The View From Everywhere Else
PERMISSION TO BE SICK
How the wealthiest country on earth became the only one that makes you ask.
There is a card in a wallet somewhere in America. It has a logo on it — a managed care organization’s branding, something forgettable and corporate. It does not say “Medicaid” anywhere on it. The person who carries it has vision coverage, prescription coverage, and access to a primary care physician. They have had this coverage for years. They do not know what it is called. They do not know who pays for it.
They voted, in a recent election, for candidates who promised to cut government health programs. They said, when asked, that they supported “reducing government dependency.” They said they did not want “socialized medicine.” They did not know they were on it.
This report is the explanation of how that is possible. It is also the explanation of what is being done to that card — and what the rest of the world, watching from the outside, makes of a country that is dismantling, piece by piece, the infrastructure that keeps its people alive.
THREAD 1: THE MIRROR
Every three years, the Commonwealth Fund publishes a document called Mirror, Mirror. It compares the health systems of peer nations — countries at roughly comparable levels of wealth and development — across 70 measures in five domains: access to care, care process, administrative efficiency, equity, and health outcomes. It is the most rigorous, most comprehensive, and most consistently cited international comparison of healthcare systems in the world. It has been published eight times since 2004. The United States has ranked last overall every time data permitted a full comparison.
Mirror, Mirror 2024 compared ten countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. The top three performers were Australia, the Netherlands, and the United Kingdom. The United States ranked tenth. Last.
Not narrowly last. The Commonwealth Fund’s own charts show the US as an outlier — not merely at the bottom of the ranking but separated from the next-lowest performer by a margin that, in any other policy domain, would constitute a crisis demanding immediate national attention. The US ranked last on access to care. Last on health outcomes. Ninth on equity. Second — its sole strong performance — on care process, which measures whether the care that is delivered, when it is delivered, is technically competent. Americans, when they can get care, generally receive good care. The problem is getting it.
The health outcomes finding is the one that should stop every reader cold. According to the Commonwealth Fund, Americans have the shortest life expectancy and the highest rates of preventable deaths among all ten peer nations studied. These are not statistical abstractions. They are the counted bodies of people who died from conditions that, in nine other wealthy countries, would not have killed them — because those countries found and treated the disease earlier, covered the medication that managed the chronic condition, or simply did not allow a billing dispute to delay the procedure long enough for the patient to deteriorate past saving.
The spending numbers complete the picture. The United States spent $4.9 trillion on healthcare in 2023 — more than any other nation in the study, by a significant margin, as a share of GDP. Healthcare spending grew 7.2 percent in 2024. Americans spend more per person on healthcare than the citizens of any peer country. They get less for it, measured by every outcome metric that matters: how long they live, how many of them die from preventable causes, how many of them cannot afford care at all. Joseph Betancourt, president of the Commonwealth Fund, put it plainly in the report’s press release: “The US is failing one of its principal obligations as a nation: to protect the health and welfare of its people. The status quo — continually spending the most and getting the least for our health care dollars — is not sustainable.”
One more number: 26 million Americans remain uninsured. In every other peer nation in the Commonwealth Fund study, universal or near-universal coverage is not a policy aspiration — it is the baseline from which system performance is measured. The US is the only country in the study where a meaningful percentage of the population has no coverage at all, leaving them “fully exposed to the cost drivers in the system,” as the report notes. A country that spends the most and covers the fewest is not a healthcare system. It is a system organized around the transaction, with healthcare as a byproduct.
The three top-performing countries — Australia, the Netherlands, and the United Kingdom — represent three different structural approaches to healthcare. Australia has a public system (Medicare) with a regulated private supplement. The Netherlands has a universal mandate with tightly regulated private insurers. The United Kingdom has a public system funded by taxation. The thing they have in common, the thing that every top-performing country in the Mirror Mirror study has in common, is this: affordable, universal access to healthcare as a non-negotiable baseline. Not a benefit. Not a product. A floor below which no citizen falls. The United States does not have that floor. What it has, instead, is a card in a wallet that the person carrying it does not recognize.
THREAD 2: THE NAME GAME
Before the rebranding examples that follow, a clarification. Medicare and Medicaid are not the same program, though the names are close enough that the confusion is common — and not accidental. Medicare is the federal health insurance program for people 65 and older, and for certain people with disabilities, regardless of income. It is funded entirely by the federal government and administered directly by it. Medicaid is different. It is a joint federal-state program covering low-income adults, children, pregnant women, elderly people in nursing homes, and people with disabilities who meet income requirements. The federal government pays between 50 and 83 percent of costs depending on the state; the states administer the program. Medicare recipients generally know they are on Medicare. Medicaid recipients, for reasons this thread will explain, often do not.
Medicaid is the largest health insurance program in the United States. It covers approximately 80 million Americans — roughly one in four. It is, by almost any measure, the most important safety net program the US government operates.
Most of the people on it do not know they are on it.
That is not an accident. When the federal government created Medicaid in 1965, it gave states significant latitude in how to administer and brand their programs. Over the decades, states have exercised that latitude in ways that have had a profound effect on public understanding of what Medicaid is — and what is at stake when politicians propose cutting it. Tennessee’s Medicaid program has been called TennCare since 1994. TennCare has been in operation for 32 years. An entire generation of Tennesseans has grown up on TennCare without the word “Medicaid” appearing anywhere on their card, their approval letter, or their benefits statement. When a politician says “cut Medicaid,” a TennCare enrollee may hear a policy debate about someone else’s program.
Tennessee is not unusual. Across all 50 states, Medicaid programs carry names that often bear no relationship to the word “Medicaid” at all. In California, it is Medi-Cal. In Washington state, Apple Health. In Wisconsin, BadgerCare Plus. In Maine, MaineCare. In Missouri, MO HealthNet. In Indiana, Hoosier Healthwise. In Kansas, KanCare. In Massachusetts, MassHealth. In Virginia, Virginia Cardinal Care. In New Mexico, Centennial Care. In Connecticut, HUSKY Health. In Colorado, Health First Colorado. In each of these states, millions of people receive federally funded health coverage under a name that their state government chose — a name that is often designed to sound like a local product, a state initiative, something homegrown and community-minded rather than a federal entitlement program subject to federal budget negotiations.
The effect on public understanding is documented and dramatic. Survey after survey has found that Americans systematically underestimate how many people are on Medicaid, systematically underestimate the likelihood that they themselves might need it, and systematically support cuts to “Medicaid” while opposing cuts to the specific programs they actually use. This is not a coincidence of ignorance. It is the predictable outcome of a system designed, whether intentionally or not, to make the federal safety net invisible at the moment of use.
The same dynamic, at even larger scale, defined the political history of the Affordable Care Act. “Obamacare” and “the Affordable Care Act” are identical. They are the same law. For years, polling consistently found that more Americans supported the Affordable Care Act than supported Obamacare — often by double-digit margins — and that a meaningful percentage of people who said they wanted Obamacare repealed did not know they were enrolled in ACA coverage. In Kentucky, during the height of the repeal debate, the state’s ACA exchange was called kynect — a local brand with no visible connection to the federal law. Enrollees in kynect, when told that repealing the ACA would eliminate their kynect coverage, were often genuinely surprised. They had not connected the two things because no one had designed the system to connect them.
The person in Tennessee with the TennCare card they do not connect to Medicaid is not unusual. They are the intended product of a system in which the most important public health infrastructure in American life has been named, branded, and administered in ways that make it systematically unrecognizable to the people it serves. When they vote to cut it, they are not voting against themselves in any knowable sense. They are voting against an abstraction — a word, a political label, a thing they have been told represents government overreach — while the card in their wallet continues to pay for their vision appointment.
Until it doesn’t.
THREAD 3: THE MIDDLEMAN
In France, when a physician decides a patient needs an MRI, the patient gets an MRI. In Germany, when a physician prescribes a medication, the patient receives the medication. In Australia, when a patient needs surgery, a billing intermediary does not review the surgeon’s clinical judgment and decide, on the basis of an algorithm optimized for the insurer’s profit margin, that the surgery is not medically necessary.
In the United States, all of these things happen routinely. They are called prior authorization denials. They are administered by private health insurers. The people who make the decisions — on initial review — are often not physicians. Increasingly, they are not people at all.
The American Medical Association published a new survey on May 13, 2026 — one day before this report was drafted — showing that three-quarters of physicians, 74 percent, report that prior authorization denials have increased over the past five years. Six in ten are concerned that AI is making the problem worse. They are right to be concerned. According to the AMA’s 2025 Prior Authorization Survey, AI-driven denial decisions now return results in hours rather than days — but at denial rates 40 percent higher than human-reviewed decisions. The speed improvement serves the insurer. The accuracy deterioration falls on the patient.
The scale of the prior authorization system is staggering. In March 2026, for the first time in American history, health insurers were required to publicly report their prior authorization metrics under the CMS Interoperability and Prior Authorization Final Rule. The data, now public, is striking. Across 1,110 health plans — Medicare Advantage, Medicaid, and ACA marketplace plans — standard prior authorization denial rates range from under 2 percent to more than 26 percent. A patient enrolled in a high-denying plan is roughly twelve times as likely to have a care request blocked as a patient in a low-denying plan offering identical coverage. Appeal overturn rates — the share of denied decisions reversed when challenged — range from near zero to more than 90 percent, depending on the plan. That spread is not a feature of a well-functioning system. It is evidence that a significant portion of denials are simply wrong, and that the system is designed, structurally, to make it difficult for patients to find out.
Nineteen percent of in-network claims submitted through HealthCare.gov marketplace insurers were denied in 2023. Fewer than 0.2 percent of those denials were appealed — despite evidence that 40 to 90 percent of appeals succeed when patients fight back. The math is not complicated: the system denies a large number of claims that should be approved, counts on the vast majority of patients not appealing, and retains the premium savings from the denials that go unchallenged. This is not an edge case or an abuse of the system. It is the system operating as its incentive structure dictates.
No peer nation in the Commonwealth Fund Mirror Mirror study has built this structure into its healthcare architecture. In countries with universal or near-universal coverage — whether publicly funded, regulated private, or hybrid — the insurer’s role as an active, algorithmic gatekeeper between physician judgment and patient care simply does not exist at this scale or with this degree of clinical override. When a French physician orders a test, there is no prior authorization process. When a German patient needs a specialist, a non-medical administrator does not review the referral. The administrative efficiency domain of the Mirror Mirror study, where the US ranks near the bottom, is a direct measurement of this: American physicians and patients face more hurdles related to insurance rules, billing disputes, and reporting requirements than those in any other peer nation.
On December 4, 2024, Luigi Mangione shot and killed Brian Thompson, the CEO of UnitedHealthcare, outside a hotel in midtown Manhattan. The public response was not what you might expect from the assassination of a corporate executive. There were celebrations on social media. There were memes. There were people expressing, openly, that they understood why it had happened. The reaction was widely reported as shocking. It should not have been. It was the documented public rage of millions of people who had received denial letters, had treatments delayed, had surgeries canceled at the last minute, had medications switched to inferior alternatives because the original was not on the insurer’s approved formulary — all by an entity that had never examined them, did not know their history, and had a documented financial incentive to say no. The UnitedHealthcare CEO shooting was reported, mostly, as a crime story. It was also a data point about what the prior authorization system has done to the relationship between Americans and the companies that control their access to care.
In June 2025, roughly 60 health insurers pledged to streamline and reduce prior authorization requirements, with implementation deadlines through 2027. The AMA’s May 2026 survey found that physicians are “pervasively skeptical that meaningful change will occur — reflecting years of similar commitments that have failed to produce lasting improvements.” Seventy-four percent say denials have increased anyway. The pledge was a press release. The denials are a business model.
THREAD 4: WHAT IS ACTUALLY BEING DISMANTLED
The Mirror tells us where the United States stands among its peers. The Name Game tells us why so many Americans do not recognize the system that keeps them alive. The Middleman tells us how that system has been quietly captured by an intermediary whose financial interests are not aligned with patient health. Thread 4 is about what is happening to the remaining public infrastructure — the parts of the American health system that are not run by private insurers, that are funded by taxpayer dollars, and that have, for decades, represented the United States’ commitment to its own people’s survival.
Robert F. Kennedy Jr. became Secretary of Health and Human Services in January 2025. In the sixteen months since, the department he leads has undergone a transformation with no modern precedent. The HHS discretionary budget for fiscal year 2026 was cut by 25 percent, from $130.7 billion to $94.7 billion. The proposed FY2027 budget would cut a further $16 billion. The cuts are not being distributed evenly. They are targeting, specifically, the agencies responsible for the scientific foundation of American public health.
The National Institutes of Health, the largest funder of biomedical research in the world, faced a proposed cut of $18 to $27.5 billion — approximately 38 to 58 percent of its budget. Kennedy ordered 10,000 HHS job cuts in March 2025. In the first month of the new administration, approximately 1,800 NIH research grants were abruptly canceled. Four NIH institute directors were fired. $500 million in mRNA vaccine development contracts were terminated. The FDA’s former vaccine chief was fired. The CDC director — hired by Kennedy himself — was fired after less than a month. A 54 percent cut to CDC funding was proposed, alongside the complete elimination of the CDC’s Global Health Center, which had a FY2024 budget of $711 million and supported disease surveillance, outbreak response, and public health capacity in countries whose epidemics become America’s epidemics when left uncontrolled.
On January 22, 2026, the United States formally completed its withdrawal from the World Health Organization — one year after Trump signed the executive order initiating the process. The US had been the WHO’s largest financial contributor, providing $1.284 billion in 2022-23. Its departure created, in the words of a peer-reviewed analysis published in PMC, “uncertainty for the organisation, potentially delaying responses to global health crises and exacerbating inequities.” That is the measured language of academic research. In plainer terms: when the next pandemic begins, the surveillance and response system that might catch it early enough to contain it will be operating with a billion-dollar annual hole where American funding used to be.
Kennedy’s framework for all of this is the MAHA agenda — Make America Healthy Again. Its stated focus is chronic disease, which is a genuine and serious public health problem. The US does have catastrophic rates of obesity, diabetes, heart disease, and other preventable chronic conditions. Kennedy is not wrong that this is a crisis. Where the MAHA agenda breaks with evidence-based public health practice is in its insistence that the institutions that have documented, studied, and developed interventions for these conditions are themselves the problem — that the NIH’s research agenda has been captured by pharmaceutical interests, that the CDC’s recommendations have been politicized, that the FDA’s approval processes have been compromised. These are not entirely baseless concerns. But the response — eliminating the institutions rather than reforming them — is not supported by any evidence from peer nations that have achieved better health outcomes. The countries that rank above the United States in the Mirror Mirror study did not get there by cutting their public health agencies. They got there by funding them adequately and holding them accountable to population health outcomes.
Congress has not been entirely passive. House appropriators, in September 2025, rejected the administration’s proposed 40 percent cut to NIH and funded it at $48 billion instead. But the cuts that did proceed — to the CDC, to global health programs, to the public health workforce — are already producing measurable consequences. Federal data collection systems that tracked pregnancy outcomes, adolescent health, and food insecurity have been dismantled. States are seeking alternative data sources for public health surveillance that the federal government no longer provides. The scientific infrastructure that supports everything from vaccine safety monitoring to cancer screening guidelines is operating with fewer staff, fewer grants, and fewer of the institutional safeguards that took decades to build.
The Affordable Care Act subsidies that have extended coverage to millions of Americans are expiring, and Congress has not acted to extend them. Medicaid work requirements — struck down by courts repeatedly in the Obama and first Trump administrations — are being pursued again, with a Congress more amenable to passing them. The budget reconciliation bill led by House Republicans, at time of publication, proposes major Medicaid cuts that Kennedy has said HHS would not pursue — a tension between the secretary’s stated position and his party’s legislative agenda that has not been resolved.
The person with the card still has it. For now.
THREAD 5: WHAT THE WORLD SEES
The rest of the world is watching.
WHO Director-General Tedros Adhanom Ghebreyesus announced in November 2025 that external health aid had dropped 30 to 40 percent in 2025 compared to 2023. A WHO survey of 108 low- and middle-income countries found that services including maternal care, vaccination, disease surveillance, and health emergency preparedness had been cut by up to 70 percent in some countries as a direct result of the funding collapse. More than 50 countries reported job losses among health workers. The WHO itself is cutting 2,371 staff — roughly a quarter of its workforce — by mid-2026, facing a $1.9 billion shortfall driven largely by the US withdrawal. Development assistance for health declined 21 percent between 2024 and 2025 overall, driven by a 67 percent drop in US financing — more than $9 billion removed from the global health system in a single year.
These are not abstractions about foreign policy. They are the conditions that determine whether disease outbreaks are caught early or spread. They are the conditions under which the next pandemic will be detected, characterized, and responded to — or not. The countries where US-funded surveillance programs have been cut are not isolated systems. They are the early warning network through which infectious disease has historically been identified before it reaches American airports. “Infectious diseases do not respect borders,” Janeen Madan Keller of the Center for Global Development told CBS News. She was describing the stakes not just for low-income countries but for the United States itself.
From the vantage point of peer nations — the ten countries in the Commonwealth Fund study, the European health ministers who have watched American public health policy with a mixture of alarm and disbelief over the past year — the trajectory is not difficult to read. A country that already ranked last on health outcomes among its peers is systematically defunding the institutions responsible for measuring, monitoring, and improving those outcomes. It is withdrawing from the international frameworks through which global health crises are managed. It is transferring more decision-making power over healthcare access to private entities whose financial interests are misaligned with patient health. And it is doing all of this while the evidence base for what actually works — the Mirror Mirror data, the OECD comparisons, the WHO performance metrics — sits in plain sight, pointing in the opposite direction.
The Johns Hopkins Bloomberg School of Public Health, in its 2025 year-in-review, described the year as “the upending of public health institutions and processes.” The Health Policy Watch described 2025 as “a brutal year for global health.” These are not partisan characterizations. They are the assessments of the professional community that has spent its careers building the infrastructure now being dismantled.
What the rest of the world sees is not complicated. It sees the country that built the world’s most influential public health institution, that funded global vaccine programs for generations, that led international disease surveillance and response for decades, retreating from all of it simultaneously. It sees a country that spends more on healthcare than any other and gets less, now proposing to spend less on the public health functions that might eventually close that gap. It sees the wealthiest country on earth making a systematic series of choices that will, by every available evidence, make its people sicker, shorten their lives, and reduce the safety net that millions of Americans depend on without knowing it.
There is a card in a wallet somewhere in America. The person carrying it does not know what it is. They do not know who funds it. They do not know that the system quietly working to eliminate it is the same system that requires them, every time they need care, to ask permission to receive it.
In every other peer country, no one asks permission.
“Whenever the people are well informed, they can be trusted with their own government.” — Thomas Jefferson, 1789