Beyond Villains and Heroes: Fixing What’s Broken in Healthcare
Clear communication and a commitment to facts are keys to better governance
Last week’s TL;dr newsletter on the complexities of healthcare and insurance sparked some thoughtful feedback, but one email from a good friend truly hit home. Earlier this year, he underwent delicate, life-saving surgery for cancer. Beyond the cutting-edge medical tools and pharmaceutical interventions, what stood out most was the skill and humanity of the doctors and nurses who supported him every step of the way. As he put it, “I got Lexus care when I needed it and Camry care as appropriate.”
His message brought to light something essential: even in a flawed and frustrating system, there are moments of grace and extraordinary service. But his perspective also underscores the importance of nuance in discussing health care and its costs. It’s a complex issue — one where structural inefficiencies collide with compassionate care, and where public frustration often focuses on the wrong targets.
Compelling Communication = Better Governance
My friend’s story serves as a powerful reminder for those in the governing business: tackling big issues requires not just thoughtful policy but also clear, honest communication with the public. Frustration often boils over when systems feel impossible to navigate or when problems are reduced to simplistic narratives of villains and heroes. Details and facts matter. A lot. And a personal narrative often helps illuminate complex issues. Those are lessons that go well beyond health care — it applies to nearly every corner of governance.
So, I’m taking my own advice in revisiting this topic today. I found one essay that uses facts and data to identify a core problem, while another offers a practical solution based on the author’s real-world experience. Together, they challenge how we think about health care — its failings and its strengths — and what lessons they hold for leaders striving to balance complexity, transparency, and public trust.
Let’s get started.
Insurers Aren't the Main Villains in Healthcare Costs
Thus argues Noah Smith, who writes about economic issues in his insightful Substack, Noahopinion. In the wake of insurance CEO Brian Thompson’s murder, Smith points out that while health insurers like UnitedHealthcare are widely hated, they’re not the primary drivers of America’s exorbitant health care costs. Despite the anger directed at insurers over denied claims and high premiums, their profit margins are modest (2-6%) compared to the immense profits of hospitals, pharmaceutical companies, and medical device suppliers. He writes:
It’s not hard to understand why people hate health insurers. When you interact with the U.S. health care system, the providers — the hospital staff, the doctor, the nurses, the technicians — all just take care of you. The only time they ask you for money during your doctor visit is when you pay your copay at the front desk, and that’s usually not that big — if the bill is big, they’ll send it to you later. So for the most part, your interaction with the providers is just you walking up and asking to be taken care of, and them taking care of you.
Your interaction with the health insurer, on the other hand, feels like a struggle against an enemy who wants to destroy you. If you get a big hospital bill days after your visit, it’s because the insurer wouldn’t cover the whole cost. If the bill is a surprise because the provider didn’t tell you they were out of network, that also feels like the insurance company’s fault — why wasn’t that provider in their network?
The real issue? U.S. health care providers charge far more than their counterparts in other developed countries. Here’s the data.
Hospitals and drug companies have outsourced the “bad guy” role to insurers, leaving patients furious at the middlemen while the root cause — sky-high provider charges — remains overlooked. Smith compares return on equity (ROE) between insurance companies and healthcare providers to underline his point. While health insurers hover around the S&P 500’s average ROE of 15%, providers and suppliers like HCA Healthcare (272%) and Eli Lilly (59%) are in a completely different league.
Smith suggests solutions like giving government insurers more power to negotiate prices, as seen with Medicare’s recent drug price talks, but warns that real reform must focus on reducing provider costs rather than scapegoating insurers.
A Modest Proposal on Healthcare
Veteran journalist Joe Klein has an idea on how to do just that. Klein notes he’s “spent more time than I’d like to remember trying to figure out health care policy over the decades. It’s a heavy slog. But it seems to me there is one possible reform that might wring much of the waste, and some of the frustration, from the system.”
He advocates for salary-based compensation for doctors rather than the traditional fee-for-service model. Drawing from personal experiences with his parents’ end-of-life care, Klein highlights how a salary-based approach eliminated unnecessary procedures, encouraged honest communication, and reduced costs — all while preserving dignity for patients and their families.
It wasn’t pleasant, overseeing the death of my parents…but I felt confident that the decisions I made were good ones—the decisions they would have wanted me to make—and that I had complete information from the doctors. Instead of the tens, perhaps hundreds-of-thousands of dollars that would have been spent on fee-for-service procedures to keep them alive, they died with dignity.
Klein contrasts this with the broader U.S. system, where fee-for-service incentivizes over-treatment and inflates costs. He points out private Medicare Advantage plans, which already use salary-based models, enjoy high patient satisfaction and could serve as a foundation for wider reform. While acknowledging resistance from both political parties — Democrats’ distrust of private solutions and doctors’ preference for lucrative fee-for-service arrangements — Klein suggests incremental changes, like expanding Medicare Advantage, as a pragmatic alternative to fully socialized medicine.
Celebrate Excellence While Pushing for Reform
My friend’s email shows how personal experience can add depth to public debates. He’s alive today because of the extraordinary skill and compassion of his providers. But we can also demand more from our leaders — reforms to ensure this exceptional care is accessible and affordable for all. Celebrating what’s good while striving to fix what’s broken isn’t just possible; it’s necessary.
GovOvertime: Hits & Misses
MISS: The 6% Office Myth. The claim that only 6% of federal employees work in-person full-time is about as accurate as saying there’s never a line at the DMV. Official data reveals 54% of federal employees are fully on-site, with just 10% working remotely full-time. The 6% figure gained attention when U.S. Sen. Joni Ernst included it in a report for the Senate Department of Government Efficiency (DOGE) Caucus. Her statistic came from a non-scientific survey conducted by Federal News Network and does not reflect official government data. In reality, workplace arrangements vary across agencies, with hybrid schedules being common. Misinterpreting such data risks creating unnecessary confusion and undermining discussions on workforce policies. The takeaway? When citing numbers to make a case, accuracy matters.
HIT: State of Florida CIO Gets Personal with Tech. Florida’s Rich Evans envisions government tech as smooth and intuitive — more like ordering coffee on an app than deciphering an ancient scroll. Speaking at a recent workshop, Evans championed an “individualized” customer experience, where navigating state services feels less like a chore and more like second nature. Florida’s upgrades are already making waves. State certifications that used to take 45 days now process in under 30 minutes.
MISS: Drone Panic in the Skies. When my son, 25, texted me that drones were searching for “loose nukes,” I knew the rumor mill was in overdrive. Mystery drones buzzing across the East Coast have sparked public panic and wild theories — everything from Iranian motherships to Project Blue Beam. Meanwhile, the federal government insists there’s “no threat” but offers few concrete answers, leaving state and local officials and residents in the dark. As a Wall Street Journal op-ed notes, the real issue isn’t the drones — it’s the information vacuum. Without clear communication, conspiracy theories take flight faster than the drones themselves. Lesson for government? Fill the void with facts, or someone else will fill it with fiction.
Programming Note
This is the last TL;dr of 2024, as we’ll be taking a break for the holidays. But we’re not done for the year just yet — we’ll have one more Friday deep dive this week before going into holiday mode.
The Last Word
Actor Carl Weathers left us earlier this year with an unforgettable legacy of passion, energy, and purpose — punctuated by one final, iconic reminder: There IS no tomorrow. He delivered the line with all the fire of Apollo Creed during what would tragically become his last public interview on the Chasing Scratch golf podcast. And in a bittersweet twist, he passed away the night before the episode first aired, bringing haunting truth to his words.
For younger readers not familiar with Rocky III and that memorable line, here’s the clip.
Known for his beloved roles (like Chubbs, the one-handed golf pro in Happy Gilmore) and unforgettable presence, Weathers didn’t just talk about showing up with passion — he lived it. Even in a podcast interview with two strangers about a sport he didn’t play, he gave his whole heart, leaving an indelible mark on the hosts and listeners alike. Here is Weathers, in his own words, from the podcast:
Showing up is NOT enough—I’m sorry folks, it’s not enough. What are you going to do after you get there? What are you going to do with all that energy—with the life God has given you? What are you going to do with it?
My advice to anybody is to just go after it and go after it with as much love and energy and as much passion as you have, because man it’s infectious when you walk in the door with that, you know? People around you just pick up on it. And that’s part of what is the key to success in life. How you affect other people is directly a result of how you go about what you’re doing.
Onward and Upward.