Why Universal Healthcare without Cost Controls Won’t Fix Anything
EDITOR’S NOTE: Here’s an installment from Tillamook County’s State Representative Cyrus Javadi’s Substack blog, “A Point of Personal Privilege.” Oregon legislator and local dentist. Representing District 32, a focus on practical policies and community well-being. This space offers insights on state issues, reflections on leadership, and stories from the Oregon coast, fostering thoughtful dialogue. Posted on Substack, 12/26/25
By State Representative Cyrus Javadi
At some point in any failing enterprise, someone finally asks the most dangerous question in the room:
“Are we actually making enough money to run this thing?”
After four essays walking through the slow unraveling of American healthcare—the math that doesn’t work, the history that boxed us in, the carnival financing tricks we pretend are normal, and the tourniquet known as Obamacare—it seems only reasonable to finally ask the question everyone keeps circling.
“Okay. So what’s the answer?”
In the Capitol, this is the moment when the conversation stops being a conversation and turns heated debate. Quickly.
Someone says single payer with the confidence of a man who believes he has just discovered fire. Someone else says free markets with equal conviction, as if healthcare were simply a poorly run cable company in need of better branding and a customer-loyalty program.
Everyone nods vigorously at their own opinion. No one listens very carefully. And, the problem is kicked down the road. Again.
Which makes sense. Americans like fixes. We like clean answers. We like the idea that somewhere in Oregon (or Washington, D.C.) there exists a Big Lever that, once pulled, causes costs to fall, access to rise, wait times to shrink, and hospital billing departments to disappear in a cloud of morally satisfying smoke.
The problem is that healthcare is not that kind of problem.
Because healthcare is not a broken appliance. It’s not even a complicated machine. It’s more like an old house remodeled by six different owners, each of whom fixed the thing bothering them most without ever touching the foundation. The windows don’t line up. The floors slope slightly toward the kitchen. And everyone keeps arguing about paint colors while pretending the creaking noise is just the wind.
A Quick Return to the Tourniquet
(Because People Keep Forgetting This Part)
The Affordable Care Act was never designed to fix American healthcare. It wasn’t a master plan. It wasn’t a cure. And it certainly wasn’t elegant.
It was a tourniquet.
It stopped the bleeding in a system already quietly failing. It forced participation. It ended the practice of treating sick people as actuarial mistakes. It cut uncompensated care roughly in half from $40–50 billion a year pre-ACA to about $28–30 billion today. It slowed medical bankruptcies. It kept hospitals open long enough for us to keep arguing about what comes next.
Premiums went up (a lot) not because insurers suddenly discovered greed in 2010, but because the system finally had to acknowledge something we had spent decades avoiding: modern healthcare is expensive to deliver.
Since 2019 alone, hospital labor costs are up 21–25%, supplies 18–20%, pharmaceuticals 13–15%, and construction costs 25–30%. Contract labor spiked even higher. You don’t need ideology to understand what that does to prices, but a calculator helps.
See, the mistake wasn’t applying the tourniquet. The mistake was pretending we could leave it there forever without curing the gaping wound underneath.
Because while we argued about Obamacare, everything underneath it kept changing. Labor got scarcer. Medicine got better and more expensive. Technology advanced like it had somewhere urgent to be. People lived longer (and with more chronic disease) requiring more care over more years.
And we kept pretending the payment system would somehow absorb all of that.
It didn’t.
The Two “Solutions” Everyone Pretends Are Mortal Enemies
Once you strip away the slogans, there are really only two ideas serious countries return to. They are not opposites. They are siblings who refuse to sit next to each other at dinner.
The first is universal, government-run insurance. Everyone pays in. Everyone is covered. Prices are set. Budgets exist. Canada is the usual reference point. No choice. No options. No out-of-pocket expenses. If you need it, you go to the doctor. No bill afterwards.
The second is mandatory universal coverage with private insurers operating under strict rules. This is Switzerland. Participation is required. Benefits are standardized. Prices are controlled. Subsidies make it affordable. A few choices (more cosmetic than functional), payroll taxes, out-of-pocket expenses. You go to the doctor when you need it.
Both systems work. Both ration care. They just ration it differently.
Yes—rationing happens either way.
And, news flash, we already ration care in the United States. We just do it through deductibles, networks, prior authorizations, and geography instead of wait lists. If you live near a major academic center, you enjoy the illusion of abundance. If you don’t, you learn quickly that choice often just means drive farther.
What the Numbers Actually Say
Here’s where things get uncomfortable.
The United States spends about $13,500 per person per year on healthcare. That’s roughly 17.3% of GDP. The average among wealthy nations is closer to $6,500 per person and 9–10% of GDP.
Canada spends about $6,300 per capita—roughly 11% of GDP. Germany spends $8,100 per capita, also around 12% of GDP. Switzerland, often cited as the “expensive” European system, spends about $9,800 per person, still far below us.
Japan spends about $4,800 per capita, just under 11% of GDP, while maintaining the highest life expectancy in the world.
So yes, we pay dramatically more.
But here’s the part most comparisons conveniently skip:
those countries also have lower labor costs, healthier populations, fewer specialists, fewer high-tech interventions, smaller geographic footprints, and cultural acceptance of limits that Americans openly reject.
Japan has 12 hospital beds per 1,000 people. The U.S. has 2.8. Germany has 7.9. You don’t need to guess how that affects surge capacity.
Physicians in the U.S. (especially specialists) are paid two to three times what their counterparts earn elsewhere. That isn’t greed. It’s supply, training cost, malpractice exposure, and opportunity cost rolled together.
And our population is sicker. Six in ten American adults have at least one chronic disease. Four in ten have two or more. Obesity sits around 42%, roughly double the OECD average. Diabetes prevalence is about 11%, compared to 4–7% elsewhere.
No financing model escapes those realities.
The Part Everyone Avoids Saying Out Loud
Here’s the sentence that ruins everyone’s favorite talking point:
Universal coverage solves how we pay for healthcare. It does not, by itself, solve how much healthcare costs.
You can nationalize insurers tomorrow. You can regulate them into polite submission. You can replace every executive with a golden retriever wearing a lab coat. If labor remains scarce, drugs remain expensive, and medicine keeps advancing faster than the system that pays for it, prices will keep chasing costs.
Every country that “solved” healthcare did so by explicitly controlling prices, volumes, workforce supply, and technology adoption. Not vibes. Not slogans. Actual constraints.
They decide how many specialists to train.
They decide which drugs they will pay for—and which they won’t.
They accept wait times as a tradeoff instead of a scandal.
Americans say they want European healthcare.
They recoil from European decisions.
The Cost We Never Talk About: Running the System Itself
Here’s the number that quietly explains why American healthcare feels so expensive even before you get sick.
It costs about $2,700 to $3,000 per person, per year just to run the U.S. healthcare system. Not to deliver care. Not to pay doctors or nurses. Not to buy drugs or MRI machines. Just to move money around.
That’s the cost of administration: billing departments, coding teams, prior authorization, network negotiations, utilization management, claims appeals, employer benefits offices, compliance staff, and an insurance ecosystem so complex that entire careers are built on knowing which box to check on which form for which payer on which day of the week.
By comparison, Canada spends roughly $500 per person on administration. Germany spends about $400–500. Switzerland, despite relying on private insurers, lands around $600–700. Japan runs one of the leanest systems in the world at roughly $150–200 per capita, thanks to a single national fee schedule and minimal billing variation.
In percentage terms, the United States spends 18–20% of all healthcare dollars just on administration. Most wealthy countries spend 3–7%.
Put differently: even if America somehow matched European prices for doctors, hospitals, and drugs tomorrow (no miracles required, just pretend) we would still be spending roughly $2,000 more per person every year than our peers simply to operate the system.
That gap alone is larger than what many countries spend to cover an entire citizen’s healthcare.
This isn’t because Americans are uniquely inefficient people. It’s because we built a financing system that treats complexity as a feature. Multiple payers. Nonstandard prices. Constant network churn. Prior authorization as cost control. Employer-based insurance as a middleman. Pharmacy benefit managers skimming value in ways even experts struggle to fully explain.
Every layer added to manage cost creates another layer that has to be managed. And managed layers need staff. And staff cost money. And eventually, someone gets handed the bill.
Usually the patient. Or the employer. Or the hospital trying to keep its doors open.
So What’s the Fix?
Here’s the answer that won’t fit on a bumper sticker.
We have to choose a universal financing system and pair it with real cost control.
That means admitting healthcare is not a normal market. It means standardizing prices where markets don’t function. It means expanding the workforce instead of treating burnout like a personal failing. It means simplifying administration so clinicians spend less than 25% of their time feeding billing portals that collectively cost $90 billion a year.
It means confronting drug pricing where 2–3% of prescriptions drive half of all spending. It means acknowledging that consolidation raises prices, but also that thin margins force survival mergers.
And it means accepting out loud that better medicine costs money, whether we pay through premiums, taxes, or time.
Obamacare bought us time. We spent that time arguing about whether the tourniquet caused the wound.
It didn’t.
But time is running out. And choosing nothing is still a choice—just one where the system keeps deciding for us, hospital by hospital, county by county, mile by mile.
Which is fine.
Unless you think healthcare matters.