is healthcare getting worse?

market failure, tech innovation, and the equinox-ification of wellness

When I first moved to San Francisco, I was sick and in the middle of a series of intravenous iron infusions. I have decent health insurance, but my only apparent option was waiting two and a half months for an appointment with a new hematologist for the hospital referral I needed, and waiting another month or two after that to receive the infusion at the hospital. (Or go to the ER, which is something of a phobia of mine.) I could barely work, let alone settle into a new city and meet people. My boyfriend got sick of me wasting away in bed all day and found an enterprising new startup online which offered iron infusions alongside “hangover IVs” and other “wellness products.” I went three days later. It looked like a hair salon inside and I was prompted to tip on an iPad when the procedure was completed. Months later, when it finally came time to see my new hematologist, he laughed when I’d told him where I’d received my last infusion. “But I don’t blame you,” he said. 

And that’s the beauty of the American system: structural inefficiencies get solved in the private market, right? But what if we’re actually just spending more and getting sicker?

Many of you may have seen the neurosurgeon who quit his career and climbed to the top of the mountain to talk about the structural issues inherent to the medical system. He explains that the system is basically just incentivized to keep people sick. He often performed surgeries which only temporarily fixed the problem, rather than employing an approach rooted in long-term healing.

There’s a lot of issues with the practice of medicine he calls out in his video–largely, the system is built to prioritize profits over patient health – which I doubt is a surprise to anyone. In 2022, health spending represented 17.3% of the U.S.’s GDP. Current models predict that Americans will spend $7.7 trillion per year by 2032 (more than doubling annual health spending in 2019). 

Despite spending more than other countries, our ROI isn’t great, as other nations often outperform our health outcomes. 

“In 2020, life expectancy at birth in the U.S. was 77 years, three years lower than the OECD average.” (Axios)

Beyond profit maximization, medicine also often reflects the biases of the population it treats—conditions that primarily affect women seldom get the attention that other conditions receive. Endometriosis affects 10% of all women but has barely seen any research or attempts at a cure. I’ve noticed it’s often hard for my symptoms to be taken seriously by physicians who aren’t also women (which is unfortunately a well-known concern). It took me six months of seeing doctors about constant dizziness and muscle weakness until someone thought to prescribe a simple blood test (at which point I learned I was iron deficient enough for a hospital visit). If I’d seen some ad in that six months promising freedom from those symptoms, regardless of the price, I sure as hell would have bought whatever they were selling. 

So maybe that’s how we ended up with HIMS for erectile dysfunction and HERS for weight loss and period pain. And a thousand other consumer-facing healthcare startups. Because of the inefficient ways our healthcare system is structured and the profitability of concepts like fitness and wellness, savvy young women can get help right away with birth control and anxiety medication from NURX or therapy from BetterHelp. It’s really striking that a lot of these services are offered without insurance and are still cheaper than the price of the traditional version with insurance. 

Healthcare and fitness startups are as numerous as they are profitable–which is to say there’s a lot of unicorns out there. The market is almost too big to calculate, considering that we already spend more on health per capita than any other nation. It makes sense: the system is fundamentally broken, so there’s plenty of room for innovation. 

The trouble is, handing something as important as your physical and mental health to this patchwork, fractured landscape of startups lends it to all sorts of problems. These are companies “bootstrapping” and “blitzscaling” their way to greatness (being bought out by a larger company). They’re here today and some of them even take your health insurance, but who knows for how long? This is far from ideal for personal health, which relies on a long-term relationship with a provider who understands your unique needs and goals. They also generally don’t have or really contribute to your medical records, further fracturing the medical universe’s understanding of your well-being. (At the same time, I strongly suspect the data management practices at these quirky startups are suspect, despite the FTC’s best efforts.) 

These companies also fundamentally operate on the standard startup profit equation: get users today, raise prices tomorrow. In a universe where we are relying on these startups rather than fixing what’s wrong with our traditional network of providers, consumers may be footing even larger healthcare bills tomorrow–which is almost impossible to conceive.

Consumers must also work harder. The belief that food in Europe is healthier due to “better food regulations” is all over TikTok right now, sparking widespread discussion on how sick Americans are. People feel like the work of avoiding the over-processed foods that will kill you falls on the individuals eating them, rather than relying on the FDA to regulate or ban them — contributing to the growing perception that taking charge of your own health is the only way to survive. In this universe, healthcare is not societal, but a matter of individual responsibility. You, the atomized consumer, must advocate for yourself - even if society loads you with environmental contaminants and food deserts and workplace stress.

Self-managing “health,” it turns out, is a pretty difficult thing to do. I obviously want to laugh at the libertarians convinced that seed oils are killing them, and especially the tech guys taking their lives into their hands consuming organ meat at the advice of someone called “the Liver King.” But admittedly on some fundamental level I sympathize with their anxieties, which are rooted in the distrust of a contemporary system that has, in many ways, failed us. 

Advice as simple as eating well and exercising is kind of opaque due to how the system is structured. (This opaqueness is very profitable.) In an ideal society, these concerns would be easy to address thanks to better regulations and more subsidies for healthy foods (rather than just for corn — the main input for processed foods). Instead, entirely reasonable people shell out record amounts for healthy prepared food from Factor and Goodeggs and Purple Carrot and HelloFresh and then work out at various Pelotons and Equinoxes and Soulcycles and Bodyroks and OrangeTheorys. Sure some of these things are fun, but the prominence of managing your health via multiple hundred dollar-per-month wellness subscriptions seems to me more an indictment of the broader system as a whole. I don’t think Hippocrates envisioned $400 gym subscriptions and isolated treatment from a dozen healthcare startups when he first philosophized medicine.

Market forces just seem a lot less interested in curing endometriosis than they do in finding a rare mineral that will allow billionaires to live to 150 (see: Silicon Valley’s fascination with “longevity research”). We can’t rely on them for something as vital as keeping our vitals intact. With as many people falling for shady, deeply unscientific online cures as they are, distrust in the broader system needs to be addressed head-on with structural reform. Profits are no indicator of wellness.