Hundreds of San Franciscans took to the streets this week to protest proposed health care cuts, and look — nobody wants to see people lose access to medical care. That's not a partisan statement. That's a human one.

But here's the thing nobody at the rally seemed interested in discussing: why are cuts on the table in the first place?

San Francisco spends more per capita on public health than virtually any city in America. The city's Department of Public Health budget has ballooned past $3 billion — yes, billion with a B — and yet we still have residents showing up to rallies terrified they're about to lose basic services. At some point, someone needs to ask the uncomfortable question: where is all that money actually going?

The rally featured the usual calls for more funding, more programs, more government intervention. What it didn't feature was any serious conversation about efficiency, accountability, or whether the bureaucratic apparatus sitting between taxpayer dollars and actual patient care might be part of the problem. When you're spending $3 billion and people still feel underserved, the answer isn't automatically "spend more." Sometimes the answer is "spend better."

This city has a remarkable talent for conflating budget size with compassion. Bigger line items don't automatically mean better outcomes. We've seen this play out with homelessness spending, with transit, with education — the pattern is unmistakable. Money goes in, middlemen multiply, and the people who are supposed to benefit end up at a rally begging for scraps.

The protesters aren't wrong to be worried. Health care access matters, full stop. But if we're going to have an honest conversation about protecting services, we need to start by demanding transparency about how existing funds are spent before reflexively demanding more.

Cuts are scary. But so is a system that burns through billions and still can't deliver.