valid question without simple answers. there are many things to try to balance, but also factors that we have no hope of changing.

for instance, south africa has a law governing drug companies. let's say your company makes a blood pressure drug and an HIV drug. SA law requires you sell the HIV drug at YOUR cost (not wholesale) before you can sell the BP drug for any profit. while SA has a tremendous need for HIV drugs, it's not far from saying they're OK with the rest of the world paying their bills.

drug costs in the US are terrible, and we conduct a ton of drug research the world benefits from. again, the US taxpayer shouldering a lot of development cost the world benefits from. litigation in the US over drugs is also terrible. for instance, when Metformin was going to be brought to the US after about 15 years in west europe, FDA wouldn't allow the european studies and track record to be used - so the research on a well understood drug had to be repeated.... to come up with the same results at high cost. this wasn't free. few molecules become marketable drugs but the research must be paid for all of them. ozempic costs about $5/mo to make the drug, more is spent on packaging shipping and regulatory compliance.

the US advances a lot of medical technology, our imaging is great, access to surgical methods are great.... but they aren't cheap. some argue that costs are lower elsewhere and that's true but not contextual. maybe your dad lives due to a surgical method here that isn't available elsewhere. how do we justify that cost? what's the balance?

then insurance issues are real. i'm a fan of free markets but the ACA doesn't exactly have that. yes you can buy more or less costly policy based on your needs and finances, but that's not a free market when you are compelled by law to participate. with forced participation there's no reason for insurers to necessarily keep costs low as competition isn't really free market. we all saw the united healthcare CEO, and that frustration is shared by many even if few act on it (i am not promoting violence). why does a guy who doesn't practice medicine make that much money? more to the point, why does he make that much money doing what he can to prevent care through refusals of drugs and surgeries? happens at local levels too - hospital CEOs making several times what neurosurgeons make, and they have an MBA and no patient care experience (i've seen this personally in two different systems). why do boards of directors need hundreds of millions in pay and benefits? what do you think a hospital ceo could legitimately live on $1million a year? when the people at the top drive the prices to drive their pay to drive the prices... is that really a free market?

malpractice continues to rise. DEA licenses tripled several years ago.... pay it or quit practicing.

the problems are so widespread, and the causes so diverse there's no one solution. i see where change could be made, but where to start? have the government intervene? not always a great solution.

i average 50-60hrs/wk in an internal medicine practice, with about 15-20 of that purely on paperwork. we now get to answer questions for patients for free all day long, "hey i read about this supplement" (it might be viable but this isn't the right place for it), "what about my kidney function you said it's fine but my BUN is up and i'm in renal failure and im going to sue you" (when they're not in renal failure), "why didn't you send in my rx for 90 days" (when i did and the pharmacy dispensed 30 days because they were short on stock) and almost NOBODY TAKES RESPONSIBILITY FOR THEIR BEHAVIOR. because we now have secured messaging they treat it like text messages and want to go back and forth all day long then bitch when i say they need an appointment or don't respond in ten minutes when im with patients, just like when they're in the office. this leads to burnout of MANY clinicians not just me, but the average patient doesn't care because they want that answer at 3am and give bad reviews when they don't get it, regardless of how unreasonable it is. 20 years ago you had a question you made an appointment and paid a copay - now people want everything free right now and don't give a shit of the cost to the people they depend on.

there's a lot we do well. surgery and trauma especially. we can do prevention pretty well when patients do their part, but most won't. there's a lot of problems without a simple set of answers. i wish there were some, and that people could pursue them. for now, im not sure how to effect meaningful healthy change for the system and our patients. i wish i knew.