We keep saying “costs.” We should be saying “spending.”

Yale health economist Zack Cooper made a distinction in a recent Times op-ed that I haven’t been able to shake.

He didn’t just say “healthcare costs.” He said “healthcare spending.”

I thought it was stylistic. Then I realized it was the argument.

“Costs” is something that happens to you. A passive burden nobody controls and everyone resents. The word lets every actor in the system — pharma, insurers, hospital systems, providers — point in the same direction and feel like they’re on the same team.

“Spending” is a choice. Someone is choosing to spend. Someone is choosing to capture.

And here’s what makes that distinction structural, not just semantic:

Costs cascade downward through the chain — pharma to insurers to employers to providers to patients. Every actor absorbs some and passes the rest down, until the chain runs out of people to pass to. The patient is the floor. Costs stop there.

Spending moves the same way. But with one difference: every actor above the patient has a direct financial incentive to make sure the patient keeps spending more. The patient doesn’t just absorb costs at the bottom of the chain — he’s the revenue source the entire chain is organized to protect and expand.

He’s simultaneously the most burdened participant and the most valuable one.

That’s why the contradiction persists. For everyone except the patient, the system isn’t broken.

It’s working exactly as designed.