Sixteen years after passage of the Affordable Care Act (Obamacare), America has accumulated enough experience to ask a question that extends beyond any one administration or political party: Where did the money go?
The Affordable Care Act fundamentally reshaped American healthcare. Millions gained health insurance, and protections for patients with pre-existing conditions became permanent law. Those achievements deserve recognition. But another question deserves equal attention — not whether more Americans possess an insurance card, but whether the economics of healthcare have evolved in the public’s interest.
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Every dollar spent on healthcare ultimately comes from patients, employers, or taxpayers. If all three are contributing more than ever before, an honest accounting requires following those dollars through the system to determine where the economic value accumulates.
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The broad trends are difficult to ignore. Average employer-sponsored family health insurance premiums rose from $13,770 in 2010 to $26,993 in 2025 — nearly doubling. Deductibles and other forms of patient cost-sharing have also increased. Many middle-class Americans are therefore insured yet functionally underinsured because the financial burden of obtaining care continues to grow.
Physicians have experienced a remarkably different trajectory. Adjusted for inflation in practice costs, Medicare physician payment declined 33% from 2001 through 2026. Administrative responsibilities, meanwhile, have expanded. Prior authorization has evolved from a utilization-management tool into a routine administrative barrier: physicians report completing an average of 43 prior authorizations per week, consuming roughly 12 hours of physician and staff time.
This is not simply a physician problem. It is a patient-access problem. When reimbursement fails to keep pace with inflation and administrative burdens multiply, experienced physicians retire earlier, independent practices disappear, and communities — particularly rural ones — find it increasingly difficult to recruit and retain physicians.
At the same time, some of America’s largest healthcare corporations have experienced extraordinary growth. UnitedHealth Group, for example, reported $94.2 billion in revenue in 2010 and $447.6 billion in 2025 — nearly a fivefold increase. Its then-chief executive received total compensation of approximately $26.3 million in 2024.
These corporations increasingly function as far more than insurance companies. Major healthcare conglomerates now encompass health plans, physician practices, and care-delivery businesses, pharmacy benefit management, specialty pharmacy, data and analytics, and other health services. The same corporate family can participate in financing care, administering benefits, determining coverage, managing prescriptions, employing clinicians, and delivering healthcare.
Whether each acquisition or business combination is individually justified is not the central issue. The question is whether concentrating so much authority over financing, authorization, and delivery ultimately serves patients — or primarily strengthens the economic leverage of organizations positioned between patients and their physicians.
None of this, by itself, proves wrongdoing. Successful companies should succeed. Innovation deserves to be rewarded. Profits are not inherently evidence of failure. Public policy, however, should ultimately be judged by its outcomes.
If patients and employers are paying more for insurance, taxpayers are committing enormous resources to healthcare, physicians are receiving less inflation-adjusted reimbursement, administrative barriers continue to expand, and major healthcare corporations have grown dramatically, policymakers should ask a straightforward economic question:
Who captured the value?
This is not a Republican question or a Democratic question. It is an accounting question.
Congress should commission an independent economic audit of American healthcare that follows federal healthcare dollars from congressional appropriation through insurers, pharmacy benefit managers, healthcare corporations, providers, and major administrative intermediaries to determine where the economic surplus ultimately accumulates.
That audit should examine insurer and healthcare-conglomerate revenues, market capitalization, executive compensation, inflation-adjusted physician reimbursement, patient premiums and deductibles, prior-authorization growth, vertical integration, consolidation, and administrative costs. Most importantly, it should determine whether today’s financial incentives primarily reward patient care — or the administration of patient care.
Healthcare exists for one purpose: to improve patients’ lives. A financing system that consistently rewards administrative complexity more than clinical excellence, consolidation more than competition, and bureaucracy more than bedside care deserves careful re-examination.
The ACA answered one important question: How can more Americans obtain health insurance?
The next question may be even more important:
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Who is being paid — and why?
Until we answer it, we cannot honestly claim to understand why American healthcare has become so expensive.
Dr. Morgan P. Lorio is a retired orthopedic spine surgeon, a past president of the International Society for the Advancement of Spine Surgery, and a member of the Advisory Board of the American Academy of Interventional Spine and Neuromodulation.
