The Arsonists Are Applying to Be Fire Chief

It’s an election season, which means it’s also confession season, if you know how to translate the language.

Watch any competitive statewide race, and you’ll hear the same refrain. The system is broken, costs are out of control, people can’t get care, and someone needs to fix it. And the person saying this loudest, in a striking number of races, spent the last decade helping build the fire they’re now running to put out. Voted for the consolidation bills. Sat on the health committee. Took the hospital-system money. Shaped the regulatory environment we’re currently stuck living in. And now they’re back, reintroducing themselves as the solution to a problem they had a hand in writing.

I don’t have a grudge against any one of them, for what it’s worth, and this isn’t really about a race. It’s a pattern. Healthcare has its own version, and we live inside it every day whether we notice or not.

The same institutional voices diagnose the access crisis, the affordability crisis, the primary care shortage, year after year, and the fix on offer keeps requiring physicians to stay exactly as dependent on those institutions as before. Insurers publish white papers on the cost of prior authorization delays. They also run the prior authorization departments. Nobody seems to find that funny but me.

Here’s the tell, and it’s the same one every time: whoever pays the physician is who the physician works for. Doesn’t matter if the check comes from an insurer, a hospital system, an ACO, or some government payment mechanism wearing a reform costume. If the money and the rules come from anywhere other than the patient, the incentive hasn’t gone away. It’s just moved addresses. Most of the people proposing these fixes aren’t stupid, and a lot of them aren’t even wrong about the diagnosis. Consolidation really is the problem, and prior authorization overhead really is strangling primary care. What none of them can quite manage is a fix that doesn’t also keep them a seat at the table. Funny how that works out.

I know how this sounds. Of course the DPC guy thinks insurance is the villain again. Fair enough. But I didn’t wait around for the institutional fix, and neither has a growing number of physicians doing roughly what I did over a decade ago. No task force. No pilot program with a two-year evaluation built in. We just stopped working for whoever was cutting the check and started working for the patient instead, which turns out to not be a policy proposal at all. It’s a business model. It’s been sitting out in the open for years now, and it works.

I bring this up during an election season because the parallel is worth more than a laugh line. Trusting the person promising the fix because they sound informed, because they clearly get the problem, because they’ve “been in the room” — that instinct is exactly what keeps the healthcare establishment’s preferred solutions cycling back every year. Understanding a problem intimately isn’t the same as wanting to solve it. Sometimes it’s just proximity wearing a nicer suit. The task force veteran who’s spent fifteen years on the primary care shortage and the legislator who spent a decade shaping the policy that produced it are both, technically, experts on the crisis now. Neither fact tells you whether either one can actually unwind what they built, or whether unwinding it was ever really on the table.

Not every reform proposal is bad-faith theater. Some people genuinely do learn from the thing they built and go try to fix it. I’d like to believe that’s more common than it feels most days. But the burden of proof runs backward from where most people put it instinctively. The question isn’t whether someone sounds like they get it. Most of them do; that’s the whole pitch. The question is whether their fix leaves the physician, or the patient, or the voter, just as dependent on the fixer as before.

If it does, you’re not looking at reform. You’re looking at the arsonist putting in an application for fire chief, and citing the smoke as their qualifications.