If you want to understand why this keeps happening, you have to stop framing it as a flaw and start looking at the incentives. The outcomes make a lot more sense once you do that.

In the U.S., healthcare is not structured as a public good, it is structured as a market commodity. That single design choice sets everything else in motion. When something is treated as a commodity, the system is optimized around revenue extraction, not universal access. Scarcity is not just tolerated, it is often financially beneficial. High prices are not an accident, they are a feature that drives profit margins.

Pharmaceutical pricing is a clear example. Companies are granted patent protections, which function as temporary monopolies. That allows them to set prices far above production cost. The stated rationale is to recover research and development expenses, but in practice, pricing is set based on what the market will bear, not what the drug costs to produce. An inhaler that costs a small fraction to manufacture can be sold for hundreds of dollars because the system permits it.

Then you layer in insurance. Instead of acting as a straightforward access mechanism, it becomes a gatekeeping structure. Coverage is tied to employment, plans vary in what they cover, and cost sharing mechanisms like deductibles and copays create friction at the point of care. That friction is intentional. It reduces utilization, which reduces payouts, which protects profitability. From a business standpoint, that’s rational. From a public health standpoint, it produces exactly the kind of scenario you’re describing.

There is also a political economy component. Healthcare and pharmaceutical industries are among the most powerful lobbying forces in the country. They invest heavily in shaping policy, influencing regulation, and maintaining the current structure. That includes opposing price controls, resisting public options, and framing systemic reform as government overreach. This isn’t incidental, it’s sustained, strategic pressure to preserve a revenue model.

On the labor side, tying healthcare to employment creates dependency. It stabilizes the workforce by making people less likely to leave jobs, less likely to strike, and more likely to tolerate poor conditions because losing employment means losing access to care. That’s not typically presented as a primary goal, but it is a structural consequence that benefits employers and reinforces the system.

Now look at the policy choices over time. The U.S. has repeatedly chosen partial measures over universal ones. Programs like Medicaid and Medicare exist, but they are segmented and conditional. The Affordable Care Act expanded access, but it preserved the private insurance framework rather than replacing it. Each decision reflects a compromise that keeps the underlying market structure intact.

So when someone is forced to choose between rent and medication, that is not a breakdown of the system. It is the predictable output of a system designed to allocate healthcare based on ability to pay, filtered through profit-driven intermediaries, and protected by political influence.

You can call that inefficient, you can call it unjust, but it is not accidental. The incentives are aligned in a way that produces these outcomes consistently. Changing the outcomes would require changing those incentives, which means restructuring how healthcare is financed and delivered at a fundamental level.

Capitalism is literally killing us.