Earlier this week I shared a short piece with an uncomfortable premise: everyone wants to fix American healthcare, but almost no one wants to admit that we are part of what’s broken.
The argument was simple. It is comforting to believe the problem is “the system,” as though the system were a weather pattern moving over us. But systems don’t make decisions. People do. Every day, good people stay silent in meetings. Approve policies they privately disagree with. Look away from obvious dysfunction because challenging it is inconvenient, politically risky, or simply exhausting.
Healthcare’s greatest crisis isn’t financial or technological. It’s moral. The system isn’t failing because it’s full of bad people. It’s failing because it’s full of decent people who have learned to accommodate things they once would have found unacceptable.
Dozens of people responded. Many disagreed. The disagreements were intelligent, experienced, and specific — and reading them in bulk did not soften my view. It hardened it. Because the most common objection to the argument turns out to be the argument’s best evidence.
The objection: courage doesn’t survive an incentive that punishes it
Lauren Murray, who has spent decades inside health plans, life sciences, and provider organizations, described going to the ER with a cardiac issue and never hearing from her cardiologist’s practice — not in person, not on the phone. She couldn’t stop connecting that silence to reimbursement. Then she turned my own example against me. I had praised a heart failure program that kept patients out of the hospital and was treated internally as a revenue problem. Her reading was withering: “no margin, no mission” sounds like a budget constraint, but what it actually says is that your patients getting better is a financial threat. You’re asking for leadership courage, she wrote, but courage doesn’t survive a payment model that punishes it — and courageous people are often pushed out.
Nancy Paynter supplied the receipt. She described life science companies investing millions in quality initiatives that produced clinically meaningful gains — managing oncology patients outside the walls of the clinic — only to be told not to scale them, because scaling would reduce revenue for the cancer center. Couldn’t bill for it. Non-viable to advance. Better experience, better outcomes, longer life expectancy: not the priority.
Every fact in those accounts is correct. Incentives are real. Two-sided risk changes what’s rational. Boards reward preservation over transformation. I’ve spent my career inside these economics and I am not going to pretend individual virtue can out-run a payment model.
But look closely at what the objection actually does.
“The incentives made me do it” is the alibi
It is the most sophisticated version of the excuse precisely because it is partly correct. It is an explanation that quietly upgrades itself into an exemption. The payment model explains my silence. My silence sustains the payment model. No one in the loop is responsible for the loop. Everyone in that chain is a decent person acting rationally, which is exactly why the chain never breaks.
The incentive is the environment. It is not the decision.
Somebody set that reimbursement rate. Somebody wrote the policy. Somebody sat in the room where Paynter’s oncology program died and agreed that unbillable was the same as unwise — and that person was not a spreadsheet. He had a name, a title, a mortgage, and a perfectly defensible rationale. He went home afterward and did not think of himself as someone who had just ended a program that helped people with cancer live longer. He thought of himself as a realist.
That is what the system is made of. Not villains. Realists.
And notice who pays for the realism. Not the executive who declines to fight. Murray’s cardiologist never called — and the structural analysis of why he didn’t call is airtight, and she still sat in that ER alone. The explanation is not a defense. It’s a description of the crime scene.
The version I’ll take further, not the one I’ll trade for
Mark Young argued that a body can adapt to dysfunction until the dysfunction becomes its normal operating state, and that organizations do the same: people learn when to stay silent, what not to question, which problems are safer to work around than confront. Eventually accommodation becomes culture. He concluded that transformation requires both people willing to speak and systems willing to listen.
He’s right about the first part — it’s the mechanism I’m describing, stated better than I stated it. But the second half smuggles the old comfort back in. A system willing to listen is not a feature you install. It is a room full of people who decided, individually, to listen — or who decided, individually, that they had heard enough. There is no listening system. There are only executives who take the meeting and executives who don’t.
Which is a demand on people like me, not an escape for them. If you hold a seat where you can move a contract, a policy, or a payment model, “be courageous” is not advice you get to dispense. It’s work you’re supposed to do. Asking the people with the least protection to spend the most courage is the most respectable alibi available to anyone with a title.
The people who did it anyway
The objection says courage doesn’t survive the incentives. Some people didn’t get the memo.
Sherita Golden, a physician and longtime health system leader, has repeatedly spent social and reputational capital to change policies that didn’t serve clinicians and patients. Is it risky? Yes. Is it exhausting? Yes. Is it necessary? Absolutely. And then the line that should end the debate: seeing a patient get a better outcome because of a change you had the courage to raise is a powerful antidote to moral distress.
Read that against the incentive argument. We talk about moral injury as a wound the system inflicts on clinicians, and we treat it with resilience training and wellness apps and a pizza party in the break room. Golden is describing the actual mechanism. The distress isn’t caused by the dysfunction. It’s caused by watching yourself accommodate it. Action is the treatment.
Jon Higginbotham named the disease in one line: the things people quietly stopped pushing back on years ago are the same things now called *just how it works.*
Nobody voted for “just how it works.” It accumulated, one reasonable silence at a time — each silence defensible, each silence explained by incentives, and the aggregate a system that everyone claims to hate and no one will fight.
The question
Amy Paez, a Medicare sales agent, asked the only question in the thread that required anything of the person answering it:
*What is one thing you personally could do to make healthcare better? And what’s preventing you from doing it?*
Most people can answer the first half. The second half is where the alibi lives — where we produce the structurally accurate account of why the thing we know is right is somebody else’s job.
So let me answer it instead of admiring it.
The thing I could do: stop treating clinical programs that reduce utilization as a margin problem to be managed, and start treating the internal argument against them as the thing that needs to be defeated. What prevents me: those arguments are made by good people with real budgets and real accountability, and overruling them costs me something. That is not a systems constraint. That is a choice I make, repeatedly, with my name on it.
The system does not tolerate dysfunction. We do. Every silence is a vote for the thing you say you’d change.
The next meeting you’re in, you’ll have a vote. So will I.