U.S. health spending disparities reveal systemic market failures and inequitable resource distribution across metros

The U.S. health care spending puzzle is not an anomaly but a predictable outcome of decades of policy choices that prioritize profit over people.

High-spending metros like Charleston and New York reflect the failures of a system where hospital systems and insurers operate as de facto monopolies, incentivized by fee-for-service models to overprovide lucrative services while underfunding primary care. This pattern is deeply rooted in historical inequities, from redlining to the exclusion of marginalized groups from employer-based insurance, which concentrated poverty and poor health outcomes in specific regions. Cross-cultural comparisons reveal that the U.S. is an outlier, with systems like Canada’s single-payer or Brazil’s SUS achieving better outcomes at half the cost. The solution lies not in tweaking the current system but in dismantling its structural drivers: consolidating market power, realigning incentives toward prevention, and centering the voices of those most harmed by the status quo. Actors like private equity firms, hospital chains, and pharmaceutical lobbyists must be held accountable, while community-led models and Indigenous knowledge systems offer proven alternatives to the current paradigm.