If you want to understand what “profits before patients” means in American health care, don’t start with a spreadsheet. Start with a story.

During residency, I cared for a middle-aged mother of two who came to our community hospital emergency room struggling to breathe. It didn’t take long to realize she needed something we couldn’t offer: urgent heart surgery at a larger hospital.

After a 30-hour shift, I filed the transfer request and went home. When I returned the next morning, I found her exactly where I’d left her, except now she was in the ICU. The transfer had been denied.

Her heart failure worsened. On rounds the following day, she arrested. We jumped into CPR to save her. She didn’t make it.

It took me years to admit what I couldn’t fully face then: The transfer wasn’t denied because surgery was futile, as the paperwork claimed. It was denied because she didn’t have insurance. Put plainly, there was no money in saving her.

On her death certificate, I wrote cardiac arrest due to heart failure and valvular disease. What I should have written was this: cardiac arrest due to corruption and greed.

That line may sound overheated. But if you’ve spent enough time in American medicine, you’ve seen the softer versions of the same logic: the “optimization” that really means paperwork; the medication that isn’t covered until the cheaper one fails; the specialist appointment scheduled months out because the network is thinner every year. Each one looks defensible on paper. At the bedside, it feels like complicity.

The daily reality of rationing care

In my clinic today, I see a woman with rheumatoid arthritis. She is kind, apologetic, careful not to “take up too much time.” Her disease has stiffened her joints, deformed her wrists, and inflamed her lungs. There are medications that can halt the inflammation, prevent scarring, preserve her independence. But she is uninsured. So I treat her with a drug from the 1940s, cheap enough to buy out of pocket, and I watch her try to make peace with less-than-modern care.

When she leaves, I don’t feel relief. I feel failure, even though the failure isn’t mine alone. I stare at her chart and think of all the ways doctors are forced to improvise in a system that treats access as optional. Should I call the drug company myself? Beg a specialist friend? Push harder on a patient assistance program that requires hours she doesn’t have? This is what it means to practice medicine in the richest country on earth, at a time of medical miracles: knowing what the right care is and watching the system refuse to deliver it.

This is why “profiteering” isn’t an abstract accusation. It is an organizing principle.

The United States spends staggering amounts on health care, nearly one in every five dollars, far more than peer nations. Yet many Americans still experience health care as scarce: denied claims, unaffordable drugs, and routine care that feels like a luxury purchase.

Part of the problem is an incentive structure that rewards volume over value. Insurance companies reduce payments in one category, hospitals increase prices elsewhere to recover revenue, and insurers respond by denying coverage or shifting costs to patients. Hospitals, even those labeled nonprofit, are pulled toward doing more (more imaging, more procedures, more billing opportunities) because that is what the system pays for.

Moral injury and the human cost

Often lost in these arguments is what this machine does to the human beings inside it.

Doctors and nurses are not simply tired. Many are experiencing moral injury, the repeated harm of being forced to act against one’s values.

When a clinician is pressured to prioritize revenue, throughput, or satisfaction scores over care, it doesn’t just chip away at idealism. It reshapes identity. People who entered medicine to help begin to feel complicit in harm.

And when clinicians leave, emotionally or literally, patients lose twice: first to the system’s financial barriers, and again to the erosion of the human care that makes medicine work.

So what would a better path look like?

First, guarantee that access is real. A health care system that links lifesaving care to employment status or the fine print of a plan will always produce injustice and avoidable deaths.

Second, change what we pay for. Reimburse for outcomes, continuity, and prevention, not just the number of billable tasks performed. Pay for time, the conversations that keep patients adherent, out of the emergency department, and alive.

Third, put clinicians and patients in the rooms where decisions are made. Too often, care is designed by those furthest from the bedside. The result is a system optimized for revenue capture, not healing.

Finally, tell the truth plainly: When profit is allowed to dominate the moral purpose of medicine, the damage spreads. Patients are harmed or denied care. Clinicians are morally injured. Trust collapses.

We do not need to accept this as normal. Corruption and greed are not diagnoses we should have to write between the lines. They should be conditions we treat, urgently, before more people die of a system that mistakes revenue for care.

Shantanu Rai is a physician and writer.