This is a beta. We are publishing it early and open to being wrong, because we would rather be corrected now than after it is printed. If you think a number here is wrong, tell us.

About the numbers. American totals come from the Centers for Medicare & Medicaid Services, whose actuaries publish the official National Health Expenditure accounts each year and project them a decade forward. International rankings come from the World Bank, the WHO, and the OECD. They are computed in our companion research project rather than quoted from anyone's summary. The two do not produce the same per-person figure: the international series leaves out spending on buildings and equipment, and its most recent year for the United States is 2023. So America spends $15,475 per person on the domestic measure and $13,473 on the international one. Both are correct. Neither is small. Where a figure is our own calculation from published data, we say so and show the method.

Six trillion dollars

This year, the United States will spend about $6.02 trillion on health care.

That is the projection published by the CMS actuaries. It means 2026 is the year America crosses six trillion dollars. In 2024, the last year with final numbers, the country spent $5.28 trillion. That was 18.0% of everything the economy produced, and $15,475 for every man, woman, and child in it. By 2034 the actuaries project $8.97 trillion, and 20.6% of GDP.

One dollar in five.

Numbers at this scale stop meaning anything, so here is what six trillion dollars is next to things that are also large. American health care spends more each year than the entire economy of Germany, the third-largest country on earth by output, produces. More than Japan's. More than France's and Canada's combined. If American health care were a country, it would be the third-largest economy in the world, behind only the United States and China. And it would be growing faster than either.

The part paid by government alone (federal, state, and local) was $2.56 trillion in 2024. That is roughly the entire annual output of Italy, or of Russia.

We are told, every time this subject comes up, that the country cannot afford to guarantee health care to everyone. The country is spending six trillion dollars a year and does not guarantee health care to anyone.

And this is what it bought

Here is the same country measured against the 35 advanced nations it likes to compare itself to.

	United States	Rank among 35 advanced nations
Spending per person	$13,473	35th of 35 — the most expensive on earth
Life expectancy	78.9 years	30th of 35
Healthy life expectancy	63.9 years	34th of 35
Years lived in poor health	12.5	34th of 35
Infant mortality	5.5 per 1,000	33rd of 35
Maternal mortality	17 per 100,000	34th of 35
Hospital beds per 1,000 people	2.7	against 12.6 in Japan and South Korea
Hospitals per million people	17.9	against 65.8 in Japan, 81.9 in South Korea
Health outcomes per $1,000 spent	—	64th of 64 — last of every country that achieves good health

Japan and South Korea run the two best-performing health systems in the world. They do it for roughly 40% of what America spends. They have four and a half times as many hospital beds per person as the United States, and three to four times as many hospitals. America is not a country drowning in excess medicine. It has one of the thinnest-provisioned health systems in the developed world. It charges the highest prices on earth for access to the little it has.

That thinness is not evenly spread, either. Research by GoodRx, which mapped access county by county, found that about 81% of American counties are a health care desert of some kind: short of pharmacies, primary care, hospital beds, trauma centers, or community health centers. More than 120 million people live in one. Over 40% of counties are more than an hour from a hospital equipped to handle a major traumatic injury.

America is drowning in health care spending, not in health care.

The honest objection is that Americans are sicker. That is true. Obesity, diabetes, addiction, gun injuries, road deaths, and poverty all push costs up. No health system can be judged as though it treats an average population. But the gap is far too large to be explained that way. America spends two and a half times what Japan spends and nearly three times what Spain spends. No plausible account of disease burden covers a difference of that size. Why Americans are so much sicker than their peers is a serious question, and one for separate work. It is not the reason the bill looks like this.

This is not what rich countries do. It is what America does.

Health care costs rise everywhere. Populations age, medicine improves, and every wealthy country spends a larger share of its economy on health than it did a generation ago. That is the standard defense of the American number. It is worth taking seriously.

It does not survive the data.

In 1960, the United States spent 5.0% of its economy on health care. By 1980 it was 8.9%. By 2000, 13.3%. In 2024, 18.0%. The country roughly tripled the share of everything it makes that goes into medicine, inside a single lifetime.

In 2000, when America was already at 12.5%, Germany was at 9.8%, France at 9.6%, Canada at 8.2%, Britain at 7.1%, and Japan at 7.0%. Over the 23 years since, America added 4.2 percentage points. So did South Korea. Britain and Sweden added 3.8, and Japan added 3.7. The rich world has been rising at broadly the same rate as America; America simply started from a level nobody else has ever reached, and has never given any of it back.

So this is not the natural cost of being rich and old. Germany is rich and old and spends 11.7%. Japan is the oldest country on earth and spends 10.7%. The American position was established decades ago and has been held ever since, which means it was built. And that means it can be dismantled.

Where the money goes, and it is not care

If a country spends the most and has among the least, the money is going somewhere between the two. Three places. All three are measured.

It is not going into more care. Americans see a doctor 3.6 times a year. The average across comparable rich countries is 8.2. Germans see a doctor 9.6 times a year, Japanese 11.7, South Koreans 17.5. Of the peer countries that report this figure, only Sweden goes to the doctor less often than Americans do. Whatever the extra trillions buy, it is not extra visits.

It is going into prices. RAND's hospital price transparency study, which reads actual claims paid by employers rather than list prices, found that private insurers pay American hospitals 254% of what Medicare pays for the same service (279% for outpatient care). The same scan, the same operation, the same night in the same bed, at two and a half times the price depending on who is being billed. The late Uwe Reinhardt, the Princeton economist who spent a career on this, reduced it to four words: it's the prices.

It is going into billing. America runs a private claims-adjudication industry that no other country has. Researchers at Hunter College and Harvard measured what American insurers and providers spend on administration and compared it with Canada, which had a nearly identical system before it changed. The United States spends $812 billion a year on health administration, $2,497 per person, or 34.2% of national health spending. In Canada the figure is 17.0%. A separate study broke out billing-and-insurance costs specifically and found $471 billion, of which $375 billion (four fifths) exists only because the country has many payers instead of one. That is not the cost of running a health system. It is the cost of arguing about who pays for it.

Put the three together and you get the peer-reviewed estimate. A 2019 review in JAMA totaled waste across six categories: failed care delivery, failed coordination, overtreatment, pricing failure, fraud, and administrative complexity. It arrived at $760 billion to $935 billion a year, about a quarter of all health spending. Pricing failure alone was $230.7 billion. Administrative complexity alone was $265.6 billion.

A quarter of $6 trillion is $1.5 trillion. America wastes more on health care than China spends on health care. American health administration alone costs more than the entire health systems of Germany, Japan, Britain, and France put together.

Two cautions, because these numbers get abused. The JAMA review and the administration study use different definitions of overhead and cannot be added together. And both were measured on 2017 to 2019 spending; carrying their percentages forward to today assumes the proportions held, which is an assumption rather than a finding. The honest version is the one the studies support: somewhere between a fifth and a third of American health spending does not treat anybody.

Three cents of the dollar builds anything

Inside the national health accounts, the CMS actuaries publish a line called Investment: research, plus structures and equipment. It is the part of the health dollar that becomes a physical thing: a hospital, a clinic, a scanner, an operating theater. The CMS series covers 1960 through 2034, and it shows what share of total health spending that line represents.

Year	Total health spending	Structures and equipment	Share of the health dollar that builds something
1960	$27 billion	$2 billion	6.9%
1970	$74 billion	$6 billion	7.8%
1980	$253 billion	$15 billion	6.0%
1990	$719 billion	$36 billion	5.0%
2000	$1.37 trillion	$60 billion	4.4%
2010	$2.59 trillion	$103 billion	4.0%
2020	$4.20 trillion	$140 billion	3.3%
2024	$5.28 trillion	$168 billion	3.2%
2034 (CMS projection)	$8.97 trillion	$262 billion	2.9%

Calculated from the CMS National Health Expenditure series, 1960–2034.

In 1970, America put nearly eight cents of every health dollar into buildings and equipment. Today it puts three. The actuaries expect that to keep falling.

The country more than tripled the share of its economy going into health care, and more than halved the share of that money that becomes a hospital.

This is the answer to the question people ask when they see the spending figures: if we spend so much, where are the hospitals? They were never bought. Health spending grew more than seventy-fold since 1970 in nominal terms while the fraction devoted to physical capacity shrank by more than half. That is why a country spending six trillion dollars a year has 2.7 hospital beds per thousand people and 81% of its counties short of something.

One more line from the same table, for scale. All health research in America (public and private, every laboratory and every trial) comes to about $70 billion a year, or 1.3% of health spending. Administrative complexity alone was estimated at $265.6 billion. The country spends roughly four times as much on the complexity of paying for medicine as it spends on discovering it.

You have already paid for this

The most common objection to a public health system is that America cannot afford one. The country is already buying one and not receiving it.

In 2024, the federal government spent $1.7 trillion on health care and state and local governments spent $859.7 billion. Together that is $2.56 trillion of public money, about $7,526 for every person in the country.

Set that next to what other countries spend in total: not their government's share, their entire health system, public and private, every premium and every payment at every counter. Japan spends $5,365 per person. Spain, $4,935. South Korea, $5,081. Israel, $4,033. Britain, $6,606.

American taxpayers already pay more per person, in tax, than any other advanced nation pays in total. They just do not get a health system for it. Then they pay again, in premiums, deductibles, copays, and cash, and get the worst outcomes in the rich world.

And that understates it, because the tax subsidy for employer-sponsored insurance is not counted in those figures at all. Neither is the research. The National Institutes of Health spends tens of billions a year on the basic science that medicine is built from. A study in the Proceedings of the National Academy of Sciences traced the published research behind every new drug the FDA approved between 2010 and 2016. There were 210 of them. NIH funding contributed to all 210: more than $100 billion of federally funded project cost, concentrated on the biological targets the drugs were later designed to hit.

So the public pays for the science, and then buys the medicine at whatever the patent holder charges, and owns nothing at the end of it. Every serious argument about drug prices in America begins there.

This is why the phrase "government takeover of health care" describes something that already happened. Government funds the majority of American health care today. What it has never done is get anything for the money.

What it is doing to the country

On 20 August 2026 the United States Treasury put the national debt at $40,033,256,786,764.

Health care is a large part of how it got there, and the projections say the pressure grows: CMS expects the federally funded share of national health spending to rise from 31% in 2024 to 33% by 2034, while total spending climbs to $8.97 trillion.

The conclusion usually drawn from this is that the country must spend less on health, which in practice means covering fewer people and paying for less care. That conclusion does not follow.

A system that wastes between a fifth and a third of what passes through it does not have a spending problem in the ordinary sense. It has a design problem that produces a spending problem. Cutting the budget of a system like that removes care first, because care is the part that is easy to cut, while the prices, the billing, and the complexity are contractual and defended. That is the history of every American cost-control effort of the last 40 years: the spending kept rising and the capacity kept thinning.

The waste is not a side effect of spending too much. It is the reason the spending is too much, and it is why more money has never worked and less money has never worked.

The question is not whether America spends more or less. It is whether the money buys hospitals, clinicians, and medicine, or buys prices, billing, and margin. Every dollar of the six trillion is already committed. The only question on the table is what it is committed to.

Where six trillion dollars actually sits

UnitedHealth Group booked $447.5 billion in revenue in 2025, which makes it the third-largest company in the United States and the fourth-largest in the world. That single firm takes in more money each year than the entire health system of France, public and private combined, and about as much as the whole of Britain's. It is no longer usefully described as an insurance company: it employs or contracts with roughly one in 10 American physicians, and it owns clinics, surgery centers, data businesses, and one of the three pharmacy benefit managers that between them handle most of the prescriptions filled in the country.

That is the shape of the system now: not a market of many sellers, but a small number of very large firms that increasingly own the doctor, the pharmacy, the claim, and the company that decides whether the claim is paid.

Private operators concentrate where the margins are: elective procedures, imaging, well-insured suburbs, profitable service lines. The work that loses money (the rural trauma center, the burn unit in a state with too few burns to pay for one, the psychiatric bed, the maternity ward in a county of nine thousand people) falls to public hospitals and public budgets, or does not exist at all. Alaska's regional burn center, which is also the referral center for Montana and Idaho, is Harborview Medical Center in Seattle, 1,445 miles from Anchorage. Flying a burn patient that distance is cheaper than maintaining a unit in a state with too few burns to fill one, which is true, and which is not the same thing as better.

The result is a comparison rigged before it starts. Hand the public sector only the work that cannot make money, and public provision will always look expensive. It is being asked to do the expensive part by definition. Any honest accounting of what public and private health care cost has to compare like with like, and in America it almost never does.

The constraint was never money

America spends more on health care than any country ever has. It has among the fewest hospitals, beds, and doctor visits in the developed world, and the worst results of any rich nation. Between a fifth and a third of the money never reaches a patient at all.

A country in that position does not need to spend more, and cannot fix this by spending less. It needs the six trillion dollars it is already spending to buy hospitals instead of billing departments, clinicians instead of prior authorizations, and medicines at the price the rest of the world pays. That is a question of what the money is asked to do, and it is answerable.

When a system like this is reformed, waiting lists appear, and opponents will say the reform caused them. It did not. Waiting lists are what a shortage looks like when price stops hiding it. America has the shortage now (it is in the 2.7 beds per thousand, the 81% of counties, the 3.6 visits a year) and rations it by cost instead of by queue, which is quieter and falls on people with less money. Any serious plan has to build the missing capacity first, and be honest that it is building it because the capacity was never there.

That is what our plan is for.

Read the plan →