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Few people outside the health care industry have a comprehensive understanding of the interplay between health care delivery and the fees charged and the payments made. “Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants,” writes Elisabeth Rosenthal, a Harvard‐trained physician and former New York Times reporter. “That’s how the healthcare market works” [27].

To further illustrate this point, consider a story from Alex Azar, the current U.S. secretary of health and human services. In a March 2018 speech, he recounted his own battle with opaque pricing in a hospital:

A few years ago, my doctor back in Indiana wanted me to do a routine echocardio stress test. I figured this could occur within the scope of his practice, which was connected to a major medical center. Instead, I was sent a few floors down, where I was told to start handing over all sorts of information to a receptionist. Soon enough, I have a plastic wristband slapped on me, and, to my surprise, what I thought would be a simple test in the room next door had resulted in my being admitted to the hospital.

Now, I had a high‐deductible plan, so I would be paying for this test out of pocket. As someone who works in healthcare, I knew that the sticker price on the test had just jumped dramatically by my receiving it within a hospital—something that might never occur to most healthcare consumers. So I asked how much the test was going to cost, and was told that information wasn’t available. Fortunately, I didn’t just fall off the turnip truck, so I persisted, and, eventually the manager of the clinic appeared and gave me the answer. The list price was $5,500.

I knew that wasn’t the right answer either. The key piece of information was what my insurer would pay as a negotiated rate, or what I’d pay with cash. That information didn’t come easily, but eventually, I was told it would be $3,500.

I happened to know of a website where you could search typical prices for such procedures, so I looked up what it would have been if I’d received it outside of the hospital, in a doctor’s office. The answer was $550.

Now, there I was, the former deputy secretary of Health and Human Services, and that is the kind of effort it took to find out how much I would owe for a procedure. What if I had been a grandmother? Or a 20‐something with a high‐deductible plan [28]?

The opaque pricing Azar describes is a source of exasperation for countless individuals, but it also points to the inefficiencies in the system and a reason why health care spending over the past decade has been rising five times faster than the inflation rate.

Overlooking the Biggest Determinants of Health

The U.S. health care system is primarily devoted to the treatment of diseases after they occur. That has led to the creation of a health care delivery system that often provides leading‐edge treatments for a range of conditions and diseases. But medical care directed toward treating disease plays only a small role in determining our health outcomes. Much more important are behavioral, environmental, and social factors. Those factors are largely overlooked within the U.S. health care system—something I explore in detail in the next chapter.