John E. McDonough, a professor of practice at the Harvard T.H. Chan School of Public Health, worked for the late US senator Ted Kennedy in creating the Affordable Care Act. He is the author of “America’s Wrong Turn: US Healthcare in the Neoliberal Era.”
American patients face daunting challenges: frightening medical debt, sky-high premiums and deductibles, massively consolidated providers and insurers, private equity takeovers, burned-out physicians and nurses, and dismal health outcomes
What can explain such wide-ranging awfulness?
I have spent decades studying the American health care system. I was part of the drafting process that led to the Affordable Care Act, the landmark health care legislation enacted by President Obama in 2010. And I have been a professor at Harvard for years. From what I’ve seen, all of those disparate problems trace their origins back to a singlensformed American society starting in the 1970s and 1980s
The neoliberal ideas of figures such as economist Milton Friedman and President Ronald Reagan have gotten a bad rap on both the left and the right in recent years, and for good reason. Reagan’s obsession with cutting taxes and repealing regulations encouraged laissez-faire policies that damaged families and communities, supercharged income and wealth inequalities, and wreaked havoc on the environment, just for starters
But while these outcomes have been recognized for years, neoliberalism’s damage to our health care system has not been as well understood
The hallmarks of neoliberal excess, though, are all there: Elite players have reaped vast rewards through financial gamesmanship, stock manipulation, corporate takeovers, and political bribery. Huge megahospital systems (for-profit and nonprofit), vertically integrated insurers, pharmaceutical giants, and a dizzying array of invisible financial middlemen have come out on top — all resulting in the most expensive health care system in the world
I could write a book on all of neoliberal’s disastrous effects on our collective health. And in fact I have: “America’s Wrong Turn: US Healthcare in the Neoliberal Era.” But here, I’ll offer a brief on just three of them:
Corporate consolidation. In his influential 1978 book “The Antitrust Paradox,” neoliberal activist Robert Bork — best known for his later failed US Supreme Court nomination — called for abandoning nearly a century of US antitrust enforcement. Government, he argued, should greenlight any takeover or merger that resulted in lower prices for consumers. In 1982, the Reagan administration rewrote the nation’s federal antitrust guidelines to implement his ideas
His views came to dominate health care, just as they did in many other sectors of the US economy. Today, roughly 90 percent of hospital markets, 74 percent of health insurance markets, and 65 percent of specialized physician markets are categorized as “highly concentrated” according to one common measure of market concentration. As antitrust expert Phil Longman told the news site Axios: “America’s health care crisis is brought to you by monopoly.” This sort of concentration can now be seen in just about every corner of the health care industry. For example, more than 90 percent of all US dialysis provider revenue goes to just two companies.
Private Equity. It’s not just mergers. The neoliberal affinity for private equity has invaded medical care. Though private equity emerged in the 1990s, the sector mostly avoided health care until the 2000s. Since then, its penetration has been astonishing: from $41.5 billion in activity in 2010 to $120 billion in 2019, according to researchers at the American Antitrust Institute; the University of California, Berkeley; and the University of California, Los Angeles, with a total of $750 billion in investments over the course of that decade. Only recently have researchers documented the impacts: higher prices, poorer quality, closed facilities, disempowered and discouraged workers.
Privatization. Neoliberalism’s impact is also evident in the privatization of public goods. Medicare is the New Deal-era pillar that provides health insurance to 65 million seniors and persons with disabilities. But 55 percent of beneficiaries are enrolled in its privatized part, called Medicare Advantage. That program’s principal “advantage” accrues to vertically integrated private insurance giants such as UnitedHealth Group and Humana, which together enroll 46 percent of all Medicare Advantage enrollees.
These are just a few of the tangible legacies of neoliberalism in US health care. There is also something less tangible: Between 1975 and 2026, according to Gallup, Americans’ trust in our medical care system deteriorated badly. The share of Americans with “a great deal” or “quite a lot” of confidence in US medicine dropped from 79 percent in 1975 to 28 percent in 2026. That’s bipartisan: just 26 percent of Democrats and 30 percent of Republicans have “a great deal” or “quite a lot” of confidence in the system. Reversing this distrust cannot happen overnight. But what can we do in the long run?
Vermont Senator Bernie Sanders’s “Medicare for All” bill offers one solution — establishing a Medicare fee-for-service system for all Americans. Our health care system’s original sin is its wasteful fragmentation among employer-sponsored insurance, Medicaid, Medicare, Affordable Care Act coverage, Veterans Health, Indian Health Services, and more. No other advanced nation divides coverage into such an inefficient and inequitable mess
Perhaps Sanders’s proposal will become a national mandate for our next president in 2029, and perhaps not. Other steps are needed and shouldn’t wait. Here are just a few I cover in my book:
The president and Congress must reverse the extraordinary consolidation of US health care. Congress must provide the Federal Trade Commission and the Department of Justice with greater authority and re from involvement in patient-facing medical care organizations
A new and updated patients’ bill of rights should protect patients from a neoliberal system run amok. Consumers need relief from excessive premiums and copays. Drug prices should be regulated at the time of product launch, not years later
During his term, President Joe Biden implemented dramatic reversals to neoliberal policies in health care and across the economy by strengthening antitrust enforcement, consumer protections, progressive tax policy, and more. President Donald Trump has rejected some key neoliberal planks while advancing others, such as deregulation and tax cuts for corporations and the wealthy
What comes next, when Trump passes from the scene, is crucial
The underlying diagnosis of our system’s ailments is clear: The neoliberal revolution sickened us. Getting better will be difficult. But get better we must
