a lens through which clinical options are evaluated. The question "is this the best option?" becomes subtly contaminated by "is this the option I benefit from?"
Correcting this does not require assuming bad faith. It requires acknowledging that financial structure shapes behaviour — and redesigning accordingly.
Between insurers, pharmacy benefit managers, hospital systems, and billing intermediaries, a vast infrastructure has grown up around the administration of American healthcare. Much of it generates cost without generating care. A system paid a percentage to manage spending has no incentive to reduce it.
Thirty years of clinical practice, 280 peer-reviewed papers, and a Wharton MBA do not, by themselves, change a single patient's behaviour or a single company's healthcare strategy.
What changes behaviour is trust. And trust is not conferred by credentials — it is built through consistent honesty, genuine advocacy, and the willingness to say difficult things without a financial agenda.
The framework is straightforward: clinical truth, communicated with conviction and humanity, generates the trust that makes change possible. Without the truth, it is just persuasion. Without the belief, it is just data. The combination is what moves people.
This is why the conversation about healthcare reform cannot be owned by the institutions that benefit from the status quo. It has to come from voices that people actually trust — and that means building those voices carefully, honestly, and over time.
Listen to the podcast →Employees systematically distrust their employers and their insurers on healthcare decisions. The most valuable healthcare asset a company can have is not a benefits package — it is a trusted clinical voice that employees actually believe is on their side.