A week ago Tuesday, around the same time our nation experienced a moral and fiscal body blow, I experienced an unwanted hiccup on my way to recovery from cancer. The blow was delivered by Vice President J.D. Vance, as he cast his tie-breaking vote for Senate tax and budget reconciliation legislation. The hiccup came via a mistaken $330 bill for a twenty-minute doctor’s visit. Someone in Billing got confused and read me as uninsured. I was not happy. In fact, in my “chemo brain” I was furious and scared.
These two events were, of course, directly related only because they took place on the same day. But in a policy sense high national debt and high health care prices are closely related. Both are threats to national, local, and household prosperity. And the threats are of course linked—health care costs, while perhaps a hiccup for me personally, are in fact the single largest driver of federal spending.
Which suggests a political opportunity. If we want to create abundance, to use the trendy word of the day, we need to create a system that provides universal access to health care and does so at lower prices, much like the systems that exist everywhere else in the developed world. In this, just as in other policy areas like paid parental leave, American exceptionalism does not serve us. We need to let it go.
The body blow bill
The fiscal blow delivered by President Trump’s budget legislation ought to be apparent to all, but especially to the Republican senators and members of Congress who betrayed the instinct any genuine conservative should have to avoid debt. Based on analysis of Congressional Budget Office data by the Committee for a Responsible Federal Budget, this Republican budget will increase national debt by $5.5 trillion, a move nearly certain to hike interest rates and borrowing costs, and absolutely certain to expand the share of the federal budget allocated to debt service.
$5.5 trillion is a gargantuan number. So is the more conservative $4.1 trillion estimate also put forward by the Committee for a Responsible Federal Budget, or for that matter the $3 trillion suggested by the Yale Budget Lab. However many trillions you wish to add together, projected deficits are so severe as to risk not just higher interest rates and debt service payments. Other much more severe long-term consequences are possible. Consider, as one bleak but suddenly not completely out of place historical comparison, the experience of Argentina with excessive debt.
Meanwhile, the moral body blow delivered by Trump’s “big beautiful bill” is equally severe. As journalist Annie Lowry summarizes the matter in The Atlantic, “To pay for these tax cuts for rich people, the bill destabilizes the American medical system, guts anti-hunger programs, hikes utility costs, and makes education more expensive.” I would only add to this pithy summary that the budget mostly does not even attempt to pay for tax cuts, and instead just adds to debt.
But while Republican cruelty comes across several dimensions, it is most on display in the way budget strips health coverage from poorer Americans, a great many of them Trump voters. Vice President Vance has stated on X that “the minutiae of the Medicaid policy – is immaterial.” And maybe we can take him at his word that this is what the man truly thinks. We have to assume our Vice President does not care that, as has been widely reported, some 17 million people will become uninsured as a result of Republican actions. We have to assume that Vance, President Trump, and Republican legislators, do not care, truly, that 51,000 Americans a year may die as a result of health care cuts.
As a cancer patient, even one with good insurance and a good prognosis, I can say that being sick is incredibly difficult. Chemo is not fun. It’s harder and more stressful than usual to get things done, even things like calling my health plan over my stupid bill. I can’t even imagine needing to fill out paperwork designed expressly by the government to impose administrative burdens. I can’t imagine, instead of having good long-term disability benefits like I do, having to constantly prove I meet work requirements.
Nobody should have to prove to anyone that they deserve to get cancer treatment. Nobody should need to disprove the negative assumption that because they need Medicaid, they are probably lazy, undeserving, and not looking for work. But this paperwork-based proving of moral worth is exactly how Republican legislators, most at least nominally Christians, propose to find budgetary savings to pay for tax cuts for richer people who do not need them.
Yet another way to put this is that, as Minority Leader Jeffries has eloquently quoted Martin Luther King, budgets are moral documents. Above all other goals, including even conservative goals like fiscal health or national security, today’s Republican politicians seem to find putting more money in the pockets of already prosperous Americans an urgent moral value. Most Americans do not share this skewed morality, a fact that Democratic leaders (and caring Americans generally) now have the opportunity to use to great political effect if they (we) are sufficiently disciplined.
More than a hiccup: high health care prices
Now I want to turn from what I called the body blow at the beginning of the post to what I called the hiccup. Because that doctor’s bill, while hopefully a hiccup personally, is also a symbol of a national disgrace in which economically comfortable Democrats such as myself are deeply implicated. After all, in a great many cases, my own included, our own economic comfort (and freedom from expensive health bills) comes through a personal connection to a health care industry that imposes impossibly high economic burdens on working families, government budgets, and the society at large.
A couple of data notes on high prices. First, as is known to anyone who pays attention to the news, America is a flagrant outlier when it comes to medical spending. According to Petersen-KFF, in 2023 the US spent $13,432 per person on health care, or roughly 16 percent of per capita GDP. Countries like France and Japan, to cite just two examples, have better health outcomes than ours. But France only needs to spend $7,136 per person or roughly 12 percent of per capita GDP to generate those better outcomes. In Japan, the figures are $5,640 per person and 11 percent of per capita GDP. Both France and Japan, it might be noted, are “mixed” health care systems to a large degree unlike the public sector-dominated systems in places like the UK or Canada. I don’t necessarily oppose what used to be called “socialized medicine” or what Bernie Sanders called “Medicare for all.” But to get better health care access at lower prices, countries like France and Japan show we don’t even need to go there.
Second, as is perhaps less widely known, health care prices, while high across the US, vary so widely by region as to seem arbitrary. In researching this essay, I found the great website “FAIR Health,” which documents prices by procedure by US zip code. You can pick your procedure, but one that interested me as perhaps relatable was vaginal childbirth. It turns out that if you are uninsured, this procedure would cost you $8,734 in the Sacramento area, to which you might add an additional $5,153 for anesthesia. But if you lived near Pasadena in Southern California, your hospital would bill you only $4,728 for vaginal childbirth. The bill for anesthesia would be higher though, at $6,069. Maybe obstetricians in Sacramento are almost twice as effective as those in Pasadena, but Sacramento anesthesiologists are slightly less effective?
We know, of course, that the answer to this question is that both obstetricians and anesthesiologists are marvelously effective in both places. Health care across the developed world is a modern miracle, including here in the US. Moreover, in my experience, providers tend to be intelligent, well-trained, and kind human beings at a personal level. I am married to one, after all. It’s too bad that high and seemingly arbitrary prices so severely delegitimize the system US health providers work within, and even worse that the burdens of these high prices are felt so unequally, with wealthier people bearing hardly any burden at all.
Meanwhile, the most vulnerable members of society, like the Medicaid patients so eloquently described in this article, are subject to constant financial threat and stress related to health care access; threat and stress that Republican legislators and President Trump are purposely increasing. I repeat this: they are doing it on purpose.
But their actions take place in a context where not just Republicans politicians but also a great many citizens seem to find it awfully comfortable not to confront the pricing structures that deform the American health care industry. Maybe this should not be surprising. These same pricing structures are defended by a lot of organized lobbies and generate a lot of income for “nice” middle- and upper middle-class voters. (See this study by the Commonwealth Fund on how excess US health care spending is distributed to administrative costs of insurance, administrative costs borne by providers, high provider salaries, high drug prices, and other cost drivers mostly absent in countries not afflicted by American health care exceptionalism.)
Owning high prices as an opportunity
This post has had a bit of the quality of a rant. I apologize if it’s been too much. Chemotherapy has me in a more agitated state of mind than usual, at least when I am not exhausted and even sometimes then. This too shall pass.
The consequences of the awful “big beautiful bill,” by contrast, are unlikely to pass anytime soon. But new opportunities will one day come, once the fundamentally-unfit-human-now-president leaves the White House, as must happen eventually. When this does take place, I wonder whether the work of figuring out how to provide universal health care access under a less inflated price regime might end up at the center of a true abundance agenda; a new politics of shared American prosperity.