Explaining America’s spendthrift healthcare system: the enduring effects of public regulation on private competition

The United States is often described as the only developed nation without a public commitment to universal health care. Instead, its health care system is widely considered a product of bio-scientific free enterprise – technologically sophisticated, extremely expensive, but inaccessible to the poor. This chapter offers a contrasting account, refuting the conventional narrative of U.S. health policy as private, competitive, and entrepreneurial. Beginning over 20 years ago, the poor performance of the American health care system has been slowly revealed. For nearly as long, steps that might improve that performance have been identified. But little has changed. Why? The answer, in large part, lies in an accumulation of laws, regulations, self-regulatory practices, and financial subsidies which locks US health care into inefficient, unfair patterns and practices. While most of these provisions were well-intentioned when put into place, this “deep legal architecture” now serves mainly to prevent meaningful competition in medical markets and to distort or limit collective investment in the nation’s health