A Learning a Day

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? This question is the inspiration for this weekly series chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

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By the early 1980s, a quiet crisis had been building in American emergency rooms.

Hospitals across the country were denying medical care to roughly a quarter million patients annually because they were uninsured or couldn’t afford to pay. The practice had a name: patient dumping. Private hospitals refused to treat patients who couldn’t pay. Ambulances were rerouted mid-route if a patient’s insurance didn’t meet a hospital’s standards. Women in active labor were sent to other facilities, even when doing so endangered their lives.

In Dallas, the number of dumping victims jumped from 70 per month in 1982 to over 200 per month in 1983. Physicians at Cook County Hospital in Chicago — the public hospital absorbing the transfers — started tracking what was arriving from private ERs. Of 467 transferred patients: 22% needed intensive care within 24 hours, 24% arrived medically unstable, and 9.4% died — compared to 3.8% of patients who hadn’t been transferred.

EMTALA passed largely under the radar — a four-page bill tucked inside the Consolidated Omnibus Budget Reconciliation Act of 1985. It barely registered until after Reagan signed it in 1986.

The law was simple: any hospital accepting Medicare — nearly every hospital in America — had to screen and stabilize any patient arriving at their emergency department, regardless of ability to pay, insurance status, or citizenship.

It passed with broad bipartisan support. The problem it addressed was one members of both parties found unconscionable. Almost nobody argued against the principle.

What nobody fully debated was the consequence.

The employer-based system covered working Americans. Medicare covered the elderly. Medicaid covered some of the poor. EMTALA, with one stroke, turned every emergency room into a guaranteed safety net for everyone the rest of the system had left behind.

The ER became America’s doctor for the uninsured.

Emergency rooms are the most expensive possible setting for routine care. A diabetic patient who can’t afford $15 a month for insulin doesn’t stop being diabetic. They manage without medication, deteriorate quietly, and eventually arrive in crisis — at a cost that can run into tens of thousands of dollars. EMTALA required the hospital to treat them. It created no mechanism to prevent them from getting there in the first place.

Between 1990 and 2009, ER visits per 1,000 population increased by 18%. Uncompensated care grew from $6.1 billion in 1983 to $40.7 billion in 2004. Those costs didn’t disappear — they were absorbed by hospitals, shifted onto insured patients, or passed back to the government.

EMTALA is one of the most humane laws in the history of American healthcare. People who would have died in parking lots lived. Women in labor received care.

And it became the most expensive patch ever applied to a system that had never decided who it was supposed to serve. Every unresolved question from the posts in this series found its way, eventually, to an emergency room.

The only approach that works long term is to deeply feel the pain of a mistake and use it to change how we operate.

First-time mistakes, especially those that are a mix of painful and fixable, are a part of life.

Second-time mistakes don’t need to be.

We systematically overestimate the amount of context people have about the matter at hand — the decision that needs to be made, the problem that needs to be solved.

Start by ensuring everyone is operating with the same context.

I recently got a traffic ticket for stopping a touch late at a stop sign — missing the line by two feet. Undoubtedly fair by the rule of law, but I felt aggrieved. It was a late brake, a spillover, at 8am on a quiet Sunday street without a soul in sight.

My subjective feelings aside, I noticed my “why me” reaction and sat with it for a moment.

Three years ago, I accidentally drove past a stop sign on a similarly quiet road. The officer was kind, understood it was a genuine mistake, and sent me on my way without a ticket*.

I’m pretty sure I didn’t dwell on that stroke of luck anywhere near as long as I dwelt on this one.

It’s easy to ask “why me” when misfortune strikes. If we find ourselves stuck in that loop, it’s worth reflecting on the many times good fortune came our way — and we never thought to ask the question at all.

*I was clearly due a ticket from a karmic perspective. :-)

Growing up, the game I watched along with my friends was cricket. And there was a familiar story about the Indian team — Sachin Tendulkar, the iconic batsman, would do well all the way to the finals, and then inevitably get out, and the team would fold. It took an entire changing of the guard before India became capable of winning in clutch moments.

It was hard not to see the parallel in this year’s NBA Finals between the Spurs and the Knicks.

The Spurs led in the first quarter of every game. Across the series, they outscored the Knicks by nearly sixty points in first quarters. And yet the Knicks won four out of five — because when it came to the second half, and especially the fourth quarter, they were a different team. By Game 5, down ten in the fourth, they went on a ten-nothing run and it felt inevitable. You just knew they were going to come through.

The Chicago Bulls had the same journey. Years of being unable to get past the Detroit Pistons before they finally summoned the ability to rise to the occasion.

There are really only two things that build clutch. Practice hard enough that it becomes second nature. And learn to embrace the big moment rather than shrink from it.

We don’t face NBA Finals. But we face big meetings, big weeks, big decisions. And in the long run, the ability to show up in those clutch moments that add up.

The difference in our perception of people we love is that we assume good intent. Every quirk, every friction — we interpret it charitably.

The wider we expand that circle of assumed good intent, the more likely we are to find community wherever we choose to spend time.

And it’s why love is a verb. Especially in relationships that have lasted a long time, it’s easy to forget to choose it. To fall into patterns where all we see are the quirks, all we feel is the friction. Reminding ourselves of the intent takes real commitment.

It is why it takes commitment and character to consistently choose to love.

In any group discussion where feedback is given, it helps to distinguish between input and allergic reactions.

Input is a perspective worth considering. An allergic reaction is something stronger — a signal that something is fundamentally wrong for that person.

Focus your group time on the allergic reactions. Deal with input async.

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? This question is the inspiration for this weekly series chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

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Across the last few posts, one institution kept appearing as the immovable object in American healthcare — the American Medical Association. They killed Truman’s universal coverage plan with a fabricated Lenin quote. They tried to shut down Kaiser’s shipyard health plan by barring his doctors from existing hospitals. They called both “socialized medicine.”

To understand how a professional association accumulated that kind of power, we need to go back to 1910. To a report written by a man who had never treated a single patient in his life.

In the early 1900s, American medicine was chaotic. Medical schools resembled today’s for-profit colleges. There were no common standards for curriculum or matriculation. Many didn’t require students to have a high school diploma, and only the most elite programs took more than a year to complete. In 1904, there were 160 medical schools. The word “quack” was in common use.

The AMA had been pushing for standardization for years — but their conclusions carried the smell of self-interest. They needed an outside voice.

They found him in Abraham Flexner. He was not a doctor. He held a Bachelor of Arts degree and ran a for-profit school in Louisville, Kentucky. The Carnegie Foundation hired him to survey every medical school in North America. He visited all 155.

What he found was damning — students with no clinical training, schools admitting anyone who could pay fees, facilities barely functional. His 1910 report called for a complete restructuring: all schools connected to universities, two years of basic science followed by two years of clinical training, rigorous admissions standards. The model he described is still the foundation of American medical education today.

The results were swift. By 1920 there were 85 medical schools — down from 160. By 1935, more than half had merged or closed. The survivors were stronger, better funded, university-affiliated.

But something else happened alongside the quality improvement.

Fewer schools meant fewer doctors. Fewer doctors meant less competition and higher fees. Standardized licensing, controlled by state boards the AMA influenced, gave the profession a gatekeeper it had never had before. The reform that cleaned up American medicine simultaneously handed the AMA extraordinary control over who could enter it.

The report had other unintended consequences. For example, the cost of the report fell disproportionately on Black Americans as well. In 1910, there were seven historically Black medical colleges. They existed because mainstream schools almost universally refused to admit Black students. These institutions trained the doctors who served Black communities — communities that had no other access to care.

Flexner recommended closing five of them, saying only Howard University in Washington DC and Meharry Medical College in Nashville were worth developing. Five schools closed. Estimates suggest those institutions might have trained between 30,000 and 35,000 Black physicians over the following century. No new Black medical school opened between 1920 and 1987, when Morehouse School of Medicine opened in Atlanta. The AMA’s own local chapters prohibited Black doctors from membership well into the late 1960s.

This is what makes the story of American Healthcare fascinating. The Flexner Report genuinely improved American medical education. It built the scientific foundation that made the US a world leader in research and innovation — the breakthroughs in cancer treatment, vaccines, and medical technology that appear later in this series all rest on the infrastructure it helped create.

And it concentrated power, reduced access, and closed the schools serving communities the mainstream profession had no interest in serving.

The AMA that killed Truman’s plan, that attacked Kaiser, that shaped American healthcare policy for most of the twentieth century — that institution’s authority runs directly through 1910. Through a report written by a schoolteacher from Louisville, funded by Carnegie, embraced by an establishment that understood that controlling the supply of doctors was the foundation of everything else.

Paul Starr’s quote “The dream of reason did not take power into account” is an apt place to end today’s story.

Coastal redwoods are the tallest tree species on earth. They exist only within a mile of the California coast, sustained by fog — drawing water directly from the air to feed themselves.

But the most intriguing thing about these majestic giants isn’t their height. A four-hundred-foot tall redwood has roots only eight to twelve feet deep. What keeps them standing is that those roots spread up to two hundred feet outward — intertwining with the roots of neighboring trees, connected through mycelium, sharing nutrients, holding each other steady, supporting the younger ones still growing.

Their survival isn’t a solo act. It takes a village.

For a species so rare and so majestic, it’s a beautiful reminder of what it actually takes to survive on this planet.

The easiest reward a company can give good talent is compensation.

The hard kind is creating an environment where they can actually thrive — where they have the tools and resources to get important things done without being hampered by bureaucracy and red tape.