Make America Healthy Again
Market solutions for healthcare costs
Description
Anyone who has ever received a hospital bill in the United States knows the particular feeling it produces. A single line reads several thousand dollars for something that took twenty minutes. Another charges for a bag of saline at a markup a grocery store would blush at. The insurer pays a fraction, the patient pays some unpredictable remainder, and nobody in the transaction — not the doctor, not the billing office, not the person holding the envelope — can explain how the number was reached. Nicole Saphier, a practicing radiologist, opens from inside that confusion, and she treats it as a symptom rather than an accident.
The United States spends more on healthcare than any comparable nation, by a wide margin, and does not buy longer lives with the money. That gap between spending and results is the puzzle Saphier sets out to work through in her book. She is a physician who sees the machinery daily — the coding, the prior authorizations, the incentives that reward volume over outcome — and she writes as someone convinced the system's problems are structural, not the result of any single villain. Her diagnosis leads somewhere specific and contested: away from expanding government-run medicine, and toward market mechanisms she argues could restore both quality and price.
That conclusion sits at the center of one of the longest-running arguments in American public life, and Saphier does not pretend to stand outside it. Hers is a conservative case, argued from the exam room rather than the think tank, and it is worth following on its own terms — what she believes drove costs up, what she thinks a fix requires, and why she distrusts the remedy so many others reach for first.
The question we’re asking : What has made American healthcare so expensive, and can competition, rather than government, bring the price back down?What we’ll see : A physician's account of how costs climbed, why she resists a single-payer answer, and the market reforms she puts in its place.
Table of contents
01Chapter 1 — The bill nobody can read
Saphier begins with the strangeness that most Americans have stopped noticing: healthcare is one of the only things we buy without knowing the price beforehand, or often afterward. Walk into almost any other transaction and the cost is posted, comparable, negotiable. Walk into a hospital and the same procedure can carry three or four different prices depending on who is paying, and none of them is disclosed until the bill arrives. For a working physician, this is not an abstraction. She describes ordering tests without any idea what they will cost the patient, because the information genuinely does not exist in a usable form at the point of care.
The book traces this opacity to what she calls a broken feedback loop. In a functioning market, prices tell buyers and sellers something true — what a thing is worth, whether it is worth buying. In American healthcare, the person consuming the service, the person providing it, and the person paying for it are three different parties, and the price signal never reaches any of them cleanly. The patient does not shop because they are shielded by insurance. The insurer negotiates rates the patient never sees. The provider bills against a chargemaster — an internal price list — that bears little relationship to what anyone actually pays.
02Chapter 2 — Why the price keeps climbing
Having named opacity as the mechanism, Saphier turns to the forces that drive spending upward through it. She is careful not to reduce the story to any one cause, but several recur. The first is the fee-for-service model, in which providers are paid for each test, procedure, and visit rather than for keeping a patient well. The incentive is straightforward and, she argues, corrosive: the system rewards doing more, not doing better. A model built on volume produces volume, and volume in medicine is expensive whether or not it improves anyone's health.
The second force is the layering of intermediaries. Between the patient and the doctor now sit insurers, pharmacy benefit managers, hospital systems, and government programs, each with its own incentives and its own take. Saphier gives particular attention to pharmacy benefit managers — the companies that negotiate drug prices on behalf of insurers — arguing that their rebates and undisclosed arrangements can push list prices higher rather than lower, because a bigger sticker price makes room for a bigger negotiated discount that never fully reaches the patient. The middle of the system, in her account, has grown fat on the confusion at the edges.
03Chapter 3 — The government-medicine question
If costs are the disease, the most prominent proposed cure is a larger government role — a single-payer system, or Medicare extended to all. Saphier devotes the book's most argumentative chapters to explaining why she believes this would deepen the problem rather than solve it, and this is where her conservative orientation becomes explicit. Her objection is not primarily ideological in the abstract; it is grounded in how she sees existing government programs already behave inside the current system.
Her central worry is that government-run medicine treats the symptom — high prices to patients — by hiding the cost rather than lowering it. A single-payer system, she argues, does not eliminate the expense; it shifts it into taxes and into the less visible currency of rationing and waiting. She points to the trade-offs that appear in single-payer systems abroad, where costs are contained partly through queues and limits on access to newer treatments. Lower prices at the counter, in her framing, can mask higher prices measured in delay and in the technologies that never get adopted because a central budget could not accommodate them.
04Chapter 4 — What a market for health might mean
Step back from the specific proposals and Saphier's book is a contribution to an argument older than any current policy fight: how a society should allocate something that everyone needs, that arrives unpredictably, and that no one can easily price. Healthcare resists the ordinary logic of markets. A person having a heart attack does not comparison-shop. Illness is not a discretionary purchase, and suffering is a poor bargaining position. This is precisely why so many conclude the market cannot govern medicine at all, and it is the objection Saphier's whole framework has to answer.
Her answer is not that all of medicine behaves like a market, but that far more of it could than currently does. Emergencies are genuinely different; a great deal of healthcare is not an emergency. Imaging, routine procedures, chronic-disease management, prescriptions, elective surgery — these are decisions made with time to think, and they are the areas where she believes transparency and competition could bite. Her reforms cluster there: published prices, so patients can compare; direct arrangements between patients and providers that cut out intermediaries; health savings accounts that give people a stake in what they spend; and a loosening of the rules that shield incumbents from newer, cheaper competitors.
05Conclusion
The book returns, in the end, to where it started: the unreadable bill in the patient's hand. For Saphier, that bill is the compressed evidence of everything she has argued — a system so thick with hidden prices and misaligned incentives that no one inside it can say what anything costs or why. Her remedy is to make the numbers visible and let patients act on them, on the conviction that competition disciplines what secrecy protects. It is a physician's argument as much as an economist's, drawn from the daily experience of ordering care whose price she cannot know.