Bryce Canyon National Park

#OurWorldIsAwesome – Edition 21 | Context on this series – we live in a beautiful world and National Parks are akin to the crown jewels of this planet. These landscapes remind us of the fine balance and complexity woven into the fabric of the world around us. Every time I spend a while inside one of these places, I’m reminded of how precious that balance is, and how much it matters that we try to understand the complexity and our own small role within it.

I think that’s what awe really is. We reach for the word “awesome” in the moments something helps us see our own insignificance — and windows into nature do that for me every time. So this is my small way of sharing it, and passing it along.

There’s a tree at Bryce Canyon whose roots hang a foot or two above the ground, gripping nothing but air. The soil that once held them has eroded. In a way, the tree is standing on the memory of a floor that no longer exists.

The whole landscape was made this way — by rain, snow, and ice patiently working the rock, freezing and thawing close to two hundred times a year, carving a plateau into a forest of stone spires over millions of years.

These stone spires are called “hoodoos” and their life tells a fascinating tale.

The most striking stretch is a dense maze of hoodoos called the “Silent City.” Standing above it, you really do feel like you’re looking down at a city — streets, towers, walls — except nothing moves and nothing makes a sound.

The name, to me, was symbolic of the quiet beauty of Bryce Canyon National Park. A reminder that everything that shaped this beautiful place happened quietly.

Just water and time patiently working away, day in and day out over many centuries.

People and dots

A lesson I keep reflecting on: given time and opportunity, people surprise you.

Some unravel in unexpected ways when the going gets tough. Others come through in those same circumstances. And some have a knack of following a poor first impression with interactions that just keep getting better.

It’s in our nature to form first impressions and have strong initial reactions. But those first impressions are just single data points — dots. Best to make decisions based on lines, not dots.

The $12,873 Six-Mile Ride – American Healthcare Chronicles

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.

Mathe shared a fantastic post by David Oks that made for a powerful sequel to last week’s post on “EMTALA”. I’ll weave David’s notes (which you should read in full) with some additional context as we continue pulling on the thread of “how did we get here.”

In July 2023, a 25-year-old named Jagdish Whitten was hit by a car crossing a street in San Francisco. He waved off the ambulance that arrived and called a friend instead.

Doctors found a mild concussion, a broken toe, some bruising. Because of the traumatic nature of the injury, they transferred him to San Francisco General — the city’s only trauma center. This time he had no choice. A six-mile ambulance ride, an evaluation, and he was sent home the same night.

Weeks later: a bill for $12,873 or $737 per mile traveled. $314 for cardiac monitoring. $151 for infection control. $11,670 as a “base rate.” After an appeal, his insurer covered $9,967. Whitten paid $2,900 out of pocket — more than any other part of his hospital experience — for a ride he never chose.

This is not an anomaly. About half of privately insured Americans who take an emergency ambulance ride receive an out-of-network bill. A 2024 poll found 23% of Americans have avoided calling an ambulance because of cost.

To understand why, we need to go back to 1965 — and to a vehicle that served two purposes depending on who was being carried.

As late as 1966, about half of the country’s ambulance services were run by funeral homes. Hearses were among the few vehicles that could carry a patient lying flat. In rural areas, funeral homes scanned radio frequencies for accident reports so they could dispatch before a competitor. The attendant sent was whoever was free and medical training wasn’t a requirement.

These rides were cheap — which is why, when Medicare classified ambulance transportation in 1965, it treated rides as a per-ride fee billed after the fact. At the time, that made sense.

Then everything about ambulances changed.

CPR arrived in 1960. Portable defibrillators in 1965. Paramedics emerged as a profession. A 1966 National Academy of Sciences report found that a soldier gravely wounded in Vietnam had a better chance of survival than a motorist seriously injured on an American street. Funeral homes fled the industry. Fire departments stepped in. Professional EMS systems were built — trained crews, expensive equipment, stations staffed around the clock.

The cost structure transformed entirely. However, the 1965 payment structure did not.

Ambulance services are not transportation businesses. They are readiness businesses. The cost of dispatching an ambulance on any given call is trivial. The cost of keeping it staffed, equipped, and available around the clock is enormous.

Medicare sets its own rates well below that cost. The average transport costs roughly $2,673 to provide. Medicare pays around $329. Billing Medicare patients for the balance is illegal. Medicaid pays even less.

The privately insured absorb the rest of the cost — i.e., every Medicare shortfall, every Medicaid gap, every idle hour of standby readiness. The result: 4.5 million Americans now live more than 25 minutes from the nearest ambulance station. Rural residents make up more than half of that population. The billing system that overcharges urban patients is simultaneously bankrupting rural services entirely.

When Congress passed the “No Surprises Act” in 2020 — banning surprise billing across most of emergency care — ground ambulances were the single explicit exception. Restricting ambulance billing, Congress concluded, would render much of the industry insolvent.

So the exception remains. People wave off ambulances at accident scenes. A 25-year-old with a broken toe calls a friend instead.

Victor Fuchs put it plainly in 1996: “Part of the problem is that we have not decided what we want our healthcare system to do.”

A system that had answered that question would have asked a simpler one first: who pays for the ambulance nobody called, but everyone needs standing by?

Until that question has an answer, the bill goes to whoever is unlucky enough to need the ride.

MCL sprain reflections

I sprained my MCL a couple years ago. Two things about that experience have stayed with me.

The first: eighty percent of the healing happened in the first week. The remaining twenty percent took another three weeks. Sprains work like so many projects we take on — the first eighty percent comes relatively quickly. The last twenty percent is a different beast.

The second: I was fascinated by how the MCL was invisible to me until it wasn’t. Walking straight was fine. But any lateral movement and the muscle screamed. Even attempting a forearm plank — something I’d never have connected to the MCL — lit it up. I thought about this recently when I sprained my upper calf. Normal walking, no problem. The moment I tried to accelerate or push off, it announced itself loudly.

It never ceases to amaze me how incredible our body is. So beautifully engineered and so intricately interconnected that we barely notice it when everything works together. And the moment one part breaks down, the whole web of dependencies reveals itself.

There’s so much gratitude owed to a body that’s just quietly doing its job. We never think about it — until we have to.

Muscle memory and the big moment

There’s a sequence at the end of Court of Gold — Netflix’s documentary on Team USA’s path to the basketball gold medal at the Paris Olympics — that I’ve watched three times now.

France had cut a fifteen-point lead down to four. Victor Wembanyama was having a great game. The home crowd was starting to believe. And then Steph Curry took over.

He asked Steve Kerr to give him the ball at the start of the play (called “ear tug”). He knew what he wanted to do.

Three consecutive three pointers followed. Then, with fifty seconds left, doubled-teamed and fading back from well behind the arc, he launched a shot that French captain Nicolas Batum described as something only Steph could make from that angle. It went in. Steph turned to the crowd for the first time all night and made his famous sleep gesture — the game was done.

What stayed with me wasn’t the shot itself. It was Steph’s description of the moment. Missing was not an option. He’d made that shot before — thousands of times in practice. When it mattered most, he didn’t think. He trusted his muscle memory and went for it.

Dwyane Wade said it well: big players show up in big moments because they feel the big moment. They don’t run from the stakes — they tune into them. And then they let the reps do the talking.

For most people, high-stakes moments are when their worst shows up. For the best, it’s when their best does. The difference isn’t talent. It’s a combination of the practice reps and the willingness to trust everything you’ve already put in.

Slaying demons

I went to bed recently knowing the next day had at least three potential issues waiting for me. One had already made a surprise arrival that evening. Another looked like a tricky conversation. The third could go either way.

I fell asleep with a simple reframe: the job description is to slay demons. If it were easy, anyone could do it. I woke up repeating the same thing.

All I did was create some space in the day to deal with each one separately. And it turned out — one conversation went better than expected, another was a nothing burger, and the third went smoothly.

Three lessons stayed with me.

The first: when things seem difficult, all you have to do is put one foot in front of the other and take action. The results aren’t guaranteed, but you’ll be on your way.

The second: I was reminded of the old saying — I have worried about many things in my life, most of which never happened. It’s so easy to spend energy on things that don’t deserve it. Worry less, act more. Easier said than done — but worth the effort.

And finally, the job is slaying demons. In our own small way as part of our own fascinating tale.