There is a medical code for being struck by a turtle — the unmemorable W59.22XA.

Every time a doctor sees a patient in America, the encounter has to be translated into a diagnosis code from the ICD-10-CM system before anyone gets paid. ICD-10 is one of several coding systems that turn a clinical encounter into a financial event. Diagnosis codes describe what’s wrong with you. Procedure codes describe what was done about it. The combination determines what the hospital collects — and the diagnosis is where it starts. Without one, nothing else in the billing chain moves. The diagnosis code for being struck by a turtle is W59.22XA. There is a separate code for being bitten by a turtle (W59.21XA), and a third for “other contact with turtle” (W59.29XA), because someone decided the distinction between being struck, bitten, and otherwise contacted by a turtle warranted three separate categories.

There is a code for burns sustained from water-skis that caught fire (V91.07XA) — not hypothetical, but a code that exists because someone showed up at a clinic with exactly this problem and the system had no way to bill for it. There is a code for “bizarre personal appearance“ (R46.1), which feels less like medicine and more like someone at the WHO took a personal grudge and made it official. And there is a code for problems with your in-laws (Z63.1) — meaning a clinician listened to a patient describe their mother-in-law, wrote it down as a medical factor, and handed it to a person whose entire job is turning that sort of thing into six characters a payment system can read. Your relationship with your mother-in-law is now a billable event.

There are over 74,000 of these codes in the US system, not to mention the other 78,000 procedure codes. The WHO’s version has about 14,000 — enough to track disease and death across populations. America needed five times that. Medicare needed a language precise enough to calibrate payment, so the codes got repurposed for billing. More precision meant more reimbursement accuracy, and more accuracy meant more codes. Sucked into a jet engine, subsequent encounter (V97.33XD) — which sounds absurd until you realize “subsequent encounter” just means a follow-up visit. Someone survived a jet engine and came back. Pecked by a turkey (W61.43XA). Walked into a lamppost (W22.02XA). Bitten by a pig (W55.41XA). Actual codes, decided by humans on committees, and the committees keep meeting.

The turtle codes aren’t hurting anyone — most providers use maybe 200-300 codes regularly, and their EHR suggests the rest. There is no constituency for fewer codes and no incentive to consolidate.1 But every code requires matching documentation: physicians spend roughly 15 minutes per encounter writing notes that justify the code rather than delivering care. Medical coding is a $24B+ industry in the US alone — departments, certifications, training programs, auditing firms, all built to translate medicine into billable transactions.

The absurdity isn’t the problem. The problem is that the system needs the absurdity to function — and that need has real costs. The turtle is funny. The infrastructure behind the turtle is expensive. What happened to you, translated into what the system can pay for.

Z04.9 — Encounter for Observation for Unspecified Reason

One of my first consulting projects, at the tender age of 24, took me to a health system’s business park in Virginia. I got badged in at the lobby, rode the elevator up, and escorted through hallways lined with motivational posters — a single word in caps and a cheap phrase under a stock photo: TEAMWORK over a rowing crew, INTEGRITY over a mountain summit. We were there for a group Epic applications meeting with the department director named Chris (short for Christine). Two hours of workflow configurations in a fluorescently-lit conference room - another long workshop with fifteen people where nothing was accomplished.

On the way out of the conference room, Chris walked me through the coding department. It was a whole floor. Rows of cubicles stretching to the far wall, each one with a monitor, a stack of papers, and a woman reading through clinical charts. Copiers humming, fax machines whirring (only in a health system). A potluck in the break area — slow cooker of something, paper plates and Solo cups, a store-bought cake with frosting flowers. At the desks nearest me: a wooden “Live Laugh Love“ sign on the cubicle wall, photos of kids in football jerseys, a “Proud Army Mom“ bumper sticker on a filing cabinet. One of the ladies was trying to print something and the printer jammed. Chris stopped to help — the director wrestling with the paper tray while we stood in the aisle.

I noticed the woman at the next cubicle. She had a chart open on her screen — physician notes, lab results, a discharge summary — and she was reading it the way a lawyer reads a contract, looking for the details that changed the meaning. She paused at something in the operative note, scrolled back to compare it against the labs, then pulled up a reference window and checked two codes side by side before choosing one.

The distinction she was weighing — one complication versus two, one severity level versus the next — would change how the diagnosis and procedure codes combined, which would change the Diagnosis Related Group the case fell into, which would set whether the hospital was paid $8,000 or $13,000 for that admission. By the time Chris cleared the printer, the coder had made her call, entered the codes, and was already opening the next chart. Ten thousand dollars of clinical interpretation had just passed through her hands in the time it took to unjam a printer.

These women worked through hundreds of cases a day — reading physician notes, interpreting what happened to a patient, deciding which code fit. Each decision worth thousands to a hospital that couldn’t bill without them. I remember teaching one of them the hotkeys to cut and paste (Ctrl-C, Ctrl-V) during a break, and her reacting like I’d shown her a magic trick. Here was a woman who could read a surgical note, weigh the significance of a complication, and land on a five-figure financial outcome in fifteen minutes — and she was delighted to learn a keyboard shortcut.

The American medical coding workforce is roughly 195,000 people. Eighty-four percent are women. The typical coder is in her mid-forties, earns about $50,000 a year, and handles around fifteen inpatient cases a day — each one requiring her to build the full coded picture of the encounter, diagnosis and procedure codes together, that determines what the hospital gets paid.

That hospital — like every hospital in America — depended on that floor. Not in the way it depended on its surgeons or its ER, but in the way a business depends on accounts receivable: without it, the money stops. It is a workforce larger than the U.S. steel manufacturing industry, and one that determines how $1.6 trillion in hospital spending gets allocated, two charts at a time.

Z56.4 — Discord with boss and workmates

In a 2024 Black Book Research survey of 4,081 medical coders, 90% identified upcoding — assigning a more severe code than the documentation supports — as a major ethical dilemma. Eighteen percent reported pressure from their employer to engage in what they described as fraudulent coding for financial gain.

Physicians routinely under-document: a surgeon performs a procedure with three complications, the operative note mentions one, and the hospital gets paid for a less severe case than what actually happened. CMS’s own audits found $28.8B in improper Medicare payments in fiscal year 2025 — 6.55% of all fee-for-service claims — with incorrect coding and insufficient documentation as the leading causes. And that is Medicare alone.

For a mid-size hospital running $500M in revenue at a 3% margin, that margin is $15 million. The revenue at stake in coding accuracy — the accumulated weight of thousands of $5K-to-$15K decisions — can easily exceed it. The financial fate of the institution passes through the same hands that were unjamming the printer.

Clinical documentation integrity (CDI) programs exist to close the documentation gap — my firm had a whole practice dedicated to it. When they work honestly, the hospital gets paid fairly for care it delivered. But the skill required to close a legitimate gap is the same skill required to push past it, and 36% of CDI programs report to the revenue cycle department, not to clinical quality. The incentive to code accurately and the incentive to code profitably share the same office.

The physician sees this one way: the coding department is a black box that turns clinical work into billing outcomes she can’t fully control. She went to medical school to practice medicine, not to write notes optimized for DRG assignment — and she resents the queries from documentation specialists asking her to “clarify” the severity of a patient’s condition in language that happens to map to a higher-paying code.

The CFO sees it another way: coding is where revenue is captured or left on the table. A hospital on a 2-3% margin cannot afford to under-code. Every missed complication, every unqueried documentation gap, is money the hospital earned and never collected.

And the patient — the person whose suffering started this entire chain — carries whatever version of themselves the coder produced into every future encounter, every referral, every insurance decision. If the translation was accurate, the record reflects what happened. If it was distorted — by pressure, by haste, by an incentive pointing the wrong way — the patient carries that distortion forward, and may never know it.

The coder sits between all of them. If she codes conservatively, the CFO’s targets suffer. If she codes aggressively, the physician’s intent gets distorted and the patient’s record drifts from reality. If she crosses the line — and one in five has been pushed to — the False Claims Act exposes her to personal liability: treble damages, per-claim penalties, and the financial ruin that a $50K salary cannot absorb. The institution that applied the pressure negotiates a settlement. The coder does not have that option.

Ask anyone in healthcare operations what medical coding is for, and you’ll hear the same answer: it’s how we get paid. And that’s true. But it is also, if you step back far enough, a system whose incentives have learned to arbitrage revenue cycle games for profit — financial optimization layered on top of a clinical language that was meant to describe what happened to a person, not to maximize what a hospital collects for it.

R45.2 — Unhappiness

Every act of translation is a loss of fidelity. In 1956, Nikita Khrushchev’s “Мы вас похороним” was translated as “We will bury you” — a phrase that nearly defined the Cold War — when what he actually meant was closer to “We will outlast you.” One word shifted in register, and the gap between intent and interpretation widened into a geopolitical crisis.

Medical coders are translators — between what was meant and what gets recorded. They take the physician’s clinical language and render it in a language the payment system can process. The stakes are not geopolitical, but they are constant: thousands of dollars on each interpretation, hundreds of interpretations per week, tens of millions in revenue accumulating in the decisions of people making $24 an hour. A diplomatic mistranslation becomes a headline. A coder’s interpretation becomes the official record — the version of the patient that follows them through the system, that determines what they owe, what the hospital collects, and what shows up the next time a physician opens their chart.

Something is always lost in the crossing — a shade of meaning, a clinical nuance, the way a patient described what was wrong. When the translation is honest and the translator is protected, the loss is small. The system works well enough. When the translator is under pressure, the loss widens — and it widens in the direction of whoever is applying the pressure.

There is a code for “verbosity and circumstantial detail obscuring reason for contact“ (R46.7) — the patient who talks too much, who circles and digresses, who can’t quite say what hurts. The system noticed this and gave it a code. There is a code for “malingerer, conscious simulation” (Z76.5) — a billing category for faking it, which means the system that classifies disease also classifies the performance of disease. And ICD-10 code R45.2 is “Unhappiness”. Not major depressive disorder, not adjustment disorder — unhappiness, the feeling, given a billing code, placed between R45.1 (”Restlessness and agitation”) and R45.3 (”Demoralization and apathy”). Not every code moves money — R45.2 won’t swing a DRG. But a coder still has to assign it. The system still processes it. The feeling still has to pass through a clinical language and come out as data, whether or not anyone pays for it. The translation happens regardless.

A coder reads a physician’s note about a patient who is simply unhappy, translates that feeling into six characters, and sends it into the machinery. Whether the data that comes out still resembles the experience that went in depends on the state of mind of the person doing the translating, and the pressures she was under when she made the call.

We built an extraordinary machine of seventy-four thousand codes. A workforce of nearly 200,000. A woman on the aisle of Chris’s coding floor, who could read the clinical significance of a surgical complication and land on a ten-thousand-dollar outcome before the printer was fixed. The entire financial architecture of American hospital care rests on her judgment, and the entire pressure of that architecture pushes down on her desk. And every day she sits down, opens the next chart, and hopes the translation is close enough.

The office birthday cake is a relic of the before-times, when we all used to work in the same building. Deb from accounting’s birthday is coming up, so somebody sets up a Venmo, everyone chips in five bucks, someone picks up a sheet cake, you sing in the break room, and Deb gets her moment. And unless you work at Dunder Mifflin, it’s a low-stakes process that costs forty dollars of sugary frosting.

For years I was happy to chip in a few bucks whenever someone’s name came up on the calendar, vaguely pleased when it was my turn and someone brought something with whipped topping. The ratio of people-to-cake was more than enough for me.

But now scale that up. Instead of Deb’s birthday, the office chips in when someone’s baby arrives three months early, and the NICU bill hits $2M. Or when someone’s spouse gets a cancer diagnosis that requires a drug costing $15,000 a month. Or a new hire at the office — you’ve said hi passing her in the hallway (but don’t remember her name) — starts a Wegovy prescription at $1,000 a month because her doctor said her BMI qualifies. You’re no longer splitting a sheet cake, but you’re paying for it.

If you've had a job (and I presume you do, to read this on the Internet), at some point you got a 1095-C in the mail, had some money taken from your paycheck, and never thought much about what connected those two facts. As a once-young and still-healthy man, I hardly used my benefits. I was simply happy enough to have a salary and a card in case something bad happens, and never thought about where the money went. But then I became the head of a family and saw my precious premiums proliferating. In 1999, the average family premium was $5,791, which was roughly the cost of a used car. In 2024, it was $25,572 — roughly a new car. Premiums have outpaced wages 3-to-1 over that period. And most of the money disappears into a loop between your paycheck and your doctor that's surprisingly hard to trace. I wanted to know what I was paying for. So I traced it using my patented Tsang-key diagrams :

Between your deduction and your employer’s contribution — which, for most companies, runs 2x to 3x what comes out of your check — I counted eight to ten separate companies handling that money before it reaches your doctor, depending on where you draw the lines.

For every $100 your employer spends on your healthcare, roughly $16.50 goes to administrative processing before a dollar reaches anything clinical1 — the brokers, claims administrators, carriers, utilization managers, pharmacy benefit managers, and revenue cycle firms that sit between your premium and your doctor. Those fees look small on their own — a broker takes 2.5%, the claims administrator takes 5%, the carrier skims 1.5% — but they stack, and each one operates independently, its own approval process, its own software, its own timeline. Six steps between “your doctor says you need this” and “you get it.”

The biggest slice, $39, goes to the people who deliver care — but most of that isn’t your physician. It’s nurses, technicians, therapists, the intake coordinator who checks you in, the clinical workforce that keeps a hospital running twelve hours after the doctor goes home. Another $27 goes to drugs and supplies, $14 to facilities and equipment, and the hospital keeps about $3 in margin.

Healthcare is a funny industry — with payers, providers, and pharma believing they’re the good guys getting squeezed by everyone else. After mapping this, I get why: the incentives point in different directions at every layer. I went in expecting to find a villain, one layer extracting more than its share. Instead, I found a chain of answers to the same question: “Who decides what the money is for?“

The principle hasn’t changed since the first office collection — everyone chips in so the money’s there when something goes wrong. Who should pay when someone gets catastrophically sick? Since 1943, the American answer has been: your employer. Not the government, not the individual, not the community — your employer, because during the war, the government froze wages, companies offered health benefits instead, the IRS decided not to tax them, Congress made it permanent, and a wartime workaround became the single largest tax expenditure in the federal budget — $300B a year in foregone revenue. Employer-sponsored insurance covers more Americans than any other source — 160 million people, more than Medicare and Medicaid combined.2

And because those health dollars are tax-free — for both employer and employee — every dollar routed through the plan buys more than a dollar of wages. Congress tried to cap it once (the Cadillac tax), but it was delayed four times and repealed in 2019 before it ever took effect. The system doesn’t just spread the cost — it rewards spending more, routing more compensation through the cake instead of the paycheck.

Buying the Cake

So the pool exists, and someone has to manage it. Most large employers self-fund — keep the premiums, pay claims out of operating funds, and hire a third-party administrator (TPA) to handle the paperwork: processing claims, building the provider network, mailing the cards, answering the phone when you call the number on the back. The TPA runs the plan day-to-day for about 5% of premium, instead of the 15-20% a fully insured carrier keeps. Two-thirds of American workers with employer coverage are in self-funded plans. But self-funding means your company’s HR department is now, functionally, running an insurance company — and most HR departments didn’t sign up for that, which is how you end up hiring the next layer.

The biggest brokers — Marsh McLennan, Aon, Gallagher — are publicly traded companies running the shopping layer for thousands of employers, handling the RFP process, presenting carrier options, benchmarking costs, and managing compliance. A mid-size company might pay its broker $50,000 a year in commissions. A large employer group can generate up to $150,000 in additional carrier bonuses on top of that — bonuses that, until 2021, the employer never saw. When one person’s recommendation steers millions in premium revenue, the carriers have every reason to make that person’s life pleasant.

ProPublica documented an arrangement in 2019: carriers using cash bonuses, Super Bowl tickets, and Bermuda resort trips to steer broker recommendations. When they asked the ten largest brokerage firms whether they accepted these bonuses, four declined to answer. Six never responded.

When I was researching this, my first thought was that I’d picked the wrong career. I’ve spent years working in hospitals and insurance — no one ever sent me to the Super Bowl. But it’s not uncommon: I worked on integrating a dental insurance product into a new sales process, and the brokers who sold the most got a free week-long trip to Ireland. Every VP on the call had a jealous little chuckle that they weren’t getting comped a free trip to Europe. The perks suggested a margin that the rest of healthcare hadn’t figured out how to capture.

A broker’s commission is a percentage of premium — when premiums rise, the broker makes more, with no built-in incentive to bring costs down. But without a broker, most employers are negotiating blind in a market designed to be opaque.

Each layer of the cake — the broker navigating the market, the administrator running claims, the carrier managing the network — took on a question the pool couldn’t answer on its own. Each answer costs a fee. But the plan is built now, the managers are hired, and those fees only matter when someone actually uses the pool — when the money has to move.

The Last Slice

Every claim starts with the same thing: a doctor orders something, and a patient should get it. Between those two points, someone turns the order into a billing code, formats it to a specification, routes it to the right payer... and waits. Thousands of payers, each with its own formatting requirements, its own submission portals, its own adjudication rules, and a layer of clearinghouses translating between them — the rails of the system, running on a standardization problem that was supposed to be solved decades ago.

Getting paid is its own industry. Revenue cycle management — submitting claims, posting payments, fighting denials — is a $61B market, projected to hit $100B by 2030. U.S. hospitals spend 25% of their total budgets on administration — $667 per person in America — compared to 12% in Canada, where there’s one payer and one set of rules. The bakery is spending a quarter of its budget figuring out which office sent the five bucks.

Then there’s the drugs.

PBMs — pharmacy benefit managers — started as claims processors. You handed a card to a pharmacist, the pharmacist submitted the claim, the plan paid the bill. A transaction layer, no different from a credit card company skimming a processing fee.

Today, three companies — Express Scripts (Cigna), CVS Caremark (CVS Health/Aetna), and OptumRx (UnitedHealth Group) — control roughly 80% of the pharmacy benefit market, covering 270 million lives and managing $600B in annual drug spending, each vertically integrated with its parent insurer. The same parent company that insures you manages your drug benefits and fills your prescriptions through its own mail-order and specialty pharmacies. One entity decides what’s covered, negotiates the price, and captures the margin at the pharmacy counter — choosing the bakery, setting the recipe, and pocketing the difference between what the cake costs and what you’re told it costs.

The FTC spent years investigating and found $7.3B in profit from specialty generic markups alone, $1.4B in spread pricing — charging the plan one price, reimbursing the pharmacy less, pocketing the difference — and a rebate structure where higher list prices meant more money flowing through the PBM. The opacity is the business model.

In September 2024, the FTC sued all three for inflating insulin prices through exactly this mechanism.

But every wealthy country has drug intermediaries — Japan has more individual payers than the United States and a fraction of the overhead, because Japan set the prices.

Every pool in the United States negotiates separately — with every hospital, every manufacturer, every pharmacy chain. No standard rate for an MRI, a hip replacement, a vial of insulin. The same procedure, performed in the same city, billed at wildly different prices. It depends on which pool your employer built and which network your carrier negotiated.

Why didn’t we just set the prices?

Moving the money costs money, more every year, and most of it happens where you can’t see it. Does every dollar leaving the pot actually need to leave — and who gets to decide?

Who Ordered This?

Every October it’s the same ritual: open enrollment, premiums up again, the plan costs more, the deductible creeps higher, and at some point you stop shrugging and start wondering who’s reaching into the pot.

Prior authorization — getting permission — is a straightforward way to gate the money draining the pool. For decades, doctors would do more, bill more, then earn more. But with prior auth, before a doctor orders an expensive test, a surgery, a specialty drug, someone reviews the request against clinical criteria and decides whether the pool should pay. A checkpoint between the physician’s judgment and the pool’s wallet.

And it makes sense, in the same way the birthday cake made sense — if the pot is collective, everyone’s money, then somebody has to be the steward, somebody has to check the receipt before the bakery charges you for three cakes when you ordered one. Roughly a quarter of U.S. healthcare spending is wasteful — duplicative, low-value, or clinically unsupported. If prior authorization catches even a fraction of that, it’s doing its job.

Except.

Your carrier subcontracts the approval decisions to utilization management companies — firms your employer has probably never heard of, operating on platforms your employer has probably never seen, deciding case by case whether the pool pays for your MRI, your specialist referral, your kid’s therapy. Your employer built the plan, the carrier promised to manage it, and someone three contracts removed says yes or no. The total annual cost of running this approval layer — across all payers — is $35B.

I was on a Teams call at an insurance plan, helping write eligibility criteria for an advanced therapy, and all I could think about were the hours I’d spent on the provider side proving patients met criteria just like these.

The gatekeeping function makes sense — a quarter of U.S. healthcare spending is genuinely wasteful, and doctors will tell you privately that defensive medicine drives a significant volume of unnecessary orders. But 88% of physicians say that prior authorization increases overall healthcare resource utilization, through delays that escalate conditions and workarounds that route patients to more expensive settings. The honest answer from the research is that it’s unclear whether the checkpoint saves more than it costs, and no one has stopped doing it long enough to find out.

And stopping would mean someone at your company — an HR director, a benefits committee, a colleague you eat lunch with — has to look at a claim and say no themselves.

But when the gatekeeper says yes — when the claim goes through, the surgery is approved, the drug is covered — and the bill is $4M, somebody has to absorb the hit. There are 38 FDA-approved gene therapies, up to $4.25M per treatment, with over 2,000 in the pipeline. One diagnosis can drain the pool.3

Everyone’s Cake

You get your 1095-C, you start paying for health insurance. Down the hall, a hundred other people check the same box — the guy by the window with four kids who may need braces, the woman who just came back from medical leave for a private reason, the new hire no one’s met yet. All of you, paying into the same pot. So when something goes catastrophically wrong for one of you, the money’s there.

That’s all insurance ever was — everyone chips in for the cake.

But your pot doesn’t stay in your office. Your employer’s pool — your premiums, your coworkers’ premiums — merges with thousands of other employers’ pools inside the same carrier’s book. UnitedHealthcare covers 50 million people. You’re in a pot with auto workers in Michigan and hotel staff in Phoenix, people you’ve never met — your money paying their claims, their money paying yours. And at the hospital, the pools dissolve completely — there’s no UnitedHealthcare wing and no Aetna wing, just beds and doctors and everyone converging in the same building.

With catastrophic claims, we pool risk again with other employers’ catastrophic risk, and a reinsurer bundles it again into global capital markets, so a gene therapy claim in Ohio ends up as a line item on a balance sheet in Munich.

And then there’s the biggest pot of all, the one that doesn’t even look like insurance — $300B a year in foregone tax revenue. The employer health coverage exclusion basically means every taxpayer in America subsidizing the system whether they’re in it or not. The pot was never your office, and the tax code has been telling your employer to make it bigger every year.

The Receipt

We blame the middlemen — the PBMs, the utilization managers, the brokers collecting Super Bowl tickets — for making the system expensive (and they do). But they’re expensive because we hired them, and the tax code rewards every dollar we route through them.

We built every layer between our paychecks and our doctors because we couldn’t look at each other and decide what the money’s for — the broker so we don’t have to shop, the carrier so we don’t hold the risk, the UM company so no one has to say “no” to a coworker’s face. The 16.5 cents of frosting on every dollar is what it costs us to not decide — enough layers that when something goes wrong, the denied treatment, the surprise bill, the delay that costs someone their life, every entity can point somewhere else.

It’s meant to be morally provocative: a $4M gene therapy for a colleague’s child — should the pool pay for that? A $1,000-a-month Wegovy prescription for a coworker you barely know — should it pay for that? An 82-year-old employee who wants the freedom to choose her own hospital, even if the out-of-network option costs the pool twice as much — should it? These aren’t questions with clean answers, and I think the tension is that we don’t like that we’ve deferred the answers to someone else rather than confronting it ourselves.

Just Desserts

I’ll be honest, all this stuff is hard to confront — it’s so convoluted, and now there’s this huge moral entanglement on top of it, that the decisions we make about each other’s coverage actually matter for the people we work with, and it’s bizarre to me that we don’t really talk about it. But one organization did it.

I caught a wonderful podcast episode of Trade-offs, which showed a company running into the problem of making decisions on health benefits. It’s a bold, and empathetic, way to think about the morality and feasibility of managing employee benefits.

They gave employees 70 poker chips representing the health budget and said: the full plan costs 92 chips, you can’t have everything, decide together. Not by vote — by consensus. Every person in the room had to agree, which meant every person in the room had to listen.

They read scenario cards — the cancer treatment, the weight-loss drug, the fertility coverage — and talked through what the shared money should cover, out loud, with the people whose money it was. They declined Wegovy. They approved infertility treatment. A younger employee changed her vote after hearing an 82-year-old colleague explain why hospital choice mattered to her. The empathy wasn’t just a moving patient story — it came from sitting in a room with the person whose coverage you’re deciding.

One group voluntarily chose to reduce their own salaries to buy more coverage once they understood the constraints. 85% liked the outcome. The NPC published a case study, Health Affairs covered it, and the conclusion was what you’d expect if you’d been paying attention: when people sit in a room and make these decisions together, they accept the limits as fair, because they made them, looking at each other.

When I traced my $100 of premiums, and I wanted to know where the money went. I learned it went to everyone — to the coworker whose kid needed the NICU, to the colleague on Wegovy, to the retiree who wants her hospital — and the 16.5 cents of frosting went to making sure I never had to sit in a room and face any of them while it happened.

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Health is Other People is (obviously) an allusion to Jean-Paul Sartre, and he called this mauvaise foi — or bad faith — pretending you don’t have a choice when you do. The original sin of America’s employer-sponsored insurance is that we assumed there was no way out. It’ll stay this way until we sit down and ask, “what do you want it to cover?”

Anyway, open enrollment is in October. You’ll get the email, you’ll compare two plans you don’t understand, you’ll pick the one that costs slightly less, and somewhere between your paycheck and your doctor, ten companies will collect their slice. The cake, at least, is tax-free.

In March 2025, politicians and hospital leaders held a press conference at the Enders Research Lab where they helped cure polio - not to announce a breakthrough, but to push back against the 24-hour news cycle coming out of Washington. Standing at the podium next to the governor was Dr. Kevin Churchwell, a slender man in a sharp suit who serves as the CEO of Boston Children’s - a pediatric ICU physician by training who would later tell the Boston Globe that “panic is for wimps”, a statement full of bravado if I’ve ever heard one.

Three seemingly unrelated decisions happened shortly after the second Trump inauguration: cutting NIH research grants, limiting foreign visas, and settling scores with Harvard. Boston Children’s felt all of them. The hospital receives roughly $230M in NIH research funding annually - third-highest among all hospitals in the country. Immigration restrictions threatened the international researchers who run the most advanced pediatric studies in the world. And they’re literally right next door to Harvard Med School - a teaching hospital affiliation that was purely prestigious until it became a political liability. It was a flurry of blows, with the knockout punch still winding up.

The Medicaid cuts in the One Big Beautiful Bill Act (OBBBA) landed the biggest hit of all. For those who aren’t healthcare policy wonks: OBBBA cuts nearly a Trillion in Medicaid spending over the next decade. The major provisions (work requirements and redeterminations, among others) don’t take effect until December 2026, but pediatric hospitals are already losing sleep.

Nearly half of all children in America — about 37 million kids — are covered by Medicaid or CHIP. What Medicaid pays doesn’t cover what it actually costs to treat a child, so states negotiated supplemental payments to close the gap. Nearly two of every five Medicaid dollars children’s hospitals receive now flow through these supplements, and the OBBBA caps them. People assume the cuts won’t touch kids, but it’s hard to imagine a future where struggling hospitals keep unprofitable pediatric service lines open.

The past year was filled with questions from clients — hospital COOs, FQHC directors, a Medicaid managed care plan I was working with — all trying to decipher what the Medicaid cuts would actually do to their organizations. I’d been wrestling with this since October (wrote a version of this essay, was too chicken to post it), but eventually gathered the courage to call out the Medicaid doom loop in January. “Teach them well and let them lead the way” - my hot take: pediatric hospitals are the best model to predict how Medicaid will impact American healthcare.

Not Small Adult Hospitals

There’s probably not a more venerated building in the world than a children’s hospital - what could be more sacred than a place that heals the future of society? Which is odd because the economics of pediatric care are wildly underanalyzed across health policy - everyone models policy impacts of adult specialties. But if you want to model out healthcare policy at a small scale, it’s easier to study the ~250-ish pediatric hospitals rather than the 6000+ hospitals across the country. Children’s hospitals are a great microcosm: they’re geographically spread out, but people are willing to travel further for pediatric care.

Until I became a parent, I never thought about who runs the pediatric emergency room, or what happens when the nearest one closes. My son had a run of allergy episodes, literally on the night he turned one — swelling on his face, multiple ER visits in a couple of months — and the policy question isn’t abstract when it’s your baby.

Children are not small adults. A six-month-old metabolizes drugs differently than a six-year-old, who metabolizes differently than a sixteen-year-old… pediatric dosing requires weight-based calculations and specialized formulations. You can’t just cut an adult pill in half. Children’s hospitals operate as a completely separate network from adult healthcare, with their own economics, their own referral patterns, their own geography.

And their economics are uniquely exposed. Compared to about twenty percent of adults, the majority of children are covered by Medicaid. Children’s hospitals can’t chase commercial volume the way adult hospitals can; it’s not like other businesses where you can just sell more widgets to customers who can afford it. You’re not going to drum up elective hip replacements on eight-year-olds. And if a kid shows up in the ER, you’re legally required to treat them - regardless of what your CFO thinks of the payer mix.

Children’s hospitals aren’t even the first layer to feel it: the pediatricians and specialists out in the community, the small practices where families actually take their kids, are even more exposed and have none of the safety net a hospital does — no endowment, no philanthropy, no backup when Medicaid doesn’t cover the cost — and when those practices close, their patients end up at children’s hospital clinics.

There are also far fewer of them and parents like me are willing to drive as far as it takes to see a pediatric specialist, which means each institution’s reach extends wider and each closure displaces patients across more geography. Margins across children’s hospitals have already collapsed from double digits to barely one percent.

Children’s hospitals make up about five percent of the hospital market, but they’re a compressed version of every pressure facing American healthcare - the same dynamics, playing out faster and with nowhere to hide. What that looks like, up close, starts in Boston.

Where the World Comes for Answers

Boston Children’s motto is “where the world comes for answers“, which sounds like marketing until you learn that the hospital runs a Global Services department coordinating care for families from Gulf countries. Wealthy oil sheikhs bring families to Boston because there is nowhere else on earth that can treat their children - and BCH runs the largest pediatric research enterprise in the world, pioneering research in sickle cell anemia and cystic fibrosis.

But they’re dependent on the most vulnerable members of society - poor children.

Forty-six percent of BCH patients are covered by MassHealth (Massachusetts’ Medicaid program), and the hospital loses over $250M a year providing care for publicly insured kids. Sixty percent of their most medically complex patients — the ones with conditions so rare or severe that only BCH has the expertise — are on Medicaid. The hospital operates at a negative four percent operating margin — in an industry where breaking even is a good year — and stays afloat through investment returns and philanthropy.

Where the world comes for answers - and half the patients Medicaid-dependent.

Down the Pike

The oncoming storm doesn’t rain on BCH alone: other pediatric hospitals feel it even more deeply. In 2022, a struggling Tufts Medical Center closed the Floating Hospital for Children, because adults are more profitable - and redirected nearly two thousand kids a year to Boston Children’s. One closure in Boston, where alternatives exist.

Where I live in Worcester — forty-five minutes west — UMass Memorial Children’s posted an $87.5M operating loss in nine months, closed the state’s only teen substance use detox center, and shuttered psychiatric programs. I see their ads everywhere — YouTube, billboards, a campaign called “Relentless” — because when your pediatric families are drifting toward Boston, you spend money you don’t have trying to hold them. Specialist wait times are stretching to two months - parents in Worcester are calling Boston Children’s because they can get seen within a week.

My hometown of Springfield is nearly two hours west, and Baystate Health — the safety net for all of western Massachusetts — has slashed jobs losing a combined $300M since 2022 . The CEO, Peter Banko, projects the OBBBA will cost Baystate $146.7M annually, and he’s said publicly that “pediatric health care is among the valuable programs that don’t make money that would close in the community”. My high school buddy Keno has four kids - if Baystate can’t handle pediatric emergencies (and Banko basically telling us it can’t), Keno is driving his kids two hours east to Boston.

And even further past the state lines, the same issues bring it all back to Boston. Connecticut Children’s is closing its satellite unit in Waterbury - average daily census dropped to 1.3 patients, and you can’t staff a unit for a number that rounds to 1. In Maine, MaineGeneral closed its pediatric center after 67 years - 80% of its kids were on Medicaid. It’s not hard to imagine that parents in Connecticut and Maine are willing to travel even further into Boston.

BCH and Mass General for Children now handle 58.1% of pediatric discharges in the state — nearly six in ten kids who need a hospital bed — up from roughly half in 2011. Every closure that sends patients to BCH makes it more dependent on the Medicaid funding being cut.

It’s like when every side street goes under construction and the main highway gets congested - the highway wasn’t designed for this volume, and building new lanes takes a decade you don’t have.

One Big Beautiful Irony

Medicaid spending has been growing faster than almost anything else in the federal budget. Some states have gotten “creative” with supplemental payments in ways that are, in some cases, straight up gaming the federal match. So when it’s time to trim the federal budget, the logic seems straightforward: slow the growth, close the loopholes, reduce the government’s role. But Econ Policy 101 missed the part where cutting payments doesn’t reduce dependence - it concentrates it.

This is why I looked at pediatrics, it’s easier to model out here, but it applies in other spaces in healthcare too. Simply put, struggling hospitals can’t serve poor patients, the better hospital absorbs them, but then, it’s stuck with more poor patients. The flagship becomes more dependent on the extra funding that keeps it solvent - ironically the same payments capped by the OBBBA. Kids who lose coverage still show up at the ER, and the hospital absorbs more uncompensated care. The hospital’s own filings show it - BCH absorbed nearly seven thousand additional days treating Medicaid kids in just two years, meaning roughly half the beds in the hospital are now occupied by publicly-insured children, before the bill had even passed. A policy designed to shrink the government’s role in healthcare ends up concentrating it into fewer institutions that become too critical to let fail.

History rhymes with itself: the Balanced Budget Act of 1997 - or BBA, the older cousin of the OBBBA — cut Medicare spending to teaching hospitals and overshot the target by $88 Billion (!) — Congress had to pass emergency relief to undo the damage. The money came back, but the smaller programs that closed during the crisis didn’t - Congress funded the concentrated system, not the distributed one it replaced, and teaching hospitals ended up more dependent on federal payments than before the cuts started.

Think of it as cutting water to a garden. The deep-rooted plants survive by tapping reserves the shallow ones don’t have. The shallow ones die. But the survivor inherits everything the dead plants used to carry, and ends up needing more water than the whole garden did before the cuts. The bill meant to lower government-dependency, increases it.

State by State

It’s hard to imagine a life outside New England (is there such a thing?), but the dynamic plays out around every major pediatric flagship in the country - each at the center of a region where surrounding hospitals are shedding services and patients are concentrating inward.

I have consulting colleagues do real estate planning for Seattle Children’s, since it covers nearly a million square miles — Washington, Montana, Idaho, and cold-ass Alaska — and more than half its patients are on Medicaid. Alaska has no Level I pediatric trauma center - critically ill children transfer to Seattle by Learjet. These aren’t the same closures in Mass; they’re pediatric care deserts where the infrastructure never existed, and the cuts will only widen them. A pediatric cardiologist at Seattle Children’s, told a senator that without the hospital, “these babies could die, frankly, because they wouldn’t be able to get diagnosed.” Seattle’s Medicaid share of inpatient days jumped from 28% to 36% in just two years - one hospital absorbing the pediatric needs of five states, growing more government-funded with every patient it takes on, not less.

In Philadelphia, CHOP added 56 beds and $671M in revenue between 2022 and 2024 - expanding into the vacuum. Across town, St. Christopher’s Hospital for Children watched its commercial patients leave for CHOP and survives on a $76M local tax scheme — exactly the kind of supplemental payment the OBBBA caps. Just across the state line in Wilmington, Nemours Children’s — where BCH’s Dr. Churchwell was CEO before coming to Boston — is now under federal investigation and scrambling to invent an entirely new payment model to survive Medicaid instability. If any of them shutter services, the kiddos end up at CHOP - already at 91% occupancy, basically bursting at the seams (85% is considered at-capacity).

In every market, the flagship absorbs what the regionals shed. But that assumes there’s a flagship.

Where There Are No Deep Roots

And then you look at a place like Mississippi: where rural children already face double the mortality rate of urban children, where infant mortality runs 8.5 per thousand live births and for Black infants, 11.9 — the national average hovers around 5.5 — and the whole dynamic breaks, not because the mechanism is wrong, but because there’s nothing to concentrate into.

Greenwood Leflore Hospital sits in the heart of the Mississippi Delta — Leflore County, where more than half of children grow up below the poverty line. Before the pandemic, it was a 208-bed community hospital. By October 2022, it had closed its pediatric unit, its labor and delivery ward, and its ICU. By 2023, it had suspended use of 173 of its 208 beds, sold off neurosurgery and urology, and shuttered dialysis and rehab. What remains is an emergency room and some outpatient services. A shell.

The state’s only children’s hospital — Children’s of Mississippi, in Jackson — is two hours south and not nationally ranked in any pediatric specialty. Mississippi never expanded Medicaid; the OBBBA closes the door on ever doing so. A parent in Greenwood with a sick kid has three options: drive two hours and thirty-seven minutes to Jackson on a Medicaid salary with one car and no public transit, take the child to a rural ER that likely lacks pediatric equipment, or wait and see if it gets better. The data can count the first two options. It can’t count the third, but as a parent, I couldn’t fathom being stuck without the option.

What separates Boston from the Delta isn’t the policy, it’s what was already there when the cuts arrived.

Children’s Hospital Deserts

Two outcomes, determined by one variable: is there a deep-rooted institution in range?

• If there is — BCH, CHOP, Seattle Children’s — the flagship absorbs what closes around it, each through a different route: in Boston, nearby closures funnel patients inward; in Seattle, the alternatives were never built, so one hospital covers five states by default; in Philadelphia, CHOP expands into the vacuum until there’s no capacity left to absorb more.

• If there’s no deep-rooted institution — the Delta, rural Montana, the communities where the nearest children’s hospital is two hours away and not nationally ranked — care doesn’t concentrate. It vanishes. The first outcome is the irony — every closure meant to discipline spending just shifts the weight to fewer institutions that become harder to walk away from. The second outcome isn’t ironic at all, just a straight line from funding cuts to gone.

You could draw circles around the twenty or thirty elite children’s hospitals in the country and say with reasonable confidence what happens inside each radius versus outside all of them. Inside the circles, the flagship gets bigger and more government-dependent. Outside the circles, care thins out until it’s gone. Three states — Wyoming, Idaho, Montana — have no freestanding children’s hospital at all. Trace a two-hour drive radius and nearly half of all counties fall outside every circle - about 13 million children with no children’s hospital within a reasonable drive, which is manageable if your kid has a scheduled appointment - but not if your kid suddenly starts wheezing at 2AM.

And a lot of those circles are drawn around hospitals that are already in financial trouble - institutions running at negative margins, shedding services, closer to the next Tufts closure than the next CHOP expansion. Roughly thirty-two million children, about 43% of all kids in the country, live in a county that is either already a pediatric care desert or one hospital closure from becoming one.

Each closure erases a circle from the map and pushes those patients toward whatever flagship is left, which absorbs them, runs hotter, and becomes more dependent on the public funding that the OBBBA caps. But the flagship that inherits the patients also inherits the vulnerability - a hospital that was 46% Medicaid-dependent at the start of the cycle is 55% dependent after absorbing the closures around it, which means the next round of cuts hits it harder, which means the circle everyone assumed was permanent starts to look fragile too.

The Grown-Up Version

Pediatric hospitals model the dynamic, but they don’t own it. Before someone accuses me of using sympathetic children as a cudgel to make my point - fine, let’s talk about pregnant women instead. Take rural obstetrics: Medicaid covers about 40% of all U.S. births nationally, rising to 50% in rural areas and around 60% in states like Louisiana - the same lopsided dependence on Medicaid. You can’t upsell a C-section, you can’t market your way into more commercially insured pregnancies (maybe a campaign for increasing procreation?), and your patient volume is determined by whoever lives in the area and decides to have kids, which doesn’t exactly show up on a CFO’s strategic plan. And the expertise is spread thin in exactly the same way pediatrics is.

One hundred and seventeen rural hospitals have stopped delivering babies since 2020, and 59% of rural hospitals no longer offer obstetric services. The March of Dimes coined the term “maternity care deserts” (inspiration for my Children’s Hospital Deserts), which illustrates that a thousand counties — a third of the country — are classified as maternity care deserts, with no birthing facility and no obstetrician.

The same two outcomes are visible. In Maine, twelve birthing centers have closed in the past decade — four in 2025 alone — and virtually all obstetric training and care concentrates toward Portland, the state’s single remaining OB residency program pulling the gravity of the whole system toward one city, and becoming more Medicaid-dependent with every closure it absorbs. In the Delta, Greenwood Leflore lost its maternity ward along with everything else - mothers now drive a hundred miles for prenatal care, and the state declared a public health emergency over infant mortality in 2024, the highest rate in a decade.

Obstetrics is actually more vulnerable: children’s hospitals are freestanding institutions with their own endowments, their own research enterprises, their own philanthropic bases. Maternity wards are service lines inside general hospitals — in the language of hospital finance, delivering babies is a product line — and when a hospital needs to cut a money-losing department, labor and delivery is often the first to go. There’s no freestanding equivalent of Boston Children’s for obstetrics — no institution with the depth of roots to be the last one standing. Which means in many parts of the country, there’s no institution to absorb what closes, and the maternity care just disappears.

The same conditions — most patients on Medicaid, specialists few and far between, no way to make it up on privately insured patients — show up in burn care, where 130 centers serve 330 million people and eight states have no burn center at all, and in psychiatric care, where 169 million Americans live in a mental health shortage area and nearly 59% of counties have never had an inpatient psychiatric bed. Each follows the same fork: where a flagship exists, it absorbs what closes around it and grows more government-dependent; where there’s no flagship, care disappears. Any specialty that serves patients who can’t choose their provider or their payer is running the same finances - and there are more of them than anyone is counting.

Too Essential to Fail

The worst of it hasn’t arrived yet. Work requirements take effect in December 2026, the heaviest Medicaid cuts land through 2027 and 2028, and the rest of the cuts phase in through 2032.

The policy was built to shrink the government’s role in healthcare - slow the spending, close the loopholes, let the market absorb what government retreats from. What it’s producing, in every system where you can trace the effects, is fewer institutions doing more of the work, more dependent on public funding than the landscape they replaced, too essential to the communities they serve for any administration to let them fail. The opposite of the stated intent, arrived at by the most direct route possible.

Every few years the country will have some version of this argument — how much to spend on Medicaid, where to cap it, who qualifies — and almost every time it will be about the dollars, not the infrastructure underneath them, not the question of what happens to institutions you can’t rebuild once you’ve let them close.

Whether that’s better or worse probably depends on whether you’re a sick kid in Vermont who now has to travel to Boston, or a sick kid who gets access to world-class care they wouldn’t have gotten at their regional hospital. Or whether you’re a kid in the Mississippi Delta who doesn’t get to make the trip at all.

The city has drama everywhere. Terry, my girlfriend at the time (now wife), and I strolled through SoHo and saw a classy couple shouting at the top of their lungs. Suit and cocktail dress, dressed for a night at Carbone’s — not squared up about to throw down outside a bodega. Everyone around them pretended not to hear.

I caught fragments of the fight. She said something like “You do this EVERY. SINGLE. TIME.“

He threw his hands in the air. “Then maybe I should just fucking leave?!”

It’s rude of me to eavesdrop. Terry tugged at my arm — a signal to keep walking: mind your own business. But I can’t help it; I’m a busybody, and I’ve heard this fight before.

Whatever happened that evening was just the thing that broke the surface. The actual fight was older than that. I always wonder what happens behind the scenes. Anyone in a relationship knows how heavy baggage can be.

People love public fights. We’ll speculate on celebrity divorces, political palace intrigue, pro athletes beefing with their franchises. What could have led to this?

Hospitals and insurance companies fight in public too. Louder, honestly — and with a lot more at stake. But the general public doesn’t really care. Most people do what Terry did: keep walking, mind your own business. But I can’t help it - I wonder what led up to this point.

Rules of Engagement

I bet the couple on the sidewalk didn’t set out to fight in public. Something had been simmering, and that night it boiled over.

Healthcare fights work the same way. For decades, insurance contract negotiations happened behind closed doors, in the privacy of conference rooms. Hospitals and insurers would exchange spreadsheets to support their rates, eventually find a number, and renew the contract. Patients never really cared to know.

But healthcare costs have become untenable. And it gets to the point where conference calls can’t contain it. That pressure has to go somewhere — so it spills into public view. Both sides lob shots through local news. Letters go out to patients warning them their doctors might not be covered anymore. Crisis communication firms get hired. There’s an increasing trend of public contract disputes. The public theater is just part of the process now.

“We learned it’s important to make sure that you’re telling your story before the payer does,” one hospital CFO said.

Why go public? Because it’s leverage. Hospitals set up patient advocates to help members do “just cause transfers” — switching insurance carriers mid-year, outside of open enrollment — when their doctors are about to fall out-of-network. When employers start getting calls from angry employees, when membership numbers start dropping, the insurer’s negotiating position changes. “When the payer starts to see their actual membership numbers change,” one hospital executive explained, “they approach the negotiation differently.”

Breaking Up

Out-of-network is the healthcare contract equivalent of a break up. When a hospital threatens to go out-of-network with an insurance company, even uninterested bystanders hear it, whether they know it or not. OON means the hospital loses its insurance contract and guaranteed patient volume. The insurer loses members who want that hospital.

We call these “contract disputes”, but that undersells it. These are negotiations for who gets to stay in the bundle. Think of a health insurance network like Amazon Prime Video — hospitals, doctors, and labs bundled together and sold to employers. When a show like Friends falls out of the catalog, you can still watch it, but now you’re paying $4.99 per season instead of getting it with your subscription.

Except when Friends leaves Prime, you just go watch it on HBO Max. When your hospital leaves your network, you might be renting each visit to your oncologist at OON prices — or switching doctors mid-treatment.

Even if they come to an agreement, they drag their fights out in public. Below are a list of disputes across the country in the past few years post-COVID.

Every one of those disputes meant lawyers on retainer, consultants managing the fallout, and staff fielding calls from patients asking if they need to switch doctors. When you notify patients that they might lose their hospital, you’re not doing them a courtesy. You’re creating pressure.

He Said, She Said

Last year, I watched one play out in my own backyard in Worcester, surprisingly the second-largest city in New England. The fight between Blue Cross of Massachusetts and UMass Memorial Health — the dominant insurer and the dominant health system in Central Mass — spent weeks playing out in public. Nearly 200,000 people waited to find out if they’d lose access to the biggest hospital in the region. A mother in Gardner got a letter reassigning her 16-year-old son to a clinician two hours away in Boston. “It’s just infuriating,” she told the Boston Globe. “I feel they are using us as pawns.”

UMass has the highest Blue Cross exposure of any hospital system in the state. Blue Cross sends 85% of its Worcester-area payments to UMass. Nearly 200,000 Blue Cross members — about one in five UMass patients — depend on this relationship working. This is a codependent relationship.

During the standoff, both sides did what they always do: lob shots through the press. Blue Cross said UMass charges too much and wanted a 6.7% increase. UMass countered that Blue Cross squeezes them on primary care rates. Each side accuses the other of being unreasonable.

There’s emotional baggage that causes people in relationships to act out. I like to think that no one sets out to be an asshole - there’s usually a reason why they act that way.

Blue Cross Blue Shield of Mass lost $400 million in 2024 — their worst year ever. They’ve since bought out 750 jobs, casualties of healthcare economics. UMass posted $86 million in operating losses in just the first half of fiscal 2025. And while it’s hard to conjure up sympathy for healthcare institutions, it has been an extremely unprofitable year for these two non-profit organizations.

But beneath the theater, both sides faced bleak futures.

If Blue Cross held the line at 0-1%, UMass faced insolvency. The hospital cuts services, doctors leave, and the only trauma center in Central Mass starts to collapse. If UMass got everything they asked for, Blue Cross’s spiral toward bankruptcy and premiums spike 15-18% — employers start dropping coverage entirely.

Spreadsheets don’t negotiate. People do — and these people had their backs against a wall.

This isn’t two organizations negotiating at arm’s length. It’s a marriage (technically a polygamous one, since both have dozens of other partners, but for the sake of this argument, they’re each other’s primary). A stressed one, where both partners are broke, neither can afford to leave, and the fight is about how to split bills they can’t pay.

The question with any stressed marriage: what’s keeping them together? And is it enough?

Every payer-provider dispute has a story like this underneath it. The headlines show the fight. But to understand why neither side could walk away, you have to understand how they got here — the choices that made sense at the time, the dependencies that built up slowly, the moment they realized they couldn’t leave even if they wanted to.

UMass Memorial: Absorbing Everything

UMass Memorial didn’t exist until 1998 - it’s younger than Google. Before the merger, Memorial Hospital and UMass Medical Center were crosstown rivals. They reluctantly merged out of fear of getting pulled into Boston’s gravitational pull.

“There’s nothing like the threat of a provider in Boston coming in to get two rivals to come together,” one executive said at the merger’s 20th anniversary.

That consolidation made sense: build scale before someone else builds it for you. But scale meant responsibility. UMass absorbed every struggling hospital within reach - HealthAlliance, Marlborough, Wing Hospital. Each one came with underfunded services, Medicaid-heavy patients, obligations the previous owners couldn’t afford. Revenue grew from $640 million to $4.1 billion, but so did the obligations.

UMass became the only major nonprofit left in Greater Worcester, the only Level 1 trauma center in Central Mass, the only academic medical center in the state outside Boston. UMass sees seventy percent Medicare and Medicaid patients - programs that pay below cost. The scale they built to compete became the cage they’re trapped in. That gap gets covered by commercial payers, and dependency on commercial payers to cover the gap means vulnerability. In Central Mass, that mostly means Blue Cross.

When Eric Dickson took over as CEO in 2013, UMass was near bond default. He’s an ER physician who still takes shifts, and he thinks like a trauma surgeon. His response to the 2013 crisis: 600 layoffs, sold off a hospital. “I’ve seen times with trauma patients where you have to take the leg to save the patient,” he said. “I felt that’s a little like what we did.”

Now the knife is out again. UMass lost $86 million in the first half of FY25. Dickson has closed clinics, shuttered a teen substance treatment center, ended behavioral health services. The trauma surgeon is still cutting because the patient is still bleeding.

“It’s going to get ugly the next three years,” he says. “I mean, I should have retired last year.”

UMass has its back against the wall - and they’re not the only ones. Hospital CEOs across the country are saying versions of the same thing. With increasing medical costs, Medicaid and Medicare getting slashed, and ACA subsidies getting cut, the outlook for hospital reimbursement looks grim.

Blue Cross Blue Shield of Massachusetts: Carrying Everyone

Blue Cross of Massachusetts ended up with a dominant, yet highly exposed position for the state. They have over 60% market share (!) in Mass, but have a member base designed to lose money. How could that be? A landmark 2006 paper titled “Roadmap to Coverage” helped make the case to cover uninsured populations. The paper was driven by Sarah Iselin, a policy wonk who worked with the authors to make the case that Blue Cross would help cover uninsured patients.

Massachusetts passed near-universal coverage in 2006 - the blueprint for Romneycare, which became Obamacare. Blue Cross had to absorb those newly covered patients, the ones with chronic conditions that other insurers avoided. They stayed nonprofit when other Blues went for-profit. Stayed local when others consolidated nationally. Those choices positioned them as the politically essential insurer — the one making coverage expansion work.

Sarah Iselin became Commissioner of the Division of Health Care Finance and Policy a year after the law passed - the regulator overseeing these negotiations.

Medicaid expansion states saw similar dynamics. Their Blues plans absorbed the populations no one else wanted. The insurers that stayed nonprofit, that stayed local, ended up with members who cost more to cover than they pay in premiums.

Blue Cross of Mass built a business model around populations designed to lose money, making themselves a politically valuable institution - even when the finances suffered.

The $400 million loss in 2024 was their worst year ever. GLP-1 drugs alone are projected to add $1 billion over five years. Post-COVID utilization never came back down. Hospital prices keep rising faster than premiums can follow.

Blue Cross can’t do what for-profit insurers do: exit unprofitable markets, narrow networks aggressively, design benefits to discourage sick enrollees. They’re stuck with the member base their market positioning created. Every new expensive drug hits them first. Every hospital that can’t survive without them becomes a hospital they can’t drop.

In 2023, Sarah Iselin became CEO of BCBS MA - the who pushed for coverage expansion, then regulated it as Commissioner, now runs the company that expansion depends on.

Healthcare has a tight loop. The people who build the systems end up inside them. Iselin helped create the model where Blue Cross absorbed expensive members in exchange for being politically essential. Now she’s negotiating from inside an insurer losing $400 million because that member base costs more than premiums cover. It’s not an easy position to argue from.

Let’s Stay Together

After months of public sparring, Blue Cross and UMass released a tepid announcement. They landed on a 3.6% rate agreement, which doesn’t make anyone really happy - but then again, a good compromise is when both sides are equally unhappy.

So why did they go through all that effort of airing it out in public? To understand why, let’s work backward again through the counterfactual scenarios.

Blue Cross could have held the line - offered 1% or nothing, forced UMass to take it or leave. But Massachusetts has some of the most aggressive network adequacy regulations in the country. An insurer that drops a region’s only trauma center doesn’t just face bad press - they face state regulators, employers asking why premiums pay for unusable coverage, and members leaving at the next open enrollment. It’s an existential threat for a plan that already lost $400 million.

If Blue Cross drops them, 200,000 members lose access to emergency care. Not “have to drive further” — lose access entirely. Patients caught in the middle of a fight they couldn’t control breathed a sigh of relief when the deal was announced, but months of uncertainty had already taken their toll.

UMass could have held out for 6.7%. But Blue Cross represents 35% of their revenue. For a system already $86 million in the red, walking away means bond default. Dickson already closed the clinics, ended behavioral health. The next round of cuts hits the trauma center itself.

So both sides were negotiating inside a very narrow band. Too low, and UMass collapses. Too high, and Blue Cross’s losses become unsurvivable. They found a number that kept them together... whether times are good or bad, if I’m happy or sad...

Every Couple Has Their Reasons

People in Massachusetts breathed a sigh of relief when UMMH and BCBS MA made up - but just an hour away across the state border, UConn Health and Aetna couldn’t close a gap.

Maybe it’s a morbid curiosity, but I spent a few months tracking these disputes. Every hospital juggles contracts with multiple insurers. Every insurer negotiates with every hospital in town. It’s hard to know the nuances of every market, but relationship patterns have two variables: can either side walk away, and how far apart are they.

• When one side has alternatives, they use them.
  The case for UConn and Aetna follows the typical “he said, she said”: UConn wanted higher rates, but Aetna said those rates would drive up costs for employers. Neither budged and the contract expired, leaving 15,000 patients out-of-network.

  What was the difference from UMass/BCBS? UConn Health is a single academic center in a state dominated by Hartford HealthCare and Yale New Haven. Aetna had alternatives — Hartford Hospital, Yale, a dozen community hospitals happy to take the volume. When an insurer has options, losing one hospital is manageable. UConn didn’t have enough leverage to make walking away hurt. So Aetna walked. First Connecticut insurer/hospital dispute to extend past deadline in recent memory.

• When neither side can afford to walk away, even huge gaps close.
  In my old stomping grounds in NYC, Memorial Sloan Kettering and UnitedHealthcare went into some brinksmanship right up until the deadline fighting over a 30% rate increase. MSK said United’s rates didn’t cover rising costs. United said 30% would add $400 million in costs by 2027. Neither side had a good exit. MSK is where you go for cancer in Manhattan. United couldn’t tell 19,000 cancer patients to find another oncologist.

  They settled just after midnight, hours after the contract expired. But when neither side can walk, someone blinks.

• When there’s a power imbalance and the gap is too wide, someone gets hurt.
  In Oregon, Salem Health demanded a 35% increase in 2025 plus another 15% in 2026. Regence offered 3.4%, citing Oregon’s healthcare cost growth target. Salem is the only hospital in town — which should mean leverage. But when you’re ten times apart, leverage doesn’t matter. It just feels like you’re asking too much.

  They broke up and 30,000 Regence members lost in-network access. After this acrimonious divorce, Salem started canceling patient appointments - the equivalent of taking our marital disputes on your kids. Oregon regulators stepped in to ensure continuity of care for 900 members mid-treatment, but mostly stayed on the sidelines. The state’s cost growth target gave Regence political cover to hold the line. Salem’s monopoly position wasn’t enough.

Divorce is contagious - and the trend is expected to grow. Everybody got along during COVID, but higher utilization and expiration of subsidies created an environment of contentiousness in a post-COVID world. That’s why you see increases since 2021. Most recently, a high profile case is how Johns Hopkins has been out-of-network with United since August. Duke is threatening to leave Aetna in North Carolina. Nearly one in twelve hospitals had a public dispute with an insurer between 2021 and 2025.

The Data Behind the Drama

I’ve captured 200+ disputes so far, affecting over 6 million patients across 38 states. The data is messy — some disputes get national coverage; others I only find buried on page six of a regional business journal.

Here’s a link to the Airtable (I think I should start charging for this data)

It’s like watching a couple fight on the sidewalk. I can’t look away. I built some research agents to track the press releases, local news stories, state insurance filings - a record of the healthcare institutional drama leaving lives at stake. The hospital, the insurer, the stated gap, whether they settled or divorced, how long it took.

The map below shows where these fights are clustered. Texas. California. The Northeast corridor. Zoom in and you’ll see the names: Cedars-Sinai and Anthem. Ascension and United. Regional systems you’ve never heard of, fighting insurers you have.

The data might predict whether they stay or walk away, but human nature shows that the couples who can’t leave find a way, the ones who can walk often do, and the gap determines how bloody it gets. The stories underneath are still being written — and I’m still adding to the database (feel free to check it out and let me know what’s missing/inaccurate). Hover over the circles to get more info of each dispute.

More Fights Coming

Financial stress is the number one predictor of divorce in real marriages. Hospitals and insurers across the country are telling the same story: it’s their fault, something has to give.

We’ve seen this before. The last wave hit around 2000, when hospitals first consolidated enough to say no. In 1996, zero major contract disputes — hospitals took whatever terms insurers offered. By 2000, contentious disputes had erupted in 7 of 12 markets studied. That backlash faded. Now the pressures are different — Medicare Advantage, GLP-1 drugs, post-COVID labor costs — but the dynamic is the same: pressure builds, leverage shifts, negotiations go public.

Not every couple will make it. Sarah Iselin’s prediction: “I don’t think every hospital that’s open right now will be open in five years.” The patients who depend on those hospitals won’t get to choose which ones.

Staying Together

Breaking up is hard - staying together can be just as hard. UMass and Blue Cross stuck it out, but both sides are still losing money. And who bears the brunt? The 200,000 members who need that trauma center, but will see their premiums get taken out of their paychecks. When married couples fight, the kids are the ones who get hurt.

I grew up watching my own parents fight. I learned early that sometimes couples stay together not because they’ve resolved anything, but because leaving would hurt the kids more than staying.

In the end, I think that these conflicts aren’t going to be going away. It’ll probably get worse based on what we see in the trends. But I just hope to understand them a little better, to get a better sense of empathy for all of those involved in the drama.

11 minute read time

Follow the money and you might get lost. That’s why I made a diagram for the entire US healthcare system’s financial flows - covering an incomprehensible $5 Trillion in healthcare spending.

The US healthcare system looks like an eldritch horror - tentacles reaching into every corner of American life.

But we built this creature. Like Dr. Frankenstein, we assembled it piece by piece - Medicare for the elderly, insurance through jobs, Medicaid for the poor, exchanges for everyone else. Each piece solved a specific problem. Each addition made sense in isolation.

Put them together and you get something alive. Something vast. Something no one would have designed from scratch - because we never agreed on what we were designing.

The flows in the diagram represent $4.9 Trillion - but they also trace every medical decision made in America last year. Every dose administered and every diagnosis delivered. Every ambulance ride and every rehabilitation. Every birth and every final goodbye.

The flows are the aggregate infrastructure of how we keep people alive and healthy - and also, the accumulated friction that makes it harder to stay that way.

This chart holds the confused senior on dialysis, lost between three different insurances. The branch has a brilliant researcher, waiting for approval to start her life-saving trial. Lost in the flow is a desperate parent calling six numbers to pray for one “in-network” specialist. The ends show a struggling hospital with a whole floor for billing - and a closet for social work.

Every flow in the diagram is someone’s life intersecting with the creature we created. And every flow is also a choice about obligation. Who do we owe care to? What do we owe and how much?

The question that comes up for this creation: What did we build and why?

Other wealthy nations finance healthcare too. They also have to balance costs, quality, and access. They also have powerful stakeholders fighting over money and control. But their diagrams don’t look like ours. To understand what we built - and why - we need to see what a coherent system looks like first.

Other Systems

Look, I’m not an international healthcare policy expert. But I went down a research rabbit hole reading Which Country Has the World’s Best Health Care? by Ezekiel Emanuel (my favorite of the legendary Emanuel brothers), and made some diagrams to understand what other countries actually built.

Not to propose we copy them - that ship sailed decades ago. But to see what it looks like when a country chooses a philosophy and then builds the body. Two examples: the UK’s Beveridge model (named after Lord Beveridge, not a beverage model from tacky 90s beer commercials), and Germany’s Bismarck model.

The Beveridge Model: Single-Payer, Single-Minded

The obvious place to start is the UK’s NHS - the prime example of a single-payer health system. But before we get to how it works, we need to understand the choice that made it possible.

Lord Beveridge published his report in 1942, in the middle of World War II. Britain was being bombed nightly. Citizens were already sacrificing everything for collective survival. And Beveridge asked: if we’re asking people to die for each other, shouldn’t we also keep each other alive? Healthcare as a right, funded through taxes, free at point of service - a popular position around moral framing. Shortly after the war, the National Health Service launched in 1948 to match it.

How the Beveridge Model Works

Of the £317 billion ($400B USD) of UK healthcare spend, 81% comes from general taxation - one payer for nearly everything. NHS England handles most services directly.

Social care (orange in the graph) - like long-term care - are separately managed through local authorities, which creates some coordination gaps. Private insurance is a paltry spend in comparison - Americans would call this “concierge medicine”. Brits call it “queue jumping”, which should tell you everything about their cultural relationship to fairness and waiting your turn.

Look at what disappears in the UK diagram: no insurance cards to verify, no network checks, no surprise bills, no prior authorization departments. Admin costs are low with only one payer, there’s no one to negotiate with and no one to bill.

The complexity that Americans assume is inevitable is actually optional - once you decide who owes what to whom.

What Happens

UK’s system has its problems1 - wait times, capacity strains - but Brits LOVE it anyway. The opening ceremony for the 2012 London Olympics celebrated the NHS with doctors, nurses, and (hopefully) fake sick children dancing on hospital beds. While dancing over a government agency may seem silly, they’re actually celebrating their shared moral commitment to each other.

Why Not Here?

Could America make this choice? Technically, yes. Politically, we’d need to agree that healthcare is a right we owe each other, funded collectively through taxes. That would mean massive tax increases, eliminating private insurance as the primary system, and trusting a single federal agency.

The operational resistance alone would be too much: I’ve watched hospital execs squeeze out thinning margins and payer executives navigate quarterly earnings calls. We’re talking about unwinding a $1T+ private insurance industry, reconfiguring every hospital’s revenue model, and convincing Americans to trust the federal government with something they currently (sort of) get through their jobs. That ship didn’t just sail - it sank decades ago.

The UK made one healthcare body in 1948, but was it too simple - or is it elegantly simple? We can compare it with something much more complex, like the Bismarck model.

The Bismarck Model: Complex yet Comprehensive

Germany has roughly 140 competing insurance companies - in stark contrast to one payer of the UK. Yet Germany delivers universal coverage for over half of what the US spends per person.

Unifier of Germany, Otto von Bismarck (not named after who I initially thought) didn’t create this because he loved workers. He created it because socialists were gaining power in the 1880s and he needed to steal their thunder. “Give workers healthcare before they overthrow us” is peak realpolitik (the German word for “do what works, not what feels righteous”).

Americans are told you must choose: government control OR market competition. Germany said “both“ and built something Americans are told is impossible.

How the Bismark model works:

Employers and employees split a 14.6% payroll contribution, meaning wages automatically have a healthcare price tag to them. German workers get to choose from 140 competing sickness funds (aka “insurance companies” in American parlance).

But that competition is morally-bound by regulation: to accept any applicant, cover the same baseline benefits, and charge based on income (not health status). They compete on customer service, extra benefits, and operational efficiency - not on avoiding risky, expensive patients.

On the provider side, the German government sets prices to prevent gouging. Long-term care operates as a separate system (that orange flow on the diagram) instead of bankrupting families or clogging hospitals. Earn over €73,800 ($85K USD) and you can opt into private insurance (in purple).

What Happens

Germany has universal coverage through competition and cost control through regulation. There are four distinct paths: statutory (blue), private (purple), long-term care (orange), and out-of-pocket (yellow). In practice, there is a lot of complexity, but structured towards the theory of social insurance.

But the German system has trade-offs2: payroll tax is pressure on employers, the inequality between public and private tiers, and 140 bureaucracies to navigate. But the complexity serves a coherent purpose.

But imagine if American insurers competed on “who has the best nurse hotline” instead of “who can design the narrowest network to avoid costs”. That’s what happens when the obligation to cover everyone is non-negotiable.

Why Not Here?

Americans might actually like health insurers functioning as utilities, not profit-maximizing businesses. But federal price-setting across 50 states means telling every hospital and physician what they can charge - and CMS already struggles with Medicare rates alone.

The lobbying alone would be apocalyptic. While insurers would fight “utility” status, the hospitals would fight price controls. Not to mention that the entire physician payment model would need restructuring, while we’re in the midst of an upcoming clinician shortage.

But fundamentally, Americans would need to agree: your job connects you to a community of mutual obligation. Do we actually believe that? We built something like it through a historical accident (WW2 wage controls), but we’ve never committed to the moral premise.

Germany chose regulated competition in 1883 and built something complex - but the parts were designed to work together. We chose unregulated competition and built complexity that serves... what exactly?

Other Systems

There are other healthcare system archetypes as well: National Health Insurance (Canadian healthcare) and Out-of-Pocket systems. I could also build out diagrams for other countries3 too (have been suggested Singapore, Norway, and Japan). But like all other self-centered Americans, my focus is on talking about the US Healthcare System.

We can learn a lot from two distinct namesake models: the Bismarck model is “social insurance” and the Beveridge model is a “universal right”. The UK and Germany made different choices and built different systems: the UK moves money from taxpayers → NHS → services, Germany from employers + employees → sickness funds → services. But both embody their stated values.

So what does the US value? We built something that costs everyone, everything, everywhere - and still leaves 27 million uninsured.

The outcome is $4.9T - which would make it the 3rd largest economy in the world, a high 8% admin costs - compared to the UK’s 2% admin, with medical bankruptcy still possible. We’ve never agreed on what we value. So we built a system that embodies our disagreement: employer-based coverage (market choice) plus Medicare (social insurance) plus Medicaid (safety net) plus exchanges (regulated markets).

Maybe that IS the American philosophy: pluralism so deep we can’t even agree on how to keep each other alive.

Observations of the US System from this Chart

My fear with the diagram is that it just becomes gratuitous complication-porn. I’m not trying to show something to get the reaction of, “Wow, what a tangled mess! Isn’t that insightful?” Let’s look more closely to see the nuance and significance of we can take away from this chart.

What Have We Created?

Soak in the Sankey (Tsang-key?) diagram again. From a distance, it looks like chaos - maybe even like failure. But zoom in and you’ll see something else: this isn’t random. Every flow, every split, every loop represents a decision someone made.

Decision #1: Workers pay at least twice

Here’s the first thing that jumps out: if you work a job in America (and you presumably do, to afford the internet where you’re reading this), you’re already paying for healthcare in multiple places on this chart:

1. Taxes: federal, state, and local taxes finance Medicare, Medicaid, and various public health programs in so many places. Our attempt at embedding it in single payer.

2. Payroll: if you’re employed, your employer pays taxes on Medicare (even though you presumably can’t use it until you retire at 65). This is a cost that doesn’t go to your salary.

3. Insurance premiums: get deducted from your paycheck to fund the employer group plans ($688B from employees alone).

And don’t forget the most insidious payment - out-of-pocket costs - which add up to half a trillion.

We already built socialized medicine - we just made it more expensive.

Academics have pointed this out for years: Americans already finance healthcare collectively, just more inefficiently than countries with actual single-payer. Taxpayers already spend $2.35T - more than the entire GDP of Italy, the 8th largest economy in the world. That’s half the healthcare system before a single insurance premium gets paid.

Healthcare is already a collective responsibility - we just pretend it’s individual. Then make individuals pay twice: once through taxes, once through premiums.

Decision #2: “Old” Money

The second thing that jumps out: look at how much flows toward the elderly.

• While the obvious culprit is over $1T on Medicare, Nursing Homes account for $218B (split between Medicare and Medicaid) while Home Health & Hospice takes $100B. Medically speaking, old age is EXPENSIVE with the highest complications and comorbidities.

  What decision does this say aside from “care for old people”? Medicare is a collective promise - you pay in from age 22 to 65, you collect from 65 to death. And don’t forget special needs plans, which contain so much complexity and overhead for the most vulnerable of the elderly.

• Medicaid is technically for “low-income people”, but look closer: 22% of all Medicaid spending goes to nursing homes ($188B). That’s grandma’s long-term care after she runs out of money. Germany separated long-term care into its own system. The UK has a distinct local authority. The US folded it into Medicaid and pretended it’s a poverty program. Another choice we made without admitting it: we socialize the costs of aging, but only after families go broke first.

A stark contrast to Children’s Health Programs (in green). But this isn’t about whether old people deserve healthcare spending compared to our investment in children’s health. This diagram just points out that we’ve made a civil covenant to care for our elders.

Unknowing Decisions

The US diagram is a Rorschach test - whatever story you want to tell:

• The $100B in public health versus $1,452B in hospital care: the tale of treatment instead of prevention.

• The $120B in children’s health versus $1,000B in Medicare: how we repair old age instead of investing in youth.

• The $441B in prescription drugs - the story of incentivizing American innovation over price controls.

• And the administrative complexity at every handoff…

The question isn’t whether these choices are right or wrong. The question is: do we even know what we chose?

The Takeaways

When we say “just fix healthcare,” this monstrous chart shows the problem. You can’t “just expand Medicare” - Medicare is already funded by four different sources. You can’t “just cut insurance middlemen” - employer plans flow $1T+ to care. Every fix redirects one river while missing the ecosystem.

The UK built a system that moves money from taxpayers to services. Germany built a system that moves money from employers and employees to services.

We built a system that costs everyone, everything, everywhere - and we’re still arguing about whether healthcare is a right, an earned benefit, or a market commodity.

I spent weeks mapping this diagram. Actually taking away parts? That’s choosing who loses coverage, whose job disappears, which hospital closes.

The chart isn’t simply dollars flowing through programs - it tells a story of how we support each other. Whether money goes to your trusted doctor, to hospitals that save you when you’re gravely ill, to nursing homes where our elders age with dignity, to invest in programs that keep our children - and our futures - healthy.

This is American ambivalence about what we owe each other. It’s not just a creature to be fixed. It’s 330 million people living inside the creature we created.

Ernst Haeckel drew his creatures to reveal nature’s hidden order. This diagram reveals our hidden disorder - or perhaps, a different kind of order than we admitted we were building. The question isn’t whether this creature is beautiful or monstrous.

The question is: now that we see what we made, what do we want to do about it?

I've always known Boston for its universities and championship-winning teams - not in that order. It's silly because I grew up in Massachusetts, and I've taken Boston's healthcare dominance for granted. It's arguably the best city for healthcare - yet a perfect illustration of the flaws in healthcare market dynamics.

Through my healthcare career, I marvel at Boston's world-class hospitals, cutting-edge biotech, advanced medical education, and abundant health research funding. Its excellence creates a gravitational field pulling in everything healthcare-related.

You can see the wealth of health by walking through the brick-clad buildings of the Longwood Medical Area neighborhood - home to world-renowned institutions like Boston Children’s, Brigham and Women’s, Dana-Farber, Beth Israel Deaconess, and Harvard Medical School - and see more medical firepower packed into a few blocks than many entire states.

Healthcare entities in a few blocks. Net revenue estimations.

This creates a self-reinforcing cycle. More med students mean more research, leading to more breakthroughs, attracting patients who believe Harvard-affiliated care is better. That patient volume lets academic centers charge higher rates and offer salary bumps to recruit top talent. Better talent attracts more NIH grants, funding more research. Clinicians, researchers, patients… all making rational choices that fuel this concentration of healthcare.

No doubt about it: this business of healing is great for medical innovation. These institutions create treatments and technologies that benefit people worldwide. Boston's medical ecosystem drives genuine progress.

But everything comes with a cost: Boston is incredibly competitive, causing nearby metros and rural areas - struggling to stay relevant - to lose patients, clinicians, and resources to Boston. Health systems in other MA cities like Worcester and Springfield leak revenue. Cities in other states like Manchester, NH and Providence, RI watch their best doctors migrate east. Even parts of Maine lose patients and specialists to Boston's pull.

This is standard market behavior; resources flow toward jobs and money. It’s just the dynamics of successful enterprises outcompeting weaker ones - except for hospitals, doctors, and scientists. Boston is worth studying for the clear view of healthcare market forces.

The Planetary Objects

Mass General Brigham ($20.6B net revenue, 4.8% operating margin) - 16 hospitals

If you've met anyone from Harvard, they never forget to mention their university - like the Harvard-affiliated Mass General Brigham. When Mass General Hospital and Brigham & Women's Hospital merged in 1994 (originally called Partners), they created a healthcare juggernaut that dominates everything in sight. MGB is like the overachieving sibling who got into the Ivy League, became a doctor, married rich, and is now in the elite society. They've got the prestige, research dollars, and political connections.

That dominance is well-earned with amazing contributions to healthcare and humanity - but it comes with envious competitors. Market watchers can probably trace every healthcare strategy in Boston as a direct response to MGB. When they tried to expand into affluent suburbs recently, state regulators had to step in and block them because it would have financially gutted community hospitals. That's the MGB paradox - they're so good at what they do that their success threatens everyone else's survival.

Beth Israel Lahey Health ($8.2B net revenue, 2.1% operating margin) - 14 hospitals

Back in 2018, I started a job at another consulting firm. When I first visited the Boston office, only a few people were busy with the merger forming Beth Israel Lahey Health (BILH). That meant merging Beth Israel Deaconess, Lahey Health, and three other hospitals, creating one of the biggest health systems in the state by March 2019. It was obvious to market-watchers: it was to compete with Partners (rebranded to Mass General Brigham in retaliation in Oct 2019).
Hospital mergers are the astronomical event of the healthcare market - like a binary star forming a larger celestial body, creating gravitational waves rippling through the system.

You can see the aftershocks in 2023: the combined BILH, now operationalized, partners with Dana-Farber Cancer Institute’s inpatient oncology program, landing a blow to MGB - Dana-Farber’s previous partner. The acrimonious rift between DFCI and MGB made it to op-ed pieces in the Boston Globe, showing a competitive Boston healthcare market. MGB counter positions by opening their own oncology center. Suddenly, BILH wasn’t just an alternative - it was a serious counterweight to MGB’s dominance.

Boston Medical Center ($3.8B net revenue, 1.4% operating margin) - safety net hospital system with 3 hospitals

Here’s where we discuss smaller, but arguably more “essential” hospital systems in Boston’s healthcare ecosystem: the safety-net Boston Medical Center (BMC) stands out as a nationally respected institution, serving Boston’s vulnerable patient populations, covering 40% of the state’s Medicaid enrollees. BMC and other community hospitals also absorb most uninsured patients, facing political risk (especially due to the recent OBBBA Medicaid cuts), clinical complexity, and financial precarity from other health systems. In the orbit of the city’s academic giants, safety-nets remind us that world-class care often exists because someone else is subsidizing the margins.

Tufts Medicine ($2.1B net revenue, 0.8% operating margin) - 3 hospitals

The last player I’ll get to is Tufts Medicine - the small fish in a crowded New England pond - lacking the scale to compete. And unless it catches the next wave of M&A, it faces the rising tide of Medicare risk adjustments. It risks being swallowed whole or dashed against the rocks.1

This is what market consolidation looks like in real time - you either get big enough to compete, find a merger partner, or get squeezed out. There's no middle ground.

It’s a fun exercise to look at institutional profiles within a market2 - you quickly notice how every merger, partnership, and expansion responds to Boston’s competitive pressure. The forces they exert ripple through every healthcare market in their orbit.

Most people may not recognize the market dynamics in their cities (I certainly didn’t until recently). It’s different when real estate companies, auto dealers, or retail stores compete. The competitive dynamics in one of the densest healthcare markets in the country create more waves than other industries.

These aren't just hospitals and health systems: they're landlords of commercial real estate, the largest employers of a huge tax-paying base, political players connected to city and state agencies, and often competitors for the same pool of funding. They clash and battle like any other free market, and their forces create aftershocks through the region.

The Outer Orbit

Let's drive west down the Mass Pike3 and reflect on the economic impact of the American healthcare system:

Hover over the circles to learn more about each health system

I've lived in Worcester for over a decade, feeling Boston's pull. In 2022, when MGB tried to expand to nearby Westborough - the public health commission, community advocates, and local committees fought back. Why wouldn't a local community want the largesse of a top-tier health system nearby? Well, the other local hospitals who have a history of meeting community needs.

Central Mass has many hospitals, with UMass Memorial Health ($2.9B, 1.9% margin) as the largest outside Boston and the state's only other academic medical center. It occupies a crucial but underappreciated role: sophisticated enough for complex cases, big enough for contract leverage, but ultimately in a smaller pond, constrained by economics in ways Boston's centers aren't.

The patient population is more diverse - serving more rural patients and those with lower socioeconomic status than Boston’s academic medical centers. UMMH generally offers lower-cost care than Boston. Yet, people in Worcester County who choose outmigration to Boston hospitals for specialty referrals, faster appointments, or the prestige of Mass General. That results in tens of millions in losses in commercial insurance payments, Medicare dollars, and procedure revenues flowing east.

The talent drain follows the money - you’re a smart young doctor finishing residency at UMass Chan Medical School (UMMH’s teaching hospital). You can stay in Worcester with modest salaries and its opioid-riddled patient base, or move to Boston where Mass General offers a 50% pay bump, cutting-edge research, and maybe equity in a biotech startup. Such decisions relegate UMass Chan as the farm team that pays to develop talent for the major leagues in Boston.

My hometown Springfield has it even rougher. I was born at the Wesson Women’s Unit at Baystate Health ($2.4B revenue, 0.6% margin), and it pains me to see it lose over $300 million in operating losses since 2022 - forcing three rounds of layoffs and the failed sale of their integrated health plan just to stay afloat.

Baystate Health serves a population with poverty and violent crime rates double the rest of the state, with a fraction of the resources per patient of Boston's academic centers. When a complex case needs specialized care, the patient gets helicoptered to Boston. Springfield pays for emergency stabilization and transport; Boston gets the profitable procedure revenue.

It's the overachieving sibling dynamic on a regional scale. Boston gets all the attention, resources, and opportunities while Worcester and Springfield are relegated to "the other kids" status. State funding, federal research dollars, and private investment flow toward Boston's accomplishments while the rest of Massachusetts makes do with what's left.

The Collapse

Hospitals shouldn’t shut down. It feels like a moral, not an economic, failure. Healthcare system competition and extraction isn’t hypothetical. In 2024, Steward Health Care - once a $6 billion system and Massachusetts’ third-largest - collapsed. The headlines covered the (deserved) story of the greedy private equity’s yacht, but overshadowed how Steward’s community hospitals needed investment to survive in Boston’s hypercompetitive market.

You can drive past the shuttered Carney Hospital in Dorchester, and in its place is a healthcare desert. Carney served a population that was 75% Medicaid and uninsured - the patients that MGB and BILH don't fight over. But even serving this essential safety-net role, Carney couldn't generate the returns that private equity demanded while competing in Boston's orbit.

Running community hospitals with private equity debt loads was a losing battle in a market where academic medical centers have advantages. MGB and BILH duke it out for complex, well-insured patients and research dollars, while Steward gets stuck with high-risk, low-margin cases that academic centers prefer to transfer out.

When Carney closed, those 30,000 annual emergency visits scattered to already-strained Boston emergency departments. The ripple effects hit everywhere - UMass Memorial absorbed more complex transfers, Baystate in Springfield faced tougher physician recruitment as the collapse spooked potential hires about non-academic systems.

Boston's competitive healthcare market isn't just tough - it's becoming existentially brutal for anyone without academic medical center advantages. The same forces that make MGB world-class can crush a $6 billion system.

Physics of the Healthcare Economy

Boston shaped American history. When Paul Revere hopped off his horse on the midnight ride, he became America’s first public health officer. What happens in Boston’s healthcare market plays out in every major American city and state.

Massachusetts is not unique in its market dynamics. New York concentrates everything in Manhattan while upstate struggles. Chicago attracts Midwest talent. Houston drains East Texas. Every major medical hub draws in healthcare resources while suffocating surrounding regions.

There’s nothing unusual about resources collecting around a center - except healthcare is different from every industry. When your local hardware store closes because Home Depot is nearby stealing their business - it sucks, but you just have to go further to get your nails at a cheaper price.

Except in healthcare, costs don’t get cheaper because the larger health system has more negotiating power over the insurance plans. Resource consolidation drowns out competition, and prices actually go up.

Market concentration has life-and-death consequences. When your community hospital loses its cardiac unit because all the cardiologists migrated to the downtown academic medical center, people die waiting for ambulances to make longer trips.

Larger, dominant systems gain more power, leading to innovation and medical breakthroughs - but at a cost to the overall market. Struggling small and mid-sized systems slowly wither away, and large systems weather the storms. It reflects our economy, but in a healthcare system not meant to be financially optimized.

Boston does this more efficiently than most places. We've convinced ourselves it's the only way excellence is possible.

Breaking Orbit

The slow drain of healthcare to dominant metros isn't inevitable - smaller regional health systems have fought this for decades. You could argue for progressive state-level tax policy to redistribute resources, but there are also long-term strategies that lean into homefield advantage.

A friend at Baystate mentioned they'd partnered with UMass Chan Med School partly because their researchers kept leaving for Boston - not just for better pay, but because publishing papers with a Harvard affiliation opens doors that Baystate letterhead won't. It's about keeping talent and the institutional credibility it brings.

The oncology arms race tells this story perfectly. While MGB and BILH vie for cancer prestige in Boston, UMass Memorial built their own Dana-Farber partnership and comprehensive cancer center. Baystate did the same. The marketing is aggressive - running radio ads to stay local for advanced care in Worcester. Every regional system knows that once patients go to Boston for specialized care, they rarely come back for routine stuff. If you handle their cancer treatment locally, you keep their primary care, family's care, and referrals - the whole patient ecosystem.

UMass Memorial's hospital-at-home program works the same way. Patients who would have driven to Boston for complex care are staying in Worcester because they can get the same monitoring and support in their own beds. It's clever market positioning under the guise of patient-centered care.

These approaches sidestep traditional competition. Instead of trying to out-recruit Mass General for cardiac surgeons, they're making geography and convenience the competitive advantage instead of prestige and research funding. When patients can get high-quality care close to home, Boston's gravitational pull doesn't seem so inevitable.

Whether these partnerships can generate enough revenue to offset what these systems lose to Boston remains to be seen. But there's something hopeful about watching regional systems stop playing the big city game and start playing their own.

The Machine We Built

Living an hour west of Boston, you get used to being the little sibling. The one who didn't get into Harvard, didn't make it to the big leagues, didn't measure up to the golden child. Worcester tries hard - we've got decent restaurants now, a minor league baseball team, and a new cancer center partnership with Dana-Farber. But we know who the favorite is.

Boston earned its reputation - the medical breakthroughs are real, the innovation genuine, and the talent undeniable. Take the Longwood Medical Area station off the Green Line and see some of the best healthcare humanity has ever created. The problem isn't Boston's excellence - it's that we've built a system where excellence can only happen in a few special places.

Have we convinced ourselves that healthcare is like any other economic industry? Every research dollar to Harvard Med instead of UMass Chan, every specialist taking the higher-paying Boston job, every patient driving past local care for that prestigious zip code - these are rational choices. They're features of an economic system we designed to reward winner-takes-all competition.

It's the most sophisticated medical extraction machine ever built, and we call it American healthcare.

There was this cynical joke when I started in healthcare finance consulting: from the moment you're born, you're a patient - and you get a hospital bill to prove it.

That dark humor captures something real about how we think about healthcare reform. Everyone starts as a patient, which is why most proposed solutions are “patient-centered”. But after fifteen years bouncing between hospitals, insurance companies, pharma, tech, and a little policy - I've learned that other stakeholders in the American healthcare system have their own challenges and incentives.

So I modeled this serious, complex system of imbalanced power dynamics into an advanced framework: the Healthcare Five-way Seesaw (a serious name, I know).

The Seats on the Seesaw

Every complex system serves multiple constituents. In a system of law, stakeholders include citizens, police, courts, and lawmakers. In an economic system: businesses, workers, consumers, and regulators have differing incentives that serve to push the goals of the overall system forward.

Healthcare has five main constituencies: Patients, Providers, Payers, Government, and Suppliers.¹

To see how this plays out, let's look at where each group sits on the seesaw right now:

These stakeholder groupings each react differently to the same health policy, the same innovation, the same market dynamics. Some will win, some will lose, some are born to sing the blues. But the second- and third-order ripple effects will go on and on...

Let’s explore each stakeholder to learn more about incentives and challenges:

Patients: The People Healthcare is Supposed to Serve

We the Patients are the center of healthcare, but we have the least control over what happens to us. Patients are the only “customers” who regularly get services they didn't ask for, can't refuse, and don't directly pay for. If your appendix bursts, you’re not comparison-shopping emergency rooms. You go where the ambulance takes you, get whatever treatment the doctor orders, and hope your insurance covers it.

Let’s see how this plays out when the balance shifts - say, through hospital price transparency where patients can finally comparison-shop for procedures.

In the immediate term, you can see how patients move up while providers get pushed down - but notice how Payers and Suppliers stay relatively neutral. But providers worry about price wars cutting their already-thin margins, which puts hospitals at risk and could harm patient access. Payers and Pharma may even out in the near-term, since operations are largely unimpacted…

…but Payers and Pharma may lose negotiating leverage since everyone can see the real rates in a longer-term horizon. Suppliers face pressure to justify their pricing. The five-year view shows how the secondary effects kick in - now payers and suppliers are getting squeezed as the transparency creates new market pressures they didn't anticipate.

It’s arguable that in the current U.S. healthcare system, the seesaw is most imbalanced away from the patient. However, that’s not always the case: patients are becoming increasingly savvy consumers - doing their own research, demanding better experiences, and taking more control of their health. Big wins are sorely overdue for the patient, there are trade-offs to other stakeholders to consider.

Providers: The People Who Actually Deliver Care

Every medical director I’ve come across has run into same problem: “They want my staff to have higher quality scores AND higher patient volume with the same resources.”

That's healthcare Providers in a nutshell - caught between wanting to help people and needing to make the numbers work, with everyone assuming they can somehow do both perfectly.

This group includes everyone from neurosurgeons pulling down $2,000 an hour to nursing assistants making $20/hour in a retirement home. They all technically “provide care”, but face completely different pressures. Even where they are employed changes their incentives: the doctor at a hospital balances productivity against patient satisfaction (volume vs quality), while the independent doctor worries about keeping the lights on while insurance pays them less each year.

This seat on the seesaw can get out of balance quickly with the wrong policy: Government quality metrics might improve care standards, but require providers to hire data analysts instead of nurses. Patient demand for convenience might drive telemedicine adoption, but reduce the personal connection that makes providers most effective.

Providers are also the best positioned to fix healthcare's problems because they see where the waste and inefficiency actually occur. Generally the best healthcare is where providers have the most input in the system - that is, when they are aware of the other parts of the system.

Payers: The People Who Pay the Bills

This is where healthcare gets confusing, even for insiders. The term Payers - in layman’s terms - usually refer to health insurance. But that's oversimplifying it. Your “payer” might be a massive insurance company, your employer who pools funds to provide employee benefits, or government programs like Medicare and Medicaid - each operating under completely different rules and pressures.

Think of payers as risk managers, which is essentially just a bet. They collect money today (premiums) and bet that it will be enough to pay for expenses later (medical claims). They make money when people don't use healthcare, which puts them at odds with literally everyone else in the system.

The seesaw dynamics are most prominent here: When payers move up - say, through higher deductibles or prior authorization requirements - healthcare costs might stabilize and risk is better managed… but patients face more financial barriers and out-of-pocket costs, providers deal with administrative overhead and delayed payments, suppliers face coverage restrictions that limit market access, and government officials field complaints about access problems.

When other stakeholders push back against payers, the math gets messy fast. Patient advocacy for coverage mandates - say, covering pre-existing conditions - means higher medical costs that eventually flow through to premiums. Government regulations like essential health benefits expand coverage, but increase baseline costs. Supplier innovation creates new treatment options that patients want covered, putting payers in the position of either saying no to medical progress or raising everyone's costs.

The real problem isn't that payers exist (or that we have a multi-payer vs single-payer system). They get a bad rap because they have to say no when it comes to healthcare spending. Resources are finite, yet healthcare demand is essentially infinite. The payers are put in the position of saying “no” because no one else can.

Government: The People Who Make the Rules

The next constituent is the Government, or in this case, policymakers and regulators. The government sets the rules for how healthcare works, but those rules often have unintended consequences that ripple through the entire system.

Government also wears multiple hats in healthcare. Sometimes it's the regulator (FDA), sometimes it's the payer (Medicare and Medicaid), sometimes it's the provider (VA hospitals), and sometimes it's all three at once.

This creates hilarious contradictions: The FDA wants drugs to be safe and effective, which takes time and money. CMS wants healthcare to be affordable, which means paying less. The CDC wants to prevent disease outbreaks and improve population health, which requires more reporting and surveillance. These are all reasonable goals that work against each other.

When the government decided that hospitals should be penalized for patient readmissions, suddenly every hospital in America started calling patients at home to make sure they were taking their medications. Good for patients (better follow-up care), challenging for providers (new administrative burden), neutral to positive for payers (fewer expensive readmissions), but it created a whole new market for suppliers building patient engagement technology.

Government also moves like a glacier in a world that needs quick fixes. When Medicare decided to cover annual wellness visits, millions of seniors got preventive care. A noble aim, but it took years to implement and created new administrative overhead that providers are still complaining about.

The thing is, Government is also healthcare's most powerful force for positive change to realign incentives across the whole system - which makes every regulatory change a potential earthquake for the other four corners.

Suppliers and Innovators: The People Who Build Healthcare's Tools

One of the most obvious, but also overlooked, parts of the healthcare system are the Suppliers and the innovators. For this framework, I lumped everything into a pretty big category, but basically it's the stakeholders creating the tools or the medicines or the technologies that help providers give care. So this can be pharma, biotech, health IT, medical devices - anything that kind of feeds into the supply chain of healthcare.

My experience in pharma and health IT have shown a similar pattern: the aim is to speed up innovation with expensive bets - but the payoff of that bet depends on your perspective. A pharmaceutical company might spend $2.6 billion developing a new cancer drug that extends life by six months. Is that worth it? The patient facing cancer says absolutely. The insurance company looking at costs says maybe not. The doctor says it depends on the patient. The pharmaceutical company says they need to recoup their investment or they can't afford to develop the next drug.

But when other stakeholders push back against suppliers, the innovation equation gets complicated. Payer formulary restrictions might control costs, but limit patient access to newer treatments. Government price controls might make drugs more affordable, but reduce R&D investment for future innovations. Provider consolidation creates fewer, but more powerful buyers who can negotiate volume discounts - great for Epic selling to major health systems, brutal for smaller health IT companies trying to get innovative pilot programs off the ground. Patient advocacy for faster approvals might speed access, but potentially compromise safety testing that took years to design.

Therefore, suppliers and innovators are constantly balancing three competing pressures: clinical effectiveness (does it work?), economic viability (can we afford to make it?), and market acceptance (will providers use it and payers cover it?). But when this balance works well, you get genuine breakthroughs - like insulin pumps that automatically adjust dosing, or AI systems that can spot cancer earlier than human radiologists.

It’s easy to complain that healthcare innovation happens slowly - but having been inside pharma and health IT, it’s slow because the stakes are so high. You can't beta test a pacemaker the way you beta test a social media app. People's lives depend on this stuff working perfectly the first time.

Disclaimer

Obviously each of these groups contains multitudes - this is not meant to be a mutually-exclusive grouping - but this best shot at a comprehensive framework illustrates the major fault lines.

When the Seesaw Tips

The thing about complex systems is that there are second- and third-order effects you can't see coming. With a regular seesaw, you might eventually find balance. With a five-way seesaw, every movement creates reactions across all corners that nobody predicted.

To make this more than just theory, I built an interactive simulator that lets you test healthcare scenarios before they become trillion-dollar policy experiments. You can input any scenario - Medicare for All, telehealth expansion, drug pricing reforms - and explore how each stakeholder group might respond over different time horizons.

Watch how it affects all five stakeholder groups simultaneously - immediate effects, five-year impacts, ten-year consequences. Play with the prototype here.

Look, I'm not claiming this thing predicts the future - healthcare is way too messy for that (and honestly we might as well be trying to forecast the stock market). But what it does is make you consider stakeholder perspectives you probably weren't thinking about - the ethos here at Health is Other People.

When you input “Medicare for All”, it doesn't just show you the obvious effects on patients and government. It makes you think about how providers would handle new payment structures, how insurers would reshape their business models, and how pharma companies would deal with negotiating against a single massive customer.

Finding Balance

Most “fixes” in healthcare just move problems around - shifting costs from patients to providers, from payers to the government, from this year’s budget to next year’s health crisis. But every major change in healthcare raises the same questions: Who wins? Who loses? What are the unintended consequences? And when the stakes are life-or-death, how do you actually implement changes without breaking something else?

The rare wins create positive outcomes for multiple stakeholder groups both immediately and long-term, but those are hard to find and harder to implement.

This Five-way Seesaw framework helps explain why healthcare reform is uniquely difficult. Policy proposals aren't just about helping patients or controlling costs - they’re about managing competing pressures across five different groups with fundamentally different incentives.

The most important industry in America runs on stakeholder dynamics that shape everything from the health economy to your doctor's appointment availability. Understanding those dynamics doesn't solve healthcare's problems, but it might help explain why solving them is so damn hard.

It has taken me at least three months to write this first post. Not because I didn't have anything to say (I’ve been writing for weeks, boring anyone who comes within earshot), but because it's hard to put my ambition into real words.

My career in healthcare has conditioned me to keep my head down and mouth shut - you can make a comfortable living by not saying the wrong things to doctors, executives, and lawyers who are all technically right, but completely missing each other's point. But I'm done with the beautiful torture of watching brilliant people talk past each other in conference rooms, year after year, because we're all too unsure to say what we actually think.

In the age of AI, strategy decks and tech solutions are cheap - none of those things have fixed healthcare yet. What's going to be rare is someone willing to explain the hidden truth that might actually move us forward. So I have an irrepressible belief that we can change the way we talk about American healthcare in order to fix it. This is crazy and audacious (and naive), but I'd rather fail trying to fix this cultural mess than spend another decade talking in circles.

Why Healthcare Became So Damn Boring (and Hard to Talk About)

Healthcare is literally how people live and die. It’s science, economics, policy, ethics, innovation, and heartbreak all rolled into one impossibly complex system. It touches every single person, drives one-fifth of the U.S. economy, and shapes society’s future. We're talking about an industry with the most innovative strategies, incomprehensible amounts of money, sci-fi levels of medical advancement, and stakes that couldn't be higher... yet somehow we've managed to make it boring.

This vital industry drowns in incomprehensible medical jargon and self-serving talking points. It's buried under mind-numbing technical details and empty policy platitudes that say nothing while sounding important. It’s the most exciting story, but blandly told. Unless it’s a pandemic, healthcare is relegated to the back of a newspaper - an afterthought, tucked away after the sports section.

That’s part of the problem why the U.S. can’t figure out healthcare: There is no compelling conversation to keep people engaged for meaningful dialogue.

My mission is to cut through the jargon, nagging, and performative policy-speak. I want to shift the conversation towards common values, rather than the tug-of-war of special interests. I want to help smart leaders see the whole system - not just their silo - and inspire us to move towards something, ANYTHING better than this.

Why Me? (Fair Question)

I don't possess a medical mission, a policy passion, a scientific specialty, nor any tech talents. And evidently, I’m an amateur writer.

But according to the Partners who sell my billable hours, I'm a management consultant (whatever that means) with over a dozen years of healthcare consulting work across this entire messy ecosystem. Providers, payers, pharma, policy, tech - I've worked in both private and public sectors, been elbow-to-elbow with everyone from C-suite suits to staff in scrubs.

As a healthcare consultant, I've felt like an outsider watching this dysfunction unfold. It's like being a therapist observing an argument - you can see exactly why everyone's fighting while they're completely blind to it. I've sat on the provider side helping hospitals collect more revenue from insurance, then moved to the payer side working with health plans to manage those same costs. It's like watching your parents argue about money, except you're secretly working for both sides and making it worse.

Most people who talk about healthcare reform usually focus on their corner: Providers complain about how hard it is to deliver care. Payers obsess about the economics. Policymakers just talk in circles. But I've been in rooms with all of them, so maybe I can actually make sense of this mess.

Money, People, Philosophy

Am I truly naive enough to think that I can fix healthcare? Barack freaking Obama couldn’t do it, and he won a Nobel Prize. But if I'm going to take on such an ambitious mission, I should lay out the three things I've learned from sitting in rooms across this entire system:

• The Money Has to Flow Differently
  Don Berwick said "every system is perfectly designed to get the results it gets." Our healthcare system is incredibly efficient at generating profit, which tells you exactly what we've designed it to do. If we want different results (better outcomes, lower costs, actual equity), we have to change what gets rewarded. Right now we pay for volume, procedures, and complexity. Until we pay for health, relationships, and simplicity, we'll keep getting expensive sickness care.

• Other People Have to Come First
  The U.S. healthcare system is phenomenal at processing transactions - sending referrals, prescribing meds, selling insurance. What it's terrible at is human relationships. Patients feel like widgets on an assembly line. Doctors are running on hamster wheels. Administrators are drowning in paperwork. Everyone's optimizing for their own efficiency instead of connection, which is insane for an industry that's fundamentally about caring for other human beings.

• The Philosophy Has to Get Real
  Here's what we collectively can’t seem to talk about: healthcare is a moral imperative disguised as a business problem. We keep trying to solve it with market mechanisms and technical solutions while ignoring that we're dealing with fundamental questions about human dignity, social responsibility, and what we owe each other. Until we have an honest reflection about the philosophical choices we're making - and stop pretending they're just economic ones - we'll keep building systems that work great on spreadsheets and terrible for actual people.

Money, People, Philosophy aren't separate problems - they're interconnected. The money flows the way it does because of our philosophical assumptions about what healthcare should be. Those assumptions shape how we treat people within the system. And how we treat people determines what kind of outcomes we're willing to accept for our money.

Change one without changing the others, and you'll just create new dysfunction in a different place.

The Actual Plan (Such As It Is)

I'm going to use my writing to do three things:

First, craft a vision for shifting healthcare culture to articulate our shared values. The healthcare system is ultimately made of people, and real change requires culture shift - not just policy tweaks or new technology. Whether that happens through this newsletter, a book, or building a community of people who actually want to solve this thing, I'm not sure yet.

Second, turn my thoughts and observations into something that might actually move the needle. I've done plenty of corporate healthcare jobs, but what feels meaningful is trying to influence the culture itself. Maybe that's a book, maybe it's getting published somewhere that matters, maybe it's just finding the right people to have better conversations with. My dream is to create something that changes how we think about healthcare, because I believe changing hearts and minds is our only real shot at fixing this.

Third, show you exactly who I am without the professional filter. I'm at this weird sweet spot where I have enough experience to offer a perspective, but I'm not so entrenched that I won't say risky things. It's now or never for speaking up, because in another decade I'll either be too invested in the status quo or too burned out to care. I'm not here to be intellectual or detached. This is a place to demonstrate my sincere beliefs.

The format? We'll figure it out as we go. I know I want to write deep dives that explain why healthcare works the way it does, covering strategy, operations, technology, and culture from multiple angles. Maybe some longer pieces about regional healthcare markets (Boston’s impact on Worcester), maybe my dream of The Wire-meets-revenue-cycle TV script I wish existed (The Cycle sounds awesome). I have more drafts than published posts right now, so honestly, we'll see what resonates with readers.

Who This Is For (And Why You Should Care)

I'm looking to talk to people who are tired of the same healthcare conversations that go nowhere. If you've ever sat in a meeting thinking "we're all talking past each other" or wondered why smart people keep building systems that make everyone miserable - you're my people.

In the age of AI disruption, I believe this is the best time to fix this. Strategies, policies, and science will have evolutionary leaps in this era, but the missing piece is speaking truth to power through conversation. Not with another policy paper or another digital health startup promising to disrupt everything, but by actually talking to each other like human beings who want the same basic thing: healthcare that doesn't suck.

So here we are. "Health is Other People" - because it really is, and other people are complicated, but maybe we can figure this out together.

Welcome to the conversation I've been wanting to have for years.

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