When Alarms Ring

For decades, health system leaders have worked within a shared assumption: that our hospital-centric, specialist-driven, acute-care model was fundamentally sound. Reform efforts from managed care to value-based purchasing focused on reducing inefficiencies, not questioning the core design.

But today, that foundation is cracking.

The United States spends more on healthcare than any other nation, yet ranks near the bottom in life expectancy, maternal health, chronic disease burden, and behavioral health outcomes. In parts of rural America, life expectancy is falling at rates typically seen in war-torn nations. Depression, suicide, and addiction are surging, especially among working-age adults without college degrees.

Public confidence in the system is deteriorating. In 2023, only 34 percent of Americans reported strong trust in the healthcare system—the lowest level in decades. The widespread dissatisfaction is not just about access or affordability. It is about the growing sense that the system itself was never designed to make people healthy.

This frustration gives strategic weight to a message once dismissed as political theater: the call to “Make America Healthy Again.” The branding may be partisan, but the core grievance is real. What if our healthcare system is not simply inefficient, but structurally incapable of producing population health?

That possibility reframes the conversation. It is no longer about tweaks. It is about transformation.

The Spending-to-Outcome Paradox

The U.S. spends over $4.5 trillion annually—18 percent of GDP—on healthcare. That’s more than $12,500 per person, twice the spending of peer nations like Germany. Yet the outcomes are worse.

In any other sector, such a gap between cost and performance would be intolerable. Imagine an airline industry where ticket prices doubled and crashes increased. Or a defense department that outspent the world but lost every battle. Healthcare’s paradox is not only wasteful. It is dangerous. The sector would be open to the threat of a hostile shareholder takeover if it were a publicly traded company.

Engineered for Rescue, Not Resilience

The American healthcare economy is technically brilliant. It excels at rescue. It saves lives with precision surgery, powerful drugs, and high-intensity care. But it reacts after crisis strikes. It treats symptoms of decline, not the causes of health.

The entire architecture reinforces this orientation. Hospitals are paid when beds are full. Specialists are rewarded for procedures, not prevention. Pharmaceutical companies profit more from lifelong disease management than from cures.

This is not failure by accident. It is success by a design that I believe no longer matches what people need. Prevention is not rewarded. Primary care is underpowered. Relationship-based care is viewed as a luxury rather than a necessity.

Incentives make it irrational to focus on upstream drivers of health. Cultural narratives celebrate heroic intervention and overlook sustained support. The result is a system that can delay death but cannot foster life.

The Moral Erosion Behind the Mortality Crisis

The collapse in life expectancy is more than a clinical failure. It is a societal warning. The rise of diseases of despair—suicide, overdose, alcohol-related deaths—signals a deeper breakdown. These trends are most acute in regions like Appalachia, the Rust Belt, and mid-South that are already burdened by economic decline and institutional mistrust.

Where healthcare is viewed as distant, costly, and indifferent, it loses moral authority. It becomes part of the problem. In some communities, the health system is seen not as a partner in wellness, but as another institution extracting value without delivering hope.

These perceptions are not irrational. They reflect real gaps between healthcare’s promises and its performance.

Time to Rethink the Foundation

Much of the current medical model stems from Abraham Flexner’s 1910 Report, which pushed for scientific rigor and hospital-centered care to combat infectious disease. Funded by the Rockefeller Foundation, sponsored by some of the leading U.S. medical schools, it was the right response for its time given the most common causes of morbidity and mortality in the early parts of the 20th century. In the Flexner model, physicians were scientists, medicine was anchored in the lab, and health care was defined by billable encounters with evaluation and management and procedural codes.

But today’s primary killers are chronic conditions shaped by behavior, community, and social connection. Heart disease, diabetes, cancer, and addiction are not defeated in operating rooms. They are prevented through relationships, routines, and resilience.

Flexner's framework built an elite medical enterprise to detect, diagnose, and defeat pathogens. That model struggles when the enemy is loneliness, diet, inactivity, or despair. The healthcare system was never rebuilt for this shift.

Recent policy shifts have made matters worse. Public health infrastructure has eroded. Trust in vaccines and prevention has frayed. We are now vulnerable to both slow-moving chronic threats and fast-moving outbreaks—yet structurally and increasingly politically prepared for neither.

What Must Change

Healthcare leaders must confront a hard truth: no amount of efficiency will redeem a model that rewards sickness more than health. Fixing this will require:

• Reengineering payment to reward prevention and resilience, not just rescue.
• Rebuilding public health as critical infrastructure, not a partisan issue.
• Restoring trust through care that is personal, relational, and embedded in communities.

If our health system continues to operate as reactive, high-cost rescue machine disconnected from the sources of health, we will face a reckoning. Not just from budget pressures, but from the public the system was meant to serve.

This is not a political moment. It is a leadership test. Will we double down on a failing design, or finally commit to building a system that makes health—not just care—our national aim?

J. Michael Eaton — SVP, Healthcare Strategy, Nexcurve

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