Washington is spending like tomorrow doesn’t exist. The national debt has blown past $38 trillion, rising at a pace unprecedented outside of war or crisis. The government will pay roughly $1 trillion in interest this year alone, money that produces nothing, builds nothing, and feeds no one. Interest is now one of the largest line-items in the federal budget, rivaling or exceeding what we spend on education, transportation, or housing. Congress keeps borrowing, as if the bill will never come due. Elections change the faces, but not the habit: Washington spends, and future taxpayers are left to clean up the wreckage. (RELATED: How Did We Reach a $38 Trillion Debt During a ‘Shutdown’?) Bureaucracies succeed when they grow larger, not when they deliver value, so expansion becomes the proof of purpose. Waste isn’t a glitch. It is the architecture. The Government Accountability Office lists 38 federal programs at high risk for mismanagement or fraud. In a single enforcement sweep, prosecutors charged more than 300 defendants in schemes exceeding $14 billion. Americans routinely estimate that more than half of federal spending is wasted, and in context, that belief is less cynicism than observation. Bureaucracies succeed when they grow larger, not when they deliver value, so expansion becomes the proof of purpose. (RELATED: The Forces Fueling America’s 45-Year Debt Addiction) Nowhere is the system more strained than in health care. National spending reached roughly $4.9 trillion last year, or about $14,500 per person. Families pay rising premiums for shrinking networks, independent physicians disappear, emergency rooms overflow, and hospitals consolidate into regional monopolies. Patients wait longer for fewer appointments while the United States spends more on health care than any nation in history. If $5 trillion a year cannot produce timely care, then the incentives governing the system need rethinking. (RELATED: DOGE Is Missing $2 Trillion in Healthcare Waste) The federal machinery directing this spending is immense. The Department of Health and Human Services employs around 80,000 people and oversees a budget larger than the GDP of most sovereign states. The Centers for Medicare & Medicaid Services alone manage roughly $1.6 trillion with over 6,000 staff. Improper Medicaid payments exceed five percent annually, and millions are enrolled in duplicative health programs. (RELATED: Washington’s Reverse Midas Touch) Much fraud and waste go undetected — Minnesota proves it. Feeding Our Future alone diverted roughly $250 million in federally funded child-nutrition aid while serving few, if any, meals. At the same time, separate fraud schemes have exploited Medicaid,  including via housing-stabilization and therapy-billing scams — siphoning off millions more and exposing how porous oversight of government-funded welfare programs has become. (RELATED: Yes, the New York Times Really Ran a Story About Social Services Fraud by Immigrants) States have learned that if Washington keeps giving, they’ll keep spending — wasteful or not. And, the government spends billions trying to stop fraud, most of the time unsuccessfully. A system designed this way cannot be accountable. (RELATED: Five Quick Things: Traitors, Traitors Everywhere) I experienced this personally. While negotiating Medicaid waivers, I had to travel to Washington and spend days outside the Eisenhower Executive Office Building waiting for officials to return from coffee breaks, because phones often went unanswered and follow-up was rare. Decisions affecting real patients, budgets, and providers remained stuck while staff cycled through internal meetings. During one negotiation, a federal official asked, without irony, if we grant states more flexibility, what will our job be? The bureaucracy has become the mission. The Trump Administration’s Department of Government Efficiency couldn’t even live for a year. (RELATED: Bureaucracy Beats Entrepreneurship — Musk Leaves Washington) Americans live with the consequences. Inflation still sits near three percent year-over-year. The dollar has lost most of its purchasing power since the 1970s and fell eleven percent against major currencies in 2025 alone. A household can work hard, save diligently, and still fall behind because the federal government is expanding the money supply faster than wages grow. Healthcare costs compound the problem. Coverage now resembles a second mortgage. Employers respond by reducing benefits or shifting costs to workers. Americans are not choosing between good and better care. They are choosing between affordability and access. The answer is not another task force or oversight panel. It is discipline. A federal balanced-budget requirement would force Congress to confront the reality it has postponed. Every federal program should carry a sunset provision to ensure survival is earned, not assumed. Agencies with overlapping mandates should be consolidated, and funding should follow measurable outcomes rather than personnel counts. States should receive block-grant authority without federal micromanagement, because experimentation is impossible when permission is always pending. (RELATED: Aristotle on a Balanced Budget Amendment) There is still time to choose reform over crisis, but the window narrows with each trillion spent on borrowed funds. Debt service will crowd out discretionary spending. Inflation will continue eroding household income. Health systems will strain under demand they cannot meet. Arithmetic is patient, but it is not merciful. Washington won’t restrain itself; citizens must. Prosperity requires limits. Government needs boundaries. We can demand them now, or wait until the bill arrives and choice is totally gone. Gary D. Alexander served as secretary of health and human services in Rhode Island and Pennsylvania. READ MORE: A 50-Year Mortgage Is a Financial Narcotic What Does the Great Gold Spike Signify for the World Economy?