For most of its history, NASA didn’t buy transportation to space. It owned the rockets, specified every bolt and weld, and paid contractors on a cost-plus basis, an arrangement in which overruns function less as a failure than as a revenue stream. Congress could see and control every variable. It was also glacial and staggeringly expensive.
The model cracked when the Space Shuttle retired in 2011 and left NASA no domestic way to reach the International Space Station. For nine years, every seat had to be purchased abroad, at prices that climbed toward $86 million a seat by the end of that stretch, according to NASA’s own Office of Inspector General. Rather than design a shuttle replacement in-house, NASA tried something it had never really attempted for human spaceflight: it stopped being a builder and became a customer.
Under the Commercial Crew Program, NASA began writing a simpler kind of contract — reach the station and come home safely, and keep whatever margin you can find along the way. In September 2014, the agency awarded Boeing $4.2 billion and SpaceX $2.6 billion on that premise, both fixed-price, meaning the contractor, not the taxpayer, absorbs any cost overrun.
Two Contracts, Two Outcomes
The two programs have since told opposite stories from the identical contract. Crew Dragon has flown routinely since 2020, at a seat price near $55 million, a fraction of what NASA had been paying to fly astronauts on borrowed capacity. Starliner, under the same fixed-price terms, has run into years of delay: after its first crewed flight went wrong in 2024, Boeing brought two astronauts home on a SpaceX capsule instead, and by 2026 the company had absorbed more than $2 billion in losses on the program. NASA’s Inspector General has estimated that developing crew transport entirely in-house would have run $5 to $8 billion per vehicle before a single flight; in 2020 the agency’s own commercial spaceflight director put the total savings from the dual-contractor approach at $20 to $30 billion against the cost of building it themselves.
The savings were the smaller part of the story. What the arrangement set loose mattered more. Crew Dragon didn’t stay a government vehicle once it existed. The same spacecraft has since carried Inspiration4, the first fully civilian crew to reach orbit; several private missions for Axiom Space; and Polaris Dawn, whose crew performed the first commercial spacewalk. A machine built to satisfy one government specification has become infrastructure for uses nobody had written into the contract.
But What Does it Have to do With Health Policy?
Strip away the rockets and this is a story about regulatory posture — about what changes when an agency stops prescribing how something must be built and starts specifying only what it must achieve, then lets more than one qualified competitor race for the answer. Health policy is still largely run on the older instinct. An agency guaranteeing a market for a therapeutic before it exists is the same move as NASA committing to buy seats before a rocket was built: it is what let SpaceX borrow against a future NASA already believed in. BARDA’s advance-purchase contracts for pandemic countermeasures work on that logic already; the commercial crew experience is an argument for extending it further, into antibiotics and rare-disease therapeutics that current grant funding treats as too commercially thin to bankroll.
The obvious challenge to this argument comes from the free-market side: if the goal is genuine competition and lower cost, why does the story still run through a single government buyer writing the specifications? NASA isn’t absent here — it’s the only customer, and the case for extending this model to health policy has to answer that directly rather than wave it away.
The answer is that Commercial Crew was never a substitute for a market; it was the fastest route to building one where none existed. No private company was going to sink billions into human-rated spacecraft on the hope that a market for orbital transport might eventually materialize. The capital costs and certification risk were too front-loaded, and NASA was for years the only conceivable buyer. What the anchor-tenant contract did was absorb exactly the risk a genuine market couldn’t yet price, just long enough for a real one to exist behind it. That the payoff arrived on schedule is the point: once Crew Dragon was flying, it stopped needing NASA as its only customer. Inspiration4, Axiom, and Polaris Dawn are the proof that the anchor tenant’s job was to make itself optional. A subsidy that produces a customer base it no longer needs is a different animal from a subsidy that produces permanent dependence on the subsidizer, which is the usual and fair complaint against industrial policy.
Health policy’s version of this test is whether an advance-purchase contract or a milestone-based award is built to expire, not renew indefinitely. BARDA’s pandemic-countermeasure contracts, and the model NASA itself pioneered with cargo resupply before crew, both work the same way: government demand exists to de-risk a specific capital hurdle, priced and time-bound instead of installing the agency as a permanent customer of last resort. However, this only works if the exit actually happens. Yet NASA’s own record of being a monopoly buyer for nine years, deliberately contracted itself down to one of several customers, is the evidence for that scenario being possible.
The same applies further down the pipeline. NIH grant review still rewards the safest, most incremental proposal that can survive a study section: peer reviewers have been shown to penalize risky proposals more heavily than they reward strong ones, and researchers who track the system describe a creeping conservatism in what actually gets funded. A milestone-based contract works on a different logic, releasing money only when a trial clears a defined bar, in the way NASA released funds only when a capsule cleared a defined test, and that reallocates risk the way the 2014 contracts did, moving it from the agency’s checklist to the product’s actual performance. The same commercial dynamic that let Crew Dragon carry passengers NASA had never selected, flying older and less rigorously screened civilians instead of a curated astronaut corps, is an argument for building the same breadth into clinical evidence. Digital-health and wearables partnerships already show what that looks like in practice: platforms like PowerMom are gathering longitudinal data from pregnant participants that clinic visits rarely capture, and decentralized, device-based trial designs are documented as improving participation among older adults and other groups that conventional trial logistics tend to exclude.
How to Tell a Bridge from a Crutch
Starliner is worth keeping close, because it inoculates the argument against its own overreach. Fixed-price contracting and open competition guarantee nothing for any single company — Boeing’s losses, now past $2 billion on a $4.2 billion contract, are proof of that. A regulator that only tells the story of Crew Dragon has told half the story; the honest version includes a company that took the identical deal and still hasn’t delivered.
But look at what Starliner’s failure did and didn’t do. It didn’t blow up NASA’s timeline, because Crew Dragon was already flying. It didn’t cost taxpayers a bailout, because the losses sat on Boeing’s balance sheet, not the agency’s. And it didn’t get forgiven — the fixed-price structure kept charging Boeing for every slip, which is exactly the pressure a cost-plus contract would have relieved. That is the part of the model worth naming precisely: competition didn’t just lower the average cost, but made failure legible and contained. A single-supplier system fails all at once and takes the buyer down with it; a system built around an outcome bar and more than one qualified competitor can fail in public but will carry on the mission.
That is the piece health policy tends to leave out when it borrows the language of innovation. Note, it’s still not the “Let the market decide” situation. NASA still wrote the safety requirements, ran the certification flights, and had the authority to ground a vehicle. What changed was that the agency focused on holding a fixed bar and letting several teams fail or succeed against it in real time. The translation to medicine is fewer single points of failure. Fund enough parallel, independently backed efforts against the same bar, and one company’s stumble costs that company. One lab’s dead end costs that lab. The pipeline itself keeps moving, instead of grinding to a halt the way a single contractor’s failure once would have grounded American spaceflight for good. Insisting on one approved vendor and one approved design was NASA’s real cost. Mistaking that insistence for safety burned three decades and tens of billions of dollars.
* Tetiana Rak is the Chief Operations Officer (COO) at We Are Innovation. A journalist and freedom activist with 8 years of experience, Tania has worked with renowned media outlets including CNN, TechCrunch, Fox News, HackerNoon, the BBC, and Radio Free Europe, among others. Her unwavering dedication to championing the ideas of technological advancements and global digital transformations has earned her a distinguished reputation in the field. Through her work, Tania promotes the ideas of liberty and individual rights as a cornerstone of any rights-respecting society. Strengthened by the experience of war in Ukraine, Tania’s beliefs also stand for promoting technological advancements as a transformative tool to advance liberty, giving people the opportunity to speak, act, and pursue happiness without unnecessary external restrictions.
Source: We Are Innovation
