The Price of Extraction: How U.S. Healthcare Billing Mirrors Colonial Logic

In the spring of 2019, Maria Gonzalez, a 37-year-old single mother in Texas, walked into the emergency room with stomach pain. She walked out with an appendectomy, a stapled scar, and a bill that would follow her for years: $46,000. Though she had insurance, the hospital was out-of-network. The bills came in waves—confusing, contradictory, and relentless. Phone calls from collectors interrupted her workday. Her teenage son had to postpone applying to college so he could help with expenses. Months later, her wages were garnished, and she was forced to take a second job cleaning offices at night, often running on four hours of sleep. Maria is not an outlier. She is a citizen in an empire of extraction.

This isn’t merely a story of inefficiency or bureaucratic indifference. It is a system designed to extract wealth through nested layers of obfuscation, denial, and control—a structure that, when decoded system-inside-system, begins to resemble the architecture of colonial rule. Like the administrative machines of empire, today’s healthcare billing system obscures its violence behind complexity, technocratic language, and moral righteousness.

To understand American healthcare billing, one must see beyond the surface of paperwork and price tags. We must recognize it as a colonial engine, repurposed domestically. The U.S. healthcare system is not broken; it is functioning precisely as intended—to siphon resources from the many to enrich the few under the guise of medical care.

I. The Bureaucracy of Obfuscation: Coding as Control

Consider CPT codes—Current Procedural Terminology. Originally developed by the American Medical Association, these codes are meant to standardize medical billing. But in practice, they serve to bureaucratize care into units of economic transaction. Each procedure, each test, each interaction is reduced to a numeric cipher whose real function is to enable and enforce billing hierarchies. These hierarchies reward more lucrative procedures, often at the expense of preventive or primary care. For instance, a simple consultation may be undervalued compared to a high-tech diagnostic scan, skewing incentives toward overtesting and overtreatment.

In colonial administrations, bureaucracy was not a neutral tool but a method of control. The British Empire used reams of paperwork to regulate land, people, and taxation. Today, CPT codes and their Medicare cousins, DRGs (Diagnosis-Related Groups), do the same. They create a system where hospitals maximize profit by optimizing code usage, not patient outcomes. Doctors become clerks. Patients become ledgers.

II. Algorithmic Gatekeeping: The Denial Engine

Embedded within this system are insurance algorithms that determine which claims to pay and which to deny. These algorithms operate like the colonial census—categorizing and excluding with quiet violence. A 2023 study found that some insurers automatically denied claims within 1.2 seconds of receipt, with no human review. For example, Cigna came under scrutiny for using automated systems that rejected claims en masse without individual assessment, prompting lawsuits and public outcry.

This is not error. It is extraction through automated attrition. Patients are expected to navigate Kafkaesque appeals processes, often while ill or financially strained. In colonial contexts, native populations were often made to "prove" their eligibility for basic rights. In U.S. healthcare, sick Americans are similarly deputized to justify their own survival.

III. Debt as Domination: Medical Credit and Modern Vassalage

Medical debt is the most common form of debt in the U.S., affecting over 100 million people—surpassing even credit card and student loan debt in scale. While student loans may accumulate over years of education, medical debt can arise from a single emergency, often without warning or consent, making it both sudden and inescapable. This immediacy turns illness into economic catastrophe, especially for those already living on the margins. But it is more than a burden; it is a system of soft coercion. Patients become debtors. Debtors become servile. This mirrors the colonial practice of debt peonage, where colonized subjects were bound to plantations or mines through unpayable financial obligations.

Today, predatory medical credit cards and healthcare financing plans extract interest from low-income patients who must choose between treatment and bankruptcy. Compared to student loans—which are widespread but often deferred—medical debt exerts a more immediate and existential pressure. The result is not merely inequality, but engineered dependency—a class of citizens ensnared in perpetual payment to survive.

System-Inside-System Decoding: A Structural Lens

From the outside, the U.S. healthcare system appears as a tangle of policies, technologies, and institutions. But within each lies another system—an engine optimized not for care but for capture. The hospital is a billing center. The doctor’s note is legal documentation. The insurance company is a fortress of denial. Each layer reinforces the other in a recursive architecture of domination.

This nested extraction model mirrors the colonial plantation, where governance, labor, and punishment were distributed across interlocking systems—legal, economic, religious—each appearing discrete but functioning as one. In healthcare, billing is the plantation logic encoded in peacetime policy.

Counterarguments and Co-opted Language

Some will argue that healthcare billing is simply complex, not malicious. But this ignores how complexity can be weaponized—serving as a gatekeeping function that obscures accountability and frustrates oversight. In the context of administrative law and neoliberal governance, complexity often operates as a tool of technocratic control, where layers of procedure mask the deliberate consolidation of power. The result is not mere dysfunction, but a carefully layered architecture of inaccessibility that benefits institutional actors while disempowering the public. But this assumes complexity is neutral. In practice, complexity without transparency becomes the means of exploitation—a hallmark of neoliberal technocracy, where systemic power hides behind procedural rationality. Others claim the market drives efficiency. But efficiency for whom? For investors? For hedge funds buying up hospitals and staffing them with gig-economy doctors?

Even the language of reform is often co-opted. “Patient choice” becomes a euphemism for privatization. “Innovation” means profit. This semantic laundering mirrors the colonial logic that called conquest “civilizing missions.”

Conclusion: Toward Decolonial Care

To dismantle this system, we must abandon the fantasy that minor reforms will suffice. Just as empires cannot be reformed into justice, a colonial healthcare economy cannot be made equitable with better billing software or insurance literacy programs.

We must envision a system grounded not in extraction, but in care—one where health is a public good, not a commodity. Universal healthcare, abolition of medical debt, and the deprivatization of hospitals are not radical ideas. They are decolonial necessities. Countries like Norway and Taiwan, which have achieved universal healthcare with minimal patient cost, offer tangible models of post-extractive health economies.

Maria Gonzalez’s story is not rare. It is the rule. But rules can be broken. Systems can be remade. And every act of decoding is a step toward freedom.