Health care in the USA: money has become the mission

Despite extraordinary scientific and medical resources, the US health-care system underperforms. In this Review we consider the damage wrought by decades of market-based policies that have stimulated profit-seeking by insurers and health-care providers. Policy makers have subcontracted coverage under the public Medicaid and Medicare programmes for people with low incomes and those older than 64 years to private insurance firms-which now derive most of their revenues from those programmes-raising taxpayers' costs and constricting patients' care. Despite worrisome evidence of misbehaviour, firms obligated to prioritise shareholders' interests-and, more recently, private equity firms with a single-minded focus on short-term profit-have gained control of vital clinical resources. President Biden rescinded some of Donald Trump's most egregious first-term policies, expanded coverage for lower-income Americans, and initiated modest drug price controls. Since regaining office, President Trump has laid siege to science and public health, cut US$990 billion from Medicaid to offset tax reductions for the wealthy, and is accelerating Medicare's privatisation. State governments can tighten regulation of profit-driven abuses, and the medical community should resist Trump's health-harming agenda. But neither restoring the pre-Trump status quo, nor further attempts to reconcile the human rights of patients with the property claims of investors will suffice. Reforms must, instead, decommercialise insurance and care provision.