Is there a rich caste of doctors or pharmaceutical shareholders that don't need to work and live off these dividends? Or is the system so inefficient that most people in it aren't contributing to actual health care?
If you want to understand where the money is actually going then this Peter Attia Drive podcast episode with Dr. Saum Sutaria is the best high level overview that I've heard. Seriously it's worth listening to and will clear up a lot of the misconceptions that many people have.
Nearly all of it goes to grifters who hang on to the system but don't contribute anything. The obvious ones are all the insurance company employees who don't provide any healthcare, just push paperwork to try to find ways to deny coverage. And all the oberpaid administrators, and of course those multi-million bonuses to all executives involved need to be paid somehow.
If that sounds overly cynical, consider a primary care doctor visit. I get about 15 minutes of the time of a nurse assistant (some searching suggests average wage 50K) and 12 minutes with the doctor (searching suggests average wage of 250K).
So the cost of salaries to the people that actually provided me healthcare that day, is $6 + $24 = $30. Even if we double the salaries of both nurse and doctor, it'd be a $60 visit.
Of course, there's office overhead like rent, utilities, etc.
But I get billed $500 for that visit. SO where is all that money going? Obviously not to the health care professionals.
If we simply removed all the grifters from the system, health care would be quite affordable.
That does not match your earlier statement about administrators or health insurance, though. Or does your primary care doctor work in a big hospital that takes a 400% margin?
I don't know where the majority of the money goes, if you're looking for a precise breakdown.
The point I'm making is that only a very very tiny fraction of the bill goes to the people actually providing healthcare (the nurse and the doctor).
Of course some overhead is inevitable, but there is very clearly a vast amount of waste here that could be eliminated. A nurse + a doctor provide $30 of their time, and $470 of overhead is tacked on to that. That's why healthcare is so insanely expensive in the US.
Doctors are by far the highest paid professional occupation in America. The AMA is the most powerful trade union in history and restricts the number of new doctors, pushing up prices.
Specialist doctors are one of the highest paid professions in almost all countries. There are hardly any jobs more important than those of say a heart surgeon or a neurosurgeon.
Is there a rich caste of doctors or pharmaceutical shareholders that don't need to work and live off these dividends? Or is the system so inefficient that most people in it aren't contributing to actual health care?