Treasury projects public health spending will rise from 7.1 to 10 per cent of GDP by 2065. Over the same period, the ratio of working-age taxpayers to superannuitants will halve. Something has to give.

The question at this week’s third nib-New Zealand Initiative Health Innovators’ Summit was: “What?”

The answer was different from the two earlier conferences.

In 2024 and 2025, the lesson had been “not to wait for government.” Lloyd McCann’s Tāmaki Health, our largest privately-owned primary-care network, was building team-based care across 52 clinics. Sir Bill English was championing the social-investment ventures, Manawanui and Impact Lab.

The room had been told, in effect, that better operators would have to save the system. Both returned this year, but the conference mood had changed.

Health Minister Simeon Brown opened with recent Government commitments, but was honest about the scale of the problems that remain.

Ezekiel Emanuel, the American health policy academic, told the room New Zealand was “solidly middle” by rich-country standards. The country did not need to spend vastly more, but to spend better – by fixing incentives, infrastructure and information.

Hamiora Bowkett, the government-appointed Crown Observer at Health New Zealand, asked whether compulsory insurance, national, social or private, should fund more of the system. Most high-performing systems use compulsory insurance. New Zealand does not.

Brent Pattison, the new CEO of Heritage Lifecare, argued for aged residential care as step-down infrastructure that eases hospital pressure.

Claudia Wyss, a former health-sector chief executive, made the strongest structural case. She wanted a ring-fenced health levy modelled on ACC, insulating funding from annual budgets. And she wanted a review of the boundary between ACC and Health New Zealand, which funds patients with identical needs differently depending on whether their condition arose from an accident.

Neither is something a primary-care network or aged-care provider can deliver. They are statutory questions only Parliament can answer.

The bottom-up case has not weakened. But every entrepreneur in the room was operating inside funding arrangements not designed for the next forty years.

A fifteen-minute primary-care consultation cannot be funded out of an eight-minute payment. An older New Zealander cannot insure herself in a market that prices her out.

Two years ago, the room was excited about what entrepreneurs could achieve. This year, no one believed it would be enough.