The Book of Abundance Needs a Health Care Chapter

[Photo by Mark Wilson/Getty Images]

The “abundance” argument is straightforward: Problems facing middle- and lower-income Americans are not merely the result of inequality but also of bottlenecks that prevent the provision of essential goods and services at affordable prices.

Health care should be an obvious part of that story.

There’s the scale of demand: nearly a fifth of national income is spent in the sector, despite similar countries spending around 10%. Health programs are the dominant budget category at both the state and federal levels. And that’ll likely only grow as our population ages.

And there’s the lack of supply. We have too few providers, hospitals, over-the-counter services, and so on. More than 92 million Americans live in areas with a primary-care shortage. The United States has just 2.7 practicing doctors per 1,000 people, against an OECD average of 3.9, and more than a third of adults say they have skipped or postponed needed care because of cost.

It makes sense that health care remains a top issue for voters and a particularly winning issue for Democrats. But it doesn’t make sense that health care policy continues to revolve around the same debates: the size of exchange subsidies and the perennial question of whether we might throw it all out and go with single payer.

These are important questions, of course, and the administrative efficiency of public insurers suggests potential for savings. But we’ve been having the same polarized, partisan debates for over ten years, with little to show for it. Thankfully, abundance provides a potential way forward.

What Health Care Abundance Looks Like

A retiree who lives by herself starts feeling vaguely unwell. She is tired, a little feverish, and not quite herself. Yet when her daughter stops by after work, she notices something disconcerting. At several points in their conversation, her mother seems subtly confused. A few years ago, that would have produced an argument. Is this just the flu? Is it dehydration? Is the daughter just being paranoid? Is it worth a long, expensive trip for something that might resolve on its own?

Instead, the daughter opens her mother’s health app and enters a simple note: fatigue, fever, not acting like herself. The app processes briefly, comparing her symptoms to its vast tranche of health data. It flags several plausible causes in order of probability, including flu, COVID, simple dehydration, and urinary tract infection. It recommends a prompt in-person evaluation, books an appointment 12 minutes later at a clinic two blocks away, and sends a structured intake ahead so the clinician does not have to start from scratch.

When they arrive at the clinic, the daughter taps her mother’s phone to a kiosk and is immediately given instructions to exam room 8.

By the time the nurse practitioner walks into the exam room, the uncertainty has been narrowed into something clinically useful. Based on community epidemiology patterns and her mother’s location history, it’s likely either dehydration or an infection, but COVID can’t be ruled out. The NP uses a rapid test to rule out COVID and an old-school physical examination to rule out dehydration. The diagnosis is a potentially serious but eminently treatable UTI.

On the way out, the daughter stops at a secure medication dispenser in the clinic lobby. The antibiotic the NP approved is already loaded and labeled, ready for pickup. No extra trip to a pharmacy. No waiting until morning. Within the hour, her mother is back upstairs resting, with the first dose already taken.

Total cost to Medicare: $80, vs ~$300 in today’s system¹

The fact that this scenario likely sounds far-off and fanciful shows how the limits of our health care debates have driven scarcity in the sector. Americans are used to high costs, long waits, and disappointing service – and have accepted it all as inevitable, even when concrete reforms could lead us to a better world.

How to Get There

Providers

What’s famously true for hair braiders and dental hygienists is doubly so for health care providers: Copious requirements keep competent and willing professionals out of the market, driving up the cost of services.

States differ widely in the scope of services that they allow different tiers of clinicians — nurse practitioners, physician assistants, pharmacists, etc. — to provide. For instance, the Alabama Legislature is working on a bill to allow nurse practitioners and physician assistants to sign off on physicals for high school athletes, rather than requiring a doctor’s signature. Research suggests that states with expanded scopes of practice don’t experience worse health outcomes and have outpatient costs that are 17% lower.

Residency caps on MDs exacerbate these barriers to entry. Medicare funding is crucial for maintaining residency slots at most teaching hospitals. Yet Medicare limits the number of slots it will fund at a given hospital to levels anchored to the number of slots each hospital had in 1996.

Hospitals

Certificate-of-need laws are the exclusionary zoning of health care. They require state approval for hospitals to open or expand facilities, add beds or service lines, or make major capital investments, and they often give incumbent hospitals a chance to object. In practice, that means existing providers can use the regulatory process to suppress competition. Mercatus researchers find that states with certificate-of-need laws have about 30 percent fewer hospital beds per capita than states without them.

Those barriers to entry have helped drive consolidation into large integrated health systems. Independent medical practice has become less viable as regulatory complexity has grown, while large systems benefit from the self-reinforcing advantages of vertical integration. They’re hard for insurers to exclude, can charge more when services are billed through hospital settings, and can steer patients within their own networks. The cumulative effect is a less competitive system with fewer entrants, more consolidation, and higher prices.

Prescription Regulation

Overly strict prescription requirements act like the “minimum parking requirements” of health care. They require that the product that people want, medicines, is paired with a costly service, a physician examination, that many don’t need.

For instance, patients with stable chronic asthma must regularly see a doctor simply to renew inhaler prescriptions, despite long-term, predictable needs. People who have been wearing glasses for decades need annual vision exams, as they might not notice when they need a higher prescription. The same for basic blood pressure medication and insulin for diabetics.

That regulatory barrier often ends up being the difference between treatment and no treatment at all. For example, nearly a third of Americans who would benefit from statins, a safe and effective cholesterol-lowering drug, do not receive them. Estimates suggest that if statins were offered over the counter, 69,000 lives would be saved over the next 10 years.

More ambitiously, GLP-1s offer weight loss, addiction management, and overall inflammation reduction for many. If early results hold, shouldn’t we make these drugs as easily available as possible?

The path to systemic solutions remains murky. The FDA has outlined rules creating a third class of drugs between prescription and OTC known as Additional Conditions for Nonprescription Use (ACNU). Still, the current process for getting a drug approved is complex and fragmented. As a result, no manufacturer has applied for approval under ACNU.

AI

The introduction of generative AI has the potential to create a revolution in health care. Medical practice requires performing complex analysis based on patients’ reports of symptoms in normal language. This is precisely what generative AI excels at. In theory, AI systems can track performance, quickly identify issues, and hold the appropriate people and systems accountable.

In the near term, AI is more likely to augment clinicians than replace them. The first gains are likely to come in triage, documentation, coding, imaging support, prior authorization, and routine follow-up—the pattern recognition and administrative work that now consume clinical labor without always requiring high-level clinical judgment. But that future depends on a much better data infrastructure than we currently have.

There are not yet consistent, well-established methods for monitoring AI performance in the same way as we have drugs under the FDA. Federal policy should standardize and fund real-world AI monitoring, require performance reporting and bias audits, and condition Medicare payments for AI services on the use of validated, continuously-tracked tools.

Pulling it together

Americans have spent decades being told that health care is simply expensive, that long waits and frustrating service are unavoidable, and that the only real policy question is how to divide the bill. That is wrong. Much of what makes American health care costly and scarce is not fate but policy: limits on who can provide care, Medicare residency caps rooted in the late 1990s, rules that let incumbents block new sites of care, prescription requirements that turn routine treatment into an office visit, and licensing, prescribing, reimbursement, and data barriers that keep telehealth and AI from being used as normal tools of medicine.

The insurance debate currently dominating health care politics matters. But no payment system, public or private, can overcome a shortage of providers, a shortage of facilities, and a regulatory thicket that prevents technology from doing what it already can. Abundance does not replace the debate over coverage. It changes the terms of that debate by lowering the underlying cost of care, no matter who is paying.

1. Author’s calculations