There is a general undercurrent of dissatisfaction with health care in America that is, shall we say, palpable. Many studies and statistical analyses support this notion but I think a broader view is both valuable and less abstract than a data set. We could go measure the angle of the Leaning Tower of Pisa and evaluate the foundational errors, but it doesn’t take that level of granularity to see that there’s problems. The dearth of serious, data-driven solutions reaching the legislature over the past many decades also suggests that, to quote a satirical television show, “we’re getting nowhere slowly.”

We should first establish the setting: Getting health care in America is by and large dictated by the very literal notion of “who’s paying”? There do exist certain protections under EMTALA where emergency care is legally required regardless of financial capacity, but anyone who’s interacted with the system knows that an insurance card is always sought out long before hitting the clinical area. This might be employer-sponsored, government marketplace, Medicare, Medicaid, or any number of private insurance policies. The point is that short of all-out emergencies some kind of insurance (some payer or set of payers) is the clear expectation when it comes to accessing health care. So-called self-pay options are frequently exorbitant and come with a certain stank like dressing casual to an upscale restaurant.

Note though that the question of payer is rather silly as it is you who is paying. Middlemen have built a vast and confusing bureaucratic (read: profit center) layer chock full of smoke and mirrors, distracting you with one hand so you don’t notice the other on your wallet. If an insurance policy is affordable through your employer it’s because the employer is paying a big chunk of it, and conveniently putting their thumb on the scale when it comes to deciding what kind of care you get. Not only that, it becomes a very successful tether to a company that then intuits that treating you well or compensating you fairly isn’t so high a priority. You pay with blood, sweat, tears, and probably also a pay cut. The staggering sums demanded from marketplace insurance policies is self-explanatory, especially when government subsidies disappear. Likewise, anyone whose looked at their paycheck in disappointment knows how Medicare is paid for.

At this point many people will say: “Wait a second. I actually get [blank] medication free!” Or “Well they gave me an Apple Watch free!” In both insurance and cell phones we seem to abandon the good sense in recognizing that nothing in life is free. Those costs are made up somewhere, folded into other fees, or otherwise amortized into some marketing budget paid for by you of course. In the grand scheme a common, mass-produced medication that costs pennies and a $200 watch are rounding errors compared against lifetimes of premiums. Consider that insurance itself is a bet that claim costs won’t exceed the premiums. This revenue is then used to gamble in the stock market. What makes you think they won’t gamble with your health too?

Consider car insurance, something most of us will have at least some familiarity with. The most basic is liability, which mainly is there to pay out if your car ends up damaging other people or things you don’t own. An incident happens, it pays for things you break, and pays for the direct medical costs of others damaged by the incident. We fear the uninsured driver mainly because they usually can’t pay for any of our stuff they break and nobody else is there to pay: Thus compulsory insurance in many places. Extras like comprehensive, collision, medical costs, and more exist but my point is that auto insurance is usually focused on discrete incidents with self-limited time courses and costs. If it costs more to fix the car than its worth they pay you something approximating market value. They pay medical costs to a point and no more assuming you opt for it. This is what we expect alongside the rise in premiums should we file a claim.

Now consider health insurance again and what we have been conditioned to expect and what has been politically mandated. We expect office visits, preventive care, procedures, hospital stays, surgeries, medications, immunizations, lab studies, imaging studies, rehabilitation, therapies, medical equipment, and more to be handled, preferably at low or no additional cost. This may sound very noble of companies but look at it in a more realistic way: These are vast bureaucracies handling many elements of health that ultimately get in the way of profits. The ways in which they set your premium is proprietary, as are the ways that decide who gets something and who doesn’t. In other words you throw your money into a black box and hope the output is in your favor. You hope that this company has the decency to carefully weigh your well-being in a cost-conscious manner, compromising on profitability to ensure that you have the best care that is practically available. I think we can generally agree that this has proven to be false over and over again.

Payers are just one set of players in this. Pharmacy benefits managers are another layer of middlemen, ostensibly there to negotiate drug prices and develop a cost-efficient formulary. In reality they’re the reason why something is covered one month and not the next. Or why you have to fight tooth and nail to stay on a perfectly good medication rather than be pushed onto something cheaper or that they inked a “win-win” deal with. When you develop an illness that requires a certain type of medication (a certain expensive type of medication) they’re the ones who left a yawning chasm of options in that section, leaving you with eye-watering prices and a take it or leave it attitude.

Then come the offices you interface with the most (primary care in particular) who have steadily marched into the fold of health systems due to the middleman squeeze. The health systems thus gain market dominance and secure more favorable reimbursement from insurance companies while standardizing (read: raising) regional prices because who’s going to argue? The entire system is geared and trained towards billing the maximal amount from payers in hopes of maximizing the eventual payout, much like a Craigslist haggling strategy: List high and take the best offer. Physicians are demoted to “providers” and questionably educated/experienced stand-ins are pushed out to vault the hurdle that is your appointment. Quickly and with maximal billing of course.

If this sounds like a homogenized assembly line that’s because it is. Think back to all the things we expect from payers, the implausibility of a profit-seeking enterprise handling it responsibly, and then think about getting it all on a factory floor. You’d better hope you fit in the box. You’d also better hope that you get somebody who can tell which box. The degradation is much like the stool leg cutting prank, where the legs are cut by a tiny amount everyday. Slow enough to eventually notice but not shock. It is worth asking ourselves whether foundational institutions for human society should behave like robber barons.

The swirling complexities and chaos of this middle management is a feature, not a bug. It extracts money and labor from us while distracting from the reality of human and even Neanderthal societies: There has always been a need for health care and a cost borne by communities for it. Medicine has of course advanced to unimaginable heights since the 1900s, not to mention from the perspective of a tribal witch doctor, but that only emphasizes more that the trajectory of quality should be going up rather than down. The levers of scientific advances take time to be put to good use, time in learning and in practice. So too does it take time and expertise to guide individuals and families through a timelessly complex journey in a yet imperfect world. These core functions have been stripped away as bugs in the system when in fact they are the true fountains of our confidence in health care and its prestige.

So why is American health care so bad? The problems I detailed above explain at least a few facets of it, but it may be better distilled as a loss of core mission in favor of making millionaire-billionaire CEOs. Health care is a classic need in our societies which has been co-opted by those seeking profit at any cost except their own. These same organizations are then charged with managing everything and we seem surprised that less profitable exercises are neglected. In truth decency and common cultural unity have been sacrificed at the altars of wealth and political power, though arguably one and the same. American health care is so bad because for as much as we fear our own fragility we’re blind to that of our neighbors, comforted by insurance cards splashed with arcane policy codes like some kind of ward against mortality. But casinos don’t exist for you to win and standardized rations rarely provide good sustenance.

Way Chiang is a family medicine physician.