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Introduction: A Nation of Shoppers 7 “We cannot aff ord our health care,” dozens of health care leaders across Australia told me when I traveled there in 2013 to explore high-performing health systems. “Do you know we spend 9% of our GDP on it? It’s simply unsustainable.” After which, some would add, “Now, why have you come here to learn about our system?” Trying to avoid creeping self-doubt that I had dragged myself across the world on a fool’s errand, I would politely explain to them, and remind myself, that the United States was spending 18% of GDP on health care. I would dreamily wonder what the United States could do with an extra 9% of GDP to invest in education, infrastruc- ture, or some other valuable part of civic life. U.S. health care spending is not just obscene in some abstract macro- economic sense. Each year, Americans spend nearly a trillion dollars—a number that increases every year—out of pocket on health care and health insurance. A trillion dollars is equivalent to the gross domestic product of Indonesia, a country with more than 260 million people. 3 It’s a lot of money. Even with insurance, health care costs can hurt. Approximately 158 million people get health insurance from their employer or their spouse’s employer, 4 yet many are still vulnerable. Th e average family health plan cost more than $20,000 in 2019, 22% higher than in 2014 and 54% higher than in 2009. Employees pay more of the rising health insurance costs 82% of employees had a deductible—compared to 63% 10 years ago— averaging approximately $1,700 per year for individuals. 5 “We never got to a point where the insurance was paying for anything,” Angela told me. A 47-year-old mother of four, she earned $22,000 a year working part-time for a nonprofi t organization, while her husband got the family’s health insurance through his job at a university. “We were getting it from all sides. We were paying for the premiums we were paying the out-of-pocket and then there was all the time involved in going to all the appointments.” Angela was in physical therapy for a knee problem when they told her she needed an MRI because her condition was getting worse. Her health plan refused to pay for the MRI until she’d had an X-ray, for which she had to pay a copayment, even though she and the doctor both knew the X-ray would not be useful. At the same time, Angela’s second daughter was having recurring head- aches and one night lost her balance and fell walking up the stairs. Th e family’s pediatrician helped navigate the MRIs her daughter needed to rule out “the scary shit,” which they did. And then Angela needed knee surgery, which she could not aff ord to pay for outright. She signed up for a payment plan with the hospital and was still a long way from paying it off when I spoke with her a year later. “I realized in the middle of all this, we had a surgery and fi ve MRIs in our house and we didn’t meet the deduct- ible.” Angela’s family paid 100% of the thousands of dollars their health