Mapping the US healthcare system’s financial flows

State vs. federal roles and experimentation

• Some argue the patchwork nature of US healthcare is best fixed from the bottom up: let states experiment (e.g., Maryland’s global hospital budgets), with the federal government mainly funding and setting high-level standards.
• Others emphasize federal coordination: national public health agencies, shared data, and “one-size-fits-most” standards are seen as crucial, citing COVID failures and duplication across 50 “islands.”
• A compromise position appears: strong federal outcome targets, but diverse state implementations and even “clubs” of states voluntarily sharing stricter standards, similar to emissions rules and Canada’s provincial health systems.

Administrative complexity, insurance, and missing money flows

• Many criticize the article’s map for showing nearly all dollars as “care,” with little visibility into administration, profits, or insurance-company flows.
• Repeated calls appear for a granular breakdown of spending: physicians vs nurses vs admin, hospital overhead, and drug spending by category and age cohort.
• Several posters see health insurance as partly a “jobs program” with huge workforces devoted to billing and denials, plus parallel admin layers in providers.
• Vertical integration (e.g., insurers owning physician networks, PBMs, and tech arms) is highlighted as a way to sidestep medical-loss-ratio limits and concentrate profit.

Executives, shareholders, and rents

• There is extensive debate about executive pay and shareholder payouts.
• One side notes that C‑suite compensation is often around 0.1–0.4% of revenue and thus a small driver of total costs.
• Others counter that, aggregated across many entities, this still meaningfully raises per‑capita costs, symbolizes misaligned incentives, and that profits returned to shareholders dwarf even high executive salaries.

Equity, access, and tiered systems

• Several comments stress the system works very differently for the rich: faster access, concierge-like handling, even under the same insurer.
• Concern about “Medicare for All” with private opt-outs: this could formalize a tiny ultra‑wealthy tier that then lobbies to underfund the public system.
• Counterarguments: societies already tax people for schools, libraries, etc., they don’t personally use; the main challenge is resource allocation (e.g., provider availability), not whether the rich may also buy private care.

Markets, insurance design, and overuse

• Skepticism that a “freer market” alone can work in healthcare: needs are unpredictable, costs are highly skewed, and the “efficient” market outcome may be to let expensive patients die.
• Mandatory insurance is criticized as inflating prices and feeding a middleman industry; others say some form of pooled risk is unavoidable given modern medicine’s costs.
• Overuse is flagged, especially in the US: expensive end‑of‑life care with marginal benefit, low‑yield tests (e.g., ER CT scans), and universal private rooms. Some explicitly call for more rationing (“death panels”) similar to other OECD systems.

Politics and structural blockers

• Multiple commenters argue that solutions are known (international models, state pilots) but blocked by lobbying, “legalized bribery,” partisan polarization, and institutional incentives that diffuse responsibility.
• There is concern that any deep reform would be traumatic for current workers and investors, who will fight to preserve the status quo even if overall outcomes are poor.