Imagine a country capable of sending probes to the limits of the solar system, mapping the human genome and developing vaccines in record time — But where an ordinary citizen may hesitate to call an ambulance for fear of the bill. This country exists. Its name is the United States of America.

America remains, in the world imagination, the ultimate symbol of scientific modernity. Its universities dominate global medical research. Its pharmaceutical laboratories are developing some of the most advanced treatments. Its elite hospitals attract patients from all over the world. The United States is investing billions of dollars in biotechnology, artificial medical intelligence and genetic research. American medicine, at its peak, has not been equal.

Yet, behind this exceptional technological power, the American health care system reveals one of the greatest contradictions of contemporary capitalism: the richest country in the world is also one of the only great powers developed not to guarantee universal medical coverage to its entire population.

Millions of Americans live with permanent fear of getting sick. Hospitalization can ruin a family. Medical treatment can lead to debt over several decades. Citizens give up calling an ambulance because of the cost. Some reduce their insulin doses due to lack of means. Others postpone consultations until their condition becomes critical.

The paradox is therefore immense: America probably has the most sophisticated medicine in the world, but not the most effective health system for its population. It spends more than any other democracy, and cares less equitably than most of them. This contradiction is not a bug of the system; This is the central feature.

For the African observer accustomed to hearing the American model as an unsurpassable horizon, this reality has a valuable lesson: technological sophistication and social justice are two radically different things. A continent that would commit itself to building its health systems by taking America as a standard would risk replicating its prowess and exclusions at the same time.

A Medical Power Without Universal Protection

The American health system is an anomaly among the major industrialized democracies. In Western Europe, Canada or Japan, access to care is based on a fundamental principle: health is a collective right under national solidarity. Modalities differ — French Social Security, British NHS, Canadian Public Insurance, Nordic Mixed Models —However, the objective remains the same: to guarantee every citizen minimum access to care, regardless of his or her income.

The United States has followed a radically different path. The US system is mainly based on private employment insurance. Historically, health coverage has developed after the Second World War through companies: medical insurance has thus become a wage advantage rather than a universal right. This architecture produces a major structural fragility: losing your job can mean losing your health coverage.

In a country marked by the extreme flexibility of the labour market, this dependency creates permanent insecurity for millions of people. It is not simply a lack of organization: it is a repeated choice of society, decade after decade, to the detriment of the protection of the most vulnerable.

The exorbitant cost of a system without regulation

The first shock when we observe the American system is its cost. The United States spends a much higher share of its GDP on health than other developed countries. — around 17 to 18% compared to 10% to 12% in Europe. Yet, these colossal expenditures do not produce proportionately better health outcomes. In several key indicators, U.S. performance appears even poor.

The central problem lies in the system's economic logic. Each actor — hospitals, pharmaceutical laboratories, insurance companies, administrative intermediaries — seeks to maximize its revenues. Health thus becomes a highly financial sector where a simple consultation, ambulance or operation can reach dizzying amounts. Hospitals often charge several times the actual cost of benefits.

This constant inflation is explained by the lack of centralized price regulation. In Europe, states negotiate with laboratories and providers. In the United States, the market is supposed to do the job — and it does, but to the benefit of those who have the bargaining power, i.e. the industrial actors, never the isolated patient.

Fear of disease in the world's leading power

In European societies, getting sick is above all a medical test. In the United States, it can also become a financial disaster. Millions of Americans live with constant anxiety about unexpected hospitalization, cancer, accident or chronic illness. Medical debt has become a massive phenomenon. Whole families are getting into precariousness because of health care costs.

In the United States, personal bankruptcy related to health care expenditures is one of the most frequent causes of insolvency. In no other developed democracy is disease such a financial risk to households.

The case of insulin has become emblematic of this absurdity. This molecule has existed for a century. It is manufactured at a relatively modest cost. Yet its price has reached levels in the United States several times higher than in Canada or Europe. Some diabetics voluntarily reduce their doses to save — risk of serious complications, sometimes fatal.

This reality reveals the profound logic of the system: the solvency of the patient largely conditions his or her real access to care. The disease is not treated primarily as a biological fact to combat, but as an economic event to rate. It is an inversion of the values that certain cultures, especially Africans, in their community-to-health relationship would find difficult to conceive.

ObamaCare: historical reform or incomplete compromise?

The election of Barack Obama in 2008 gives rise to hope for a major transformation. LAffordable Care Act, better known as ObamaCare, is the most important health reform since the 1960s. Its aim is to reduce the number of uninsured persons through the extension of Medicaid, public subsidies, insurance obligations and protection against medical discrimination.

The reform does enable millions of Americans to obtain coverage. This is real progress, indisputable. But ObamaCare remains a deeply limited compromise. The private system is not challenged. Private insurance remains central. Pharmaceutical laboratories retain their power. Prices are not really regulated.

Above all, reform is immediately confronted with fierce political opposition. A part of conservative America sees ObamaCare as an unbearable intrusion of the federal state into the individual sphere. The health debate then turns into an ideological war around the place of the state in American society — to the detriment of millions of people who simply wait to be able to treat themselves without ruining themselves.

Why do the United States refuse universal coverage?

For a European — or an African who aspired to build a social protection system —The absence of universal social security may seem incomprehensible. Yet this resistance is part of American political and cultural history with disturbing consistency.

The United States built itself around a deep mistrust of central power. Individualism occupies a considerable cultural place. A large part of the population considers that everyone should be responsible for their own economic destiny. — including the disease. In this sense, health is less a collective right than an individual responsibility.

To this is added the power of interest groups: private insurance, pharmaceutical industry, large hospital groups, medical lobbies. The health sector represents thousands of billions of dollars. Any reform threatening the existing economic balances triggers massive, financed and organised resistance, which neutralizes the most intended parliamentary majorities.

American health has thus become a permanent political battlefield between commercial logic and the aspiration for more universal social protection. And so far, the market is winning.

Medicine as an industry

One of the most striking aspects of the American model is the gradual transformation of care into commercial activity. Large hospitals sometimes work like multinationals. Pharmaceutical groups have immense financial power. Insurance uses complex algorithms to limit refunds and optimize costs — do not confuse with optimising patient health.

This logic profoundly alters the medical relationship. The time spent on patients is often reduced under financial and administrative pressure. The doctors themselves denounce a system dominated by the imperatives of profitability, where the medical decision is sometimes conditioned by what insurance agrees to repay rather than by what the patient requires clinically.

The American health bureaucracy has become huge. A considerable portion of the expenditure is not used to treat, but to manage: invoicing, litigation, authorisation, administrative procedures. Some estimates suggest that administrative costs represent a quarter to a third of total expenditures. It's money that doesn't cure anyone. — and enriches intermediaries whose raison d'être is the very existence of this complexity.

Racial inequalities in health

As in the prison world, racial fractures go deep through the American health system. Black and Latin American populations often have lower life expectancy, more chronic diseases, more limited access to care and higher maternal mortality. These differences are not limited to biological factors: they mainly result from social inequalities, poverty, differentiated access to insurance, historical discrimination and residential segregation.

The Covid-19 pandemic has brutally confirmed what statistics have been whispering for decades: racial minorities have suffered disproportionate mortality rates due to their working conditions, housing and access to care. The virus didn't discriminate. The system is.

For the African observer, this is particularly instructive. African countries are often accused of stark health inequalities between rural and urban populations, between rich and poor. These inequalities are real and must be addressed. But they occur in developing countries, with limited resources. The United States produces racialized health inequalities in the richest country in human history. This is not a problem of means: it is a problem of choice.

American medical deserts

Unlike the image of a hypermodern and uniformly equipped America, vast territories suffer from chronic lack of access to care. In some rural or poor areas, hospitals close, specialists are absent, emergencies are saturated and distances become considerable.

U.S. rural hospitals are experiencing a deep crisis. Many close because of lack of financial profitability, leaving entire populations without rapid access to emergency care. The system favours profitable areas — affluent urban centres where patients are solvent —and abandon the others.

This situation illustrates once again the market logic of the system: where profit is insufficient, the medical supply withdraws. This is no different in its structure from what happens in some landlocked African regions. Except that in Africa, the argument is national poverty. In the United States, the argument is profitability. It is a chosen inequality, not suffered.

Opioids crisis: symptom of a diseased model

The opioid disaster is probably one of America's greatest health tragedies today. Pharmaceutical laboratories — first among them the Sackler family, owner of Purdue Pharma — massively promoted some painkillers while deliberately minimizing their addictive risks. Millions of prescriptions have been distributed for years, with the blessing of a regulatory system partially captured by industrial interests.

The result was devastating: massive addictions, overdoses, social collapse of entire regions, explosion of synthetic fentanyl. More than 80,000 overdose deaths are recorded in some years. Whole communities, already weakened by deindustrialisation, have been literally decimated.

This crisis reveals the drifts of a system where commercial logics can profoundly influence medical practices. The medicine in this model is only one product like another — and its promotion, subject to the same requirements as a car or soda. That lives are destroyed in the process is, in essence, an externality.

Mental Health: The Great American Bankruptcy

Mental health is one of the major dead spots in the American system. For several decades, public psychiatric facilities have been gradually reduced without sufficient alternatives being developed. Many people with serious psychiatric disorders find themselves without follow-up, without housing, in prison or in the street.

American prisons have thus become de facto some of the largest psychiatric institutions in the country. This formula, however shocking, is statistically correct. This is the perfect illustration of what happens when a society refuses to collectively deal with its vulnerabilities: they end up being criminalised.

The fentanyl crisis, the mass shootings, the social desperation of the rough bells All this converges towards the same collective psychological reality as the American health system has neither the instruments nor, often, the political will to treat. A society that treats its anxiety with prescription drugs and bars does not heal: it postpones.

Two visions of society: Europe versus the United States

The difference between the United States and countries like France far exceeds the technical organisation of care. It reflects two deeply different social philosophies.

In France, despite its financial difficulties and bureaucratic burdens, the system is based on the idea that health is a matter of national solidarity. The citizen is not supposed to be abandoned in the face of illness. In the United States, the dominant logic remains more individualistic: the market is supposed to allocate medical resources optimally. The reality shows that this is not the case.

This does not mean that European systems are perfect. They also suffer from medical shortages, administrative burdens, budgetary pressures and challenges related to demographic ageing. But they retain a fundamental principle absent from the American model: no one should be excluded from care for financial reasons.

For African countries involved in the construction of social protection systems, this debate is not abstract. It directly concerns the architectural choices to make. The American Model — privatization, fragmentation, mercantilization — is sometimes presented as inevitable or even desirable. The data suggest the opposite.

The absolute human market price — Conclusion