The framework's predictions in [§9.10.3](<9.10.3 What is Predicted.md>) are put against the empirical and theoretical literature on healthcare-system performance. This section reviews the confirmations.

*First.* Insurance occupying the floor produces structural-extraction patterns. US healthcare administrative costs are estimated at approximately 25–30% of total spending; comparable single-payer systems run administrative costs at approximately 10%. The gap is direct empirical confirmation of the gatekeeping-and-bloat prediction. Himmelstein et al. record that medical bankruptcy is a US-distinctive phenomenon, comprising a substantial share of personal bankruptcies in the US while being effectively absent in peer OECD systems with collective-investment healthcare. The Commonwealth Fund's repeated cross-OECD healthcare-system comparisons show the US ranking last or near last on quality, access, equity, and efficiency among comparable countries despite spending substantially more per capita. The structural-extraction-at-vulnerability pattern is the operating record, not an aberration.

*Second.* Outcomes track upstream investment, not spending volume. The Commonwealth Fund comparisons (multiple editions through 2024) trace the spending-versus-outcomes mismatch: the US spends approximately twice the OECD average per capita and underperforms peer countries on life expectancy, infant mortality, maternal mortality, and avoidable mortality. The OECD's *Health at a Glance* series confirms the pattern across decades. The empirical record is unambiguous on this prediction.

*Third.* Routing mental-health and substance conditions through criminalization underperforms. The Portugal decriminalization natural experiment, beginning in 2001, has produced a substantial empirical literature (Hughes and Stevens 2010; Greenwald 2009) showing that decriminalization combined with treatment access produces lower addiction prevalence, lower HIV transmission, and lower overdose mortality than equivalent prohibitionist regimes. Housing First programs across multiple US and European cities have produced lower per-capita costs than chronic-homelessness alternatives that route the same population through emergency, justice, and shelter systems. The CAHOOTS program in Eugene, Oregon, and similar mental-health-first crisis-response architectures register substantially lower per-incident costs and better outcomes than police-first responses to mental-health crises. The routing-mismatch prediction is confirmed across multiple natural experiments.

*Fourth.* Under-investment in healthcare for excluded populations costs more downstream. Medicaid-expansion natural experiments (Sommers et al. on mortality effects of state-level expansion decisions) map mortality reductions in expanding states that would be difficult to attribute to anything except the expansion itself. The empirical literature on emergency-room as default-care for the uninsured surfaces the cost-shifting the framework predicts: care that would be cheaper in primary settings is more expensive in emergency settings, with the cost ultimately borne by the political community through hospital write-offs, public-hospital subsidies, or insurance-premium pass-through.

*Fifth.* Health-insurance-industry political resistance is structurally maximal. The industry's lobbying expenditure, regulatory-capture footprint, and rhetoric around collective-investment alternatives are public record. The pattern is consistent with the framework's prediction that an industry occupying space it is structurally redundant for will resist alternatives more intensely than industries occupying space they are structurally fitted for. Quantitative confirmation is in lobbying-expenditure databases; qualitative confirmation is in the rhetoric deployed against single-payer proposals across decades.

*Sixth.* Prohibitionist drug regimes underperform combined approaches. The Portugal experiment cited above, the Swiss heroin-assisted treatment program, the Vancouver Insite supervised-injection-site evaluation literature, and the harm-reduction literature broadly show that combined-approach regimes outperform prohibitionist regimes on the specific health, justice, and participation metrics the evidence tracks. The empirical record on US prohibition (mass incarceration of substance offenders, persistent addiction prevalence, overdose-mortality increases) is the inverse confirmation: where the framework predicts underperformance, the empirical record delivers it.

*Seventh.* Population-scale conditions need collective-investment responses. The history of vaccination programs, sanitation infrastructure, communicable-disease control, and tobacco-control policy is uniform: population-scale collective-investment responses dominate individual-scale market-mediated responses on every measurable health metric. Vaccination coverage tracks public-investment commitment; outbreak control tracks public-health-infrastructure capacity. The COVID-19 pandemic provided a natural experiment whose results were unambiguous in this direction across cross-national comparisons.

*Cross-national and US-state confirmations.*

*Taiwan and Japan.* Taiwan and Japan deliver universal healthcare at costs well below the United States per capita, with superior population health outcomes. These are partial implementations of the conditions of participation whose population-health metrics confirm what the framework predicts.

*Portugal's drug decriminalization.* Portugal's 2001 drug decriminalization moved drug use from criminal punishment to public health treatment (Hughes and Stevens 2010; Greenwald 2009). In the two decades following, drug-related HIV infections fell by over 95 percent, drug-related deaths fell sharply, and incarceration for drug offenses dropped dramatically, while drug use rates did not rise above European averages. The prevention-weighted arrangement delivered both prevention and correction as backup, at lower total cost, with better outcomes for every affected party. (The same case is cross-listed with [§9.13](<9.13 Justice.md>) Justice; the routing of substance dependence through health rather than punishment is the structural lesson on either side.)

*United States as controlled experiment across states.* Fifty states operate under the same federal law, the same currency, and the same constitutional framework. Outcomes diverge radically depending on whether the state has invested in the conditions of participation. CDC mortality data shows a life expectancy gap between Massachusetts and Mississippi of roughly eight years (a difference comparable to that between the United States and significantly less developed nations). People born in New York and California have a life expectancy of 77.7 and 79 years respectively; people born in Mississippi and Louisiana live on average until 71.9 and 73.1 (CDC 2023). Nine of the ten highest-poverty states are states with weaker social floors; nine of the ten states with the longest life expectancy are states with stronger ones (U.S. Census Bureau; CDC). Cultural and regional factors no doubt contribute, and the comparison is partially controlled rather than fully so (demography, industry mix, urbanization, migration patterns, and state capacity vary alongside social-floor investment). What the comparison does control for is the federal baseline: the same Constitution, the same currency, the same national economy. The remaining variance correlates with the variables the account derives as constitutive of political maintenance, in the direction the account predicts. The differences are at least substantially the outputs of a structural choice: to invest or not invest in the conditions the account derives as constitutive of what a political structure is for. The confirmation is robust without being clean.

*On theoretical convergences.* The same conclusions are independently reached in: capabilities-approach health economics (Sen 1999; Nussbaum 2011 on bodily-integrity capability), public-health theory broadly, the WHO social-determinants-of-health framework, and Daniels (2008) on just health distribution. The convergence is from independent premises and supports the prediction that the conclusion is robust under alternate framings.

*What does not confirm the framework.* Strong-form medical-market-efficiency accounts predict that competitive insurance markets clear at efficient outcomes; the empirical record refuses this prediction across every measurable margin. Strong-form individual-responsibility accounts predict that exclusion of populations from healthcare reduces aggregate cost; the empirical record refuses this prediction through the cost-shifting and downstream-burden pattern documented above. Where the framework's predictions and these accounts diverge, the empirical record is on the framework's side. The confirmations stated in this subsection are made under engagement with the contested classical-liberal-health-policy traditions [§9.10.1](<9.10.1 What is Disputed.md>) names at premise: Milton Friedman's medical-licensure and consumer-directed-care critique (*Capitalism and Freedom* 1962, chapter IX), the contemporary Cato-tradition health-policy position and Singapore medical-savings-account architecture, and the Pauly moral-hazard analysis (*The Economics of Moral Hazard* 1968). Those traditions are engaged at section length in [§9.10.1](<9.10.1 What is Disputed.md>), and the confirmation record stated here applies under that engagement.


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← [9.10.3 What is Predicted](<9.10.3 What is Predicted.md>) | [9.10.5 What is Concluded](<9.10.5 What is Concluded.md>) →
