The future of healthcare requires careful attention to present problems, said Martin Makary, MD, MPH, FACS, at Clinical Congress on Monday, September 28. Dr. Makary, a surgical oncologist and the 27th Commissioner of the US Food and Drug Administration (FDA), shared his perspectives on the healthcare system in a special, hourlong lecture.
Dr. Makary, a professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, led the FDA through May 2026, where he pursued reforms in drug approval, food policy, and artificial intelligence regulation. Clifford Y. Ko, MD, MS, MSHS, FACS, Senior Vice President of the ACS Division of Research and Optimal Patient Care, introduced Dr. Makary by calling him “one of the country’s most prominent voices on the way healthcare is delivered, evaluated, and regulated.”
His speech began with remarks about inaccuracies in historical accounts and art, which he used to illustrate how, irrespective of truth, “We tend to latch on to the inspiring news stories.”
He used that observation to frame his discussion of four major problems in healthcare: administrative waste, pricing failures, low-value care, and lack of attention to root causes.
He first argued that conventional wisdom about healthcare as a percentage of the federal budget tends to overlook healthcare spending included in defense, Social Security, the Veterans Administration, interest payments, and other categories. By his calculation, 51% of all federal spending goes to healthcare, an enormous amount.
“The money is not going to doctors,” he said. “Adjusted for inflation, physicians are making 30% less than they did in 2001.”
Rather, he said, much of the spending goes toward administrative waste, including brokers who capture lucrative payments from employers, insurers, and pharmacies; pharmacy benefit managers, who “charge the employer for each drug their employees take, pay less to the pharmacy, and pocket the rest”; claim adjudicators; and others.
As a result, he said, healthcare now experiences two kinds of innovation. While some are meaningful “impact innovations,” many are “distract-ovations,” innovations that “address a pain point in the system and make our broken healthcare system a little less broken” without addressing fundamental problems.
Dr. Makary then discussed pricing failures through an analogy. “What if you bought a plane ticket, and they had no prices because they had no idea how the flight was going to go?” he asked, before describing issues, such as bad weather, that could increase prices, plus the possibility that “they send an invoice with a beverage for $500.”
The result, he said, would be an eruption of public mistrust and concerns about price gouging—problems he said are now widespread in a healthcare system that often bills patients without clear upfront prices.
He shared his own research, which he said found that negotiated insurance prices are higher than cash prices in 65% of cases, raising questions about the value patients receive from insurance in some circumstances. He also described another study he coauthored, which documented 24,500 people sued by a single hospital in Virginia. He said he and his colleagues helped change the situation by arguing in court that “under contract law, it’s not a valid contract” to bill as hospitals do. “We were able to get thousands and thousands of people to avoid having their wages garnished.”
Dr. Makary’s third point focused on low-value care in medicine. His argument included data on lumbar spine procedures completed either with stabilizing hardware or laminectomy alone. While noting that physician choice remains essential, he showed data documenting “a bit of an epidemic of hardware”—including some surgeons who used it in 100% of cases, which he called “indefensible.”
He noted that showing such outlier surgeons their own data resulted in many reducing their hardware use. Thus, Dr. Makary said, “millions and millions and millions of dollars for unnecessary procedures” were avoided through “simple internal transparency.”
His final argument concerned the need to examine root causes. “We do not allow people to get into the root causes of why people are in the hospital,” he said.
His examples primarily focused on research findings or medical guidance that he said were flawed, misunderstood, or later contradicted, with consequences for public health. He cited an American Academy of Pediatrics advisory that children should not be fed peanuts until age 3 years, which said contributed to an increase in the prevalence of peanut allergies. He also discussed what he characterized as misconceptions about associations between hormone therapy for menopausal women and breast cancer and between saturated fat intake and mortality, among other examples.
Dr. Makary argued that such errors can have significant consequences for public health. “Medical dogma can do a lot of damage,” he said.
Although he noted early in the speech that there is “so much complexity in the system that it’s very hard to adjust these problems,” Dr. Makary’s message for the future of healthcare centered on confronting all four issues.
“The real battle is not between left versus right. It’s between people who are lying to you and people who are trying to tell you the truth,” he concluded, drawing strong applause from the audience.
