The Gap

On eigenquestions, morality, and paradoxes

To what extent should the better-off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in health care? — Uwe E. Reinhardt, Priced Out

“Are the best days of this company ahead of you or behind you?” — Neil Mehta, Greenoaks, Invest like the Best

Two questions

If I were to drag you to the US and ask you to assess the healthcare system, what would you do? You might try to be really structured and take it bit by bit. Maybe you spend time with some providers, maybe with a payer, maybe at a health system. You turn up at a conference. You wear a tie! If you’re particularly enthusiastic, you might even interview some patients. Maybe you even start asking what a Pharmacy Benefit Manager (PBM) does. But you realise life is a bit too short for that. Then, eventually, exhausted, you might produce a leather-bound report that examines these various constituents and attempts to weave a compelling narrative that brings them together.

I might even read the report! I might send you some comments back. I’m impressed! But what if I told you that the report is great, but I’d really just like you to break down the US healthcare system into two questions? You might be baffled. Look at my leather-bound report, you cry?! The US healthcare system is so confusing! I couldn’t possibly reduce it down to two questions! And so on.

Well, thank god you’ve found this article, where I’ll attempt to do just that. To be clear, the US healthcare system is weird. These two questions by no means explain it. However, lacking a framework for some of the more bizarre things I was seeing, I kept going back to the questions above to make sense of what I was observing.

The first question

Uwe Reinhardt, in his book, Priced Out, tries to reduce the overwhelming complexity at the heart of the US healthcare system to the idea of “distributive social ethics”. The other, clearer, framing of the original question above is:

As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family. — Uwe E. Reinhardt, Priced Out

What Professor Reinhardt was getting at is that we often discuss US healthcare through a technical, economic, and policy lens. Instead, he orients us to what he thinks might be the eigenquestion¹, suggesting that the true nature of the healthcare quandary is moral. A choice that, as T.R. Reid frames it in The Healing of America, is one that other democracies have already faced. And answered with aplomb.

All the countries like us have already made the essential moral decision—every person shall have access to a doctor when needed—and all of them have developed mechanisms to make that guarantee a reality. — T.R. Reid, The Healing of America

Go on. Answer it

So when I try to answer Reinhardt’s question based on policy outcomes, the picture looks damning. I don’t claim to understand the motives of an entire health system, but the evidence points in one direction. The US healthcare system believes a child of a poor American family should not have the same chance of avoiding preventable illness or being cured from a given illness as does the child of a rich American family. And just to be clear: no, the better-off members of society should not be their poorer and sicker brothers and sisters’ keepers in care.

How did I get to this answer? With minimal effort. The latest estimates from the Congressional Budget Office (CBO) suggest that, due to cuts to Medicaid and reversals to the Affordable Care Act, the One Big Beautiful Bill Act (OBBBA) is on track to result in 15 million more people being uninsured by 2034.

For context: Medicaid covers people with low incomes—pregnant women, families with children, and people with disabilities. The Affordable Care Act expanded that coverage, stopped insurers from denying people with pre-existing conditions, and created subsidies so that millions more could afford insurance.

The OBBBA reverses much of this. Nearly $1 trillion in Medicaid cuts over ten years, stricter eligibility requirements, new administrative barriers, and the removal of subsidies that made coverage accessible. The policy is clear about who it prioritises, and it isn’t the poor. Tax cuts for the wealthy, financed by removing healthcare access for those who need it most.

The second Question

What a satisfying flourish it would be to end the essay there. The US healthcare system is immoral! We’ve found what’s rotten in the state of Denmark! A villain, a satisfying narrative arc, and an almost catholic sense of moral righteousness. The European healthcare system superiority starter pack. However, the reality is (of course) much more nuanced than this.

That brings us to the second question. In the Invest Like the Best podcast, at 31:25, Neil Mehta, whose life's work is investing in the best companies of each generation, asks this question of employees when visiting any new potential investment.

Neil insinuates that with this question, he is trying to get at something much less tangible than growth rates or discounted cash flows; he’s trying to understand the company’s vibe.

It’s another eigenquestion, which, upon being answered, will capture qualities such as an employee’s excitement, their drive, their belief in the product/company/CEO, as well as the market opportunity. The essence of the enterprise’s potential as it looks toward the future.

As I’ve spent time with academics, physicians, policymakers, start-ups, venture capitalists, and students over the last few weeks, this is the question I’ve been asking. The answer, delivered with an almost dead-eyed certainty, is that the best days are indeed ahead, not behind. This is despite the National Institutes of Health (NIH) funding cuts, the gutting of the Centers for Disease Control and Prevention (CDC), the general scepticism of academia and its outputs, and the strange vilification of paracetamol (Tylenol).

This optimism looks different in each constituent. The start-ups and venture capitalists are staunchly confident that their particular technological approach or portfolio of approaches will succeed. The policymakers, like the Bene Gesserit, make plans on the order of decades, not reflexively in each election cycle. The physicians and academics focus on solving the problem in front of them each day, whether that’s doing everything in their power to deliver excellent care or pushing the research frontier forward. And god the students, born with chips surgically attached to their shoulders as they constantly hunt for leverage and opportunity to do good and do well. There was no insidious immorality. No moral failing. Just good people doing good work in a system they had no hand in creating.

Mind the gap

When I try to answer Reinhardt’s question based on policy outcomes, the answer seems clear. I adhere to the maxim, attributed variously to Gandhi, Mandela, and Churchill, that to understand a nation’s character, one must examine how it treats its most vulnerable. On this measure, the United States falls woefully short.

But when I ask it based on the individuals I’ve met, there is dissonance. The people I’ve met are motivated to do right by everyone, not just the most affluent amongst us. Every person I spoke with believed their work mattered, that progress was possible, and that the best days were yet to come.

I kept wondering: what would it take for that gap to close? For the moral failures at the policy level to align with the optimism and capacity I’d seen at the individual level? Tsung-Mei Cheng, who helped design Taiwan’s universal healthcare system, offered an answer that felt both hopeful and frustrating. She added one more vector: time.

The Taiwanese healthcare system is often regarded as a model for high-quality, efficient, and accessible care. It provides mandatory, universal coverage at a fraction of the cost of the US, while earning consistent public approval ratings of over 80% and boasting a high life expectancy. Roughly a decade after it was established, Cheng published an assessment of how it was working, where she reported why Taiwan was able to succeed when it did:

First, there was a strong public demand for universal health insurance. Second, an entrenched political party with a parliamentary majority found itself challenged by a rising opposition party that had openly embraced universal health insurance. Third, sustained economic growth…made financing a major new program of this sort feasible. The confluence of these conditions presented Taiwan’s political leadership with an opportunity that it recognized and seized boldly. The lesson for policymakers elsewhere is that such windows of opportunity come along only every so often.

So there’s the answer. Time. Everyone I’m speaking to is working hard, but waiting. Waiting for a window of opportunity that can be seized boldly, where they can confidently answer the questions posed by Professor Reinhardt. Yes, the better-off members of society should be their poorer and sicker brothers and sisters’ keepers in care. And yes, the child of a poor American family should have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family. But to be ready for that time, it’s just work. Unglamorous work, performed dutifully, until the time comes for radical change.

Not a satisfying ending

I know. I wanted this essay to resolve the paradox neatly. To find a bridge between the systemic outcomes and the individual effort. To answer Reinhardt’s moral question in a way that accounted for the optimism I’d witnessed. But perhaps the gap itself is the point.

The Purpose of A System is What It Does—and what the US healthcare system does is inexcusable by the measure of distributive justice. But systems are also made of people, and those people are waiting. Working, yes, but also waiting. Waiting for the political window that Taiwan found, for the moment when optimism and capacity can reshape structure rather than just persist within it.

I don’t know if that optimism comes from a genuine belief in improvement or if it’s the cognitive dissonance necessary to function in a broken system. I don’t know where moral responsibility lies when good people produce bad outcomes. What I do know is that the gap exists, that it’s wider than I expected, and that I believe it's within our power to change it.

1. A made-up word that roughly means, this is the question, if answered, likely answers all the subsequent questions as well